bluuebunny/crossref_metadata_2025 huggingface dataset:
“A-OK”: Chest Radiograph during Primary Survey Facilitates Faster, More Accurate Endotracheal Tube Position in Injured Children
Authors: Doud Andrea N. , Gaffley Michaela , Hostetter Olivia , Talton Jennifer W. , Petty John K.
Published: June 2020

The Advanced Trauma Life Support algorithm recommends bedside confirmatory techniques to confirm correct endotracheal tube (ETT) depth, a critical component in the care of pediatric trauma patients. We hypothesized that bedside confirmatory techniques are inaccurate and that early chest X-ray (CXR) would overcome such inaccuracies, allowing for faster intervention of malpositioned ETTs. An “A-OK” algorithm of immediate CXR following intubation in injured children aged <16 years was implemented. Eligible patients the years before and after implementation were identified. The accuracy of bedside confirmatory techniques (use of length-based depths and auscultation of breath sounds) was assessed. Post-“A-OK” patients were compared with pre-“A-OK” controls regarding the speed of malpositioned ETTrepositioning. Twenty-eight post-“A-OK” cases and 23 pre-“A-OK” controls were identified. The groups did not differ in baseline characteristics. Bedside confirmatory techniques were accurate in only 61 per cent (length-based depth) and 58 per cent (auscultation of breath sounds) of patients. Time to ETT repositioning was significantly longer in pre-“A-OK” controls than in post-“A-OK” cases (35.2 ± 15.9 minutes vs 21.1 ± 11.8 minutes, P = 0.03). Bedside confirmatory techniques to determine ETT positioning are inaccurate in children. Inclusion of CXR in the primary survey is safe and allows for more rapid repositioning of malpositioned ETTs.
Variations in Nationwide Readmission Patterns after Umbilical Hernia Repair
Authors: Eidelson Sarah A. , Parreco Joshua , Mulder Michelle B. , Dharmaraja Arjuna , Hilton L. Renee , Rattan Rishi
Published: June 2020

Up to one in three readmissions occur at a different hospital and are thus missed by current quality metrics. There are no national studies examining 30-day readmission, including to different hospitals, after umbilical hernia repair (UHR). We tested the hypothesis that a large proportion were readmitted to a different hospital, that risk factors for readmission to a different hospital are unique, and that readmission costs differed between the index and different hospitals. The 2013 to 2014 Nationwide Readmissions Database was queried for patients admitted for UHR, and cost was calculated. Multivariate logistic regression identified risk factors for 30-day readmission at index and different hospitals. There were 102,650 admissions for UHR and 8.9 per cent readmissions, of which 15.8 per cent readmissions were to a different hospital. The most common reason for readmission was infection (25.8%). Risk factors for 30-day readmission to any hospital include bowel resection, index admission at a for-profit hospital, Medicare, Medicaid, and Charlson Comorbidity Index ≥ 2. Risk factors for 30-day readmission to a different hospital include elective operation, drug abuse, discharge to a skilled nursing facility, and leaving against medical advice. The median cost of initial admission was higher in those who were readmitted ($16,560 [$10,805–$29,014] vs $11,752 [$8151–$17,724], P < 0.01). The median cost of readmission was also higher among those readmitted to a different hospital ($9826 [$5497–$19,139] vs $9227 [$5211–$16,817], P = 0.02). After UHR, one in six readmissions occur at a different hospital, have unique risk factors, and are costlier. Current hospital benchmarks fail to capture this sub-population and, therefore, likely underestimate UHR readmissions.
Prevalence and Clinical Significance of Biliary Intraepithelial Neoplasia (BilIN) in Cholangiocarcinoma
Authors: Yoon Kyung-Chul , Yu Young-Dong , Kang Woo-Hyung , Jo Hye-Sung , Kim Dong-Sik , Kim Joo-Young
Published: June 2020

Biliary intraepithelial neoplasia (BilIN) is the most common noninvasive precursor lesion which progresses to cholangiocarcinoma (CC) and is often found synchronously adjacent to the tumor or at the surgical resection margin. The aim of this study was to elucidate the prevalence and prognostic effect of BilIN on survival after resection for CC. We retrospectively analyzed the database of patients with CC who underwent surgery performed at our institution from 2010 to 2017. There were 142 patients who underwent surgery for CC. BilIN was detected in 42 patients (29.5%). On univariate analysis, extrahepatic CC (ExtraH CC) patients with BilIN lesions significantly showed better disease-free survival ( P = 0.05). Also, although not statistically significant, ExtraH CC patients with BilIN lesions revealed better overall survival (OS) ( P = 0.09). On multivariate analysis, presence of BilIN lesion, irrespective of location, was significantly associated with better disease-free survival (HR = 2.059, 95% confidence interval (CI): 1.057–4.432, P = 0.041) and OS (HR = 1.831, 95% CI: 1.149–3.534, P = 0.044) in ExtraH CC patients. The presence of BilIN lesions was not uncommon in CC patients and was significantly associated with better disease-free survival and OS in ExtraH CC patients. However, larger studies with longer follow-up are needed to accurately determine its clinical significance.
Is Tracheostomy Insertion an Indication for Gastrostomy Insertion?
Authors: Dvorak Justin , Ridder David , Martin Brendan , Ton-That Hieu , Baldea Anthony , Gonzalez Richard P.
Published: June 2020

The aim of the study was to determine the frequency of surgical patients who undergo tracheostomy and gastrostomy insertion during the same hospitalization. Secondary outcomes included ICU and hospital length of stay (LOS) for patients who underwent concomitant tracheostomy and gastrostomy versus those who did not. This study is a retrospective review of trauma and acute care surgery (ACS) patients between 2006 and 2015 who underwent tracheostomy. Patients who also underwent open gastrostomy or percutaneous endoscopic gastrostomy during the same hospitalization were identified. Data collected included patient demographics, hospital LOS, ICU LOS, and timing of tracheostomy and gastrostomy. Three hundred one trauma and ACS patients who underwent tracheostomy were identified. Seventy- three per cent of tracheostomy patients underwent gastrostomy during the same admission. Of patients who had both tubes inserted, 79 per cent (175) underwent gastrostomy with tracheostomy as the concomitant procedure, whereas 21 per cent received gastrostomy as a delayed procedure. Median hospital LOS for patients who underwent concomitant procedures was 25 days versus 22 days for those who had delayed or no gastrostomy ( P = 0.24). Eighty-four per cent of patients who had tracheostomy for prolonged or anticipated prolonged mechanical ventilation were receiving tube feeds at discharge, and 78 per cent had not been advanced to an oral diet at discharge. Most trauma/ACS patients who undergo tracheostomy also undergo gastrostomy during their hospitalization. Concomitant gastrostomy is not associated with a decrease in hospital LOS; however, most patients who undergo tracheostomy for prolonged mechanical ventilation are discharged receiving enteral nutrition. These patients may benefit from concomitant ICU gastrostomy as a way to improve efficiency and cost-saving.
Improving Resident-To-Attending Communication: Implementing a Tool to Facilitate Attending Notification of Critical Patient Events at a Single Academic Institution
Authors: Senders Zachary J. , Aeder Mark , Semrau Susan , Ammori John
Published: June 2020

Ineffective communication between surgical trainees and attending surgeons is a significant contributor to patient harm. The aim of this study was to evaluate a tool to improve resident-to-attending communication regarding changes in patient clinical status. Ten critical patient events were compiled into a list of triggers for direct attending surgeon notification at a single academic institution. Residents and faculty were surveyed to assess communication before and after implementation of the list. Institution of the triggers list was associated with a nonstatistically significant increase in resident-to-attending notification regarding 7 of 10 critical patient events. There was no reported change in frequency of calls associated with the list's implementation. Most residents felt that the list improved patient care and increased their comfort with calling attending surgeons. Comments were generally positive; however, both groups expressed concern that the list could negatively impact resident autonomy and supervision. Implementing a list of triggers for attending notification of critical patient events subjectively improved resident-to-attending communication in an environment with high baseline levels of communication.
The Understated Malignancy Potential of Nonoperative Acute Appendicitis
Authors: Seawell Jaimie , Sciarretta Jason D. , Pahlkotter Maranda , Muertos Keely , Onayemi Ayolola , Davis John M.
Published: June 2020

Cancer of the appendix is rare and is most commonly found incidentally on pathology after an appendectomy for uncomplicated appendicitis (UA). The medical management alternative with antibiotics and observation remains an ongoing debate. The purpose of our study was to develop modern epidemiological data for adult patients completing an appendectomy for UA secondary to an appendiceal neoplasm (AN). ACS-NSQIP database was queried (2005–2016) to identify patients completing an appendectomy. Cohorts of patients who were diagnosed with UA and an AN were included in the study. Relevant perioperative clinical and outcomes data were collected. Type of AN, surgical procedure, and mortality were analyzed. A total of 239,615 UA patients were identified, of whom 2,773 (1.2%) met the inclusion criteria of AN. Patients with AN were predominantly white (79.5%), with a mean age of 54.5 ± 15.9 years, and 54.6 per cent were females. AN pathology findings included malignant neoplasm (64.5%), malignant carcinoid (17.3%), benign carcinoid (9.3%), and benign neoplasm (8.8%). The overall reported incidence was 1.2 per cent and the mortality rate was 0.7 per cent. Our study emphasizes surgical intervention in adult UA maintains a 1 per cent incidence of AN, and treatment with antibiotics alone will presumably lead to a delay in surgical treatment and progression of disease.
Evaluation of Operative Waste in a Military Medical Center: Analysis of Operating Room Cost and Waste during Surgical Cases
Authors: Rose Elizabeth D. , Modlin David M. , Ciampa Maeghan L. , Mangieri Christopher W. , Faler Byron J. , Bandera Bradley C.
Published: June 2020

Operating rooms (ORs) contribute to at least 40 per cent of hospital costs. There is an existing cost waste in ORs for surgical devices that are opened without being used. There is a paucity of data evaluating the hospital cost of opened but unused OR supplies. The goal of this observational study is to examine the cost of opened but unused OR supplies for general surgery cases. We performed a quality improvement project of OR cost waste by observing 30 cases. Surgical cases of a senior surgeon who had been at the institution for more than five years were evaluated for items opened appropriately and whether the items are used. The cases evaluated ranged from open hernia repairs to robotic-assisted hernia repairs. We found that the cost of instruments opened but not used was $4528.18. Of the cases evaluated, we found that a range of 0 per cent to 27 per cent of total items were wasted, an average of 8.3 per cent. We found that for the open inguinal hernia case, there was minimal waste. The highest waste was among complex cases such as the robotic-assisted inguinal hernia with an average waste and cost of 15.8 per cent and $379. We found that on average for less complex cases such as open inguinal hernia repairs, $1.44 was potentially wasted per case, whereas for more complex cases up to $379 was wasted per case. We identified the outdated preference cards, lack of instrument knowledge, circulating nurse, and surgical technician distractions as reasons for contributing to waste.
Comparing Machine Learning Algorithms for Predicting Acute Kidney Injury
Authors: Parreco Joshua , Soe-Lin Hahn , Parks Jonathan J. , Byerly Saskya , Chatoor Matthew , Buicko Jessica L. , Namias Nicholas , Rattan Rishi
Published: June 2020

Prior studies have used vital signs and laboratory measurements with conventional modeling techniques to predict acute kidney injury (AKI). The purpose of this study was to use the trend in vital signs and laboratory measurements with machine learning algorithms for predicting AKI in ICU patients. The eICU Collaborative Research Database was queried for five consecutive days of laboratory measurements per patient. Patients with AKI were identified and trends in vital signs and laboratory values were determined by calculating the slope of the least-squares-fit linear equation using three days for each value. Different machine learning classifiers (gradient boosted trees [GBT], logistic regression, and deep learning) were trained to predict AKI using the laboratory values, vital signs, and slopes. There were 151,098 ICU stays identified and the rate of AKI was 5.6 per cent. The best performing algorithm was GBT with an AUC of 0.834 ± 0.006 and an F-measure of 42.96 per cent ± 1.26 per cent. Logistic regression performed with an AUC of 0.827 ± 0.004 and an F-measure of 28.29 per cent ± 1.01 per cent. Deep learning performed with an AUC of 0.817 ± 0.005 and an F-measure of 42.89 per cent ± 0.91 per cent. The most important variable for GBT was the slope of the minimum creatinine (30.32%). This study identifies the best performing machine learning algorithms for predicting AKI using trends in laboratory values in ICU patients. Early identification of these patients using readily available data indicates that incorporating machine learning predictive models into electronic medical record systems is an inevitable requisite for improving patient outcomes.
Service-Based Advanced Practice Providers: The Surgeon's Perspective
Authors: Eaton Barbara , O'Meara Lindsay , Herrera Anthony V. , Tesoriero Ronald , Diaz Jose , Bruns Brandon
Published: June 2020

The ACGME work hour restrictions facilitated increased utilization of service-based advanced practice providers (APPs) to offset reduced general surgery resident work hours. Information regarding attending surgeon perceptions of APP impact is limited. The aim of this survey was to gauge these perceptions with respect to workload, length of stay (LOS), safety, best practice, level of function, and clinical judgment. Attending surgeons on surgical teams that employ service-based APPs at an urban tertiary referral center responded to a survey at the completion of academic year 2016. Perceptions regarding APP impact on workload, LOS, safety, best practice, level of function, and clinical judgment were examined. Twenty-two attending surgeons (40%) responded. Respondents agreed that APPs always/usually decrease their workload (77%), decrease LOS (64%), improve safety (68%), contribute to best practice (82%), and decrease near misses (71%). They also agreed that APPs decrease resident workload (87%), but fewer agreed that APPs contribute to resident education (68%). The majority perceived APPs function at the PGY1/2 (43%) or PGY3 (39%) level and always/usually trust their clinical judgment (72%), and felt there was variability in level of function among APPs (56%). This single-center study illustrates that attending surgeons perceive a positive impact on patient care by service-based APPs.
Clavien-Dindo Analysis of NSQIP Data Objectively Measures Patient-Focused Quality
Authors: Gurien Lori A. , Ra Jin H. , Crandall Marie , Kerwin Andrew J. , Tepas Joseph J.
Published: June 2020

Current quality measures intended to drive improved clinical performance are perceived as an inappropriate administrative burden. Surgeon-constructed quality measures, including the NSQIP, are more closely aligned with provider performance and relevant outcome. We hypothesized that NSQIP participation would be associated with measurable improvement in surgical outcomes. Elective general surgical cases were compared by case volume and incidence of postoperative adverse events (AEs) from 2014 to 2017. Using the Clavien-Dindo severity scaling system, we summed the grades for each AE and defined the patient population burden of these AEs as this sum divided by case volume. Case volume samples increased 67 per cent from 2014 (n = 526, 30 day complete) to 2017 (n = 878). Ratio of patient burden to case volume improved from 0.92 (2014) to 0.73 (2017). Comparison of AE incidence was not significantly different; however, the majority decreased over time. Analysis of individual AE interval change identified sepsis-related respiratory care as the top priority performance improvement target. These data reflect improved performance for a growing volume of surgical procedures. The impact of perioperative morbidity and their associated burden on affected patients has decreased, demonstrating the value of combining NSQIP with Clavien-Dindo to measure the quality of surgical care in objective and patient-specific terms.
The “Headstrike” Protocol: A Retrospective Review of a Single Trauma Center's Operational Change in the Management of Anticoagulated Ground-Level Falls
Authors: Keyes Michael , Alley Ashley , Muertos Keely , Anderson Barbie , Howerton Stephanie , Burns Alison , Pepe Antonio
Published: June 2020

Anticoagulated older adults suffering ground-level falls are a specialty trauma population at risk for intracranial hemorrhage (ICH). Delays in diagnosis or initiation of anticoagulation reversal can lead to increased morbidity/mortality. A novel “Headstrike” protocol was implemented to improve the treatment efficacy and disposition of these patients. The study objective was to determine effectiveness of the “Headstrike” protocol in providing these patients with timely treatment and disposition, while maintaining positive outcomes. A trauma performance improvement database was queried for all “Headstrike” activations for a 12-month period after implementation. Demographics, patient care, and health data were collected. Descriptive statistics were used for cohort analysis. Five hundred fifteen patients were activated as a “Headstrike” during the study period. Thirty eight patients were diagnosed with ICH (7.4%), 35 of whom were identified on initial imaging. Anticoagulation reversal was ordered for 84.6 per cent of these patients. Of the patients with negative initial CT, only three patients (0.8%) were found to have a delayed ICH on routine follow-up imaging. No anticoagulant/antiplatelet agent was associated with a significantly higher risk of ICH. Implementation of the “Headstrike” protocol resulted in trauma service line resources being used more efficiently, while ensuring high-quality, expeditious care to this population.
Retrospective Validation of an Algorithmic Treatment Pathway for Necrotizing Pancreatitis
Authors: Pickens Ryan C. , Sulzer Jesse K. , Cochran Allyson , Vrochides Dionisios , Martinie John B. , Baker Erin H. , Ocuin Lee M. , Iannitti David A.
Published: June 2020

The role of surgical intervention for necrotizing pancreatitis has evolved; however, no widely accepted algorithm has been established to guide timing and optimal modality in the minimally invasive era. This study aimed to retrospectively validate an established institutional timing- and physiologic-based algorithm constructed from evidence-based guidelines in a high-volume hepatopancreatobiliary center. Patients with necrotizing pancreatitis requiring early (≤six weeks from symptom onset) or delayed (>six weeks) surgical intervention were reviewed over a four-year period (n = 100). Early intervention was provided through laparoscopic drain-guided retroperitoneal debridement (n = 15) after failed percutaneous drainage unless they required an emergent laparotomy (due to abdominal compartment syndrome, bowel necrosis/perforation, or hemorrhage) after which conservative, sequential open necrosectomy was performed (n = 47). Robot-assisted (n = 16) versus laparoscopic (n = 22) transgastric cystgastrostomy for the delayed management of walled-off pancreatic necrosis was compared, including patient factors, operative characteristics, and 90-day clinical outcomes. Major complications after early debridement were similarly high (open 25% and drain-guided 27%), yet 90-day mortality was low (open 8.5% and drain-guided 7.1%). Patient and operative characteristics and 90-day outcomes were statistically similar for robotic versus laparoscopic transgastric cystogastrostomy. Our evidence-based algorithm provides a stepwise approach for the management of necrotizing pancreatitis, emphasizing minimally invasive early and late interventions when feasible with low morbidity and mortality. Robot-assisted transgastric cystogastrostomy is an acceptable alternative to a laparoscopic approach for the delayed treatment of walled-off pancreatic necrosis.
Hospital Enforcement of Early Cholecystectomy for Acute Cholecystitis
Authors: Cockcroft April , Verrico Elizabeth , Xing Shirley , Westerman Seth , Jung Matthew , Sullivan Ryan , Chen David , Briggs Jessica , Veera Simrat , Davis John Mihran
Published: June 2020

International guidelines state that early laparoscopic cholecystectomy (ELC) is appropriate for all severity grades of acute cholecystitis and leads to reduced hospital stays and costs. A multicenter prospective randomized controlled trial recommends ELC over delayed laparoscopic cholecystectomy (DLC) management because in addition to reduced hospital stays and costs, ELC also leads to reduced patient morbidity. Therefore, ELC is standard of care for acute cholecystitis. We hypothesize that 1) international guidelines are not presently followed and that 2) a quality improvement (QI) project enforcing ELC for acute cholecystitis will increase rates of ELC management. A retrospective chart review of all surgical consults for cholecystitis from January 2016 to December 2018 was undertaken. A total of 307 patients diagnosed with acute cholecystitis were included. ELC was defined as cholecystectomy within hospital admission. Pre-QI ELC versus DLC rates were 77.4 per cent (233/301) versus 22.6 per cent (68/301). Eight DLC patients (11.8%) returned to the ED after discharge secondary to persistent signs and symptoms of cholecystitis and 62.5 per cent (5/8) received an immediate cholecystectomy before their elective surgery date. After QI initiatives, ELC rates rose to 100 per cent (6/6). These data show there was a lack of consistent ELC management of acute cholecystitis.
Outcomes in Hepatocellular Carcinoma Liver Transplantation before and after the Mandated Six-Month Wait Time
Authors: Potluri Venkat Sumanth , Sokolich Julio , Buggs Jacentha , Mcclellan William , Rogers Ebonie , Barber Kristina , Cocuy Kristal , Kumar Ambuj , Bowers Victor
Published: June 2020

The United Network for Organ Sharing (UNOS) implemented a policy that requires patients with hepatocellular carcinoma seeking liver transplantation to wait six months before being granted Model for End-Stage Liver Disease exception points. We investigated the difference in resource utilization between patients who underwent liver transplantation before and after the present policy. We conducted a retrospective cohort study of adult liver transplants from 2013 to 2018. Patients were classified into prepolicy or postpolicy groups based on 964 days before or after the wait-time policy. We also retrieved national survival outcome data from United Network for Organ Sharing. Differences across compared groups for continuous variables were assessed using the independent sample t test, and the chi-squared test was used for binary variables. We found statistical differences in recipient age ( P = 0.005), days on wait-list ( P = 0.001), sustained viro-logical response ( P < 0.001), and hepatocellular carcinoma recurrence one year posttransplant ( P = 0.04). There were statistically significant differences in the number of treatment days pretransplant and length of transplant admission stay, indicating an increase in resource utilization in the postpolicy group. No statistically significant differences were found between groups in one-year graft or patient survival despite an observed increase in resource utilization by the hepatocellular carcinoma postpolicy group.
The Glove Made from Love: A History of Surgical Attire
Authors: Britt Rebecca C.
Published: June 2020

The development of surgical attire is well documented in historical photographs and evolved in response to the changing understanding of aseptic and antiseptic techniques. Surgeons throughout time remained significantly opposed to changes in attire, and it was over a century that we evolved from wearing black frock coats to the current attire of today. Interestingly, surgical attire remains a source of controversy even today, with a recent argument regarding skull versus bouffant caps that was quite publicly debated.
The Evolving Landscape of Esophageal Cancer: A Four-Decade Analysis
Authors: Rosemurgy Alexander , Wilfong Chandler , Craigg Danielle , Co Franka , Sucandy Iswanto , Ross Sharona
Published: June 2020

The incidence of esophageal cancer in the United States seems to have significantly increased since the 1970s. In undertaking this study, we sought to describe changes in the incidence, histologic type, and presenting stage of esophageal cancer over the past four decades. With Institutional Review Board approval, the Surveillance, Epidemiology, and End Results database of the National Cancer Institute was queried. Regression analysis was used to analyze data, and significance was accepted with 95 per cent probability. Forty-two thousand seven hundred thirty-nine patients had squamous cell carcinoma or adenocarcinoma located in their upper, middle, and/ or lower esophagus from 1973 through 2010, reflecting a 7.5-fold annual increase from 1973 through 2010. Squamous cell carcinoma increased annually 2.5-fold ( P < 0.001) and esophageal adenocarcinoma increased annually 57-fold from 1973 through 2010 ( P < 0.001), whereas the overall population in the United States increased only 43 per cent (215,092,900 to 308,745,538) in the same period. From 1973 through 2010, there was a significant increase in the incidence of esophageal cancer in the United States. This increase was much greater than the increase in the population in the United States. The incidence of adenocarcinoma increased much more than that of squamous cell carcinoma of the esophagus from 1973 through 2010.
Ventilator-Associated Pneumonia: How Do the Different Criteria for Diagnosis Match Up?
Authors: Carr Christopher , Smith Alison , Marturano Matthew , Hakki Lynn , Friedman Jessica , Guidry Chrissy , Mcgrew Patrick , Mcginness Clifton , Duchesne Juan , Schroll Rebecca
Published: June 2020

Ventilator-associated pneumonia (VAP) affects up to 30 per cent of ICU patients and has been associated with increased morbidity and mortality. We identified factors associated with prolonged latency of VAP and evaluated its effects on survival and additional outcomes. We also determined the sensitivity of various clinical definitions of VAP, including the Centers for Disease Control and Prevention (CDC) 2013 criteria. We hypothesized that the CDC 2013 criteria would have poor sensitivity. We collected data on 102 subjects who developed VAP between 2012 and 2017. We conducted a Kaplan-Meier survival analysis with Cox proportional hazards regression and generalized linear models/ANOVA to look at predictor variables along with multivariate models for each outcome. White patients, nonsurgical patients, patients with renal failure, altered mental status, increased FiO2, and increased positive end-expiratory pressure had worse survival. Trauma patients, patients with positive sputum cultures, and patients with suspected pneumonia had better survival. Sensitivity of the CDC 2013 criteria was only 44.1 per cent. Our results emphasize the importance of having a high index of suspicion for VAP in ventilator-dependent patients. The 2013 CDC criteria failed to detect 55.9 per cent of confirmed VAP cases. These results are concerning because undetected VAP can have devastating consequences for patients.
Transversus Abdominis Plane Blocks in Laparoscopic Colorectal Surgery: Better Pain Control and Patient Outcomes with Liposomal Bupivacaine than Bupivacaine
Authors: Guerra Lucinda , Philip Sunu , Lax Elizabeth A. , Smithson Lauren , Pearlman Ralph , Damadi Amir
Published: June 2020

Transversus abdominis plane (TAP) blocks are a safe and effective way to provide immediate postoperative pain relief in surgical patients, and have been shown to decrease narcotic requirements. Concerns about complications of narcotics, increase in hospital length of stay (LOS), and health-care costs make this of particular interest. We compared standard bupivacaine TAP blocks with those carried out using liposomal bupivacaine to evaluate postoperative outcomes. Fifty patients undergoing elective laparoscopic colectomy received laparoscopic liposomal bupivacaine TAP blocks using 80 cc of local anesthetic, and data were collected prospectively during hospitalization. Data collected included amount of narcotic medication used during hospitalization, number of days to ambulation, number of days to bowel function, and LOS. These patients were compared with the last 50 patients recruited to the control/bupivacaine TAP block arm of the study. The same data parameters were collected and all patients were on an enhanced recovery protocol, which included scheduled acetaminophen, ibuprofen, and gabapentin by mouth, as well as clear liquid diet starting on postoperative day zero. Statistical analysis was performed using Student's t test and Fisher's exact test; P < 0.05 was considered statistically significant. Patients treated with liposomal bupivacaine needed less narcotics (5.06 vs 18.75 mg, P = 0.0002), had earlier bowel function (1.7 vs 2.4 days, P = 0.0002), and shorter LOS (2.7 vs 3.4 days, P = 0.0146). Patients undergoing laparoscopic colon resections seem to require fewer narcotics and have better patient outcomes with liposomal bupivacaine TAP blocks. Based on our data, liposomal bupivacaine seems to be superior to bupivacaine for TAP blocks.
Human Acellular Dermal Matrix is a Viable Alternative to Autologous Skin Graft in Patients with Cutaneous Malignancy
Authors: Lewis Rachel E. , Towery Emily A. , Bhat Sneha G. , Ward Andrew J. , Heidel Robert E. , Bielak Kendall M. , Simpson Hannah E. , Mcloughlin James M. , Lewis James M.
Published: June 2020

Skin substitutes have shown success in complex wound reconstruction. We evaluate the use of a human acellular dermal matrix (ADM) as a viable alternative to autologous skin grafting for defects secondary to skin cancer excision. An institutional review board–approved, retrospective review of ADM-reconstructed defects secondary to skin cancer excision between 2012 and 2018 was conducted. ADM was indicated in patients with preclusive factors for general anesthesia, protracted procedure time, reluctance for additional donor site wound, and personal choice. We reviewed defect characteristics, healing time, postoperative outcomes, and patient demographics. The 228 participants (151 males, 77 females) had a median age of 72 years (range, 29–95 years), with melanoma diagnosed in 113 (49.6%), squamous cell carcinoma in 61 (26.8%), and basal cell carcinoma in 28 (12.2%) patients. The median interval to complete epidermal coverage was 42 days, with graft failure evident in six patients (2.6%). ADM is a viable, low-morbid alternative for reconstruction of defects secondary to skin cancer excision, with no donor site morbidity. With exception to complete healing time, outcomes are similar to those of autologous grafting.
Geriatric Events among Older Adults Undergoing Nonelective Surgery are Associated with Poor Outcomes
Authors: Dworsky Jill Q. , Childers Christopher P. , Copeland Timothy , Maggard-Gibbons Melinda , Tan Hung-Jui , Saliba Debra , Russell Marcia M.
Published: June 2020

Older adults undergoing nonelective surgery are at risk for geriatric events (GEs: delirium, dehydration, falls/fractures, failure to thrive, and pressure ulcers), but the impact of GEs on postoperative outcomes is unclear. Using the 2013 to 2014 National Inpatient Sample, we analyzed nonelective hospital admissions for five common operations (laparoscopic cholecystectomy, colectomy, soft tissue debridement, small bowel resection, and laparoscopic appendectomy) in older adults (aged ≥65 years) and a younger referent group (aged 55–64 years). Nationally weighted descriptive statistics were generated for GEs. Logistic regression controlling for patient, procedure, and hospital characteristics estimated the association of 1) age with GEs and 2) GEs with outcomes. Of 471,325 overall admissions, 64.7 per cent were aged ≥65 years. The rate of any GE in older adults was 26.9 per cent; GEs varied by age and procedure ( P < 0.001). After adjustment, the probability of any GE increased with age category ( P < 0.001); having any GE was associated with higher probability of all outcomes ( P < 0.001): mortality (4.5% vs 0.8%), postoperative complications (61.7% vs 24.9%), prolonged length of stay (24.3% vs 7.9%), and skilled nursing facility discharge (46.6% vs 10.3%). In addition, there was a dose–response relationship between GEs and negative outcomes. GEs are prevalent in the nonelective surgery setting and associated with worse clinical outcomes. Quality improvement efforts should focus on addressing GEs.
Laparoscopic Cholecystectomy is Safe in Emergency General Surgery Patients with Cirrhosis
Authors: Okamuro Kyle , Cui Brian , Moazzez Ashkan , Park Hayoung , Putnam Brant , Virgilio Chris De , Neville Angela , Singer George , Deane Molly , Chong Vincent , Kim Dennis Y.
Published: June 2020

Cirrhosis is associated with adverse outcomes after emergency general surgery (EGS). The objective of this study was to determine the safety of laparoscopic cholecystectomy (LC) in EGS patients with cirrhosis. We performed a two-year retrospective cohort analysis of adult patients who underwent LC for symptomatic gallstones. The primary outcome was the incidence of intraoperative complications. Of 796 patients, 59 (7.4%) were cirrhotic, with a median model for end-stage liver disease (MELD) score of 15 (IQR, 7). On unadjusted analysis, patients with cirrhosis were older, more likely to be male (both P < 0.01), diabetic ( P < 0.001), had a higher incidence of preadmission antithrombotic therapy use ( P < 0.02), and experienced a longer time to surgery (3.2 vs 1.8 days, P < 0.001). Coarsened exact matching revealed no difference in intra- or postoperative complications between groups ( P = 0.67). Operative duration was longer in patients with cirrhosis (162 vs 114 minutes, P = 0.001), who also had a nonsignificant increase in the rate of conversion to an open cholecystectomy (14% vs 4%, P = 0.07). The results of this study indicate that LC may be safely performed in EGS patients with cirrhosis.
Bile Duct Injury Repairs after Laparoscopic Cholecystectomy: A Five-Year Experience in a Highly Specialized Community Hospital
Authors: Arcerito Massimo , Jamal Mazen M. , Nurick Harvey A.
Published: June 2020

Bile duct injury represents a complication after laparoscopic cholecystectomy, impairing quality of life and resulting in subsequent litigations. A five-year experience of bile duct injury repairs in 52 patients at a community hospital was reviewed. Twenty-nine were female, and the median age was 51 years (range, 20–83 years). Strasberg classification identified injuries as Type A (23), B (1), C (1), D (5), E1 (5), E2 (6), E3 (4), E4 (6), and E5 (1). Resolution of the bile duct injury and clinical improvement represent main postoperative outcome measures in our study. The referral time for treatment was within 4 to 14 days of the injury. Type A injury was treated with endobiliary stent placement. The remaining patients required T-tube placement (5), hepaticojejunostomy (20), and primary anastomosis (4). Two patients experienced bile leak after hepaticojejunostomy and were treated and resolved with percutaneous transhepatic drainage. At a median follow-up of 36 months, two patients (Class E4) required percutaneous balloon dilation and endobiliary stent placement for anastomotic stricture. The success of biliary reconstruction after complicated laparoscopic cholecystectomy can be achieved by experienced biliary surgeons with a team approach in a community hospital setting.
Median Arcuate Ligament Syndrome and Its Associated Conditions
Authors: Huynh Desmond T. K. , Shamash Kevin , Burch Miguel , Phillips Edward , Cunneen Scott , Van Allan Richard J. , Shouhed Daniel
Published: June 2020

The risk factors and associated conditions of median arcuate ligament syndrome (MALS) have not been well characterized in the literature. In this study, we aim to investigate the presentation and outcomes of MALS patients with an emphasis on the prevalence of other uncommon disorders. To this end, data of patients with MALS who underwent surgery between 2013 and 2018 were collected and compiled into a retrospective database and analyzed. Eleven patients were identified. Seven of these eleven patients underwent diagnostics to evaluate gastric emptying. Five of these seven patients (71.4%) had radiographic evidence of delayed gastric emptying. Four of the eleven patients (36.4%) were found to have anatomic abnormalities of their visceral vasculature. Two of the eleven patients (18.2%) were found to have connective tissue disorders, both with Ehlers-Danlos syndrome. Three of the eleven (27.3%) had a diagnosis of postural orthostatic tachycardia syndrome. This is the first case series reporting on an association between MALS and delayed gastric emptying. We also explored the relationship between MALS and visceral vascular abnormalities, Ehlers-Danlos syndrome, and postural orthostatic tachycardia syndrome. It is notable that these conditions are more prevalent in the MALS population than in the general population, suggesting a possible pathophysiologic relationship.
The Impact of IV Electrolyte Replacement on the Fluid Balance of Critically Ill Surgical Patients
Authors: Wang Andrew S. , Dhillon Navpreet K. , Linaval Nikhil T. , Rottler Nicholas , Yang Audrey R. , Margulies Daniel R. , Ley Eric J. , Barmparas Galinos
Published: June 2020

Avoiding excess fluid administration is necessary when managing critically ill surgical patients. The aim of this study was to delineate the current practices of IVelectrolyte (IVE) replacement in a surgical ICU and quantify their contribution to the fluid balance (FB) status. Patients admitted to the surgical ICU over a six-month period were reviewed. Patients undergoing dialysis and those with ICU stay <72 hours were excluded. A total of 248 patients were included. The median age was 60 years, and 57 per cent were male. Overall, 1131 patient ICU days were analyzed. The median daily FB was 672 mL. IVEs were administered in 62 per cent of ICU days. In days that IVEs were used, negative FB was significantly less likely to be achieved (62% vs 69%, P = 0.02). The most commonly administered IVE was calcium (32% of ICU days); however, the largest volume of IVE was administered in the form of phosphorus (median 225 mL). Diuretics were administered in 17 per cent of ICU days. Patients who received diuretics were significantly more likely to receive IVE (70% vs 61%, P = 0.02). Administration of IVE may contribute to the daily positive FB of surgical ICU patients. Implementation of practices that can ameliorate this effect is encouraged.
International Normalized Ratio (INR) is Comparable to MELD in Predicting Mortality after Cholecystectomy
Authors: Rudasill Sarah E. , Dipardo Benjamin , Sanaiha Yas , Mardock Alexandra L. , Cale Mario , Antonios James W. , Benharash Peyman
Published: June 2020

Guidelines suggest targeting a preoperative international normalized ratio (INR) < 1.5. We examined and compared the predictive value of INR relative to the Model for End-Stage Liver Disease (MELD). We reviewed the American College of Surgeons NSQIP from 2005 to 2016 for adult patients undergoing open or laparoscopic cholecystectomy. Patients with a preoperative INR were stratified into groups: ≤1, >1 to ≤1.5, >1.5 to ≤2, and >2. Thirty day postoperative mortality was the primary outcome. Multivariable logistic regressions controlled for baseline differences. Of 58,177 cholecystectomy patients, 15.2 per cent had INR ≤ 1,80.4 per cent had INR > 1 to ≤1.5,3.7 per cent had INR > 1.5 to ≤2, and 0.7 per cent had INR > 2. Patients with INR > 2 were older and more likely to have diabetes and hypertension ( P < 0.001). Multivariable regression demonstrated a stepwise increase in mortality for INR > 1 to ≤1.5 (odds ratio (OR) = 1.50 [1.10–2.05]), INR > 1.5 to ≤2 (OR = 2.96 [1.97–4.45]), and INR > 2 (OR = 3.21 [1.64–6.31]) relative to INR ≤ 1. C-statistic for INR (0.910) and MELD (0.906) models indicated a similar value in predicting mortality. INR groups also faced an incremental, increased risk of bleeding. Although unable to track preoperative correction of INR, this analysis identifies that INR remains an excellent predictor of postoperative mortality and bleeding after both open and laparoscopic cholecystectomies and is comparable to MELD.
Predictors of Morbidity and Mortality in Complex Paraesophageal Hernia Repair: A NSQIP Analysis
Authors: Dubina Emily D. , Moazzez Ashkan , Park Hayoung , Shover Andrew , Kim Dennis Y. , Simms Eric R.
Published: June 2020

Paraesophageal hernia (PEH) repair is typically performed electively. Complex PEHs (obstructed or gangrenous) require more urgent repair and can have significant complications. Although elective repair is primarily laparoscopic, limited data are available on the use of laparoscopy for complex cases. Patients undergoing complex PEH repair were identified from the NSQIP database, and predictors of morbidity and mortality were compared for 2473 laparoscopic and 861 open repairs. Compared with the laparoscopic approach, emergent surgeries (36.7% vs 10.8%, P < 0.001) and preoperative sepsis (22.9% vs 7.4%, P < 0.001) were more common in the open group. Operative times were shorter for open repairs (152.6 vs 172.2 minutes, P = 0.03). However, open repair was associated with increased morbidity (28.2% vs 11%, P < 0.001) and mortality (5.2% vs 1.4%, P < 0.001), likely because of higher rates of preoperative comorbidities in the open group. On multivariable regression analysis, preoperative sepsis was associated with increased mortality and morbidity, whereas laparoscopic repair was associated with decreased morbidity. If laparoscopic repair can be safely completed, it is associated with decreased morbidity, despite longer operative times.
It is Not Just Cosmesis: Straight Laparoscopy with Stoma Site Extraction Improves Outcomes in Ulcerative Colitis Patients Undergoing Total Colectomy
Authors: Chough Ino , Zaghiyan Karen , Ovsepyan Gayane , Fleshner Phillip
Published: June 2020

Minimally invasive approaches to total abdominal colectomy (TAC) in ulcerative colitis (UC) patients include straight laparoscopy (SL), hand-assisted laparoscopic surgery (HALS), and robotics. In this study, short-term outcomes of patients undergoing SL and HALS TAC were compared. Prospectively collected data on UC patients undergoing TAC were tabulated. The study cohort included 36 (27%) patients in the SL group and 95 (73%) patients in the HALS group. The groups were comparable in terms of preoperative characteristics and demographics. The mean operative time was 151 (range, 73–225) minutes in the SL group versus 164 (range, 103–295) minutes in the HALS group ( P = 0.09). Total 48-hour IV morphine use was 30 (range, 0–186) mg in the SL group compared with 56 (0–275) mg in the HALS group ( P < 0.01). Although overall morbidity was comparable between the groups, Clavien-Dindo Class III complications did not occur in any of the SL group patients versus 11 (11%) of the HALS group patients ( P = 0.03). The postoperative length of stay was 3 (3–21) days in the SL group versus 5 (3–15) days in the HALS group ( P < 0.01). Compared with HALS, SL is associated with lower postoperative narcotic use and hospital length of stay in UC patients undergoing TAC.
Reduction in Prescribed Opioids after General Surgery Procedures at a Public Hospital
Authors: Angelo Jillian L. , Wu Jennifer , Sirody Joseph , Deugarte Daniel A.
Published: June 2020

Overdose of opioids is the number one cause of accidental death in the United States, and surgeons are overprescribing these medications. The aim of this study was to assess the feasibility of implementing postoperative opioid prescribing guidelines for general surgery procedures at a public hospital, where patients have lower socioeconomic status, public insurance, and limited access to care. We implemented a quality improvement project, which included in-service training for surgical staff and distribution of standardized guidelines. An infographic for patients was created to facilitate education on postoperative pain management. Pre- and postintervention opioid prescriptions and emergency room visits were compared for patients undergoing common general surgery procedures (inguinal hernia repair, appendectomy, and laparoscopic cholecystectomy). The median number of narcotic pills prescribed significantly decreased from 30 (n = 64) to 15 (n = 63) after the intervention ( P < 0.0001). Morphine milligram equivalents decreased from a median [range] of 150 [20,600] to 90 [5,300] ( P < 0.0001). The percentage of patients with postoperative pain-related emergency department visits remained low (1.6%). Standardization of postoperative opioid prescription practices was successfully implemented at a public hospital without an increase in the number of emergency room visits for pain.
Long-Term Outcomes of Crystallized Phenol Application after Punch Excision for the Treatment of Pilonidal Sinus Disease
Authors: Demirel Arif Hakan , Polat Mikail
Published: June 2020

The aim of the study was to present the outcomes of topical crystallized phenol application in the treatment of pilonidal sinus disease. Under local anesthesia, a punch biopsy tool is used for the excision of the sinus opening holes; after cleaning the cavity, 150 to 250 mg of crystallized phenol was administered. Three sessions of additional therapy were given one week apart without anesthesia. The technique was well tolerated, and early results were observed two months after the procedure. Recurrence was detected in five patients (11.9%), one of whom underwent two more sessions, resulting in recovery. In the long-term results, 39 patients were available after 16 to 38 months (mean 23.7 months). Of these, recurrence was detected in five patients (12.8%). Analysis of the data was unable to identify significant effects of the characteristics of the disease (primary or recurrent), gender of patients, and the number of opening holes (single or multiple) on early and late recurrence ( P > 0.05). A close correlation can be drawn from the early- and long-term results after treatment ( P < 0.0001). In this study, the use of the punch biopsy tool in the treatment of pilonidal sinus disease with crystallized phenol was described first. This minimally invasive method achieved excellent aesthetic outcomes, and it can successfully be applied without the need for surgical intervention, especially in patients who are at the initial stage and with small in size openings.