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Introduction: Pancreas divisum (PD) is a common congenital anomaly of the pancreas, but its genetic basis remains unknown. The purpose of this genome-wide association study was to identify genetic loci associated with PD., Methods: Using the Mass General Brigham Biobank, patients diagnosed with PD were identified. Quality control and imputation were performed using standard approaches. Single nucleotide polymorphisms (SNPs) with minor allele frequency (MAF) ≥ 5% were tested for association with PD using mixed linear model-based association analysis. The significance threshold was set at 5 × 10 -8 ., Results: A total of 13,940 subjects were included, of which 251 (1.8%) were diagnosed with PD. A genetic locus in chromosome 3q29 was found to be associated with PD (lead SNP rs3850646, MAF PD  = 34.6% vs. MAF controls  = 26.4%, beta = 0.0106, P = 1.47 × 10 -8 ). The identified locus is located in the phosphatidylinositol glycan anchor biosynthesis class Xand p21 activated kinase 2genes. The heritability of PD was estimated at 27.5%. (Expression quantitative trait loci) and chromatin interaction analysis found 12 genes whose expression may be regulated by SNPs in this genomic locus., Conclusions: The results of this study suggest that a genetic locus at 3q29 is associated with PD. This locus is in the phosphatidylinositol glycan anchor biosynthesis class X and p21 activated kinase 2 genes. Twelve candidate genes were identified whose expression may be regulated by this locus. These findings may help us understand both normal and aberrant pancreatic development and may aid in clinical evaluation and genetic counseling of patients with PD and associated diseases, such as acute pancreatitis., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To determine if lymph node yield (LNY) is associated with improved overall survival (OS) and time to recurrence (TTR) in patients with node-negative pancreatic ductal adenocarcinoma (PDAC) treated with neoadjuvant therapy (NAT)., Background: Lymph node yield has been associated with survival in solid gastrointestinal cancers, including PDAC., Methods: Patients with pathological T stage I-III, node-negative (N0), PDAC treated with NAT followed by pancreatoduodenectomy were identified in the Massachusetts General Hospital (MGH) pancreatectomy database and the National Cancer Database (NCDB). A cutoff point of 22 nodes was identified in the NCDB using the point with the optimal (log-rank test) split. Overall survival and TTR were evaluated using univariate and multivariable analyses., Results: In the MGH cohort, 233 node-negative patients following NAT were included. A LNY ≥ 22 was associated with prolonged median OS (59 months vs. 25 months, P<0.001) and prolonged TTR (32 months vs. 14 months, P=0.019). On multivariable analysis, LNY was an independent predictor of survival (HR 0.97, 95% CI 0.95-0.99, P=0.034) per sampled node. In the NCDB, 2,029 node-negative patients following NAT were included. A LNY ≥ 22 was associated with prolonged median OS (49 months vs. 33 months, P<0.001). On multivariable analysis, LNY was an independent predictor of survival (HR 0.99, 95% CI 0.98-0.99, P<0.001) per sampled node., Conclusion: Lymph node yield was associated with improved oncologic outcomes in patients treated with NAT followed by pancreatoduodenectomy in two independent datasets. Responsible mechanisms by which LNY impacts the outcomes of node-negative patients following NAT warrant further exploration., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: While cryoprecipitate (Cryo) is commonly included in massive transfusion protocols for hemorrhagic shock, the optimal dose of Cryo transfusion remains unknown. We evaluated the optimal red blood cell (RBC) to RBC to Cryo ratio during resuscitation in massively transfused trauma patients., Methods: Adult patients in the American College of Surgeon Trauma Quality Improvement Program (2013-2019) receiving massive transfusion (≥4 U of RBCs, ≥1 U of fresh frozen plasma, and ≥1 U of platelets within 4 hours) were included. A unit of Cryo was defined as a pooled unit of 100 mL. The RBC:Cryo ratio was calculated for blood products transfused within 4 hours of presentation. The association between RBC:Cryo and 24-hour mortality was analyzed with multivariable logistic regression adjusting for the volume of RBC, plasma and platelet transfusions, global and regional injury severity, and other relevant variables., Results: The study cohort included 12,916 patients. Among those who received Cryo (n = 5,511 [42.7%]), the median RBC and Cryo transfusion volume within 4 hours was 11 U (interquartile range, 7-19 U) and 2 U (interquartile range, 1-3 U), respectively. Compared with no Cryo administration, only RBC:Cryo ratios ≤8:1 were associated with a significant survival benefit, while lower doses of Cryo (RBC:Cryo >8:1) were not associated with decreased 24-hour mortality. Compared with the maximum dose of Cryo administration (RBC:Cryo, 1:1-2:1), there was no difference in 24-hour mortality up to RBC:Cryo of 7:1 to 8:1, whereas lower doses of Cryo (RBC:Cryo, >8:1) were associated with significantly increased 24-hour mortality., Conclusion: One pooled unit of Cryo (100 mL) per 7 to 8 U of RBCs could be the optimal dose of Cryo in trauma resuscitation that provides a significant survival benefit while avoiding unnecessary blood product transfusions., Level of Evidence: Prognostic and Epidemiologic; Level IV., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

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

Introduction: Management of hemorrhage from pelvic fractures is complex and requires multidisciplinary attention. Pelvic angioembolization (AE) has become a key intervention to aid in obtaining definitive hemorrhage control. We hypothesized that pelvic AE would be associated with an increased risk of venous thromboembolism (VTE)., Methods: All adults (age >16) with a severe pelvic fracture (Abbreviated Injury Scale ≥ 4) secondary to a blunt traumatic mechanism in the 2017-2019 American College of Surgeons Trauma Quality Improvement Program database were included. Patients who did not receive VTE prophylaxis during their admission were excluded. Patients who underwent pelvic AE during the first 24 h of admission were compared to those who did not using propensity score matching. Matching was performed based on patient demographics, admission physiology, comorbidities, injury severity, associated injuries, other hemorrhage control procedures, and VTE prophylaxis type, and time to initiation of VTE prophylaxis. The rates of VTE (deep vein thrombosis and pulmonary embolism) were compared between the matched groups., Results: Of 72,985 patients with a severe blunt pelvic fracture, 1887 (2.6%) underwent pelvic AE during the first 24 h of admission versus 71,098 (97.4%) who did not. Pelvic AE patients had a higher median Injury Severity Score and more often required other hemorrhage control procedures, with laparotomy being most common (24.7%). The median time to initiation of VTE prophylaxis in pelvic AE versus no pelvic AE patients was 60.1 h (interquartile range = 36.6-98.6) versus 27.7 h (interquartile range = 13.9-52.4), respectively. After propensity score matching, pelvic AE patients were more likely to develop VTE compared to no pelvic AE patients (11.8% versus 9.5%, P = 0.03)., Conclusions: Pelvic AE for control of hemorrhage from severe pelvic fractures is associated with an increased risk of in-hospital VTE. Patients who undergo pelvic AE are especially high risk for VTE and should be started as early as safely possible on VTE prophylaxis., (Copyright © 2022 Elsevier Inc. All rights reserved.)

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

Background: Initially used in trauma management, delayed abdominal closure endeavors to decrease operative time during the index operation while still being lifesaving. Its use in emergency general surgery is increasing, but the data evaluating its outcome are sparse. We aimed to study the association between delayed abdominal closure, mortality, morbidity, and length of stay in an emergency surgery cohort., Methods: The 2013 to 2017 American College of Surgeons National Surgical Quality Improvement Program database was examined for patients undergoing emergency laparotomy. The patients were classified by the timing of abdominal wall closure: delayed fascial closure versus immediate fascial closure. Propensity score matching was performed based on preoperative covariates, wound classification, and performance of bowel resection. The outcomes were then compared by univariable analysis., Results: After matching, both the delayed fascial closure and immediate fascial closure groups consisted of 3,354 patients each. Median age was 65 years, and 52.6% were female. The delayed fascial closure group had a higher in-hospital mortality (35.3% vs 25.0%, P &lt; .001), a higher 30-day mortality (38.6% vs 29.0%, P &lt; .001), a higher proportion of acute kidney injury (9.5% vs 6.6%, P &lt; .001), a lower proportion of postoperative sepsis (11.8% vs 15.6%, P &lt; .001), and a lower proportion of surgical site infection (3.4% vs 7.0%, P &lt; .001)., Conclusion: Compared with immediate fascial closure, delayed fascial closure is associated with an increased mortality in the patients matched based on comorbidities and surgical site contamination. In emergency general surgery, delaying abdominal closure may not have the presumed overarching benefits, and its indications must be further defined in this population., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Balanced blood component administration during massive transfusion is standard of care. Most literature focuses on the impact of red blood cell (RBC)/fresh frozen plasma (FFP) ratio, while the value of balanced RBC:platelet (PLT) administration is less established. The aim of this study was to evaluate and quantify the independent impact of RBC:PLT on 24-hour mortality in trauma patients receiving massive transfusion., Methods: Using the 2013 to 2018 American College of Surgeons Trauma Quality Improvement Program database, adult patients who received massive transfusion (≥10 U of RBC/24 hours) and ≥1 U of RBC, FFP, and PLT within 4 hours of arrival were retrospectively included. To mitigate survival bias, only patients with consistent RBC:PLT and RBC:FFP ratios between 4 and 24 hours were analyzed. Balanced FFP or PLT transfusions were defined as having RBC:PLT and RBC:FFP of ≤2, respectively. Multivariable logistic regression was used to compare the independent relationship between RBC:FFP, RBC:PLT, balanced transfusion, and 24-hour mortality., Results: A total of 9,215 massive transfusion patients were included. The number of patients who received transfusion with RBC:PLT >2 (1,942 [21.1%]) was significantly higher than those with RBC:FFP >2 (1,160 [12.6%]) (p < 0.001). Compared with an RBC:PLT ratio of 1:1, a gradual and consistent risk increase was observed for 24-hour mortality as the RBC:PLT ratio increased (p < 0.001). Patients with both FFP and PLT balanced transfusion had the lowest adjusted risk for 24-hour mortality. Mortality increased as resuscitation became more unbalanced, with higher odds of death for unbalanced PLT (odds ratio, 2.48 [2.18-2.83]) than unbalanced FFP (odds ratio, 1.66 [1.37-1.98]), while patients who received both FFP and PLT unbalanced transfusion had the highest risk of 24-hour mortality (odds ratio, 3.41 [2.74-4.24])., Conclusion: Trauma patients receiving massive transfusion significantly more often have unbalanced PLT rather than unbalanced FFP transfusion. The impact of unbalanced PLT transfusion on 24-hour mortality is independent and potentially more pronounced than unbalanced FFP transfusion, warranting serious system-level efforts for improvement., Level of Evidence: Therapeutic/Care Management; Level IV., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

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

Purpose: Enteral nutrition is associated with improved outcomes in acute pancreatitis (AP), but previous studies have not focused on critically-ill patients. Our purpose was to determine the association between nutritional support and infectious complications in ICU-admitted patients with AP., Methods: A retrospective analysis of patients with AP admitted in ICUs of 127 US hospitals from the eICU Collaborative were included. Patients were classified by type (initial and any use) of nutritional support they received: none (NN); oral (ON); enteral (EN); and parenteral nutrition (PN)., Results: 925 patients were identified. Length of stay was longer in the initial PN group (PN 21.3 ± 15.4 d, EN 19.1 ± 20.1 d, ON 8 ± 7.1 d, NN 6.6 ± 6.3 d, p < 0.001) and mortality was more common in the initial EN group (EN 16.7%, PN 8.9%, ON 2.7%, NN 10.9%, p < 0.001). Multivariate analysis found any EN use to be associated with infections (OR 2.12, 95% CI: 1.13-3.98, p = 0.019) and pneumonias (OR 2.04, 95% CI: 1.04-4.03, p = 0.039)., Conclusion: EN was associated with an increased risk for pneumonias and overall infections in critically-ill patients with AP. More studies are needed to assess optimal nutritional approaches in critically-ill AP patients and patients who do not tolerate EN., Competing Interests: Declaration of Competing Interest Nothing to declare., (Copyright © 2022. Published by Elsevier Inc.)

Objectives: A minimally invasive step-up (MIS) approach for management of necrotizing pancreatitis (NP) has been associated with reduced morbidity and mortality compared with open surgical techniques. We sought to evaluate bleeding complications in NP patients treated with a MIS approach and to describe the management and outcomes of these events., Methods: An observational, cohort study was performed using a prospectively maintained NP database at a tertiary referral center from 2013 to 2019., Results: Of 119 NP patients, 13% suffering bleeding events, and 18% underwent an intervention. There was a 6-fold higher mortality rate in patients with bleeding events (n = 3; 18.8%) compared with those without (n = 3; 2.9%) ( P = 0.031). The most common intervention for hemorrhage control was endovascular coil embolization (75%), which was successful 88% of the time. Seven patients underwent prophylactic vascular intervention, which was 100% successful in preventing bleeding events from the embolized vessel., Conclusions: Bleeding events in NP patients treated with a MIS approach are associated with a 6-fold increase in mortality. Endovascular intervention is an effective strategy for the management of bleeding events. Prophylactic embolization may be an effective technique for reducing bleeding complications., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

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

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

Background: In-field triage tools for trauma patients are limited by availability of information, linear risk classification, and a lack of confidence reporting. We therefore set out to develop and test a machine learning algorithm that can overcome these limitations by accurately and confidently making predictions to support in-field triage in the first hours after traumatic injury., Methods: Using an American College of Surgeons Trauma Quality Improvement Program-derived database of truncal and junctional gunshot wound (GSW) patients (aged 16-60 years), we trained an information-aware Dirichlet deep neural network (field artificial intelligence triage). Using supervised training, field artificial intelligence triage was trained to predict shock and the need for major hemorrhage control procedures or early massive transfusion (MT) using GSW anatomical locations, vital signs, and patient information available in the field. In parallel, a confidence model was developed to predict the true-class probability (scale of 0-1), indicating the likelihood that the prediction made was correct, based on the values and interconnectivity of input variables., Results: A total of 29,816 patients met all the inclusion criteria. Shock, major surgery, and early MT were identified in 13.0%, 22.4%, and 6.3% of the included patients, respectively. Field artificial intelligence triage achieved mean areas under the receiver operating characteristic curve of 0.89, 0.86, and 0.82 for prediction of shock, early MT, and major surgery, respectively, for 80/20 train-test splits over 1,000 epochs. Mean predicted true-class probability for errors/correct predictions was 0.25/0.87 for shock, 0.30/0.81 for MT, and 0.24/0.69 for major surgery., Conclusion: Field artificial intelligence triage accurately identifies potential shock in truncal GSW patients and predicts their need for MT and major surgery, with a high degree of certainty. The presented model is an important proof of concept. Future iterations will use an expansion of databases to refine and validate the model, further adding to its potential to improve triage in the field, both in civilian and military settings., Level of Evidence: Prognostic, Level III., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: A minimally invasive step-up approach to necrotizing biliary pancreatitis often requires multiple interventions, delaying cholecystectomy. The risk of gallstone-related complications during this time interval is unknown, as is the feasibility and safety of cholecystectomy after minimally invasive step-up treatment. In this paper, we analyzed both., Methods: Necrotizing pancreatitis patients treated with a minimally invasive step-up approach who underwent interval cholecystectomy at 2 tertiary care centers between 2014 and 2019 were included. Gallstone-related complications prior to cholecystectomy were examined, as were surgical approaches to cholecystectomy and complications. Necrotizing pancreatitis patients treated without mechanical intervention were also examined., Results: Seven of 31 patients developed gallstone-related complications between minimally invasive step-up treatment initiation and cholecystectomy. One patient developed biliary colic. Six patients developed acute cholecystitis. Two of these patients also developed choledocholithiasis, and 1 developed cholangitis, all requiring endoscopic retrograde cholangiopancreatography. Cholecystectomy was performed laparoscopically in 27 of 31 patients. One patient required open conversion, and 3 patients underwent planned cholecystectomy during another open operation. Four patients developed postoperative complications. Two of 14 necrotizing pancreatitis patients treated without mechanical intervention developed recurrent pancreatitis while awaiting cholecystectomy., Conclusion: Over 20% of necrotizing pancreatitis patients treated by a minimally invasive step-up approach developed gallstone-related complications while awaiting cholecystectomy. Laparoscopic cholecystectomy is feasible and safe in the great majority of necrotizing pancreatitis patients treated by a minimally invasive step-up approach., (Copyright © 2020 Elsevier Inc. All rights reserved.)

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

Background: Patients on prehospital anticoagulation with warfarin or direct oral anticoagulants (DOACs) represent a vulnerable subset of the trauma population. While protocolized warfarin reversal is widely available and easily implemented, prehospital anticoagulation with DOAC is cost prohibitive with only a few reversal options. This study aims to compare hospital outcomes of non-head injured trauma patients taking pre-injury DOAC versus warfarin., Methods: A retrospective cohort study at a level 1 trauma center was performed. All adult trauma patients with pre-injury anticoagulation admitted between January 2015 and December 2018, were stratified into DOAC-using and warfarin-using groups. Patients were excluded if they had traumatic brain injury (TBI). Univariate and multivariable analyses were performed. Outcomes measures included in-hospital mortality, blood transfusion requirements, ICU length of stay (LOS), hospital LOS and discharge disposition., Results: 374 non-TBI trauma patients on anticoagulation were identified, of which 134 were on DOACs and 240 on warfarin. Patients on DOACs had a higher ISS (9 [IQR, 9-10] vs. 9 [IQR, 5-9]; p<0.001), and lower admission INR values (1.2 [IQR, 1.1-1.3] vs 2.4 [IQR, 1.8-2.7]; p<0.001) than warfarin users. Use of reversal agents was higher in warfarin users (p<0.001). Relative to warfarin, DOAC users did not differ significantly with respect to hospital mortality (OR 0.47, 95% CI [0.13-1.73]). Multivariable analysis (not possible for mortality) did not show significant difference for RBC transfusion requirements (OR 0.92 [0.51-1.67]), ICU LOS (OR 1.08 [0.53-2.19]), hospital LOS (OR 1.10 [0.70-1.74]) or discharge disposition (OR 0.56 [0.29-1.11]) between the groups., Conclusion: Despite lower reversal rates and higher ISS, non-TBI trauma patients with pre-injury DOAC use had similar outcomes as patients on pre-injury warfarin. There may be equipoise to have larger, prospective studies evaluating the comparative safety of DOACs and warfarin in the population prone to low energy fall type injuries., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest. No specific funding was received for this study., (Copyright © 2020. Published by Elsevier Ltd.)

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

Background: Despite the presence of highly reliable data, studies on packed red blood cells (pRBC):fresh frozen plasma (FFP) ratio suffer from limited sample size and the presence of survivor bias. We sought to study the association between FFP:pRBC and early mortality in the hemorrhaging trauma patient., Study Design: This was a retrospective nationwide cohort that included all TQIP participating hospitals (2013 to 2016). We included all trauma patients who were transfused ≥10 pRBCs and ≥1 FFP within 24 hours. We excluded transferred patients and those who died in the emergency department or had missing/inaccurate transfusion data. Patients were assigned to 7 FFP:pRBC cohorts (range 1:1 to 1:6, and 1:6+) only if the ratio was similar at 4 and 24 hours and, to avoid survival bias, were excluded otherwise. Multivariable analyses correcting for all available confounders (age, demographics, comorbidities, vital signs, Injury Severity Score [ISS] and mechanism, procedures performed) were derived to study the independent relationship between FFP:pRBC and 24-hour mortality., Results: Of 1,002,595 patients, 4,427 patients were included. Mean age was 41 years, 79% were males, 61% had blunt trauma, and median ISS was 29. Most patients were transfused in a 1:1, 1:2, or 1:3 ratio (31%, 41%, and 11%, respectively); mortality ranged between 28% for 1:1 and 62% for 1:4. In multivariable analyses, the odds of mortality independently and incrementally increased to 1.23 (95% CI 1.02 to 1.48) for a 1:2 ratio, 2.11 (95% CI 1.42 to 3.13) for 1:4, and as high as 4.11 (95% CI 2.31 to 7.31) for 1:5 (all p < 0.05)., Conclusions: A 1:1 FFP:pRBC ratio is associated with the lowest mortality in the hemorrhaging trauma patient, and mortality increases with decreasing ratios., (Copyright © 2019 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: A minimally invasive step-up (MIS) approach has been associated with reduced morbidity compared with open surgical necrosectomy (OSN) for treatment of necrotizing pancreatitis. We sought to determine whether transitioning from an OSN to an MIS-based approach would result in reduced mortality. MIS interventions included percutaneous drainage, endoscopic transgastric necrosectomy, video-assisted retroperitoneal debridement, sinus tract endoscopic necrosectomy, or a combination of techniques, with selective use of OSN., Study Design: We conducted an observational cohort study with retrospective comparison at a single tertiary referral center (2006 through 2019). Eighty-eight patients were treated with OSN and 91 were treated with an MIS-based approach. Baseline characteristics and clinical outcomes were compared between groups. The primary end point was 90-day mortality., Results: There was no difference in baseline characteristics. Ninety-day mortality was 2% with MIS compared with 10% with OSN (p = 0.03). One-year mortality was 3% with MIS compared with 15% with OSN (p = 0.012). The rate of organ failure was lower with MIS (30% vs 45%; p = 0.029), but there was a higher bleeding rate (19% vs 9%; p = 0.064). In the MIS group, 9% were treated with percutaneous drainage, 32% with endoscopic transgastric necrosectomy, 8% with video-assisted retroperitoneal debridement, 15% with sinus tract endoscopic necrosectomy, and 27% with a combination of techniques., Conclusions: Adoption of a multidisciplinary MIS-based approach to necrotizing pancreatitis resulted in a 5-fold decrease in mortality compared with OSN., (Copyright © 2020 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Patients with mild traumatic brain injury (mTBI) are frequently transferred to level 1 trauma centers (L1TC) if they have minor findings on a computerized tomographic scan of the head due to the absence of continuous neurosurgical coverage in community hospitals (CH). We hypothesized that such patients can be safely managed at community hospitals with a qualified Trauma team., Methods: This is a multicentered Retrospective Cohort Study. Patients with mild Traumatic Brain Injury (defined as Glasgow Coma Scale [GCS] 13-15 at presentation) and with minor findings on head Computerized Tomography (CT) presenting at a L1TC or 4 Community Hospitals between March 1st, 2012 and February 28th, 2014 were included. All these community hospitals are Level III Trauma center with a well-organized trauma team. Minor CT findings were defined as 1) epidural hematoma<2 mm; 2) subarachnoid hemorrhage<2 mm; 3) subdural hematoma<4 mm; 4) intraparenchymal hemorrhage<5 mm; 5) minor pneumocephalus; or 6) linear or minimally depressed skull fracture. Our primary end point was the need for TBI specific interventions in 3 groups of patients: 1) direct admission to the L1TC (L1TC group), 2) those admitted at one of the 4 CH (CH group), and 3) those transferred from CH to L1TC (TRANSFER group). TBI-specific interventions were defined as intracranial pressure monitor (ICP) placement, hyperosmolar therapy, or neurosurgical operation. Our secondary aim was to demonstrate that these patients can be safely managed in Community Hospitals with qualified Trauma teams. We also sought to identify the clinical outcomes in these three groups of patients - in terms of mortality and complications., Results: A total of 191 patients were included - 39 CH, 64 L1TC and 88 TRANSFER. There was no difference among the groups in terms of TBI-specific interventions: one TRANSFER, four L1TC, and no CH patients required hyperosmolar therapy (p = 0.277). None of the patients required placement of an intracranial pressure monitoring device (ICP) or a neurosurgical operation and complications and mortality rates were similar among the groups., Conclusions: Patients with mild TBI and minor findings on head CT can be safely managed at CH with qualified Trauma Teams., Level of Evidence: Therapeutic/Care Management Study, Level IVhbv., Competing Interests: Declaration of competing interest No conflict of interest., (Copyright © 2020 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

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

Background: We sought to examine whether preoperative endoscopic retrograde cholangio-pancreatography (ERCP) increases the risk of surgical site infections (SSI) after laparoscopic cholecystectomy., Methods: Patients admitted to an academic hospital from 2010 to 2016, who were older than 18 and had a laparoscopic or a laparoscopic converted to open cholecystectomy for complicated biliary tract disease were included. We compared those who had a preoperative ERCP to those who did not. Our primary endpoint was the rate of SSI., Results: A total of 640 patients were included. Of them, 122 (19.1%) received preoperative ERCP and 518 (80.9%) did not. The former had different preoperative diagnoses compared to non-ERCP patients (choledocholithiasis [35.2%-7.0%], acute cholecystitis [31.2%-76.4%], gallstone pancreatitis [20.5%-16.2%], and cholangitis [13.1%-0.4%], p < 0.001). The rate of SSI was higher in the preoperative ERCP group (11.5%-4.0%, p = 0.005). In a multivariable analysis conversion to open (OR = 2.57, 95% CI = 1.06-6.21, p = 0.037) and preoperative ERCP (OR = 3.12, 95% CI = 1.34-7.22, p = 0.008) were the only independent predictors of SSI., Conclusion: Preoperative ERCP is associated with a threefold increase in the risk of SSI after laparoscopic cholecystectomy., (Copyright © 2018. Published by Elsevier Inc.)

Background: Recent small randomized trials suggest that primary anastomosis with a diverting loop ileostomy (PADLI) is a safe alternative to Hartmann's procedure (HP) for patients with acute diverticulitis necessitating emergent operation. We sought to examine the 30-day outcomes of patients undergoing emergent HP vs PADLI., Method: Using the American College of Surgeons NSQIP Colectomy Procedure Targeted Database from 2012 to 2016, all patients with acute diverticulitis who underwent emergent HP or PADLI were identified. Multivariable logistic models were constructed to compare the 30-day mortality, overall morbidity, and individual postoperative complications (eg surgical site infection, bleeding, sepsis) of the 2 procedures, controlling for all preoperative variables (eg demographics, comorbidities, laboratory values, illness severity), as well as intraoperative and procedure-specific variables (eg wound classification)., Results: Of 130,963 patients, 2,729 patients were included. Median age was 64 years, 48.5% were male; the majority of patients underwent HP and only 208 (7.6%) underwent PADLI. Hartmann's procedure patients had more comorbidities (eg COPD: 9.8% vs 4.8%; p = 0.017), were more functionally dependent (6.3% vs 2.4%; p = 0.025), and were sicker (eg septic shock: 11.1% vs 5.3%; p = 0.015) compared with PADLI patients. The mortality rates for HP vs PADLI were 7.6% and 2.9%, respectively (p = 0.011). The morbidity rates were 55.4% and 48.6%, respectively (p = 0.056). In multivariable analyses, compared with HP, PADLI did not result in increased rates of mortality (odds ratio 0.21; 95% CI 0.03 to 1.58; p = 0.129) or morbidity (odds ratio 0.96; 95% CI 0.63 to 1.45; p = 0.834). The odds of most major postoperative complications were also similar for HP and PADLI overall., Conclusions: Currently, surgeons perform HP more frequently than PADLI. When controlling for patient population differences, PADLI appears to be at least a safe alternative to HP for select patient populations needing emergent surgical management of acute diverticulitis., (Copyright © 2019 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: We aimed to determine the incidence, risk factors, and outcomes of cervical spinal cord injury (CSCI) after blunt assault., Methods: The ACS National Trauma Data Bank (NTDB) 2012 Research Data Set was used to identify victims of blunt assault using the ICD-9 E-codes 960.0, 968.2, 973. ICD-9 codes 805.00, 839.00, 806.00, 952.00 identified cervical vertebral fractures/dislocations and CSCI. Multivariable analyses were performed to identify independent predictors of CSCI., Results: 14,835 (2%) out of 833,311 NTDB cases were blunt assault victims and thus included. 217 (1%) had cervical vertebral fracture/dislocation without CSCI; 57 (0.4%) had CSCI. Age ≥55 years was independently predictive of CSCI; assault by striking/thrown object, facial fracture, and intracranial injury predicted the absence of CSCI. 25 (0.02%) patients with CSCI underwent cervical spinal fusion., Conclusions: CSCI is rare after blunt assault. While the odds of CSCI increase with age, facial fracture or intracranial injury predicts the absence of CSCI., Summary: The incidence, risk factors, and outcomes of cervical spinal cord injury (CSCI) after blunt assault was investigated. 14,835 blunt assault victims were identified; 217 had cervical vertebral fracture/dislocation without CSCI; 57 had CSCI. Age ≥55 years was found to independently predict CSCI, while assault by striking/thrown object, facial fracture, and intracranial injury predicted the absence of CSCI., (Copyright © 2018. Published by Elsevier Inc.)

Necrotizing pancreatitis has historically been treated with open necrosectomy, which carries a high morbidity and mortality rate. More recently, there has been a shift towards endoscopic and percutaneous approaches employed as part of a minimally invasive step-up approach. Herein, we describe the technical approaches to video-assisted retroperitoneal debridement and sinus tract endoscopic debridement of pancreatic necrosis. Additionally, we review important patient selection considerations and the strengths and weaknesses of each of the approaches.

Objective: Intraoperative adverse events (iAEs) are defined as inadvertent injuries that occur during an operation and are associated with increased mortality, morbidity, and health care costs. We sought to study the impact of attending surgeon experience as well as resident training level on the occurrence of iAEs., Design: The institutional American College of Surgeons-National Surgical Quality Improvement Program and administrative databases for abdominal surgeries were linked and screened for iAEs using the International Classification of Diseases, Ninth Revision, Clinical Modification-based Patient Safety Indicator "accidental puncture/laceration." Each flagged record was systematically reviewed to confirm iAE occurrence and determine the number of years of independent practice of the attending surgeon and the postgraduate year (PGY) of the assisting resident at the time of the operation. The attending surgeon experience was divided into quartiles (<6 years, 6-13 years, 13-20 years, >20 years). The resident experience level was defined as Junior (PGY-1 to PGY-3) or Senior (PGY-4 or PGY-5). Univariate/bivariate then multivariable logistic regression analyses adjusting for patient demographics, comorbidities, and operation type and/or complexity (using RVUs as a proxy) were performed to assess the independent impact of resident and attending surgeon experience on the occurrence of iAEs., Setting: A large tertiary care teaching hospital., Participants: Patients included in the 2007-2012 ACS-NSQIP that had an abdominal surgery performed by both an attending surgeon and a resident., Results: A total of 7685 operations were included and iAEs were detected in 159 of them (2.1%). Junior residents participated in 1680 cases (21.9%), while senior residents were involved in 6005 (78.1%). The iAE rates for attending surgeons with <6, 6-13, 13-20, and >20 years of experience were 2.7%, 1.7%, 2.4%, and 1.4%, respectively. In multivariable analyses, the risk of occurrence of an iAE was significantly decreased for surgeons with >20 years of experience compared to those with <6 years of experience (odds ratio=0.52, 95% confidence interval 0.32-0.86, p = 0.011). On bivariate analyses, iAEs occurred in 1.2% of junior resident cases, while senior residents had an iAE rate of 2.3%. However, after risk adjustment on multivariable analyses, the resident experience level did not significantly impact the rate of iAEs., Conclusions: The surgeon's level of experience, but not the resident's, is associated with the occurrence of iAEs in abdominal surgery. Efforts to improve patient safety in surgery should explore the value of pairing junior surgeons with the more experienced ones thru formalized coaching programs, rather than focus on curbing resident operative autonomy., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

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

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

Background: We sought to investigate the association between nighttime (NT) operating and the occurrence of intraoperative adverse events (iAEs)., Study Design: Our 2007-2012 institutional ACS-NSQIP and administrative databases were screened for iAEs using the ICD-9-CM-based Patient Safety Indicator "accidental puncture or laceration". Procedures were defined as AM (06.00-14.00 h), PM (14.00-22.00 h), or NT (22.00-06.00 h). Univariate and multivariable analyses were performed to investigate the association between PM and NT operating and the occurrence of iAEs., Results: 9136 surgical procedures were included: 7445 AM, 1303 PM, 388 NT. iAEs occurred in 183 procedures. NT patients were younger and less comorbid, but sicker, and with less complex surgeries. There was no correlation between PM or NT operations and iAEs (multivariable analysis [reference: AM operations]: OR = 0.66 [95% CI = 0.40-1.12], P = 0.123; OR = 1.22 [95% CI = 0.51-2.93], P = 0.659, respectively)., Conclusion: Operating at night does increase the risk of iAEs., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Bile spillage (BS) occurs frequently during laparoscopic cholecystectomy, yet its impact on postoperative outcomes remains unknown. We hypothesized that BS increases the risk of surgical site infections (SSI) after laparoscopic cholecystectomy., Study Design: Patients older than 18, who were admitted to an academic hospital for a laparoscopic (or laparoscopic converted to open) cholecystectomy, from May 2010 to March 2017, were prospectively included. Open cholecystectomies were excluded. Patients were assessed clinically during hospitalization and 2 to 4 weeks after discharge. We compared those who had BS during the operation with those who did not. Our primary endpoint was the rate of SSI. Stepwise logistic regression was used to identify independent predictors of SSI., Results: Of 1,001 patients, 49.9% underwent laparoscopic cholecystectomy for acute cholecystitis, 20.9% for symptomatic cholelithiasis or biliary colic, 12.8% for gallstone pancreatitis, and 16.4% for other indications. Bile was spilled intraoperatively in 591 patients (59.0%), with hydrops noted in 10.5% and empyema in 14.6% of them. In 202 (20.2%) patients, BS was accompanied by stone spillage. Patients with BS were older (median age of 52 vs 42, p < 0.001) and were more frequently male (44.8% vs 27.8%, p < 0.001). Conversion to open was more likely in operations with BS (13.0% vs 4.4%, p < 0.001). Bile spillage was associated with a higher SSI rate (7.1% vs 2.4%, p = 0.001) and longer hospital stay (median of 3 vs 2 days, p < 0.001). In the multivariable analysis, BS, conversion to open, and American Society of Anesthesiologists (ASA) score > 2 were independent predictors of SSI (odds ratios: 2.29, 2.46, and 2.1 respectively, p < 0.05)., Conclusions: Bile spillage is associated with SSI, and surgeons should take extra caution to avoid it during laparoscopic cholecystectomy., (Copyright © 2018 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Minimally invasive surgical necrosectomy and endoscopic necrosectomy, compared with open necrosectomy, might improve outcomes in necrotising pancreatitis, especially in critically ill patients. Evidence from large comparative studies is lacking., Design: We combined original and newly collected data from 15 published and unpublished patient cohorts (51 hospitals; 8 countries) on pancreatic necrosectomy for necrotising pancreatitis. Death rates were compared in patients undergoing open necrosectomy versus minimally invasive surgical or endoscopic necrosectomy. To adjust for confounding and to study effect modification by clinical severity, we performed two types of analyses: logistic multivariable regression and propensity score matching with stratification according to predicted risk of death at baseline (low: <5%; intermediate: ≥5% to <15%; high: ≥15% to <35%; and very high: ≥35%)., Results: Among 1980 patients with necrotising pancreatitis, 1167 underwent open necrosectomy and 813 underwent minimally invasive surgical (n=467) or endoscopic (n=346) necrosectomy. There was a lower risk of death for minimally invasive surgical necrosectomy (OR, 0.53; 95% CI 0.34 to 0.84; p=0.006) and endoscopic necrosectomy (OR, 0.20; 95% CI 0.06 to 0.63; p=0.006). After propensity score matching with risk stratification, minimally invasive surgical necrosectomy remained associated with a lower risk of death than open necrosectomy in the very high-risk group (42/111 vs 59/111; risk ratio, 0.70; 95% CI 0.52 to 0.95; p=0.02). Endoscopic necrosectomy was associated with a lower risk of death than open necrosectomy in the high-risk group (3/40 vs 12/40; risk ratio, 0.27; 95% CI 0.08 to 0.88; p=0.03) and in the very high-risk group (12/57 vs 28/57; risk ratio, 0.43; 95% CI 0.24 to 0.77; p=0.005)., Conclusion: In high-risk patients with necrotising pancreatitis, minimally invasive surgical and endoscopic necrosectomy are associated with reduced death rates compared with open necrosectomy., Competing Interests: Competing interests: All authors declare no support from any organisation for the submitted work, no financial relationships with any organisation that might have an interest in the submitted work in the previous 3 years, and no other relationships or activities that could appear to have influenced the submitted work., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

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

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

Objective: We sought to assess the impact of intraoperative adverse events (iAEs) on 30-day postoperative mortality, 30-day postoperative morbidity, and postoperative length of stay (LOS) among patients undergoing abdominal surgery. We hypothesized that iAEs would be associated with significant increases in each outcome., Summary of Background Data: The relationship between iAEs and postoperative clinical outcomes remains largely unknown., Methods: The 2007 to 2012 institutional ACS-NSQIP and administrative databases for abdominal surgeries were matched then screened for iAEs using the Agency for Healthcare Research and Quality's 15 Patient Safety Indicator, "Accidental Puncture/Laceration". Each chart flagged during the initial screen was then manually reviewed to confirm whether an iAE occurred. Univariate then multivariable logistic regression models were constructed to assess the independent impact of iAEs on 30-day mortality, 30-day morbidity, and prolonged (≥7 days) postoperative LOS, controlling for preoperative/intraoperative variables (eg, age, comorbidities, ASA, wound classification), procedure type (eg, laparoscopic vs open, intestinal, foregut, hepatopancreaticobiliary vs abdominal wall procedure), and complexity (eg, adhesions; relative value units). Propensity score analyses were conducted with each iAE patient matched with 5 non-iAE patients. Sensitivity analyses were performed., Results: A total of 9288 cases were included; 183 had iAEs. Most iAEs consisted of bowel (44%) or vessel (29%) injuries and were addressed intraoperatively (92%). In multivariable analyses, iAEs were independently associated with increased 30-day mortality [OR = 3.19, 95% confidence interval (CI) 1.52-6.71, P = 0.002], 30-day morbidity (OR = 2.68, 95% CI 1.89-3.81, P < 0.001), and prolonged postoperative LOS (OR = 1.85, 95% CI 1.27-2.70, P = 0.001). Postoperative complications associated with iAEs included deep/organ-space surgical site infection (OR = 1.94, 95% CI 1.20-3.14), P = 0.007), sepsis (OR = 2.14, 95% CI 1.32-3.47, P = 0.002), pneumonia (OR = 2.18, 95% CI 1.11-4.26, P = 0.023), and failure to wean ventilator (OR = 3.88, 95% CI 2.17-6.95, P < 0.001). Propensity score matching confirmed these findings, as did multiple sensitivity analyses., Conclusions: iAEs are independently associated with substantial increases in postoperative mortality, morbidity, and prolonged LOS. Quality improvement efforts should focus on iAE prevention, mitigation of harm after iAEs occur, and risk/severity-adjusted iAE tracking and benchmarking.

Introduction: Percutaneous cholecystostomy tube (PCT) placement is considered a safe alternative to cholecystectomy for the treatment of acute calculous cholecystitis (ACC), but data regarding long-term outcomes following PCT are limited., Methods: We retrospectively reviewed our institutional experience of patients undergoing PCT for ACC between 1997 and 2015. Recurrent biliary events were defined as cholecystitis, cholangitis, or gallstone pancreatitis., Results: PCT was placed for 288 patients with ACC. Mean age and age-adjusted Charlson comorbidity index were 72 ± 15 years and 5.3 ± 2.4, respectively. Following PCT placement, 91% of patients successfully resolved their episode of ACC. PCT dysfunction occurred in 132 patients (46%), with 80 patients (28%) requiring re-intervention, while 7% developed procedure-related complications. Interval cholecystectomy reduced the risk of recurrent biliary events to 7% from 21% (p = 0.002). Cholecystectomy was completed laparoscopically in 45% of patients receiving an interval operation vs. 22% of those undergoing urgent surgery for PCT failure or recurrent biliary event (p = 0.03)., Conclusions: PCT placement is a highly successful treatment for acute calculous cholecystitis and is associated with low complication rate, but high rate of tube dysfunction requiring frequent re-intervention. Interval cholecystectomy is associated with a decreased likelihood of recurrent biliary events and increased likelihood of successful laparoscopic completion.

Objective: The relationship between baseline (i.e., pre-injury) blood pressure and trauma outcomes in elderly patients is unknown. We therefore aimed to identify the independent impact of baseline systolic blood pressure (SBP) on inpatient mortality among elderly trauma patients., Methods: The 2004 to 2014 trauma registries of two Level I Trauma Centers were linked to electronic health records then reviewed to identify patients ≥65 years old with available baseline vital signs. Baseline SBP was defined as mean outpatient SBP within 2 years before injury. Trauma SBP was defined as first SBP reading after presentation for trauma. Baseline and Trauma SBP were classified as Low (<110 mm Hg), Normal (110-139 mm Hg), or High (≥140 mm Hg). Logistic multivariable regression models were constructed to assess the independent impact of Baseline SBP on inpatient mortality, controlling for demographics, comorbidities, injury mechanism/severity, and Trauma SBP., Results: Of 37,494 patient admissions, 4,233 met inclusion criteria. Median age was 81 years; 63.6% were female. Mortality was 5.39%. In unadjusted analyses, mortality rates were 11.01%, 5.28%, and 4.52% in the Low, Normal, and High Baseline SBP groups, respectively (p = 0.001). In multivariable analyses, patients with Low Baseline SBP had significantly increased mortality risk [OR 3.19 (95% CI 1.62-6.26), p = 0.001] compared to patients with Normal Baseline SBP, in particular when they presented with Low Trauma SBP (<110 mm Hg) [OR 6.14 (2.17-17.36), p = 0.001] or Normal Trauma SBP (110-139 mm Hg) [OR 3.87 (1.43-10.45), p = 0.008]. The mortality risk associated with Low Baseline SBP was particularly elevated among patients with a pre-existing diagnosis of hypertension [OR 4.78 (1.97-11.62), p = 0.001]., Conclusion: Low baseline pre-injury SBP is independently associated with more than a threefold increase in inpatient mortality among elderly trauma patients and a fivefold increase in mortality risk among patients with pre-existing hypertension. Given that blood pressure control in the elderly offers a long-term survival advantage, the paradoxical finding of decreased survival after trauma warrants further investigation., Level of Evidence: Prognostic/epidemiologic study, level III.

Background: Percutaneous drainage is the standard treatment for perforated appendicitis with abscess. We studied factors associated with complete resolution (CR) with percutaneous drainage alone., Methods: Ninety-eight patients underwent percutaneous drainage for acute appendicitis complicated by abscess (October 1990 to September 2010). CR was defined as clinical recovery, resolution of the abscess on imaging, and drain removal without recurrence. Patients achieving CR were compared with patients not achieving CR., Results: The rate of CR was 78.6% (n = 77). Abscess grade was the only radiological factor associated with CR (P = .007). The CR rate was higher with transgluteal drainage (90.9% vs 79.2%) than with other anatomic approaches (P = .018) and higher with computed tomography-guided drainage than with ultrasound-guided drainage (82.7% vs 64.3%, P = .046)., Conclusion: CR was more likely to be achieved in patients with lower abscess grade, computed tomography-guided drainage, and a transgluteal approach., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Enteric fistula is a serious complication of necrotizing pancreatitis. Endoscopic transluminal drainage and necrosectomy can significantly reduce the incidence of enterocutaneous fistula after pancreatic debridement. However, endoscopic necrosectomy may not be well-suited to debridement of necrosis that tracks laterally to the paracolic gutters, which is often more efficiently addressed by video-assisted retroperitoneal debridement (VARD). We report the combined use of endoscopic transgastric drainage and VARD for treatment of a 76 year old man with severe necrotizing acute pancreatitis complicated by infected, walled-off pancreatic necrosis. Computed tomography showed laterally tracking pancreatic necrosis and flouroscopic drain injection after percutaneous drainage demonstrated with fistulas to the stomach, duodenum, and colon. The infection and fistulas resolved completely. This approach combined the major advantage of VARD with the major advantage of endoscopic transluminal drainage. We are not aware of any reports of combining these techniques and believe the combination offers a minimally invasive approach for patients with extensive necrosis and a high likelihood of enteric or pancreatic fistulas., (Copyright © 2016 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

Background: There currently exists no preoperative risk stratification system for emergency surgery (ES). We sought to develop an Emergency Surgery Acuity Score (ESAS) that helps predict perioperative mortality in ES patients., Methods: Using the 2011 American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database (derivation cohort), we identified all surgical procedures that were classified as "emergent." A three-step methodology was then performed. First, multiple logistic regression models were created to identify independent predictors (e.g., patient demographics, comorbidities, and preoperative laboratory variables) of 30-day mortality in ES. Second, based on the relative impact of each identified predictor (i.e., odds ratio), using weighted averages, a novel score was derived. Third, using the 2012 ACS-NSQIP database (validation cohort), the score was validated by calculating its C statistic and evaluating its ability to predict 30-day mortality., Results: From 280,801 NSQIP cases, 18,439 ES cases were analyzed, of which 1,598 (8.7%) resulted in death at 30 days. The multiple logistic regression analyses identified 22 independent predictors of mortality. Based on the relative impact of these predictors, ESAS was derived with a total score range of 0 to 29. ESAS had a C statistic of 0.86; the probability of death at 30 days gradually increased from 0% to 36% then 100% at scores of 0, 11, and 22, respectively. In the validation phase, 19,552 patients were included, the mortality rate was 7.2%, and the ESAS C statistic stayed at 0.86., Conclusion: We have therefore developed and validated a novel score, ESAS, that accurately predicts mortality in ES patients. Such a score could prove useful for (1) preoperative patient counseling, (2) identification of patients needing close postoperative monitoring, and (3) risk adjustment in any efforts at benchmarking the quality of ES., Level of Evidence: Prognostic/epidemiologic study, level III.

Background: The value of additional imaging in clearing the cervical spine (C-spine) of alert trauma patients with tenderness on clinical exam and a negative computed tomographic (CT) scan is still unclear., Methods: All adult trauma patients with a Glasgow Coma Scale of 15, C-spine tenderness in the absence of neurologic signs, and a negative C-spine CT were included. The study period extended from September 2011 to June 2012. C-spine CT scans were interpreted in detail and considered negative in the absence of any findings indicating bony, ligamentous, or soft tissue injury around the C-spine. The incidence of C-spine injury was evaluated using early (<24 h) repeat physical examination, MRI, and/or flexion-extension films., Results: Of 2015 patients with a C-spine CT, 383 (19 %) fulfilled the inclusion criteria. The median age was 43 (IQR: 30-53) and 44.7 % were female. Thirty-six patients (9.4 %) underwent MRI (3.7 %), flexion-extension imaging (5.2 %), or both (0.5 %), with no significant injuries identified and subsequent removal of the collar allowed. The remaining patients were clinically cleared within 24 h of presentation. None of the patients developed neurological signs following removal of the collar. On bivariate analysis, no variable except for evaluation by trauma surgery was associated with performance of additional imaging., Conclusion: C-spine precautions can be withdrawn without additional imaging in most blunt trauma patients with C-spine tenderness but negative neurologic evaluation and C-spine CT. Focus should be placed on the detailed and comprehensive interpretation of the C-spine CT.

Background: Little evidence currently exists regarding the clinical or financial impact of intraoperative adverse events (iAEs). We sought to study the additional health care charges attributable to the occurrence of an iAE., Methods: The administrative and ACS-NSQIP databases at our tertiary academic medical center were linked for all patients undergoing abdominal surgery (January 2007-October 2012). The ICD-9-CM-based Patient Safety Indicator "accidental puncture/laceration" was used to screen the linked database for potential iAEs. All iAEs were confirmed subsequently through standardized review of all flagged medical records. Multivariate analyses controlling for demographics, comorbidities/laboratory values, procedure type, and approach and complexity of surgery were performed to assess the increase in health care charges independently predicted by the occurrence of iAEs., Results: Of 9,111 patients, 183 were confirmed to have iAEs. Patients in the iAE group had higher median total charges ($27,169 [IQR, 17,302-44,952] vs $13,312 [IQR, 8,586-22,012]; P < .001), direct charges ($17,808 [IQR, 11,520-28,930] vs $8,738 [IQR, 5,686-14,227]; P < .001) and indirect charges ($9,396 [IQR, 5,932-16,144] vs $4,568 [IQR, 2,887-7,824]; P < .001) when compared with patients without iAEs. Multivariate analyses demonstrated that iAEs independently predict an increase in total hospitalization charges by 41% (95% CI, 30-52%; P < .001). Specifically, the direct, indirect, operating room, laboratory/radiology, and alimentation/medical therapy charges increased by 42, 39, 27, 54, and 48%, respectively (all P < .001)., Conclusion: In addition to the morbidity incurred by patients, the occurrence of an iAE is associated with major additional health care charges. In an era of value-based health care, understanding and preventing iAEs can lead to major cost savings alongside improvements in patient safety and surgical quality., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Ultrasound (US) is the first-line diagnostic study for evaluating gallstone disease and is considered the test of choice for diagnosing acute cholecystitis (AC). However, computed tomography (CT) is used widely for the evaluation of abdominal pain and is often obtained as a first abdominal imaging test, particularly in cases in which typical clinical signs of AC are absent or other possible diagnoses are being considered. We hypothesized that CT is more sensitive than US for diagnosing AC., Methods: A prospective registry of all urgent cholecystectomies performed by our acute care surgery service between June 2008 and January 2014 was searched for cases of AC. The final diagnosis was based on operative findings and pathology. Patients were classified into two groups according to pre-operative radiographic work-up: US only or CT and US. The US group was compared with the CT and US group with respect to clinical and demographic characteristics. For patients undergoing both tests the sensitivity of the two tests was compared., Results: One hundred one patients with AC underwent both US and CT. Computed tomography was more sensitive than US for the diagnosis of AC (92% versus 79%, p=0.015). Ultrasound was more sensitive than CT for identification of cholelithiasis (87% versus 60%, p<0.01). Patients undergoing both tests prior to surgery were more likely to be older, male, have medical comorbidities, and lack typical clinical signs of AC., Conclusions: Computed tomography is more sensitive than US for the diagnosis of AC and is most often used in patients without typical clinical signs of AC.