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Liver transplantation offers a potential for curative-intent treatment in patients presenting with non-metastatic intrahepatic cholangiocarcinoma that is not amenable to partial hepatectomy. There is little empiric evidence evaluating the efficacy of liver transplantation in patients with intrahepatic cholangiocarcinoma.We queried the National Cancer Database to identify patients presenting with histologically confirmed clinical stage I to III intrahepatic cholangiocarcinoma between 2004 and 2016. Propensity scoring was used to develop matched cohorts of patients undergoing treatment with liver transplantation, surgical resection, or chemotherapy alone. Kaplan Meier methods were used to compare rates of overall survival.One thousand four hundred and eleven patients met inclusion criteria. Of these, 66 (4.7%) underwent liver transplantation, 461 (32.7%) underwent surgical resection, and 884 (62.6%) were treated with chemotherapy alone. On adjusted analysis, patients undergoing liver transplantation were more likely to be male (odds ratio 4.35, 95% confidence interval [0.12, 0.42]), have a Charlson Comorbidity Score ≥2 (odds ratio 3.11, 95% confidence interval [1.44, 6.57]), and to receive both neoadjuvant (odds ratio 2.78, 95% confidence interval [1.36,5.75], and adjuvant (odds ratio 1.94, 95% confidence interval [0.97, 3.87]) systemic therapy than those undergoing resection. On Kaplan Meier analysis, patients undergoing liver transplantation demonstrated rates of 5-year overall survival (36.1% vs 34.7%, P = .53) that were statistically identical to those for stage-matched and margin-matched patients undergoing resection but significantly better than those for stage-matched patients treated with systemic therapy alone (36.1% vs 5.3%, P.0001).Patients undergoing liver transplantation for intrahepatic cholangiocarcinoma demonstrate overall survival profiles similar to stage-matched and margin-matched patients undergoing surgical resection. Liver transplantation is an effective treatment modality in select patients presenting with localized intrahepatic cholangiocarcinoma.

Prior studies evaluating the safety and efficacy of local excision relative to surgical resection in early-stage rectal adenocarcinoma have primarily included low rectal cancers treated with abdominoperineal resection as control comparison cohorts. The role of local excision in early-stage rectal adenocarcinoma is incompletely defined.We queried the National Cancer Database to identify patients with cT1 N0 M0 rectal adenocarcinoma between 2004 and 2019. Patients undergoing abdominoperineal resection were excluded. Multivariable regression was used to identify factors associated with use of local excision instead of low anterior resection. Patients undergoing local excision were propensity score matched for age, sex, demographic characteristics, Charlson-Deyo comorbidity class score, and tumor grade and size to those undergoing low anterior resection. Short-term clinical outcomes and 5-year overall survival for matched cohorts were compared by standard methods.A total of 5,693 patients met inclusion criteria; 1,973 patients underwent local excision and 3,720 low anterior resection. Age (adjusted odds ratio 1.26; 95% confidence interval, 1.17-1.37), tumor histology (poorly differentiated histology: adjusted odds ratio 0.66; 95% confidence interval, 0.51-0.86), and size (4 cm: adjusted odds ratio 0.20; 95% confidence interval, 0.16-0.25) were associated with choice of intervention. On comparison of matched cohorts, patients undergoing LE demonstrated shorter hospital stay (2.4 ±9.8 vs 5.6 ±8.1 days; P.001) and lower readmission rate (4% vs 7%; P = .002) but higher margin-positive resection rates (8% vs 2%; P.001). Overall survival profiles for patients undergoing local excision were comparable with those for low anterior resection.In patients with cT1 N0 M0 rectal adenocarcinoma, local excision is associated with a higher margin-positive resection rate than low anterior resection but affords accelerated postprocedure recovery and comparable rates of overall survival.

Studies evaluating endoscopic resection for early-stage (cT1N0M0) esophageal adenocarcinoma include small numbers of patients with T1b tumors. The role of endoscopic resection in esophageal adenocarcinoma remains incompletely defined.We queried the National Cancer Database to identify patients presenting with esophageal adenocarcinoma between 2010 and 2017. Those treated with neoadjuvant chemoradiotherapy and endoscopic ablation were excluded. Patients undergoing endoscopic resection for cT1a and cT1b tumors were separately 1:1 propensity matched for relevant demographic and tumor factors to those undergoing esophagectomy for disease of like clinical stage. The Kaplan-Meier method was used to compare 5-year overall survival for matched cohorts.A total of 3,157 patients met the inclusion criteria. Of these patients, 2,024 (64.1%) had cT1a and 1133 (35.9%) had cT1b disease. Among those with cT1a tumors, 461 (22.8%) underwent esophagectomy, 1,357 (67.0%) endoscopic resection, and 206 (10.2%) treatment with chemoradiotherapy alone. Among those with cT1b tumors, 649 (57.3%) underwent esophagectomy, 293 (25.9%) endoscopic resection, and 191 (16.8%) chemoradiotherapy. On unadjusted comparison, patients treated for esophageal adenocarcinoma with chemoradiotherapy had a lower rate of overall survival than those treated with endoscopic resection or esophagectomy (26.1% vs 73.1% vs 75.5%, P.001). On comparison of matched cohorts, patients undergoing endoscopic resection for cT1b tumors demonstrated lower rates of overall survival than those undergoing esophagectomy (60.6% vs 74.1%, P = .0013), whereas those undergoing endoscopic resection for cT1a tumors demonstrated rates of overall survival statistically similar to those undergoing esophagectomy (77.8% vs 80.2%, P = .75).Esophagectomy is associated with improved overall survival relative to endoscopic resection in patients presenting with cT1bN0M0 but not in those with cT1a esophageal adenocarcinoma.

Few studies evaluate the impact of unhealthy alcohol and drug use on the risk and severity of postoperative outcomes after upper gastrointestinal and pancreatic oncologic resections.The National Inpatient Sample was queried to identify patients undergoing total gastrectomy, esophagectomy, total pancreatectomy, and pancreaticoduodenectomy between 2012 and 2015. Unhealthy alcohol and drug use was assessed by the International Classification of Diseases, Ninth Revision, and National Inpatient Sample coder designation. Multivariable regression was used to identify associations between alcohol and drug use and postoperative complication, duration of stay, hospital cost, and mortality.In the study, 59,490 patients met inclusion criteria; 2,060 (3.5%) had unhealthy alcohol use; 1,265 (2.1%) had unhealthy drug use. Postoperative complication rates were higher in patients with alcohol and drug use than in abstainers (67.5% vs 62.8% vs 57.2%; P.01). On multivariable regression, alcohol use was independently associated with increased risk of a nonwithdrawal complication (odds ratio 1.33 [1.05, 1.68]), and alcohol and drug use were independently associated with increased length of stay (1.54 [0.12, 2.96]) and 2.22 [0.90, 3.55] days) and cost ($5,471 [$60, $10,881] and $4,022 [$402, $7,643]), but not mortality.Unhealthy substance use is associated with increased rates of postoperative complications, prolonged length of stay, and costs in patients undergoing major upper gastrointestinal and pancreatic oncologic resections. Screening and abstinence interventions should be incorporated into the preoperative care pathways for these patients.

Background: We applied various machine learning algorithms to a large national dataset to model the risk of postoperative sepsis after appendectomy to evaluate utility of such methods and identify factors associated with postoperative sepsis in these patients. Methods: The National Surgery Quality Improvement Program database was used to identify patients undergoing appendectomy between 2005 and 2017. Logistic regression, support vector machines, random forest decision trees, and extreme gradient boosting machines were used to model the occurrence of postoperative sepsis. Results: In the study, 223,214 appendectomies were identified; 2,143 (0.96%) were indicated as having postoperative sepsis. Logistic regression (area under the curve 0.70; 95% confidence interval, 0.68-0.73), random forest decision trees (area under the curve 0.70; 95% confidence interval, 0.68-0.73), and extreme gradient boosting (area under the curve 0.70; 95% confidence interval, 0.68-0.73) afforded similar performance, while support vector machines (area under the curve 0.51; 95% confidence interval, 0.50-0.52) had worse performance. Variable importance analyses identified preoperative congestive heart failure, transfusion, and acute renal failure as predictors of postoperative sepsis. Conclusion: Machine learning methods can be used to predict the development of sepsis after appendectomy with moderate accuracy. Such predictive modeling has potential to ultimately allow for preoperative recognition of patients at risk for developing postoperative sepsis after appendectomy thus facilitating early intervention and reducing morbidity. (c) 2020 Elsevier Inc. All rights reserved. National Institute of Health T32 NIGMS [5T32GM008750-20]; National Institute of Health T32 NIAAA [5T32AA013527-17] Dr C. Bunn is supported by National Institute of Health T32 NIGMS 5T32GM008750-20. Dr S. Kulshrestha is supported by National Institute of Health T32 NIAAA 5T32AA013527-17.

Background The amount of time surgical trainees spend operating independently has been reduced by work-hour restrictions and shifts in the health care environment that impede autonomy. Few studies evaluate the association between clinical outcome and resident autonomy. Methods The Veterans Affairs Surgical Quality Improvement Program database was queried to identify patients undergoing partial colectomy for neoplasm between 2004 and 2019. Rectal resections, emergency procedures, and those involving postgraduate year 1 and 2 residents were excluded. Records were categorized as performed with the attending scrubbed or not scrubbed. Hierarchical logistic regression was used to identify factors independently associated with operative time, morbidity, and mortality. Results In total, 7,347 patients met inclusion criteria; 6,890 (93.6%) were categorized as attending scrubbed and 457 (6.4%) as attending not scrubbed. The cohorts were similar in terms of patient demographics, including age, race, body mass index, and American Society of Anesthesiologists class. There were no differences between cohorts in terms of operative time (attending not scrubbed 3.02 hours, attending scrubbed 3.07 hours, P = .42). On hierarchical logistic regression adjusted for age, gender, race, body mass index, functional status, cancer location, facility operative level, wound class, American Society of Anesthesiologists class, length of operation, operative modality (open or minimally invasive), postgraduate year of resident, and year, there were no differences in odds of complications, major morbidity, or mortality based on attending involvement. Conclusion Colectomies performed by residents with appropriate levels of autonomy are efficient and safe. Our results indicate that attending surgeon judgment regarding resident autonomy is sound and that educational environments can be designed to foster resident independence and preserve clinical quality, safety, and efficiency.

Prior studies evaluating the effect of margin status on clinical outcome in patients undergoing resection for intrahepatic and extrahepatic hilar cholangiocarcinoma include small numbers of patients with histologically positive margins. The value of margin negative resection in these cases remains unclear.We queried the National Cancer Database to identify patients undergoing resection for clinical stage I to III intrahepatic and extrahepatic hilar between 2004 and 2015. Patients receiving neoadjuvant therapy and those having3 lymph nodes examined were excluded. Patients undergoing positive resection were 1:1 propensity matched to those undergoing negative resection. Kaplan-Meier methods were used to compare overall survival for the matched cohorts.In the study, 3,618 patients met the inclusion criteria, and 3,018 (83.4%) underwent negative resection; 600 (16.6%) positive resection. Patients undergoing negative resection had smaller tumors (2.97 ± 0.07 cm vs 3.49 ± 0.15 cm), were less likely to have stage 3 disease (16.7% vs 25.7%) and to receive adjuvant radiation (27.1% vs 45.7%) and chemotherapy (49.4% vs 61.0%) than those undergoing positive resection (all P.05). On comparison of matched cohorts, patients undergoing negative resection had longer median overall survival (24.5 ± 0.02 vs 19.1 ± 0.02 months) and higher rates of 5-year overall survival (24.5% vs 16.7%) than those undergoing positive resection (P.01).In patients presenting with resectable intrahepatic and extrahepatic hilar, negative resection is associated with improved overall survival. Extended resections performed in an effort to clear surgical margins are warranted in patients fit for such procedures.

Health care spending is driven by a very small percentage of Americans, many of whom are patients with prolonged durations of stay. The objective of this study was to characterize superusers in the trauma population.The National Trauma Data Bank for 2008-2012 was queried. Superusers were defined as those with a duration of stay in the top 0.06% of the population and were compared with the remainder of the population to determine differences in demographic characteristics, comorbidities, prehospital factors, and outcomes. Multivariate analysis was used to determine independent predictors of being classified as a superuser.A total of 3,617,261 patients met inclusion criteria, with 34,728 qualifying as superusers. Mean duration of stay for superusers was 58.7 days compared with the average 4.6 days (P.001). Superusers were more likely to be male, black, Medicaid insured, and have a higher Injury Severity Score and lower Glasgow Coma Scale score. The hospital course of superusers was likely to be complicated by pneumonia, acute respiratory distress syndrome, decubitus ulcer, and acute kidney injury.Age, sex, race, and insurance were associated with prolonged use of inpatient care in the trauma patient population. Specific comorbidities and complications are associated with being a superuser. This subset of the trauma population confers a disproportionate burden on the health care system and can serve as a potential target for intervention.

The purpose of this study was to measure how the duration of nonoperative intervention for intestinal obstruction impacted patient outcomes and whether hospital characteristics influenced the timing of operative intervention.The State Inpatient Database (Florida) of the Health Care Utilization Project and the Annual Survey database of the American Hospital Association were linked from 2006 to 2011. Included were patients ≥18 years of age with a primary diagnosis of intestinal obstruction. Patient factors included age, sex, socioeconomic factors, and comorbid conditions.A total of 116,195 patients met our inclusion criteria, and 43,079 underwent operative intervention (37.1%). Patients who required operative correction of the intestinal obstruction after the fifth day of hospitalization, compared with patients who underwent an operation on the day of admission, had increases in mortality (6.1% vs 1.8%, P.001), complication rates (15.4% vs 4.0%, P.001), and postoperative hospital stay (9 vs 5 days, P.001). Patients cared for at a large teaching facility (with surgery residents) had increased odds of early operative intervention by 23% (odds ratio 1.23, [1.20-1.28]), whereas patients at low-volume hospitals had decreased odds of early intervention (odds ratio 0.88, [0.73-0.91]).Initial nonoperative treatment in patients with uncomplicated intestinal obstruction is an important strategy, but the odds of having an adverse event increase as intestinal obstruction is delayed. Importantly, the presence of surgery residents and increasing bed size are hospital characteristics associated with earlier operative intervention, suggesting a quality benefit for care at large teaching hospitals.

Background The fastest growing segment of the American population is the elderly (>65 years). This change in demographics also is being seen in trauma centers. Emergency department thoracotomy is utilized in an attempt to restore circulation for patients arriving in extremis. The purpose of this study was to investigate the relationship between clinical variables, particularly age, and outcomes for injured patients receiving an emergency department thoracotomy. Methods Using the National Trauma Data Bank for years 2008–2012, observations with International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes for exploratory thoracotomy were identified. Emergency department thoracotomy was defined as any observation that occurred at a time to thoracotomy less than the total time spent in the emergency department thoracotomy, and within 15 minutes of arrival. Mechanisms of injury, demographic data, and injuries were analyzed for predictors of survival and mortality rates. Mortality rates were determined for each decade and year of life. Results There were 11,380 observations for thoracotomy identified. Of these, 2,519 were emergency department thoracotomy, with the majority (n = 2,026, 80% observations) performed for penetrating wounds. Mortality rates ranged from 80% to 100% for each decade of life. Mortality was 100% for patients >57 years old with either penetrating or blunt mechanisms of injury. Conclusion Emergency department thoracotomy offered no survival benefit for patients older than 57 years of age. These data suggest that emergency department thoracotomy performed in elderly patients may be futile.

Background Incisional hernia recurrence after repair continues to be a persistent complication. The purpose of this study was to investigate the association between patient-specific factors, surgeon-specific factors, and hernia recurrence in patients undergoing repair of an incisional hernia in whom the component separation technique was used. Methods All patients undergoing incisional herniorrhaphy with component separation from October 2006 to May 2013 were reviewed. Data collected included demographics, comorbidities, postoperative complications, and factors related to mesh implantation. Computed tomography images were used to evaluate the size of the hernia and dimensions of the linea alba. Results The 85 patients were followed for a mean of 14.4 months, and 12 (14.1%) recurrent hernias were diagnosed. More than 91% of the herniorrhaphies were performed after a previous repair failed. The recurrence rate decreased to 11.1% when, in addition to the component separation, a mesh was used to reinforce the repair. There were no differences between the group who developed a recurrence and those who did not in terms of sex, age, race, body mass index, preoperative comorbidities, or type of mesh used. Conclusion In this case series of complex abdominal wall herniorrhaphies using component separation, the recurrence rate was 14.1% overall and 11.1% when a mesh was used to reinforce the repair. Recurrent hernia was not associated with patient demographics, comorbidities, thickness or width of the linea alba, presence of a contaminated wound, or postoperative surgical-site occurrences.

We hypothesized that the number of rib fractures independently impacted patient pulmonary morbidity and mortality.The National Trauma Data Bank (NTDB, v. 3.0 American College of Surgeons, Chicago, IL) was queried for patients sustaining 1 or more rib fractures. Data abstracted included the number of rib fractures by International Classification of Diseases-9 code, Injury Severity Score, the occurrence of pneumonia, acute respiratory distress syndrome, pulmonary embolus, pneumothorax, aspiration pneumonia, empyema, and associated injuries by abbreviated injury score, the need for mechanical ventilation, number of ventilator days, intensive care unit (ICU) length of stay (LOS), hospital LOS, mortality, and use of epidural analgesia. Statistical analysis was performed using the Student t test and linear regression analysis. Statistical significance was defined as a P value of less than .05.The NTDB included 731,823 patients. Of these, 64,750 (9%) had a diagnosis of 1 or more fractured ribs. Thirteen percent (n = 8,473) of those with rib fractures developed 13,086 complications, of which 6,292 (48%) were related to a chest-wall injury. Mechanical ventilation was required in 60% of patients for an average of 13 days. Hospital LOS averaged 7 days and ICU LOS averaged 4 days. The overall mortality rate for patients with rib fractures was 10%. The mortality rate increased (P.02) for each additional rib fracture. The same pattern was seen for the following morbidities: pneumonia (P.01), acute respiratory distress syndrome (P.01), pneumothorax (P.01), aspiration pneumonia (P.01), empyema (P.04), ICU LOS (P.01), and hospital LOS for up to 7 rib fractures (P.01). An association between increasing hospital LOS and number of rib fractures was not shown (P = .19). Pulmonary embolism also was not related to the number of rib fractures (P = .06). Epidural analgesia was used in 2.2% (n = 1,295) of patients with rib fractures. A reduction in mortality with epidural analgesia was shown at 2, 4, and 6 through 8 rib fractures. The use of epidural analgesia had no impact on the frequency of pulmonary complications. When stratifying data by Injury Severity Score and the presence or absence of rib fractures the mortality rates were similar.Increasing the number of rib fractures correlated directly with increasing pulmonary morbidity and mortality. Patients sustaining fractures of 6 or more ribs are at significant risk for death from causes unrelated to the rib fractures. Epidural analgesia was associated with a reduction in mortality for all patients sustaining rib fractures, particularly those with more than 4 fractures, but this modality of treatment appears to be underused.

Background Trauma systems use specific criteria based on physiologic, anatomic, and mechanistic factors for field triage. The purpose of this study was to evaluate the emergency department disposition of patients not meeting mandatory criteria (ie, physiologic or anatomic factors) for triage to a trauma center and the potential for over- or undertriage. Methods This was a retrospective review of trauma admissions from July 1999 to June 2001, to a level I trauma center. Triage criteria were classified as physiologic factors (n = 300), anatomic factors (n = 115), or mechanistic factors (n = 414), according to the criteria of the American College of Surgeons Committee on Trauma. Physiologic and anatomic factors were combined and compared with mechanistic factors. Results There were 1253 admissions during the study period. Sixty-six percent (n = 830) met study inclusion criteria. Fifty percent (n = 413) were admitted to the intensive care unit or operating room. Approximately 50% of each group (physiologic/anatomic, 52%; mechanistic, 47%; P = .08) were admitted directly to the operating room or to the intensive care unit. Conclusions Patients not meeting mandatory criteria for transfer to a trauma center often have serious injuries that require a higher level of care. The inclusion of all or select mechanistic criteria for evaluation at a trauma center is appropriate to achieve an acceptable rate of clinical undertriage, as well as resource undertriage and its subsequent complications.

Background. The identification of trauma patients at risk for the development of deep venous thrombosis (DVT) at the time of admission remains difficult. The purpose of this study is to validate the risk assessment profile (RAP) score to stratify patients for DVT prophylaxis. Methods. All patients admitted from November 1998 thru May 1999 were evaluated for enrollment. We prospectively assigned patients as low risk or high risk for DVT using the RAP score. High-risk patients received both pharmacologic and mechanical prophylaxis. Low-risk patients received none. Surveillance duplex Doppler scans were performed each week of hospitalization or if symptoms developed. Hospital charges for prophylaxis were used to determine the savings in the low-risk group. Statistical differences between the risk groups for each factor of the RAP and development of DVT were determined by the chi-squared test, with significance at a probability value of less than.05. Results. There were 102 high-risk (64%) and 58 low-risk (36%) individuals studied. Eleven of the high-risk group (10.8%) experienced the development of DVT (asymptomatic, 64%). None of the low-risk group was diagnosed with DVT. Five of the 16 RAP factors were statistically significant for DVT. Eliminating prophylaxis and Doppler scans in low-risk patients resulted in a total savings of $18,908 in hospital charges. Conclusions. The RAP score correctly identified trauma patients at increased risk for the development of DVT. Despite prophylaxis, the high-risk group warrants surveillance scans. Withholding prophylaxis in low-risk patients can reduce hospital charges without risk. (Surgery 2000;128:631-40.)

Background. The purpose of this study was to evaluate the use of dynamic helical computed tomography (CT) scan for screening patients with pelvic fractures and hemorrhage requiring angiographic embolization for control of bleeding. Methods. Patients admitted to the trauma service with pelvic fractures were identified from the trauma registry. Data retrieval included demographics, hemodynamic instability, Injury Severity Score, blood transfusion requirement, length of stay, and mortality. CT scans obtained during the initial evaluation were reviewed for the presence of contrast extravasation and correlated with angiographic findings. Data are reported as mean ± SEM, with P

We evaluated the effects of prone positioning (PP) on surgery and trauma patients with acute respiratory distress syndrome (ARDS).Patients with ARDS were studied. Exclusion criteria were contraindications to PP. Patients were evaluated in the supine position and after being turned to the PP. After 6 hours, patients were returned to the supine position for 3 hours. One hour after each position change, arterial and mixed venous blood was drawn and analyzed for blood gases and pH, and hemodynamics were measured.Over 20 months, 27 patients met the criteria, and 20 of the patients were entered into the study. On day 1, 18 of 20 patients (90%) responded with an increase in PaO(2) during PP. On day 2, 16 of 17 patients (94%) responded; on day 3, 15 of 16 patients responded (94%); on day 4, 11 of 13 patients responded (85%); on day 5, 8 of 8 patients responded (100%); and on day 6, 4 of 5 patients responded (80%). Pao(2)/Fio(2) and Qs/Qt were significantly improved (P.05) during PP. There were 91 periods of PP, lasting 10.3+/-1.2 hours. Of 91 changes to PP, 78 changes (86%) resulted in an improvement in Pao(2)/Fio(2) of more than 20%.PP improves oxygenation in ARDS for 6 days with few complications.

Objective: All zone I retroperitoneal hematomas (Z1RPHs) identified at laparotomy for blunt trauma traditionally require exploration. The purpose of this study was to correlate patient outcome after blunt abdominal trauma with the presence of Z1RPH diagnosed on admission computed tomography (CT) scan. Methods: This is a retrospective review of patients with blunt trauma who were admitted to a Level 1 trauma center and who underwent CT scan during a 40-month period. All scans with a traumatic injury were reviewed to identify and grade Z1RPH as mild, moderate, or severe. Patients requiring operative treatment were compared with those who were observed. Statistical analysis was performed with Student's t test and chi-square test, with P 4 required operative treatment. Seventy-two percent of patients with more than 1 intra-abdominal injury required abdominal exploration. Conclusions: The presence of a moderate or severe Z1RPH and more than 1 intra-abdominal injury or an SVS >4 on admission CT scan is an important radiographic finding. This injury pattern should be considered a contraindication for nonoperative treatment of the associated solid organ injury. (Surgery 1999;126:608-15.)

Measuring patient work of breathing (WOBpt) has been suggested to provide safe, aggressive weaning from mechanical ventilation. We compared WOBpt and pressure-time-product (PTP) to routine weaning parameters [breath rate (f), tidal volume (VT), frequency/tidal volume ratio (f/VT)] at different levels of pressure support ventilation (PSV).Fifteen patients in the surgical intensive care unit requiring prolonged weaning (more than 3 days) were entered in the study. A balloon-tipped esophageal catheter was placed and position confirmed by inspection of pressure and flow waveforms. Each patient was randomly assigned to breathe with 5, 10, 15, and 20 cm H2O of PSV. After 30 minutes, 40 breaths were recorded and analyzed. Measurement of WOBpt PTP, f, VT, and f/VT were made using the Bicore CP-100 monitor. Mean values for each parameter were calculated. PTP and WOBpt were plotted against f/VT to determine correlation coefficient.PTP, WOBpt and f/VT decreased in a stepwise fashion as PSV was increased. The f/VT correlated most closely with WOBpt (r = 0.983) and PTP (r = 0.972). Monitoring f alone also correlated with WOBpt (r = 0.894) and PTP (r = 0.881). All patients were weaned from the ventilator (mean duration, 22 +/- 5.9 days). Nine patients required tracheostomy before final liberation from the ventilator (mean duration, 22 +/- 5.9 days). Nine patients required tracheostomy before final liberation from the ventilator.Direct measurement of WOBpt is invasive, expensive, and' may be confusing to clinicians. Monitoring f/VT may be useful when changing PSV during weaning.

Purpose Biliary dyskinesia (BD) is described as biliary colic in the absence of gallstones. The diagnosis relies on imaging studies and decreased excretion of bile in response to cholecystokinin during quantitative cholescintigraphy. The purpose of this study was to evaluate the success of laparoscopic cholecystectomy (LC) for relieving symptoms in patients diagnosed with BD and correlate gallbladder ejection fraction (EF) with symptom relief. Methods A retrospective review was performed at a single institution of all patients who underwent LC for BD from January 2005 through January 2012. The diagnosis of BD was determined by a normal gallbladder as viewed with ultrasonography and cholescintigraphy with a gallbladder EF less than or equal to 45%. Data collection included demographics, results of imaging studies, pathologic diagnosis, and early postoperative pain relief. Patients were contacted by phone after being discharged from the surgeon's care for evaluation of symptom relief. Data were analyzed with nonparametric statistical methods, including Mann–Whitney U test, receiver operator characteristic, Fisher exact test, and χ2 test. All data are expressed as median and 25th and 75th percentile range. Results There were 126 patients who had a LC for BD during the study period. The median biliary EF was 20% (10−29%). The most common pathologic finding was chronic cholecystitis (n = 95; 75%). Median length of follow-up in the perioperative period was 11 days (8−17), during which time 98 patients (78%) had relief of symptoms. Phone interviews (n = 53; 42%) confirmed 66% (n = 35) of patients remained free of pain. There was no difference in the mean EF among those with resolution of pain 20% (10−29%) compared with patients with persistent pain 23% (11−29%), P = .62. Obese patients were more likely to have persistent symptoms in the perioperative period with a shift to lower body mass index at the time of the phone survey. Receiver operator characteristic characteristic for the association between scintigraphic EF and resolution of postoperative pain demonstrated no association, with the area under the curve equal to 0.47. Conclusion The majority of patients in this series with BD had resolution of symptoms with LC. However, cholescintigraphy EF did not correlate with outcome. Further studies are needed to better identify patients diagnosed with BD who will benefit from LC.

Background The purpose of this study was to evaluate the current practice patterns and results for use of intraoperative cholangiogram (IOC) during laparoscopic cholecystectomy (LC). Methods We performed a retrospective review of all patients who underwent LC between January 1, 2005 and December 31, 2009. Data variables included: preoperative laboratory and radiographic studies, indication for and findings of IOC, and perioperative management of choledocholithiasis and retained common bile duct (CBD) stones. Results There were 1,308 patients who underwent LC by 23 surgeons, of whom 266 also had an IOC (20%) performed. The majority had ultrasonography performed, 242 had an abdominal compute tomography (CT) scan, and 129 patients had a hepatobiliary iminodiacetic acid (HIDA) scan. Indications for an IOC included: diagnosis of choledocholithiasis or gallstone pancreatitis ( n = 116), abnormal liver function tests ( n = 187), and a dilated CBD ≥10 mm ( n = 182). Of the 266 IOCs, 36 patients (13.5%) had a CBD stone with the majority ( n = 26; 72%) having normal preoperative imaging studies. Only 6 patients (17%) with a CBD calculi on IOC underwent successful clearance of the calculi at the time of LC. Twenty-nine of the remaining 30 patients with a retained calculus on IOC underwent postoperative endoscopic retrograde cholangiopancreatography (ERCP) with extraction of the calculi. Of the 1,042 LCs performed without an IOC, 31 patients (3%) were diagnosed with a retained stone managed successfully by ERCP. Conclusion Our data reveals that the selective use of IOC is helpful in diagnosing and clearing CBD calculi, that the use of preoperative CBD size aids in selecting patients for IOC, and that choledocholithiasis identified with IOC or after discharge can be managed successfully with ERCP.

Background . Recent reports have demonstrated an increase in the number of complications associated with delayed timing of fasciotomy for trauma. This study examines the effectiveness of early (less than 12 hours) versus late (more than 12 hours) fasciotomy in the injured extremity. Methods . This is a retrospective review of 88 patients undergoing fasciotomy for extremity trauma admitted to the University of Cincinnati from January 1990 through December 1995. Records were reviewed for demographics, compartment pressures, time and type of fasciotomy, complications, limb salvage, and mortality. Statistical analysis was determined with chi-squared, multivariant regression analysis, and Student's t test with significance at p less than 0.05. Results . Sixty-one (69%) patients had fasciotomy performed before 12 hours and twenty-seven (31%) after 12 hours. Although the rates of infection differed significantly between the two groups (7.3% for early versus 28% for late), the rates of limb salvage and neurologic sequelae were similar. Age, mechanism, shock, associated injuries, and time to fasciotomy were not predictive of complications. Conclusions . Fasciotomy for trauma is most efficacious when performed early. However, when performed late, it results in similar rates of limb salvage as compared with early fasciotomy but at the increased risk of infection. These results support aggressive use of fasciotomy in extremity trauma regardless of time of diagnosis.