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Objective: To evaluate the optimal timing of thromboprophylaxis (TPX) initiation after hepatic angioembolization in trauma patients. Background: TPX after hepatic trauma is complicated by the risk of bleeding, but the relative risk after hepatic angioembolization is unknown. Methods: Patients who underwent hepatic angioembolization within 24 hours were retrospectively identified from the 2017 to 2019 American College of Surgeons Trauma Quality Improvement Project data sets. Cases with <24-hour length of stay and other serious injuries were excluded. Venous thromboembolism (VTE) included deep venous thrombosis and PE. Bleeding complications included hepatic surgery, additional angioembolization, or blood transfusion after TPX initiation. Differences were tested with univariate and multivariate analyses. Results: Of 1550 patients, 1370 had initial angioembolization. Bleeding complications were higher in those with TPX initiation within 24 hours (20.0% vs 8.9%, P<0.001) and 48 hours (13.2% vs 8.4%, P=0.013). However, VTE was higher in those with TPX initiation after 48 hours (6.3% vs 3.3%, P= 0.025). In the 180 patients with hepatic surgery before angioembolization, bleeding complications were higher in those with TPX initiation within 24 hours (72% vs 20%, P <0.001), 48 hours (50% vs 17%, P<0.001), and 72 hours (37% vs 14%, P=0.001). Moreover, deep venous thrombosis was higher in those with TPX initiation after 96 hours (14.3% vs 3.1%, P = 0.023). Conclusions: This is the first study to address the timing of TPX after hepatic angioembolization in a national sample of trauma patients. For these patients, initiation of TPX at 48 to 72 hours achieves the safest balance in minimizing bleeding while reducing the risk of VTE. [ABSTRACT FROM AUTHOR]

Objective: Evaluate associations between volatile organic compounds (VOCs) in heat and moisture exchange (HME) filters and the presence of ventilator-associated pneumonia (VAP). Background: Clinical diagnostic criteria for VAP have poor interobserver reliability, and cultures are slow to result. Exhaled breath contains VOCs related to gram-negative bacterial proliferation, the most identified organisms in VAP. We hypothesized that exhaled VOCs on HME filters can predict nascent VAP in mechanically ventilated intensive care unit patients. Methods: Gas chromatography-mass spectrometry was used to analyze 111 HME filters from 12 intubated patients who developed VAP. Identities and relative amounts of VOCs were associated with dates of clinical suspicion and culture confirmation of VAP. Matched pairs t tests were performed to compare VOC abundances in HME filters collected within 3 days pre and postclinical suspicion of VAP (pneumonia days), versus outside of these days (nonpneumonia days). A receiver operating characteristic curve was generated to determine the diagnostic potential of VOCs. Results: Carbon disulfide, associated with the proliferation of certain gram-negative bacteria, was found in samples collected during pneumonia days for 11 of 12 patients. Carbon disulfide levels were significantly greater (P = 0.0163) for filters on pneumonia days. The Area Under the Curve of the Reciever Operating Characteristic curve (AUC ROC) for carbon disulfide was 0.649 (95% CI: 0.419-0.88). Conclusions: Carbon disulfide associated with gram-negative VAP can be identified on HME filters up to 3 days before the initial clinical suspicion, and approximately a week before culture confirmation. This suggests VOC sensors may have potential as an adjunctive method for early detection of VAP. [ABSTRACT FROM AUTHOR]

BACKGROUND: Our purpose was to conduct a bibliometric study investigating the prevalence of underpowered randomized controlled trials (RCTs) in trauma surgery. STUDY DESIGN: A medical librarian conducted a search of RCTs in trauma published from 2000 to 2021. Data extracted included study type, sample size calculation, and power analyses. Post hoc calculations were performed using a power of 80% and an alpha level of 0.05. A CONSORT checklist was then tabulated from each study as well as a fragility index for studies with statistical significance. RESULTS: In total 187 RCTs from multiple continents and 60 journals were examined. A total of 133 (71%) were found to have "positive" findings consistent with their hypothesis. When evaluating their methods, 51.3% of articles did not report how they calculated their intended sample size. Of those that did, 25 (27%) did not meet their target enrollment. When examining post hoc power, 46%, 57%, and 65% were adequately powered to detect small, medium, and large effect sizes, respectively. Only 11% of RCTs had complete adherence with CONSORT reporting guidelines and the average CONSORT score was 19 out of 25. For positive superiority trials with binary outcomes, the fragility index median (interquartile range) was 2 (2 to 8). CONCLUSIONS: A concerningly large proportion of recently published RCTs in trauma surgery do not report a priori sample size calculations, do not meet enrollment targets, and are not adequately powered to detect even large effect sizes. There exists opportunity for improvement of trauma surgery study design, conduct, and reporting. [ABSTRACT FROM AUTHOR]

Background: Necrotizing soft tissue infections (NSTIs) are rapidly spreading, life-threatening infections that require emergent surgical intervention with immediate antibiotic initiation. However, there is no consensus regarding duration of antibiotic therapy after source control. We hypothesized that a short course of antibiotic therapy is as effective as a long course of antibiotic therapy after final debridement for NSTI. Methods: A systematic review of the literature was performed using PubMed, Embase, and Cochrane Library from inception to November 2022. Observational studies comparing short (≤7 days) versus long (>7 days) antibiotic duration for NSTI were included. Primary outcome was mortality and secondary outcomes included limb amputation and Clostridium difficile infection (CDI). Cumulative analysis was performed with Fisher exact test. Meta-analysis was performed using a fixed effects model and heterogeneity was assessed using Higgins I2. Results: A total of 622 titles were screened and four observational studies evaluating 532 patients met inclusion criteria. Mean age was 52 years, 67% were male, 61% had Fournier gangrene. There was no difference in mortality when comparing short to long duration antibiotic agents on both cumulative analysis (5.6% vs. 4.0%; p = 0.51) and meta-analysis (relative risk, 0.9; 95% confidence interval, 0.8–1.0; I2 0; p = 0.19). There was no significant difference in rates of limb amputation (11% vs. 8.5%; p = 0.50) or CDI (20.8% vs. 13.3%; p = 0.14). Conclusions: Short duration antibiotic therapy may be as effective as longer duration antibiotic therapy for NSTI after source control. Further high-quality data such as randomized clinical trials are required to create evidence-based guidelines. [ABSTRACT FROM AUTHOR]

BACKGROUND: Operative reports are important documents; however, standards for critical elements of operative reports are general and often vague. Hernia surgery is one of the most common procedures performed by general surgeons, so the aim of this project was to develop a Delphi consensus on critical elements of a ventral hernia repair operative report. STUDY DESIGN: The Delphi method was used to establish consensus on key features of operative reports for ventral hernia repair. An expert panel was selected and questionnaires were distributed. The first round of voting was open-ended to allow participants to recommend what details should be included. For the second round the questionnaire was distributed with the items that did not have unanimous responses along with free text comments from the first round. RESULTS: Eighteen surgeons were approached, of which 11 completed both rounds. Twenty items were on the initial questionnaire, of which 11 had 100% agreement. Of the remaining 9 items, after the second questionnaire an additional 7 reached consensus. CONCLUSION: Ventral hernia repairs are a common and challenging problem and often require reoperations. Surgeons frequently refer to previous operative notes to guide future procedures, which requires detailed and comprehensive operative reports. This Delphi consensus was able to identify key components needed for an operative report describing ventral hernia repair. [ABSTRACT FROM AUTHOR]

Background: Use of robot-assisted surgery has increased dramatically since its advent in the 1980s, and nearly all surgical subspecialties have adopted it. However, whether it has advantages compared with laparoscopy or open surgery is unknown.Purpose: To assess the quality of evidence and outcomes of robot-assisted surgery compared with laparoscopy and open surgery in adults.Data Sources: PubMed, EMBASE, Scopus, and the Cochrane Central Register of Controlled Trials were searched from inception to April 2021.Study Selection: Randomized controlled trials that compared robot-assisted abdominopelvic surgery with laparoscopy, open surgery, or both.Data Extraction: Two reviewers independently extracted study data and risk of bias.Data Synthesis: A total of 50 studies with 4898 patients were included. Of the 39 studies that reported incidence of Clavien-Dindo complications, 4 (10%) showed fewer complications with robot-assisted surgery. The majority of studies showed no difference in intraoperative complications, conversion rates, and long-term outcomes. Overall, robot-assisted surgery had longer operative duration than laparoscopy, but no obvious difference was seen versus open surgery.Limitations: Heterogeneity was present among and within the included surgical subspecialties, which precluded meta-analysis. Several trials may not have been powered to assess relevant differences in outcomes.Conclusion: There is currently no clear advantage with existing robotic platforms, which are costly and increase operative duration. With refinement, competition, and cost reduction, future versions have the potential to improve clinical outcomes without the existing disadvantages.Primary Funding Source: None. (PROSPERO: CRD42020182027). [ABSTRACT FROM AUTHOR]

Background: Social media is a growing medium for disseminating information among surgeons. The International Hernia Collaboration Facebook Group (IHC) is a widely utilized social media platform to share ideas and advice on managing patients with hernia-related diseases. Our objective was to assess the safety and utility of advice provided.Methods: Overall, 60 consecutive de-identified clinical threads were extracted from the IHC in reverse chronological order. A group of three hernia specialists evaluated all threads for unsafe posts, unhelpful comments, and if an established evidence-based management strategy was provided. Positive and negative controls for safe and unsafe answers were included in seven threads and reviewers were blinded to their presence. Reviewers were free to access all online and professional resources (except the IHC).Results: There were 598 unique responses (median 10, 1-26 responses per thread) to the 60 clinical threads/scenarios. The review team correctly identified all seven positive and negative controls. Most responses were safe (96.6%) but some were unhelpful (28.4%). For sixteen threads, the reviewers believed there was an established evidence-based answer; however, only six were provided. In addition, 14 responses were considered unsafe, but only four were corrected.Conclusions: The vast majority of responses were considered helpful; however, evidence-based management is typically not provided and unsafe recommendations often go uncontested. While the IHC allows wide dissemination of hernia-related surgical advice/discussions, surgeons should be cautious when using the IHC for clinical advice. Mechanisms to provide evidence-based management strategies and to identify unsafe advice are needed to improve quality within online forums and to prevent patient harm. [ABSTRACT FROM AUTHOR]

Background: The percentage of female surgeons and surgery residents has increased slowly to 24% and 35%, respectively. However, women remain under-represented in surgical leadership positions (<20%). Society awards and leadership positions are used for hiring and promoting surgeons. We hypothesized that within the Surgical Infection Society (SIS), females are under-represented. Methods: The SIS website and databases were consulted for the number of female members, awardees, and leaders. Representation was divided into four time periods: 2000-2005, 2006-2010, 2011-2015, and 2016-2017 and compared for changes over time utilizing a Χ2 test. In addition, we reviewed the council members of five other surgical societies and compared the percentage of female representation in leadership positions. Results: Since the SIS was founded, there have been 587 members of whom only 135 (23%) are female. There has been an increase in female membership over time (p < 0.001). The number of female awardees rose from 37% during the first two study periods to more than 50% in the last two periods (p = 0.002). However, female representation in leadership positions decreased from 26% in 2000-2005 to less than 15% in the last three study periods (p = 0.234). Similar disparities emerged when comparing the SIS with other surgical societies: Women have represented only 24% (range 8%-42%) of leaders and 4% (range 0-11%) of society presidents. Conclusions: Female surgeons are under-represented in the SIS membership and leadership positions. Whereas the number of female surgeons and residents has increased, these trends have not occurred with council membership and leadership within the SIS. There is a need to address this gender disparity. [ABSTRACT FROM AUTHOR]

Background: Venous thromboembolism (VTE) remains a major source of morbidity and mortality in severely injured patients despite current methods of risk stratification and prophylaxis, suggesting incomplete understanding of VTE risk factors. Given the liver's role in coagulation, we hypothesized that liver injury (LI) is associated with increased rates of VTE in severely injured patients., Study Design: The American College of Surgeons Trauma Quality Improvement Project database (TQIP) 2017-2021 was retrospectively reviewed for patients with a maximum abdominal Abbreviated Injury Score (AIS) ≥ 4 with or without LI. Transfers, burns, all deaths, and patients < 18 years of age were excluded. Logistic regression was performed to assess the independent effect of LI on development of pulmonary embolism (PE) and deep venous thrombosis (DVT) while controlling for potential confounding variables., Results: In 44,506 patients, there were 1,736 (3.9%) 890 (2.0%), and 18,642 patients (41.9%) with DVT, PE, and LI, respectively. After controlling for potential confounders, LI was independently associated with PE (aOR 1.279 [95% CI 1.088-1.504]) but was not associated with DVT (aOR 1.011 [95% CI 0.897-1.140])., Conclusion: In severely injured patients, LI is an independent predictor of PE, but not DVT, suggesting LI is the source of either emboli or a more complex locally prothrombotic focus leading to downstream thrombi in the lung without causing upstream systemic venous thrombi. Further work should focus on elucidation of mechanisms including the portal venous blood coagulation profile, endothelial injury in the liver, and the potential for stasis of venous blood traversing an injured liver as well as the role for including LI in VTE risk stratification., (Copyright © 2025 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Falls account for nearly ¾ of all trauma in the geriatric population. We hypothesized that history and physical could reliably identify elderly patients with ground-level falls (GLF) who require head and cervical spine imaging., Materials and Methods: Patients of age >65 y with GLF from January, 2018 to December, 2021 at a level 1 trauma center were retrospectively reviewed. Falls from height, transfers, and presentation >48 h post injury were excluded. Primary outcome was head or cervical spine injury defined by (+) computed axial tomography (CT). Data were compared with univariate and multivariate analyses at P < 0.05., Results: In 825 patients, 275 (33%) were on home anticoagulation or antiplatelet agents, half (51%) were considered frail, and most had at least one comorbidity prior to arrival. In 645 (79%) with a head CT, 174 (27%) were (+) and 20 (11%) required surgical intervention. Head CT changes were associated with male gender, Glasgow Coma Scale (GCS) score < 15, external signs of head injury, and headache, but not pre-existing anticoagulation. In 536 (65%) with cervical spine CT, 32 (6%) were (+) and 5 (17%) required surgery. Only neck symptoms were associated with (+) cervical spine injury., Conclusions: In geriatric GLF, normal GCS score with no external signs of head trauma or headache indicates a low likelihood of head injury regardless of pre-existing anticoagulation. Similarly, the absence of neck symptoms suggests a low likelihood of cervical spine injury. Thus, history and physical are reliable in the workup of head and cervical spine injuries after geriatric GLF., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: As air travel and immobility are risk factors for venous thromboembolism, we aimed to test the hypothesis that internationally transferred trauma patients have a high incidence of venous thromboembolism on arrival., Methods: A prospectively maintained registry of all international transferred trauma patients who presented to our level I trauma center from January 2023 to June 2024 was retrospectively reviewed. Patients with either lower extremity venous duplex ultrasound or computed tomography scan of the chest with contrast on arrival were included. The primary outcome was venous thromboembolism, either deep venous thrombosis or pulmonary embolism., Results: There were 161 consecutive internationally transferred trauma patients; 93% had a screening venous duplex ultrasound on arrival, and 52% had a computed tomography scan of the chest with contrast. Average time from injury to arrival was 3.3 ± 4.3 days. Of those who had screening imaging, 6% had a deep venous thrombosis and 8.3% had a pulmonary embolism. Average Greenfield risk assessment profile was greater for those with than without deep venous thrombosis (10 vs 8, P = .024) and pulmonary embolism (12 vs 8, P = .001). There was no difference in days from injury or flight time for those with or without deep venous thrombosis or for those with or without pulmonary embolism., Conclusion: To our knowledge, this is the first study to demonstrate a 6-8% incidence of venous thromboembolism on arrival in international transfer trauma patients. New protocols should include risk stratification for early thromboprophylaxis in transferring centers and screening admission venous duplex ultrasound and computed tomography scan of the chest at receiving centers., Competing Interests: Conflict of Interest/Disclosure The authors have no related conflicts of interest to declare., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: Pediatric lower extremity vascular injuries (LEVI) are rare but can result in significant morbidity. We aimed to describe our experience with these injuries, including associated injury patterns, diagnostic and therapeutic challenges, and outcomes., Methods: This was a retrospective review at a single level 1 trauma center from January 2000 to December 2019. Patients less than 18 years of age with LEVI were included. Demographics, injury patterns, clinical status at presentation, and intensive care unit (ICU) and hospital length of stay (LOS) were collected. Surgical data were extracted from patient charts., Results: 4,929 pediatric trauma patients presented during the 20-year period, of which 53 patients (1.1%) sustained LEVI. The mean age of patients was 15 years (range 1-17 years), the majority were Black (68%), male (96%), and most injuries were from a gunshot wound (62%). The median Glasgow Coma Scale score was 15, and the median Injury Severity Score was 12. The most commonly injured arteries were the superficial femoral artery (28%) and popliteal artery (28%). Hard signs of vascular injury were observed in 72% of patients and 87% required operative exploration. There were 36 arterial injuries, 36% of which were repaired with a reverse saphenous vein graft and 36% were repaired with polytetrafluoroethylene graft. One patient required amputation. Median ICU LOS was three days and median hospital LOS was 15 days. There were four mortalities., Conclusion: Pediatric LEVIs are rare and can result in significant morbidity. Surgical principles for pediatric vascular injuries are similar to those applied to adults, and this subset of patients can be safely managed in a tertiary specialized center., Level of Evidence: Level IV, retrospective study., Competing Interests: Competing interests: JPM receives research support from Takeda Pharmaceuticals. NN has received consulting fees from Merck Sharp and Dohme. CMT received funding from Bolder Surgical., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: During minimally invasive ventral hernia repair (VHR) it is unknown if a fascial defect closure, as opposed to a bridged repair (current care), is beneficial for patients. We sought to systematically review the published literature on the role of fascial defect closure during minimally invasive VHR., Methods: PubMed, Embase, Scopus, Cochrane, and Clinicaltrials.gov were reviewed for randomized controlled trials (RCTs) that compared fascial defect closure with bridged repair. The primary outcome was major complications defined as deep/organ-space surgical site infections (SSIs), reoperations, hernia recurrences, or deaths. Secondary outcomes included SSI, seroma, eventration, hernia recurrence, post-operative pain, and quality of life (QOL). Pooled risk ratios with 95% confidence intervals were obtained through random effect meta-analyses., Results: Of 579 screened articles, 6 publications of 5 RCTs were included. No significant difference in major complications (10.6% vs 10.4%, RR=1.05, 95% CI=0.51-2.14, P =.90) or recurrences (9.0% vs 10.6%, RR=0.92, 95% CI=0.32-2.61, P =.87) were found between groups. Fascial defect closure decreased the risk of seromas (22.9% vs 34.2%, RR=0.60, 95% CI=0.37-0.97, P =.04) and may decrease the risk of eventrations (6.7% vs 9.0%, RR=0.74, 95% CI=0.37-1.50, P =.41) at the expense of potentially increasing the risk of SSI (3.2% vs 1.4%, RR=1.89, 95% CI=0.60-5.93; P =.28). Reporting of pain and QOL scores was inconsistent., Conclusion: While most individual RCTs demonstrated benefit with fascial defect closure during minimally invasive VHR, our meta-analysis of fascial defect closure demonstrated only a statistically significant difference in seromas compared to bridged repair. Large, multi-center RCTs are needed., Competing Interests: Conflicts of Interest The authors declare they have no conflicts of interest., (© 2023 HCA Physician Services, Inc. d/b/a Emerald Medical Education.)