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Background: The direct association between procedure risk and outcomes in elderly patients who undergo emergency general surgery (EGS) has not been analyzed. Studies only highlight the importance of frailty. A comprehensive analysis of relevant risk factors and their association with outcomes in elderly patients who undergo EGS is lacking. We hypothesized that procedure risk has a stronger association with relevant outcomes in elderly patients who undergo EGS compared with frailty., Study Design: Elderly patients (age >65 years) undergoing EGS operative procedures were identified in the NSQIP database (2018 to 2020) and stratified based on the presence of frailty calculated by the Modified 5-Item Frailty Index (mFI-5; mFI 0 nonfrail, mFI 1 to 2 frail, and mFI ≥3 severely frail) and based on procedure risk. Multivariable regression models and receiving operative curve analysis were used to determine risk factors associated with outcomes., Results: A total of 59,633 elderly patients who underwent EGS were classified into nonfrail (17,496; 29.3%), frail (39,588; 66.4%), and severely frail (2,549; 4.3%). There were 25,157 patients in the low-risk procedure group and 34,476 in the high-risk group. Frailty and procedure risk were associated with increased mortality, complications, failure to rescue, and readmissions. Differences in outcomes were greater when patients were stratified according to procedure risk compared with frailty stratification alone. Procedure risk had a stronger association with relevant outcomes in elderly patients who underwent EGS compared with frailty., Conclusions: Assessing frailty in the population of elderly patients who undergo EGS without adjusting for the type of procedure or procedure risk ultimately presents an incomplete representation of how frailty impacts patient-related outcomes., (Copyright © 2024 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: The use of Zone 1 REBOA for life-threatening trauma has increased dramatically., Study Design: The Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database was queried for blunt and penetrating trauma between 2013 and 2021. Outcomes were examined both for mechanisms of injury combined and separately and for combinations of abdominal injury with and without traumatic brain injury and chest injuries (Abbreviated Injury Scale [AIS] score >2)., Results: A total of 531 patients underwent REBOA (408 with blunt injury and 123 with penetrating injury) and 1,603 (595 with blunt injury and 1,008 with penetrating injury) underwent resuscitative thoracotomy (RT). Mean age was 38.5 ± 16 years and mean injury severity score was 34.5 ± 21; 57.7% had chest AIS score of more than 2, 21.8% had head AIS score of more than 2, and 37.3% had abdominal AIS score of more than 2. Admission Glasgow Coma Scale was 4.9 + 4, and systolic blood pressure at aortic occlusion (AO) was 22 + 40 mmHg. No differences in outcomes in REBOA or RT patients were identified between institutions (p > 0.5). After inverse probability weighting, Glasgow Coma Scale, age, injury severity score, systolic blood pressure at AO, CPR at AO, and blood product transfusion, REBOA was superior to RT in both blunt (odds ratio [OR] 4.7, 95% CI 1.9 to 11.7) and penetrating (OR 4.9, 95% CI 1.7 to 14) injuries, across all spectrums of injury (p < 0.01). Overall mortality was significantly higher for AO more than 90 minutes compared with less than 30 minutes in blunt (OR 4.6, 95% CI 1.5 to 15) and penetrating (OR 5.4, 95% CI 1.1 to 25) injuries. Duration of AO more than 60 minutes was significantly associated with mortality after penetrating abdominal injury (OR 5.1, 95% CI 1.1 to 22) and abdomen and head (OR 5.3, 95% CI 1.6 to 18)., Conclusions: In-hospital survival is higher for patients undergoing REBOA than RT for all injury patterns. Complete AO by REBOA or RT should be limited to less than 30 minutes. Neither hospital and procedure volume nor trauma verification level impacts outcomes for REBOA or RT., (Copyright © 2023 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Intimate partner violence (IPV) is a significant cause of injury, and in pregnant patients (PIPV) poses a risk to both mother and fetus. Characteristics and outcomes for PIPV patients have not been well described. We hypothesize that PIPV patients have higher admission rates and mortality than non-IPV pregnant trauma (PT) patients and nonpregnant female IPV patients of childbearing age. We also hypothesize differences exist between PIPV and PT patient injury patterns, allowing for targeted IPV screening., Study Design: The Nationwide Emergency Department Sample database was queried from 2010 to 2014 to identify IPV in adult women patients by injury code E967.3. Patients were compared in 2 ways, PIPV vs PT and PIPV vs nonpregnant female IPV patients. Demographics, injury mechanisms, and National Trauma Data Standard injury diagnoses were surveyed. Primary outcomes were hospital admissions and mortality. Logistic regression was used to estimate risk factors of the outcomes of hospitalization and IPV victimization in pregnant injured patients., Results: There were 556 PIPV patients, 73,970 PT patients, and 56,543 nonpregnant female IPV patients. When comparing PIPV to PT, more PIPV patients had Medicaid coverage or were self-pay. Suffocation, head injuries, face/neck/scalp contusions, multiple contusions, and abrasions/friction burns were more prevalent in PIPV patients. Mortality and hospital admissions were scarce among all cohorts. Predictors of IPV victimization among injured pregnant patients include multiple injuries, head injuries, face/neck/scalp contusions, abrasions/friction burns, contusions of multiple sites, and those with Medicaid or self-pay coverage., Conclusions: Among injured pregnant patients, those with multiple injuries, head injuries, contusions of the face/neck/scalp, abrasions/friction burns, and multiple contusions should undergo IPV screening. Admissions and mortality are low; therefore, prevention measures should be implemented in the emergency department to reduce repeat victimization., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Emergency general surgery (EGS) accounts for 11% of hospital admissions, with more than 3 million admissions per year and more than 50% of operative mortality in the US. Recent research into EGS has ignited multiple quality improvement initiatives, and the process of developing national standards and verification in EGS has been initiated. Such programs for quality improvement in EGS include registry formation, protocol and standards creation, evidenced-based protocols, disease-specific protocol implementation, regional collaboratives, targeting of high-risk procedures such as exploratory laparotomy, focus on special populations like geriatrics, and targeting improvements in high opportunity outcomes such as failure to rescue. The authors present a collective narrative review of advances in quality improvement structure in EGS in recent years and summarize plans for a national EGS registry and American College of Surgeons verification for this under-resourced area of surgery., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: The impact of cirrhosis on outcomes of acute colonic diverticulitis (ACD) has been studied infrequently. We investigated the effect of cirrhosis on outcomes of surgical patients with ACD treated by either an open or laparoscopic approach., Methods: A cross-sectional study was performed using the Nationwide Inpatient Sample 2012 to 2014. Patients with ACD were stratified into compensated and decompensated cirrhosis for comparisons of demographic characteristics, hospital length of stay, complications, mortality, and cost. Groups were stratified according to surgical treatment: open colectomy and laparoscopic colectomy. A comparative effectiveness analysis of outcomes was performed between the 2 surgical treatments. Univariate comparisons between groups and multivariate regression analysis were performed to identify risk factors for mortality and specific complications., Results: Of 1,172,875 patients hospitalized with the diagnosis of ACD during the study period, 1,145 were cirrhotic. The majority were male (59%). There were 660 compensated cirrhotic patients and 485 decompensated cirrhotic patients and all underwent either open (n = 875) or laparoscopic colectomy (n = 270). Consistently, marked increases in mortality, hospital length of stay, and cost were observed in decompensated cirrhotic patients regardless of the type of treatment. Laparoscopic colectomy was accompanied by shorter hospital length of stay, lower costs, and significantly decreased mortality rate compared with open colectomy in compensated and decompensated cirrhotic patients., Conclusions: The presence of cirrhosis markedly impacts outcomes in patients with ACD, leading to prolonged hospitalization, higher cost, and increased complications and deaths. Laparoscopic colectomy is associated with better outcomes in patients requiring surgical management, including those with decompensated cirrhosis., (Copyright © 2020 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Ligation can be used as part of damage-control operations under critical conditions after IVC injury. Inferior vena cava ligation could potentially yield greater survival benefit compared with repair after injury. We hypothesized that ligation significantly improves outcomes compared with repair., Study Design: The National Trauma Data Bank dataset for 2007-2014 was reviewed. Eligible patients included those sustaining IVC injury who underwent surgical ligation or repair. Data on demographics, outcomes, and complications were collected. Comparative analysis of demographic characteristics, complications and outcomes were performed., Results: There were 4,865 patients identified in the National Trauma Data Bank with IVC injury. A total of 1,316 patients met inclusion criteria. Four hundred and forty-seven patients (34.0%) underwent ligation and 869 (66.0%) underwent repair. Before matching, the ligation group was sicker than the repair group and the in-hospital mortality was significantly higher in the ligation group (43.8% vs 36.2%; odds ratio [OR] 1.37; 95% CI 1.09 to 1.73). One to one propensity score matching generated 310 pairs. After propensity score matching, in-hospital mortality was similar (41.3% vs 39.0%; OR 1.10; 95% CI 0.80 to 1.52). However, IVC ligation was associated with significantly higher complication rates of extremity compartment syndrome (OR 5.23; 95% CI 1.50 to 18.24), pneumonia (OR 1.76; 95% CI 1.08 to 2.86), deep venous thrombosis (OR 2.83 95% CI 1.70 to 4.73), pulmonary embolism (OR 3.63; 95% CI 1.18 to 11.17), and longer hospital length of stay (17.0 days [interquartile range 1.0 to 35.0 days] vs 9.0 days [interquartile range 1.0 to 22.0 days]; p = 0.002)., Conclusions: Inferior vena cava ligation is not superior to repair in terms of decreasing mortality in patients with IVC injury, but it is associated with higher complication rates and hospital LOS., (Copyright © 2018 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: A recent prospective, multicenter, randomized controlled trial found that 4 days of antibiotics after source control of complicated intra-abdominal infections resulted in similar outcomes when compared with longer duration. We hypothesized that the subset of patients presenting with sepsis have similar outcomes when treated with the shorter course of antibiotics., Study Design: Patients from the STOP-IT (Study to Optimize Peritoneal Infection Therapy) trial database meeting criteria for sepsis (ie, temperature <36°C or >38°C and a WBC count <4000 cells/mm(3) or >12,000 cells/mm(3)) were analyzed. Patients had been randomized to receive antibiotics until 2 days after the resolution of fever, leukocytosis, and ileus, with a maximum of 10 calendar days of therapy (n = 45), or to receive a fixed short-course of antibiotics for 4 ± 1 calendar days (n = 67). Outcomes included incidence of and time to surgical site infection, recurrent intra-abdominal infection, Clostridium difficile infection, and extra-abdominal infections, as well as hospital days and mortality., Results: One hundred and twelve of the 588 patients in the STOP-IT database met criteria for sepsis and were adherent to the protocol. With regard to short- vs long-course therapy, surgical site infection (11.9% vs 8.9%; p = 0.759), recurrent intra-abdominal infection (11.9% vs 13.3%; p = 1.00), extra-abdominal infection (11.9% vs 8.9%; p = 0.759), hospital days (7.4 ± 5.5 days vs 9.0 ± 7.5 days; p = 0.188), days to recurrent intra-abdominal infection (12.5 ± 6.6 days vs 18.0 ± 8.1 days; p = 0.185), days to extra-abdominal infection (12.6 ± 5.8 days vs 17.3 ± 3.9 days; p = 0.194), and mortality (1.5% vs 0%; p = 1.00) were similar. There were no cases of C difficile infection. Days to surgical site infection (6.9 ± 3.5 days vs 21.3 ± 6.1 days; p < 0.001) were fewer in the 4-day therapy group., Conclusions: There was no difference in outcomes between short and long-course antimicrobial therapy in patients with complicated intra-abdominal infection presenting with sepsis. Our findings suggest that the presence of systemic illness does not mandate a longer antimicrobial course if source control of complicated intra-abdominal infection is obtained., (Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Intestinal ischemia and reperfusion injury results in damage to elements critical to maintaining intestinal barrier function, including neurons and glia cells, which are part of the enteric nervous system (ENS). To limit inflammation, the ENS must be restored or replaced, yet the process by which this occurs is poorly understood. Multipotent progenitor cells called enteric nervous stem cells (ENSC) can differentiate into neurons or glia when stimulated. The ability of this cell population to respond to intestinal injury is unknown. In this study, we hypothesized that resolution of intestinal barrier injury would be associated with vagus nerve-mediated expansion of ENSCs., Study Design: Ischemia and reperfusion injury was reproduced in male mice by occluding the superior mesenteric artery for 30 minutes. Abdominal vagotomy was performed in a separate cohort to study the effects of the vagus nerve. Terminal ileum was harvested at various time points after reperfusion and analyzed with histology, flow cytometry, and immunohistochemistry., Results: Enteric nervous stem cell expansion occurs at 2, 4, and 8 hours after injury compared with sham (4.6% vs 2.1%; p < 0.001) and correlated with increased glial fibrillary acidic protein on immunohistochemistry. Vagotomy prevented both ENSC expansion and increased glial fibrillary acidic protein staining after injury. Intestinal permeability was restored to baseline by 48 hours after injury, but remained elevated in the vagotomy group compared with sham and injury alone at 48 hours (3.25 mg/mL vs 0.57 mg/mL and 0.26 mg/mL, respectively; p < 0.05)., Conclusions: Vagal-mediated expansion of ENSCs occurs after ischemia and reperfusion injury and results in improved kinetics of injury resolution., (Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: There is a paucity of information about the frequency and timing of reversal after stoma creation for trauma. In addition, the barriers to reversal faced by those patients are largely unknown. We hypothesize that the rate of stoma creation and reversal are low among trauma patients. Additionally, we sought to identify patient-related barriers to stoma reversal., Study Design: Analysis of the California Office of Statewide Health Planning and Development patient database, 1995-2010. Inclusion criteria were all trauma patients with hollow viscus injury. Exclusion criteria were presence of a stoma at the time of injury or death within 48 hours of admission. Patient characteristics studied included age, sex, race, Survival Risk Ratio, Charlson Comorbidity Index, and insurance status. Kaplan-Meier, logistic regression, and Cox proportional hazard analysis were performed to identify predictors of immediate and eventual reversal., Results: A total of 35,346 patients had hollow viscus injury, 3,899 resulted in stoma creation; 249 (6.4%) were reversed during their initial hospitalization. After discharge, 41% of patients were reversed at 6 months, 61% at 1 year, and 72% at 5 years. Stoma reversals occurred at a different hospital from the initial admission 57.1% of the time. Black race was a significant predictor for stoma reversal during the initial hospitalization. After the initial admission, having insurance increased the likelihood of reversal significantly; however, those of black and Hispanic race had a decreased rate., Conclusions: The stoma reversal rate appears to be higher than we hypothesized; this is most likely due to the high rate of patient migration between hospitals. The factors that posed substantial barriers to reversal after initial admission were lack of health insurance and black and Hispanic race/ethnicity., (Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: A significant increase in industry support of professional medical associations coupled with data suggesting that gifts from industry have significant clinical influence have prompted calls from the Institute of Medicine and physician leaders to identify and manage conflicts of interest that stem from financial support of professional medical associations by industry., Study Design: A joint task force of members appointed by the Association for Academic Surgery and the Society of University Surgeons was convened in July 2009. Recommendations were developed regarding management of all potential conflicts of interest that can arise within the context of an academic surgical society, with specific focus on relationships with industry. Task force members reached consensus around each recommendation and the guidelines were subsequently adopted by the Executive Councils of both societies., Results: The committee identified 4 primary areas of need for transparent and definitive management of conflict of interest: 1) individual society activities, including general budget support, society endorsements, and journal affiliation; 2) individual personnel conflicts such as society leadership and standards for disclosure of conflict; 3) meeting activities including budgetary support, program committee associations, and abstract review process; and 4) foundation support and research and travel awards. The resulting guidelines aim to protect the societies and their membership from undue bias that may undermine the credibility and mission of these associations., Conclusions: Policy guidelines to mitigate conflict of interest are necessary to protect the integrity of the work of academic surgical societies and their fiduciary duty to members and patients. Guidelines created and adopted by the Association for Academic Surgery and Society of University Surgeons form an effective model for academic surgical societies and their members., (Copyright © 2011 American College of Surgeons. All rights reserved.)

Background: The concept of surgery and public health has been introduced in recent years, highlighting the impact of surgeons on improving public health outcomes, a relationship that has traditionally been ascribed to general practitioners. The purpose of this study is to quantify the effect of surgeon availability on deaths from motor vehicle crashes (MVC)., Study Design: Retrospective analysis of the Area Resource File from 2006 was performed. The primary outcome variable was the three-year (2001-2003) average in MVC deaths per 1 million population for each county. The primary independent variable was the density of surgeons per 1 million population in year 2003. Multiple linear regression analysis was performed, adjusting for density of general practitioners, urbanicity of the county, and socioeconomic status of the county., Results: A total of 3,225 counties were analyzed. The median number of MVC deaths per million population was 226 (IQR 158-320). The median number of surgeon per million population was 55 (IQR 0-105), while the median number of general practitioners per million population was 424 (IQR 274-620). On unadjusted analysis, each increase of one surgeon per million population was associated with 0.38 fewer MVC deaths per million population (p < 0.001). On multivariate analysis, each increase of one surgeon per million population was significantly associated with 0.16 fewer MVC deaths per million population (p < 0.001). Rural location, persistent poverty, and low educational level were all associated with significant increases in MVC deaths., Conclusions: Higher density of surgeons is associated with significant reduction in deaths from MVCs. This highlights the need for 1) consideration of surgery as primary care and 2) development of inclusive surgical systems designed to provide care commensurate with patients' degree of injury., (Copyright © 2011 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Trauma is the leading cause of death among North Americans between the ages of 1 and 44 years. Resuscitation with hypertonic saline (7.5%) solutions can reduce mortality in hypotensive and brain-injured patients., Study Design: Two multicenter, randomized, clinical trials were designed to compare hypertonic saline resuscitation with or without dextran with conventional isotonic resuscitation in patients with hypovolemic shock or traumatic brain injury. During a 3-year period, 5,848 patients will be randomized, with a primary end point of 28-day survival in the hypovolemic shock cohort and 6-month neurologic outcomes in the traumatic brain injury cohort., Results: This is a report of the study design and implementation of 2 large-scale prehospital intervention trials from the Resuscitation Outcomes Consortium that qualify for exception from informed consent required for emergency research outlined in FDA regulation 21CFR50.24 and the Canadian Tri-Council Agreement for research in emergency health situations (Article 2.8)., Conclusions: We have successfully designed and implemented two prehospital intervention trials. The proc-ess has helped define the numerous challenges that must be overcome to pursue exception from informed consent resuscitation research in the prehospital setting. The results of these studies will hopefully advance and improve the early care of the severely injured patient.

Background: Activated neutrophils play a central role in the pathogenesis of ARDS and multiple organ failure (MOF). Transfusion of packed red blood cells (PRBCs) is an independent risk factor in the development of ARDS and MOF. It has been postulated that factors present in the supernatant of PRBCs activate neutrophils. The magnitude of neutrophil activation is dependent on the age of the stored blood. Our laboratory and others have reported that pentoxifylline (PTX), a nonspecific phosphodiesterase inhibitor, decreases neutrophil activation. We hypothesized that adding PTX to PRBCs would attenuate blood transfusion-induced neutrophil activation., Study Design: Peripheral blood was obtained from healthy human volunteers. Oxidative burst, CD11b, and CD35 expression were measured by flow cytometry using a whole blood preparation. Whole blood was incubated with N-formyl-methionyl-leucyl-phenylalanine (fMLP) (1 microM) alone and 42-day-old PRBC supernatant + fMLP with or without PTX (2 mmol/L)., Results: N-formyl-methionyl-leucyl-phenylalanine alone caused a significant increase in neutrophil oxidative burst (100%). The exposure of whole blood to PRBC supernatants + fMLP led to a 1.3-fold increase in neutrophil oxidative burst as compared with fMLP alone, indicating that PRBC supernatants prime neutrophils for oxidative burst by 75%. More importantly, PTX decreased neutrophil oxidative burst by 114% in supernatant + fMLP-stimulated whole blood (p < 0.001). PTX decreased CD11b expression in both fMLP (p < 0.01) and fMLP+supernatant-stimulated whole blood (p < 0.05). Supernatant from PRBCs did not have an additive effect to fMLP alone on CD11b expression. N-formyl-methionyl-leucyl-phenylalanine-induced CD35 expression was downregulated by PTX. The addition of PRBC supernatant did not increase the already upregulated fMLP-induced CD35 expression., Conclusions: Our results suggest that adding PTX to PRBC supernatant markedly decreases neutrophil activation. The lack of successful treatment strategies to effectively modulate the inflammatory response after blood transfusion indicates the need for novel therapies. Because the deleterious effects of blood transfusion on end-organ injury and MOF are associated with neutrophil activation, the adjunct use of PTX to blood transfusion may have therapeutic potential.