Search

Background Perforated peptic ulcer is a morbid emergency general surgery condition. Best practices for postoperative care remain undefined. Surgical dogma preaches practices such as peritoneal drain placement, prolonged nil per os, and routine postoperative enteral contrast imaging despite a lack of evidence. We aimed to evaluate the role of postoperative enteral contrast imaging in postoperative perforated peptic ulcer care. Our primary objective was to assess effects of routine postoperative enteral contrast imaging on early detection of clinically significant leaks. Methods We conducted a multicenter retrospective cohort study of patients who underwent repair of perforated peptic ulcer between July 2016 and June 2018. We compared outcomes between those who underwent routine postoperative enteral contrast imaging and those who did not. Results Our analysis included 95 patients who underwent primary/omental patch repair. The mean age was 60 years, and 54% were male. Thirteen (14%) had a leak. Eighty percent of patients had a drain placed. Nine patients had leaks diagnosed based on bilious drain output without routine postoperative enteral contrast imaging. Use of routine postoperative enteral contrast imaging varied significantly between institutions (30%–87%). Two late leaks after initial normal postoperative enteral contrast imaging were confirmed by imaging after a clinical change triggered the second study. Two patients had contained leaks identified by routine postoperative enteral contrast imaging but remained clinically well. Duration of hospital stay was longer in those who received routine postoperative enteral contrast imaging (12 vs 6 days, median; P = .000). Conclusion Routine postoperative enteral contrast imaging after perforated peptic ulcer repair likely does not improve the detection of clinically significant leaks and is associated with increased duration of hospital stay.

The American Board of Surgery In-Training Examination (ABSITE) is an annual exam taken by general surgery residents as a cognitive assessment of the knowledge gained throughout each year of training. Several question banks are available for ABSITE preparation. However, ABSITE Quest (AQ) utilizes a method called spaced education which has been demonstrated to help with retaining information longer and improve exam performance. This study hypothesizes that using this method will help residents improve their ABSITE performance.Retrospective survey data was collected from residents who participated in AQ, including postgraduate year (PGY) level, as well as 2019 and 2020 ABSITE percentiles. AQ user data was used to match respondent's total number of questions completed and daily engagement level to the survey data. Paired, single-tailed student's t test was used to evaluate the significance of ABSITE percentile change between 2019 and 2020 among AQ users.ChristianaCare, Newark, DE, United States. Nonclinical.All ABSITE Quest users were surveyed (n = 390), of which 104 responded. 21 responses were from PGY1 residents and were excluded, resulting in a total of 83 responses.The mean percentile difference of AQ users from 2019 to 2020 was +15.8 (p0.00001). When categorizing by the total number of questions completed, high users demonstrated a mean percentile difference of +15.3 (p = 0.00002), average users had a difference of +19.1 (p = 0.00029), and low users showed a percentile difference of +1.2 (p = 0.45244). When categorizing by daily engagement level, high users demonstrated a mean percentile difference of +17.9 (p0.00001), low users had a mean percentile difference of +15.3 (p = 0.00124), and minimal users showed a mean percentile change of -5.7.The use of the spaced education method with ABSITE Quest, especially in users with a greater number of questions completed and high levels of daily engagement, correlated with a significant improvement on ABSITE performance.

To determine if there is a significant association between administration of tranexamic acid (TXA) in severely bleeding, injured patients, and venous thromboembolism (VTE), myocardial infarction (MI), or cerebrovascular accident (CVA). A multicenter, retrospective study was performed. Inclusion criteria were: age 18-80 years old and need for 5 units or more of blood in the first 24 h after injury. Exclusion criteria included: death within 24 h, pregnancy, administration of TXA more than 3 h following injury, and routine ultrasound surveillance for deep venous thrombosis. Incidence of VTE was the primary outcome. Secondary outcomes included MI, CVA, and death. A power analysis found that a total of 830 patients were needed to detect a true difference in VTE risk. 1333 patients (TXA = 887, No-TXA = 446 patients) from 17 centers were enrolled. There were no differences in age, shock index, Glasgow coma score, pelvis/extremity abbreviated injury score, or paralysis. Injury severity score was higher in the No-TXA group. Incidence of VTE, MI, or CVA was similar between the groups. The TXA group required significantly less transfusion (P < 0.001 for all products) and had a lower mortality [adjusted odds ratio 0.67 (95% confidence interval 0.45-0.98)]. Despite having a higher extremity/pelvis abbreviated injury score, results did not change when evaluating only patients with blunt injury. Use of TXA in bleeding, injured patients is not associated with VTE, MI, or CVA but is associated with a lower transfusion need and mortality.

The incidence of patients with trauma on novel oral anticoagulants (NOACs) for the treatment of thromboembolic disorders is increasing. In severe bleeding or hemorrhage into critical spaces, urgent reversal of this underlying pharmacologic coagulopathy becomes paramount. Optimal reversal strategy for commonly used NOACs is still evolving. Basic tenets of evaluation of patients with trauma and resuscitation remain the same. Clinical outcomes data in bleeding human patients with trauma are lacking, but are needed to establish efficacy and safety in these treatments. This article summarizes the available evidence and provides the optimal reversal strategy for bleeding patients with trauma on NOACs.