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Background: Frailty is a known risk factor for adverse outcomes following surgery and affects at least 3 of every 10 US Veterans aged 65 years and older. We designed a study to characterize the association between frailty and complications after endovascular aneurysm repair (EVAR) compared to open aneurysm repair (OAR) at our regional Veterans Affairs Medical Center., Methods: Veterans who underwent either OAR or EVAR at our institution between January 1, 2000 and December 31, 2020 were identified. We examined medical history, procedure characteristics, perioperative complications, and frailty as measured by the 5-factor modified frailty index (mFI-5). Frailty was defined as an mFI-5 score ≥2. Primary endpoints were postoperative complications, duration of surgery, and length of hospital stay. Tests of association were performed with t-test and chi-squared analysis., Results: Over the 21-year period, we identified 314 patients that underwent abdominal aortic aneurysm (AAA) repair with 115 (36.6%) OAR and 199 EVAR (63.4%) procedures. Patients undergoing EVAR were older on average (72.1 years vs. 70.2 years) and had a higher average mFI-5 compared to the open repair group (1.49 vs. 1.23, P = 0.036). When comparing EVAR and OAR cohorts, patients undergoing OAR had a larger AAA diameter (6.5 cm, standard deviation [SD]: 1.5) compared to EVAR (5.5 cm, SD: 1.1 P < 0.0001). Fewer frail patients underwent OAR (n = 40, 34.8%) compared to EVAR (n = 86, 43.2%), and frail EVAR patients had higher AAA diameter (5.8 cm, SD: 1.0) compared to nonfrail EVAR patients (5.3 cm, SD 1.2), P = 0.003. Among OAR procedures, frail patients had longer operative times (296 min vs. 253 min, P = 0.013) and higher incidence of pneumonia (17.5% vs. 5.3%, P = 0.035). Among frail EVAR patients, operative time and perioperative complications including wound dehiscence, surgical site infection, and pneumonia were not significantly different than their nonfrail counterparts. Overall, frail patients had more early complications (n = 55, 43.7%) as compared to nonfrail patients (n = 48, 25.5%, P = 0.001). OAR patients had higher rates of postoperative complications including wound dehiscence (7.0% vs. 0.5%, P = 0.001), surgical site infections (7.0% vs. 1.0%, P = 0.003), and pneumonia (9.6% vs. 0.5%, P=<0.0001). Open repair was also associated with overall longer average intensive care unit stays (11.0 days vs. 1.6 days, P < 0.0001) and longer average hospitalizations (13.5 days vs. 2.4 days, P < 0.0001)., Conclusions: Our findings demonstrate that frailty is associated with higher rates of adverse outcomes in open repair compared to EVAR. Patients who underwent open repair had higher rates of wound dehiscence, surgical site infection, and pneumonia, compared to those undergoing endovascular repair. Frailty was associated with larger AAA diameter in the EVAR cohort and longer operative times, with higher frequency of postoperative pneumonia in the OAR cohort. Frailty is a strong risk factor that should be considered in the management of aortic aneurysms., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Competing Interests: The authors report no conflicts of interest.

Background: Veterans are disproportionately affected by housing insecurity (HI), which can lead to adverse health outcomes and reduced life expectancy. We sought to examine the impact of HI on the outcomes of veterans who underwent abdominal aortic aneurysm (AAA) repair at our regional Veterans Affairs medical center., Methods: Retrospective chart review was performed on patients who underwent AAA repair at our institution between January 1, 2000, and December 31, 2020. We examined medical history, procedure details, hospitalization course, and postoperative outcomes. Primary endpoints were a 30-day mortality and median survival. Secondary endpoints were hospital length of stay, readmission rate, and perioperative complications. Hypothesis testing was performed with t-test and chi-squared analysis. Survival analysis was conducted using Kaplan-Meier estimation., Results: Of the 314 veterans that underwent AAA repair (mean age of 71.4 ± 7.8 years, 99.7% male) over the 21-year period, we identified 39 (12.4%) patients with a history of HI. The HI was associated with a positive smoking history (100% vs. 88.0%, P = 0.022), lower rate of hypertension diagnosis (69.2% vs. 84.0%, P = 0.024), and increased rate of surgical site infections (SSI) (10.3% vs. 1.8%, P = 0.016). The median postoperative survival was lower in the HI group (7.6 years [CI 6.0-11.2] vs. 8.9 [CI 6.9-10.3])., Conclusions: HI was associated with reduced median postoperative survival, greater readmission rate, and increased risk of SSI following AAA repair., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Introduction: While literature widely supports early cholecystectomy for mild gallstone pancreatitis (GSP), this has not been reflected in clinical practice. Early cholecystectomy for GSP with end organ dysfunction remains controversial., Objective: This study aims to evaluate the rate and outcomes of early cholecystectomy (<3 days from admission) in mild GSP patients with end organ dysfunction (+EOD) and without (-EOD)., Methods: Patients with GSP without necrosis were identified from 2017 to 2019 NSQIP database and categorized into GSP±EOD. Coarsened Exact Matching was used to match patients based on preoperative risk factors in each group, and outcomes were compared., Results: There was a total of 3104 patients -EOD and 917 +EOD in the aggregate cohort. Early cholecystectomy was performed in 1520 (49.0%) of GSP-EOD and in 407 (44.4%) of GSP+EOD. In the matched cohorts, there were no significant differences in 30-day mortality, morbidity, or reoperation for early cholecystectomy in either group. In GSP-EOD, early cholecystectomy was associated with shorter LOS (2.9 ± 1.5 vs. 5.6 ± 3.0 days, P < .001), shorter operative time (69.7 ± 34.4 vs. 73.3 ± 36.6 min, P = .045), and more concurrent biliary procedures (52.1% vs. 35.4%, P < .001). Similarly, early cholecystectomy in GSP+EOD was associated with shorter LOS (3.3 ± 1.8 vs. 6.9 ± 6.6 days, P < .001), shorter operative time (65.9 ± 32.1 vs. 76.0 ± 40.7, P < .001), and more concurrent biliary procedure (46.0% vs. 34.9%, P = .002)., Conclusions: This study supports early cholecystectomy in patients with mild GSP. Even with end organ dysfunction, early cholecystectomy appears to be safe given there is no difference in morbidity and mortality, and the potential benefit of reduced LOS.

Background: Endovenous ablation techniques have replaced greater saphenous vein (GSV) ligation and stripping for treatment of venous insufficiency. Our objective was to investigate our initial procedural experience and clinical presentation of patients undergoing mechanochemical ablation (MOCA) at a single institution. We hypothesized that closure level and success rate improved over time and were comparable to other endovenous ablation techniques., Methods: We retrospectively reviewed all MOCA procedures performed at the Greater Los Angeles Veterans Affairs Hospital from 2015 - 2020. Variables included CEAP and VCSS scores, patient symptoms, post procedure duplex ultrasound, closure level, and need for anticoagulation. Success was defined as GSV thrombosis on initial post procedure duplex ultrasound. Procedure associated extension of thrombus into the deep veins was defined using the American Venous Forum (AVF) endothermal heat induced thrombosis (EHIT) classification., Results: 104 venous ablation procedures were performed on 86 patients. Eleven (12.8%) patients received bilateral interventions, and six (7%) patients had asynchronous interventions on the same leg. The average age was 58.4 years (SD 12) and 93% were male. Pre-procedural symptoms included pain (102, 98.1%), varicose veins (87, 83.7%), edema (58, 55.8%), and active ulcers (19, 18.3%). A CEAP category of C2 was the most common indication (34.6%), followed by C3 (22.1%) and C6 (21.2%). Forty-five (43.2%) patients had deep system reflux, and 53% had concomitant phlebectomies. Average VCSS score was 7.5 (SD 3.5).We observed a GSV ablation rate of 92.7% (n = 89) in the 96 procedures which had post-procedure follow up, with no temporal evidence of a learning curve. On post procedure duplex of the 89 technically successful ablations, 77 (86.5%) patients had AVF EHIT level 1 closure, three (3.4%) had level 2 closure, eight (8.9%) had level 3 closure, and one had a level 4 closure. Fourteen (15.7%) patients were newly started on anticoagulation for an average of 33.2 days (SD 34.1). Of the 19 legs treated for active venous ulcers, 13 (68.4%) had improvement or resolution of their venous ulcers. No pulmonary embolic complications were reported., Conclusions: We observed a successful GSV thrombosis rate of 92.7% using MOCA without evidence of a learning curve and comparable to that reported in the literature. The rate of thrombus extension into the deep veins was 14.6%, with no adverse effects associated with anticoagulation or clinically significant sequelae of AVF EHIT level 2 or greater. Comparisons with MOCA associated thrombus extension into deep veins in the literature are limited as post procedure screening duplex are not standard of care. However, we demonstrated that MOCA ablation of the GSV is a safe procedure that may be performed with good technical success., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: The concept of mesh use during open ventral hernia repair with a concomitant intestinal procedure remains controversial and it remains unclear whether the SSI profile of contaminated fields in this setting more closely resembles clean-contaminated or dirty wounds., Methods: Patients who underwent an open ventral hernia repair and intestinal procedures were extracted from the ACS-NSQIP database. Data analysis was performed for mesh versus no mesh groups in aggregate and matched cohorts. The 30-day outcomes including mortality, morbidity, surgical site infections (SSI), readmission, reoperation, and length of stay were compared between the groups., Results: Of 5104 patients in the mesh group, 3297 patients were matched 1:1 with patients without mesh. Mesh placement was associated with higher overall morbidity (35.1% vs. 29.8%; p < 0.001), overall SSI (27.1% vs. 18%; p < 0.001), deep SSI (5.9% vs. 4.3%; p = 0.003), organ-space SSI (6.8% vs. 5.5%; p = 0.027), reoperation (9.9% vs. 8.2%; p = 0.016), readmission (16.7% vs. 12.7%; p < 0.001), and longer hospital stays (10.9 ± 15.2 vs. 9.7 ± 10.7; p < 0.001). When mesh was used, the SSI profile of contaminated fields was similar to dirty wounds (26.4% vs. 27.5%; p = 0.702), rather than clean-contaminated fields (26.4% vs. 19.2%; p < 0.001)., Conclusion: Concomitant bowel procedure and mesh placement at the time of open ventral hernia repair was associated with worse outcomes. The SSI profile of the contaminated fields was more similar to dirty wounds. When deciding whether to place mesh during ventral hernia repairs with concomitant bowel procedures, strong consideration should be given to the increased risk of short-term complications versus the potential long-term benefits.

Introduction: Guidelines recommend early endoscopic retrograde cholangiopancreatography for the management of acute cholangitis, but the definition of the term "early" remains debatable. This study analyzed national trends in the timing of endoscopic retrograde cholangiopancreatography and identified the ideal time to perform preoperative endoscopic retrograde cholangiopancreatography in patients with acute cholangitis., Methods: The 2005 to 2016 National Inpatient Sample was used to identify patients undergoing cholecystectomy for acute cholangitis. Severity of cholangitis was defined using the 2013 Tokyo Grading Criteria, where Tokyo grade III patients were defined as having organ dysfunction and non-Tokyo grade III patients were defined as grades I and II. Multivariable regressions (accounting for patient and hospital characteristics) were used to identify the timing of preoperative endoscopic retrograde cholangiopancreatography associated with the least mortality risk., Results: Of 91,051 patients undergoing cholecystectomy for cholangitis, 55% underwent preoperative endoscopic retrograde cholangiopancreatography: 24% of patients received endoscopic retrograde cholangiopancreatography on the day of admission, 41% on hospital day 2, and the use of endoscopic retrograde cholangiopancreatography decreased gradually thereafter. Mortality rates remained under 1% if endoscopic retrograde cholangiopancreatography was performed during the first 3 days and increased as endoscopic retrograde cholangiopancreatography was performed during days 4 to 7 (P < .001). On multivariable regression, endoscopic retrograde cholangiopancreatography performed >72 hours after admission was associated with increased mortality (adjusted odds ratio 1.80, P = .01). Receiving endoscopic retrograde cholangiopancreatography P > 72 hours increased risk of death among Tokyo grade III patients (adjusted odds ratio 1.88, P = .01). Overall, during the study period, the utilization of preoperative endoscopic retrograde cholangiopancreatography for all grades of acute cholangitis increased from 39% of patients in 2005 to 51% in 2016 (P < .001)., Conclusion: There has been an increase in the use of endoscopic retrograde cholangiopancreatography for acute cholangitis. Although endoscopic retrograde cholangiopancreatography on the day of admission was not associated with a decrease in mortality in patients with Tokyo grade III disease, endoscopic retrograde cholangiopancreatography within 72 hours of hospitalization was associated with decreased in-hospital mortality., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The effectiveness of colonoscopy strictly depends on adequate bowel cleansing. Recently, a 1 L polyethylene glycol plus ascorbate (PEG-ASC) solution (Plenvu; Norgine, Harefield, United Kingdom) has been introduced on the evidence of three phase-3 randomized controlled trials, but it had never been tested in the real-life., Aim: To assess the effectiveness and tolerability of the 1 L preparation compared to 4 L and 2 L- PEG solutions in a real-life setting., Methods: All patients undergoing a screening or diagnostic colonoscopy after a 4, 2 or 1 L PEG preparation, were consecutively enrolled in 5 Italian centers from September 2018 to February 2019. The primary endpoints of the study were the assessment of bowel cleansing success and high-quality cleansing of the right colon. The secondary endpoints were the evaluation of tolerability, adherence and safety of the different bowel preparations. Bowel cleansing was assessed through the Boston Bowel Preparation Scale. Adherence was defined as consumption of at least 75% of each dose, while tolerability was evaluated through a semi-quantitative scale. Safety was systematically monitored through adverse events reporting., Results: Overall, 1289 met the inclusion criteria and were enrolled in the study. Of these, 490 patients performed a 4 L-PEG preparation (Selgesse ® ), 566 a 2 L-PEG cleansing (Moviprep ® or Clensia ® ) and 233 a 1 L-PEG preparation (Plenvu ® ). Bowel cleansing by Boston Bowel Preparation Scale was 6.5 ± 1.5 overall and 6.3 ± 1.5, 6.2 ± 1.5, 7.3 ± 1.5 ( P < 0.001) in the subgroups of 4 L, 2 L and 1 L-PEG preparation, respectively. Cleansing success was achieved in 72.4%, 74.1% and 90.1% ( P < 0.001), while a high-quality cleansing of the right colon in 15.9%, 12.0% and 41.4% ( P < 0.001) for 4 L, 2 L and 1 L-PEG preparation groups, respectively. The 1 L preparation was the most tolerated compared to the 2 and 4 L-PEG solutions in the absence of serious adverse events within any of the three groups. Multiple regression models confirmed 1 L PEG-ASC preparation as an independent predictor of overall cleansing success, high-quality cleansing of the right colon and of tolerability., Conclusion: This study supports the effectiveness and tolerability of 1 L PEG-ASC, also showing it is an independent predictor of overall cleansing success, high-quality cleansing of the right colon and of tolerability., Competing Interests: Conflict-of-interest statement: The authors have no proprietary, financial, professional or other personal interest of any nature or kind in any product, service and/or company that could be construed as influencing the position presented in, or the review of this manuscript., (©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: Following appendectomy, management is often guided by surgeon determination of whether the appendicitis is uncomplicated or complicated. Our objectives were to determine the incidence of discordance between intraoperative and pathological findings and determine effect on outcomes., Methods: We performed a retrospective five-year cohort analysis of adults who underwent appendectomy for acute appendicitis. Outcomes examined were length of stay (LOS), return to ED, and 30-day readmission. We reported p-values from logistic regression., Results: Of 1479 cases, 36.4% were labeled complicated appendicitis, among which, 58.2% were discordant. When intraoperative findings underestimated pathological findings, there was a decreased LOS (p < 0.001) compared to concordant diagnoses. There was no significant difference for readmission (p = 0.592) or ED (p = 0.857)., Conclusion: Operative underestimation of appendicitis severity was associated with a shorter LOS. Discordance did not adversely affect hospital readmission or rate of return to ED. These findings suggest reliance on intraoperative findings is sufficient in guiding management., Summary: We wanted determine the incidence of discordance between operative and pathological findings and determine effect on outcomes. Operative underestimation of appendicitis severity was associated with a shorter LOS. Discordance did not adversely affect hospital readmission or rate of return to ED. These findings suggest reliance on intraoperative findings is sufficient in guiding management., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Although most surgery residents pursue fellowships, data regarding those decisions are limited. This study describes associations with interest in fellowship and specific subspecialties., Methods: Anonymous surveys were distributed to 607 surgery residents at 19 US programs. Subspecialties were stratified by levels of burnout and quality of life using data from recent studies., Results: 407 (67%) residents responded. 372 (91.4%) planned to pursue fellowship. Fellowship interest was lower among residents who attended independent or small programs, were married, or had children. Residents who received AOA honors or were married were less likely to choose high burnout subspecialties (trauma/vascular). Residents with children were less likely to choose low quality of life subspecialties (trauma/transplant/cardiothoracic)., Conclusions: Surgery residents' interest in fellowship and specific subspecialties are associated with program type and size, AOA status, marital status, and having children. Variability in burnout and quality of life between subspecialties may affect residents' decisions., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The ability to predict whether a child has complicated appendicitis at initial presentation may influence clinical management. However, whether complicated appendicitis is associated with prehospital or inhospital factors is not clear. We also investigate whether hyponatremia may be a novel prehospital factor associated with complicated appendicitis., Materials and Methods: A retrospective review of all pediatric patients (≤12 y) with appendicitis treated with appendectomy from 2000 to 2013 was performed. The main outcome measure was intraoperative confirmation of gangrenous or perforated appendicitis. A multivariable analysis was performed, and the main predictors of interest were age <5 y, symptom duration >24 h, leukocytosis (white blood cell count >12 × 10 3 /mL), hyponatremia (sodium ≤135 mEq/L), and time from admission to appendectomy., Results: Of 392 patients, 179 (46%) had complicated appendicitis at the time of operation. Univariate analysis demonstrated that patients with complicated appendicitis were younger, had a longer duration of symptoms, higher white blood cell count, and lower sodium levels than patients with noncomplicated appendicitis. Multivariable analysis confirmed that symptom duration >24 h (odds ratio [OR] = 5.5, 95% confidence interval [CI] = 3.5-8.9, P < 0.01), hyponatremia (OR = 3.1, 95% CI = 2.0-4.9, P < 0.01), age <5 y (OR = 2.3, 95% CI = 1.3-4.0, P < 0.01), and leukocytosis (OR = 1.9, 95% CI = 1.0-3.5, P = 0.04) were independent predictors of complicated appendicitis. Increased time from admission to appendectomy was not a predictor of complicated appendicitis (OR = 0.8, 95% CI = 0.5-1.2, P = 0.2)., Conclusions: Prehospital factors can predict complicated appendicitis in children with suspected appendicitis. Hyponatremia is a novel marker associated with complicated appendicitis. Delaying appendectomy does not increase the risk of complicated appendicitis once intravenous antibiotics are administered. This information may help guide resource/personnel allocation, timing of appendectomy, and decision for nonoperative management of appendicitis in children., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: The resident as teaching assistant (TA) in the operating room is an important role in the maturation of surgical trainees. One concern in the current 80-hour workweek era is that current senior residents (SRs) are unprepared to serve as TAs, potentially leading to higher complication rates and a significant increase in the length of operations. The aim of this study was to analyze whether SRs serving as TAs during laparoscopic cholecystectomy (LC) resulted in an adverse effect on complication rates in the 80-hour workweek era., Methods: A retrospective review was conducted of 1668 LC performed at 2 affiliated general surgery teaching hospitals from 2003 through 2007. Teaching hospital A was a public teaching hospital where junior residents (JR) performed the LC with a scrubbed SR as TA under faculty supervision. Teaching hospital B was a community-based affiliate hospital where the JR performed LC with only scrubbed faculty supervision. Operative case duration, JR level, patient gender/age, operative indication, final pathology, and complication data were gathered and univariate and multivariate analyses were performed., Results: Despite a higher rate of acute cholecystitis in the TA hospital, LC-associated complications occurred at similar rates with and without SR as TA. The rate of biliary injury was also the same in both hospitals. On multivariable analysis, only male gender was associated with complications (odds ratio = 1.7; p = 0.004)., Conclusions: In the 80-hour resident workweek era, SRs acting as TAs during LC is not associated with increased total complications or an increased rate of biliary injury., (© 2013 Published by Association of Program Directors in Surgery on behalf of Association of Program Directors in Surgery.)