Showing papers in "American Surgeon in 2011"
TL;DR: Although multivariate analysis identified several factors associated with SSIs of different types, LAP was the only factor found to decrease risk, whereas wound class and operative time were found to increase risk among all categories of SSIs.
Abstract: The purpose of this study was to use the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to evaluate the incidence of postoperative surgical site inf...
97 citations
TL;DR: Damage control resuscitation, beginning in the ED, used more packed red blood cells and FFP minimizing crystalloids and DCR was associated with a survival advantage and shorter length of stay in patients with severe hemorrhage.
Abstract: Damage control surgery emphasizes limited operations with control of bleeding and contamination. Traditional management centered upon correction of acidosis and hypotension with crystalloids. Damage control resuscitation (DCR) is permissive hypotension and early hemostatic resuscitation combined identified and corrects coagulopathy with fresh-frozen plasma (FFP), restricting use of crystalloids. We hypothesize a survival advantage in patients managed with DCR when compared with a historical cohort of patients. During the 2-year retrospective review, a 1-year period after institution of DCR was compared with a historical control. Resuscitation strategies were analyzed and stratified into emergency department (ED) resuscitation and intraoperative resuscitation. Univariate analysis of continuous data was done with Student's t test followed by multiple logistic regression. Fifty-seven and 61 patients were managed during the NonDCR and DCR periods respectively. Baseline demographic patient characteristics and physiologic variables were similar between groups. ED DCR patients received less crystalloids: 1.1 versus 4.7 liters (P = 0.0001), more FFP: 1.8 versus 0.5 (P = 0.001). NonDCR had a lower initial systolic pressure in the operating room when compared with DCR: 81 mm Hg versus 95 mm Hg (P = 0.03). DCR patients received less intraoperative crystalloids: 5.7 versus 15.8 liters (P = 0.0001) and more FFP: 15.1 versus 6.2 (P = 0.0001). DCR conveyed a survival benefit (Odds Ratio; 95% confidence interval: 0.40 (0.18-0.90), P = 0.024). NonDCR group had 13.2 days longer hospital length of stay. Damage control resuscitation, beginning in the ED, used more packed red blood cells and FFP minimizing crystalloids. DCR was associated with a survival advantage and shorter length of stay in patients with severe hemorrhage.
93 citations
TL;DR: Unlike contemporary series of medically treated PUD, Helicobacter pylori may not be the predominant etiologic factor in patients who experience complications requiring surgery, and a "traditional” surgical approach with liberal use of vagotomy, not antibiotic triple therapy, may well be the preferred treatment consideration in such cases.
Abstract: As the number of patients requiring operation for peptic ulcer disease (PUD) declines, presumed contemporary ulcer etiology has largely been derived from medically treated patients not subjected to...
90 citations
TL;DR: The current evidence about risk factors contributing to postoperative pancreatic fistula is examined and methods of diagnosis and treatment of this universally dreaded complication are delineated.
Abstract: Postoperative pancreatic fistula (POPF) is the most frequent complication after pancreaticoduodenectomy, results in increased morbidity and mortality, and adversely affects length of stay and costs. Reported rates of postoperative pancreatic fistula vary from 0 per cent up to more than 30 per cent. Plenty of randomized trails and meta-analysis were published to analyze the ideal procedure, technique of anastomosis, and perioperative management of patients undergoing pancreaticoduodenectomy; however, results are often discordant and clear evidence on the ideal management and surgical technique to reduce POPF rate is not yet provided. This collective review examined the current evidence about risk factors contributing to postoperative pancreatic fistula and delineates methods of diagnosis and treatment of this universally dreaded complication.
85 citations
TL;DR: The ACS model decreased time from the ED to the OR, decreased after-hours cases, decreased length of hospitalization, and decreased complications for patients with acute cholecystitis.
Abstract: In October 2009, an acute care surgery (ACS) model was implemented to facilitate urgent surgical consults This study examines the impact of ACS on the timeliness of care and length of hospitalizat
82 citations
TL;DR: TIL response is a significant predictor of SLN metastasis but is not a major predictor of DFS or OS, while nonbrisk TIL response, increased tumor thickness, and ulceration were significant independent predictors of tumor-positive SLN.
Abstract: The prognostic significance of tumor infiltrating lymphocyte (TIL) response in cutaneous melanoma is controversial. This analysis of data from a prospective, randomized trial included patients with cutaneous melanoma > or = 1.0 mm Breslow thickness who underwent wide local excision and sentinel lymph node (SLN) biopsy. Univariate and multivariate analyses were performed to determine factors associated with TIL response, disease-free survival (DFS), and overall survival (OS). A total of 515 patients were included; TIL response was classified as "brisk" (n = 100; 19.4%) or "non-brisk" (n = 415; 80.6%). Patients in the nonbrisk TIL group were more likely to have tumor-positive SLN (17.6% vs 7%; P = 0.0087). On multivariate analysis, nonbrisk TIL response, increased tumor thickness, and ulceration were significant independent predictors of tumor-positive SLN. By Kaplan-Meier analysis, 5-year DFS rate was 91 per cent for those with a brisk TIL response compared with 86 per cent in the nonbrisk group (P = 0.41). The 5-year OS rates were 95 per cent versus 84 per cent in the brisk versus nonbrisk TIL groups, respectively (P = 0.0083). However, on multivariate analysis, TIL response was not a significant independent factor predicting DFS or OS. TIL response is a significant predictor of SLN metastasis but is not a major predictor of DFS or OS.
82 citations
TL;DR: A prospective, single blinded study with convenience sampling at a Level I trauma center comparing thoracic ultrasound with chest X-ray and CT scan in the detection of traumatic pneumothorax, advocating the use of chest ultrasound for detection of pneumothsorax in trauma patients.
Abstract: Pneumothorax after trauma can be a life threatening injury and its care requires expeditious and accurate diagnosis and possible intervention. We performed a prospective, single blinded study with convenience sampling at a Level I trauma center comparing thoracic ultrasound with chest X-ray and CT scan in the detection of traumatic pneumothorax. Trauma patients that received a thoracic ultrasound, chest X-ray, and chest CT scan were included in the study. The chest X-rays were read by a radiologist who was blinded to the thoracic ultrasound results. Then both were compared with CT scan results. One hundred and twenty-five patients had a thoracic ultrasound performed in the 24-month period. Forty-six patients were excluded from the study due to lack of either a chest X-ray or chest CT scan. Of the remaining 79 patients there were 22 positive pneumothorax found by CT and of those 18 (82%) were found on ultrasound and 7 (32%) were found on chest X-ray. The sensitivity of thoracic ultrasound was found to be 81.8 per cent and the specificity was found to be 100 per cent. The sensitivity of chest X-ray was found to be 31.8 per cent and again the specificity was found to be 100 per cent. The negative predictive value of thoracic ultrasound for pneumothorax was 0.934 and the negative predictive value for chest X-ray for pneumothorax was found to be 0.792. We advocate the use of chest ultrasound for detection of pneumothorax in trauma patients.
81 citations
TL;DR: Given prospective identification of patients at risk for MT remains an imprecise undertaking, appropriate resources will need to be allocated for the completion of these studies.
Abstract: Most retrospective studies evaluating fresh-frozen plasma:packed red blood cell ratios in trauma patients requiring massive transfusion (MT) are limited by survival bias. As prospective resource-intensive studies are being designed to better evaluate resuscitation strategies, it is imperative that patients with a high likelihood of MT are identified early. The objective of this study was to develop a predictive model for MT in civilian trauma patients. Patients admitted to the University of Alabama at Birmingham Trauma Center from January 2005 to December 2007 were selected. Admission clinical measurements, including blood lactate 5 mMol/L or greater, heart rate greater than 105 beats/min, international normalized ratio greater than 1.5, hemoglobin 11 g/dL or less, and systolic blood pressure less than 110 mmHg, were used to create a predictive model. Sensitivity (Sens), specificity (Spec), positive predictive value (PPV), and negative predictive value (NPV) were calculated for all possible combinations of clinical measurements as well as each measure individually. A total of 6638 patients were identified, of whom 158 (2.4%) received MT. The best-fit predictive model included three or more positive clinical measures (Sens: 53%, Spec: 98%, PPV: 33%, NPV: 99%). There was increased PPV when all clinical measurements were positive (Sens: 9%, Spec: 100%, PPV: 86%, NPV: 98%). All combinations or clinical measures alone yielded lower predictive probability. Using these emergency department clinical measures, a predictive model to successfully identify civilian trauma patients at risk for MT was not able to be constructed. Given prospective identification of patients at risk for MT remains an imprecise undertaking, appropriate resources to support these efforts will need to be allocated for the completion of these studies.
70 citations
TL;DR: Emergent hernia repair is associated with increased mortality rates, early complications, and longer length of stay; however, long-term outcomes are equivalent to elective cases.
Abstract: This study examines the effect of emergent repair on incisional hernia repair outcomes at 16 Veteran's Affairs Medical Centers between 1998 and 2002. Of the 1452 cases reviewed, 63 (4.3%) were repa...
62 citations
TL;DR: The analysis of postoperative morbidity and mortality for emergency versus nonemergency general surgery operations suggests that there is a need for improvement in both methods and systems of care for the emergent population.
Abstract: Emergent operations are thought to carry higher morbidity and mortality than nonemergent cases. However, there is a lack of specific outcomes data for emergent general surgery procedures. The objec...
62 citations
TL;DR: Compared with open repair, laparoscopic repair was associated with superior perioperative outcomes even in cases presenting with obstruction or gangrene.
Abstract: The optimal operative approach for repair of diaphragmatic hernia remains debated. The aim of this study was to examine the utilization of laparoscopy and compare the outcomes of laparoscopic versu...
TL;DR: Surgical procedural safety checklists have the capacity to increase the frequency of positive team behaviors in the operating room during laparoscopic surgery, and participants in the intervention (checklist) group consistently rated their cases as involving less satisfactory subjective levels of comfort, team efficiency, and communication.
Abstract: Procedural checklists may be useful for increasing the reliability of safety-critical processes because of their potential capacity to improve teamwork, situation awareness, and error catching. To ...
TL;DR: Routine use of intraoperative irrigation for appendectomies does not prevent intra-abdominal abscess formation, adds extra costs, and may be avoided, and is suggested to be avoided.
Abstract: To date, no study shows a decrease in postoperative abscess with the use of irrigation during appendectomy. Postoperative abscess rate for laparoscopic and open appendectomy is 3.3 and 2.6 per cent. The purpose of this study is to determine if irrigation at appendectomy decreases the postoperative intra-abdominal abscess rate. Retrospective chart review of 176 consecutive appendectomies, open (39%) and laparoscopic (61%), at a university affiliated tertiary care facility from July 2007 to November 2008 for use of intraoperative irrigation was performed. Patients under age 18 were excluded. There were no differences between the irrigation groups in regards to age, sex, or weight. Perforation was observed in 28 per cent (50/176), of which 86 per cent (43/50) of patients received intraoperative irrigation. Eleven patients (9.6%) with irrigation developed postoperative abscess compared with two (3.3%) patients without irrigation (P = 0.22). Our results do not show decrease in postoperative intra-abdominal abscess with use of intraoperative irrigation. Thirteen patients developed postoperative abscess: 11 with irrigation, two without irrigation. Ten of 13 patients who developed abscess were perforated; nine with irrigation and one without. These results suggest routine use of intraoperative irrigation for appendectomies does not prevent intra-abdominal abscess formation, adds extra costs, and may be avoided.
TL;DR: ECST is associated with reduced wound complications compared with CST, and short-term recurrence rates with CST and ECST are comparable.
Abstract: The open components separation technique (CST) for hernia repair allows for autologous tissue repair with approximation of the midline fascia in patients with complex hernias. CST requires creation of large undermining skin flaps, whereas the endoscopic component separation technique (ECST) is performed without division of the epigastric perforating vessels and may minimize wound morbidity. A review of patient demographics and outcome measures of patients undergoing CST and ECST between November 2008 and February 2010 was performed. Twenty-five patients were identified who underwent either CST (14 patients) or ECST (11 patients). There were no differences in body mass index (CST 34.8 kg/m(2), ECST 37.5 kg/m(2), P = 0.45), operating room times (CST 268 minutes, ECST 252 minutes, P = 0.54), or hospital length of stay (CST 5 days, ECST 5.8 days, P = 0.78). Wound complications occurred less with ECST (9 vs 57%, P = 0.03). The time to resolution of wound complications in ECST was reduced *1 vs 4 months). No recurrences were seen in either group with a mean follow-up of 4months (range, 1 to 12 months). ECST and CST require similar operative times and hospital lengths of stay. ECST is associated with reduced wound complications compared with CST. Short-term recurrence rates with CST and ECST are comparable.
TL;DR: SILS was associated with decreased performance and increased surgeon workload compared with standard laparoscopy during the performance of a simulated task and the use of angulated instruments during SILS would be beneficial.
Abstract: Little is known about the effectiveness and challenges of single incision laparoscopic surgery (SILS). We hypothesized that SILS would lead to decreased performance and increased surgeon workload compared with standard laparoscopy and that the use of angulated instruments during SILS would be beneficial. General surgery residents and fellows (n = 14) voluntarily performed the Fundamentals of Laparoscopic Surgery task 1 (peg transfer) using 1) standard laparoscopic instruments and port position, 2) standard laparoscopic instruments through a SILS port, and 3) angulated instruments through a SILS port in random order. Performance was assessed with an objective score and participant workload using a modified National Aeronautics and Space Administration Task Load Index (NASA TLX) workload assessment questionnaire. Participant performance was best with standard laparoscopy followed by SILS with angulated graspers and SILS with straight instruments (scores 218 ± 26 vs 131 ± 61 vs 91 ± 57; P < 0.001, respectively). In addition, participants indicated that standard laparoscopy was easier than SILS and their workload was 35 to 53 per cent higher when performing SILS. SILS was associated with decreased performance and increased surgeon workload compared with standard laparoscopy during the performance of a simulated task. SILS performance improved when angulated instruments were used but remained inferior to standard laparoscopy. This may translate into poorer operating room efficiency and safety.
TL;DR: Identification of a set of preoperative characteristics that could predict outcome after surgery is necessary to optimize clinical management and guide surgical timing and identified factors can predict unfavorable outcomes after colectomy.
Abstract: Surgical treatment of fulminant Clostridium difficile colitis has high mortality rates. Identification of a set of preoperative characteristics that could predict outcome after surgery is necessary to optimize clinical management and guide surgical timing. Data were retrospectively collected on patients operated on for C. difficile colitis between 2000 and 2010 at our institution. Statistical analysis was performed to identify predictors of mortality. We reviewed the records of 13 inpatients diagnosed as having C. difficile colitis and who underwent colectomy during the same admission. The in-hospital mortality rate for patients undergoing colectomy for colitis was 46.2 per cent. Independent predictors of mortality included the following: white blood cell count (34,600/μL or greater), hypoalbuminemia (1.5 g/dL or less), septic shock with requirements of vasopressors, and respiratory failure. Patients who underwent colectomy earlier (mean time from presentation to surgery 2.4 ± 1.5 days) had decreased mortality (P = 0.019).). Longer length of hospital stay to the time of diagnosis was associated with higher rates of fatal outcome (P = 0.031). Parameters without significant difference (P > 0.05) included patient age, presenting symptoms, other comorbidities, creatinine levels, and CT scan findings. Identified factors can predict unfavorable outcomes after colectomy. Aggressive surgical intervention early in the course of the disease might be associated with improved survival.
TL;DR: Although suture tensile strength is greater than that of tacks, and despite numerous anecdotal reports of hernia recurrence secondary to suture failure or omission, the existing literature does not show superiority of one mesh fixation technique over the other for recurrence, whereas infection rates increase when transfascial suture is used.
Abstract: Although most surgeons report using both transfascial sutures and laparoscopically placed tacks to secure prostheses in laparoscopic ventral hernia repair, a significant minority have reported large series in which sutures were omitted. A systematic review of the available literature was conducted for large case series and controlled trials documenting long-term follow-up. Forty-three articles were identified, including 6015 patients whose prostheses were secured with transfascial sutures (with or without tacks), and 2450 patients receiving tacks or staples alone. The mean follow-up time reported was 30.1 months. No significant difference was found in rates of hernia recurrence, mesh removal, prolonged postoperative pain, patient body mass index, or hernia defect size between the two groups. The suture group did experience a significantly higher rate of surgical site infection. Although suture tensile strength is greater than that of tacks, and despite numerous anecdotal reports of hernia recurrence secondary to suture failure or omission, the existing literature does not show superiority of one mesh fixation technique over the other for recurrence, whereas infection rates increase when transfascial suture is used.
TL;DR: It is suggested that staples are associated with fewer wound infections compared with sutures in the evaluated types of surgery, however, in a rather limited number of studies, the use of staples was associated with more pain.
Abstract: Surgical sutures are conventionally used in skin closure of surgical wounds. Alternative wound closure techniques include staples and adhesive strips. We aimed to evaluate sutures versus staples as methods of surgical wound closure by performing a meta-analysis. We searched PubMed, Scopus, and Cochrane Central Register of Controlled Trials for randomized controlled trials that compared sutures with staples for surgical wound closure. Trials referring to orthopedic operations were excluded. Twenty studies (involving a total of 2111 patients) were included. Five studies referred to obstetrics/gynecological operations, seven to general surgery, four to emergency care treatment, three to head/neck operations, and one to vascular surgery. Regarding the time needed for wound closure, staples were superior to sutures; the mean difference observed between the sutures and staples groups was 5.56 minutes per wound (95% confidence intervals [CI], 0.05 to 11.07). Wound infections were significantly fewer in the staples group compared with the sutures group(s) (12 studies, 1529 patients; odds ratio, 2.06; 95% CI, 1.20 to 3.51). In five studies, the use of staples was associated with significantly more pain compared with sutures. The majority of studies with available relevant data reported nonsignificant differences regarding the cosmetic result and patient's satisfaction. Our findings suggest that staples are associated with fewer wound infections compared with sutures in the evaluated types of surgery. However, in a rather limited number of studies, the use of staples was associated with more pain. Further studies incorporating more objective methods for assessment cosmetic and patient satisfaction are required to clarify this issue.
TL;DR: Transanal endoscopic microsurgery seems to be superior to SR concerning morbidity whilst less effective in obtaining negative surgical margins, and it is associated with higher local and overall recurrence.
Abstract: The objective of this study is to assess transanal endoscopic microsurgery (TEM) as a surgical strategy for stage I rectal cancer. The literature lacks level I and level II evidence of the oncologic competence of TEM. Three randomized controlled, one prospective, and seven retrospective comparative studies were evaluated. End-points included perioperative outcomes, margin involvement, disease-free and overall survival, and recurrence. The number of patients with major (odds ratio (OR) = 0.24, 95% confidence interval (CI) 0.07-0.91) and overall postoperative complications (OR = 0.16, 95% CI 0.06-0.38) were significantly lower in TEM. The disease-free survival was higher in standard resection (SR) group compared with TEM (OR = 0.46, 95% CI 0.24-0.88). The number of patients with positive margins were less in the SR group (OR = 6.49, 95% CI 1.49-24.91), which was associated with lower local recurrence (OR = 4.92, 95% CI 1.81-13.41) and overall recurrence rate (OR = 2.03, 95% CI 1.15-3.57). No survival advantage was observed in favor of either procedure. TEM had lower rate of positive margins and longer disease-free survival when compared with transanal excision (TAE). TEM seems to be superior to SR concerning morbidity whilst less effective in obtaining negative surgical margins, and it is associated with higher local and overall recurrence. No survival advantage was observed in favor of either procedure. Unfavorable tumor preoperative histology does not seem to influence the selection between TEM and SR. TEM is more effective than TAE in obtaining negative surgical margins and shows a greater disease-free survival.
TL;DR: Open intervention for postsurgical intra-abdominal infections is associated with increased mortality compared with percutaneous drainage even after controlling for severity of illness by multivariate analysis.
Abstract: Intra-abdominal infections following surgical procedures result from organ-space surgical site infections, visceral perforations, or anastomotic leaks. We hypothesized that open surgical drainage is associated with increased patient morbidity and mortality compared with percutaneous drainage. A single-institution, prospectively collected database over a 13-year period revealed 2776 intra-abdominal infections, 686 of which required an intervention after the index operation. Percutaneous procedures (simple aspiration or catheter placement) were compared with all other open procedures by univariate and multivariate analyses. Analysis revealed 327 infections in 240 patients undergoing open surgical drainage and 359 infections in 260 patients receiving percutaneous drainage. Those undergoing open drainage had significantly higher Acute Physiology Score (APS) and Acute Physiology and Chronic Health Evaluation (APACHE) II scores and were more likely to be immunosuppressed, require intensive care unit treatment, and have longer hospital stays. Mortality was higher in the open group: 14.6 versus 4.2 per cent (P = 0.0001). Variables independently associated with death by multivariate analysis were APACHE II, dialysis, intensive care unit (ICU) care, age, immunosuppression, and drainage method. Open intervention for postsurgical intra-abdominal infections is associated with increased mortality compared with percutaneous drainage even after controlling for severity of illness by multivariate analysis. Although some patients are not candidates for percutaneous drainage, it should be considered the preferential treatment in eligible patients.
TL;DR: Elderly trauma patients with a normal admission blood pressure sustaining blunt trauma, age 55 years or older, with a systolic blood pressure 90 mmHg or higher, and who had arterial lactate and/or BD measured within 4 hours of arrival comprised the study group.
Abstract: Elderly trauma patients have worse outcomes than their younger counterparts. Early risk stratification remains difficult, particularly because traditional vital signs are less reliable. We hypothesized that arrival lactate and base deficit (BD) could be used to predict mortality in elderly trauma patients with a normal admission blood pressure. We retrospectively evaluated the prospectively collected trauma registry at our urban Level I trauma center between 2003 and 2009. Patients sustaining blunt trauma, age 55 years or older, with a systolic blood pressure 90 mmHg or higher, and who had arterial lactate and/or BD measured within 4 hours of arrival comprised the study group. Primary outcomes were in-hospital and 24-hour mortality. There were 364 patients with a lactate and 324 with a BD drawn. Patients with a lactate 2.5 mmol or greater were 3.7 times more likely to die than those with a lactate less than 2.5 mmol (95% CI, 1.6 to 8.2; P = 0.0018). The OR for mortality was 5.2 (95% CI, 2.5 to 11.2; P < 0.0001) in patients with a BD -4 or less. Elevated lactate and BD were even stronger predictors of early mortality (within first 24 hours). After increasing the hypotension threshold to a systolic blood pressure 110 mmHg or greater, lactate and BD remained highly predictive of in-hospital and 24-hour mortality.
TL;DR: It is suggested that obesity is not an independent risk factor for complications or mortality after trauma in older patients, and increasing BMI is associated with higher rates of torso and proximal upper extremity injuries.
Abstract: Current understanding of the effects of obesity on trauma patients is incomplete. We hypothesized that among older trauma patients, obese patients differ from nonobese patients in injury patterns, ...
TL;DR: Prior chemotherapy, anticoagulation, and intraoperative blood loss all increased the AL rates, and operations involving the left colon had greater risk of AL when compared with those of the right colon, sigmoid, and rectum.
Abstract: Anastomotic leak (AL) is one of the most serious complications after gastrointestinal surgery. All patients aged 16 years or older who underwent a surgery with single intestinal anastomosis at Morristown Medical Center from January 2006 to June 2008 were entered into a prospective database. To compare the rate of AL, patients were divided into the following surgery-related groups: 1) stapled versus hand-sewn, 2) small bowel versus large bowel, 3) right versus left colon, 4) emergent versus elective, 5) laparoscopic versus converted (laparoscopic to open) versus open, 6) inflammatory bowel disease versus non inflammatory bowel disease, and 7) diverticulitis versus nondiverticulitis. We also looked for surgical site infection, estimated intraoperative blood loss, blood transfusion, comorbidities, preoperative chemotherapy, radiation, and anticoagulation treatment. The overall rate of AL was 3.8 per cent. Mortality rate was higher among patients with ALs (13.3%) versus patients with no AL (1.7%). Open surgery had greater risk of AL than laparoscopic operations. Surgical site infection and intraoperative blood transfusions were also associated with significantly higher rates of AL. Operations involving the left colon had greater risk of AL when compared with those of the right colon, sigmoid, and rectum. Prior chemotherapy, anticoagulation, and intraoperative blood loss all increased the AL rates. In conclusion, we identified several significant risk factors for ALs. This knowledge should help us better understand and prevent this serious complication, which has significant morbidity and mortality rates.
TL;DR: In the largest study to date, a high admission BAC was independently associated with improved survival in patients with isolated moderate to severe TBI and the potential therapeutic implications are investigated.
Abstract: Although recent evidence suggests a beneficial effect of alcohol for patients with traumatic brain injury (TBI), the level of alcohol that confers the protective effect is unknown. Our objective was to investigate the relationship between admission blood alcohol concentration (BAC) and outcomes in patients with isolated moderate to severe TBI. From 2005 to 2009, the Los Angeles County Trauma Database was queried for all patients ≥14 years of age with isolated moderate to severe TBI and admission serum alcohol levels. Patients were then stratified into four levels based on admission BAC: None (0 mg/dL), low (0-100 mg/dL), moderate (100-230 mg/dL), and high (≥230 mg/dL). Demographics, patient characteristics, and outcomes were compared across levels. In evaluating 3794 patients, the mortality rate decreased with increasing BAC levels (linear trend P Language: en
TL;DR: There was no statistically significant difference in chest tube and cricothyroidotomy outcomes or confidence in the groups trained with live animal models or simulators at the 95 per cent confidence interval.
Abstract: There is a lack of objective analysis comparing live tissue and simulator training. This article aims to objectively determine the difference in outcomes. Twenty-four Air Force volunteers without prior experience performing emergency procedures were randomly assigned to receive training in tube thoracostomy (chest tube) and cricothyroidotomy training on either a pig model (Sus scrofa domestica) or on the TraumaMan simulator. One week posttraining, students were tested on human cadavers with objective and subjective results recorded. Average completion time for tube thoracostomy in the animal model group was 2 minutes 4 seconds and 1 minute 51 seconds in the simulator group with a mean difference of 12 seconds (P = 0.74). Average completion time for cricothyroidotomy in the animal model group was 2 minutes 35 seconds and 3 minutes 29 seconds in the simulator group with a mean difference of 53 seconds (P = 0.32). Overall confidence was 9 per cent higher in the animal trained group (P = 0.42). Success rate of cricothyroidotomy was 75 per cent in the animal model group and 58 per cent in the simulator-trained group (P = 0.67). Success rate of chest tube placement was 92 per cent in the animal group and 83 per cent in the simulator group (P = 1.00). There was no statistically significant difference in chest tube and cricothyroidotomy outcomes or confidence in the groups trained with live animal models or simulators at the 95 per cent confidence interval. Trends suggest a possible difference, but the number of cadavers required to reach greater than 95 per cent statistical confidence prohibited continuation of the study.
TL;DR: Lidocaine patches resulted in a sustained reduction in pain, outlasting the duration of therapy, and are a safe, effective adjunct for rib fracture pain.
Abstract: Rib fracture pain is notoriously difficult to manage. The lidocaine patch is effective in other pain scenarios with an excellent safety profile. This study assesses the efficacy of lidocaine patches for treating rib fracture pain. A prospectively gathered cohort of patients with rib fracture was retrospectively analyzed for use of lidocaine patches. Patients treated with lidocaine patches were matched to control subjects treated without patches. Subjective pain reports and narcotic use before and after patch placement, or equivalent time points for control subjects, were gathered from the chart. All patients underwent long-term follow-up, including a McGill Pain Questionnaire (MPQ). Twenty-nine patients with lidocaine patches (LP) and 29 matched control subjects (C) were analyzed. During the 24 hours before patch placement, pain scores and narcotic use were similar (LP 5.3, C 4.6, P = 0.19 and LP 51, C 32 mg morphine, P = 0.17). In the 24 hours after patch placement, LP patients had a greater decrease in pain scores (LP 1.2, C 0.0, P = 0.01) with no change in narcotic use (LP -8.4, C 0.5-mg change in morphine, P = 0.25). At 60 days, LP patients had a lower MPQ pain score (LP 7.7, C 12.2, P < 0.01), although only one patient was still using a patch. There was no difference in time to return to baseline activity (LP 73, C 105 days, P = 0.16) and no adverse events. Lidocaine patches are a safe, effective adjunct for rib fracture pain. Lidocaine patches resulted in a sustained reduction in pain, outlasting the duration of therapy.
TL;DR: CT scan is considered the gold standard for diagnosis, whereas ultrasonography, contrast studies, herniography and plain films are less specific and surgery is the only treatment option for obturator hernia.
Abstract: Obturator hernia is the protrusion of intraperitoneal or extraperitoneal organs or tissues through the obturator canal. The first case was published by de Ronsil in 1724. Obturator hernia is more common in older malnourished women due to loss of supporting connective tissue and the wider female pelvis. The hernia sac usually contains small bowel, especially ileum. It may follow the anterior or posterior division of the obturator nerve. In most cases, obturator hernia presents with intestinal obstruction of unknown cause. It may present with obturator neuralgia, as a palpable mass or, in cases of bowel necrosis, as ecchymosis of the thigh. A correct diagnosis is made in 20 to 30 per cent of cases. CT scan is considered the gold standard for diagnosis, whereas ultrasonography, contrast studies, herniography and plain films are less specific. Surgery is the only treatment option for obturator hernia. Hesitancy to intervene surgically for chronically ill patients results in high mortality. Transabdominal approach is indicated in cases of complete bowel obstruction or suspected peritonitis. The extra-abdominal approach is used in preoperatively diagnosed cases and in absence of bowel strangulation. The laparoscopic approach is minimally invasive and effectively reduces morbidity. The defect is closed using sutures, tissue flaps, or prosthetic mesh.
TL;DR: A geriatric trauma unit was created that expedites triage, optimizes chronic illness to facilitate definitive management, and provides safe discharge that has achieved several improvements in this population.
Abstract: Many elderly trauma patients have isolated orthopedic injuries compounded by chronic medical conditions. We organized a trauma unit, led by trauma surgeons, that is designed to expedite the care of geriatric patients through a multidisciplinary approach. The development of G-60, our Geriatric Trauma Unit, began with discussion between trauma surgeons and hospital administration. Dialogue between trauma surgeons and emergency department physicians yielded triaging, disposition, and admission criteria. Orthopedic surgeons helped implement a goal of operative management in 48 hours. Internal medicine assisted in optimizing chronic disease and providing preoperative clearance with involvement of cardiology and anesthesiology. Meetings were held among surgeons, physical therapists, occupational therapists, respiratory therapists, nutritionists, pharmacists, social workers, case managers, internists, a geriatrician, and physical medicine and rehabilitation. A unit in the hospital was chosen, and a paging system was implemented. Six months lapsed from inception to fulfillment. The multidisciplinary team has achieved several improvements in this population. Through a multidisciplinary approach, a geriatric trauma unit was created that expedites triage, optimizes chronic illness to facilitate definitive management, and provides safe discharge.
TL;DR: If LC is underused in the elderly and if it is a safe option in that group, significant disparity exists between elderly and nonelderly patients in use of LC surgery.
Abstract: Studies confirm that laparoscopic cholecystectomy (LC) is safe and efficacious for elderly patients. The purposes of this study were to evaluate if LC is underused in the elderly and if it is a safe option in that group. Open cholecystectomy (OC) and LC were compared in nonelderly (40 to 64 years) and elderly (65 years or older) matched patient groups identified with gallbladder disease using the American College of Surgeons National Surgical Quality Improvement Program database (2005 to 2008). Length of stay (LOS), 30-day complications, and mortality were evaluated as outcomes. Using multivariate logistic regression, independent predictors of OC were identified. After case-matching, each group had 11,926 patients. A χ(2) test showed that elderly (20.1 vs 15.0%, P < 0.001) were more likely to undergo OC. Elderly patients had significantly higher comorbidities and were operated on as emergent case (all P < 0.05). OC had longer LOS and mortality (all P < 0.05). Among 10 other variables in logistic regression, elderly had a higher likelihood of receiving OC (OR, 1.299; P < 0 0.001). Significant disparity exists between elderly and nonelderly patients in use of LC surgery. LC has a lower complication rate than OC; however, elderly undergo LC less often. Awareness needs to be raised for offering earlier operative intervention and the superior results of LC in the elderly.
TL;DR: It is found that those trainees achieving a career in academic surgery were statistically more likely to have committed 2 or more years to a protected research experience during training, fellowship training after general surgery residency, and a first job at an academic institution upon completion of training.
Abstract: A number of general surgery training programs offer a dedicated research experience during the training period. There is much debate over the importance of these experiences with the added constraints placed on training surgeons including length of training, Accreditation Council of Graduate Medical Education limitations, and financial barriers. We seek to quantify the impact of a protected research experience on graduates of a university-affiliated general surgery training program. We surveyed all graduates of a single university-affiliated general surgery training program who completed training from 1989 to 1999. Data was obtained for 100 per cent of the subjects. Most graduates (72/73; 98.6%) completed a dedicated research experience (range: 1-5 years). Presently, 72.6 per cent (53/73) are practicing academic surgery and 82.5 per cent (60/73) are engaged in research activities. Fifty-one of 73 graduates (69.5%) have current research funding including 32.9 per cent (24/73) with National Institutes of Health funding. Of all graduates, 42.5 per cent (31/73) have become full professors with 20.2 per cent (15/73) division/section chiefs and 14.3 per cent (10/73) department chairmen or vice chairmen. Those trainees achieving a career in academic surgery were statistically more likely to have committed 2 or more years to a protected research experience during training (P < 0.05), fellowship training after general surgery residency (P < 0.01), and a first job at an academic institution upon completion of training (P < 0.001). Understanding the importance of resident research experiences while highlighting critical factors during the formative training period may help to ensure continued academic interest and productivity of future trainees.