The American Surgeon™

Acute respiratory distress syndrome (ARDS) incidence is reported to have decreased in recent years. However, no large-scale study to date has exclusively examined ARDS in the critically injured. We sought to examine the national incidence of ARDS and its associated outcomes exclusively in adult trauma patients. The National Trauma Data Bank (NTDB) was queried to evaluate the incidence of ARDS and associated outcomes over a 6-year study period (2007–2012). Included patients were ≥18 years old, with at least one ventilator day, and complications recorded. ARDS-associated outcomes and complications were also analyzed. Mean age increased over the study period (48.1–51.4 years, P < 0.003). ARDS incidence decreased from 21.5 to 8.5 per cent (P < 0.001). Length of stay (LOS), intensive care unit LOS (ICU LOS), and ventilator days decreased over time. Mortality increased from 21.3 to 24.9 per cent (P < 0.002). Incidence of pneumonia and acute kidney injury increased marginally (39.5–40.9% and 11.4–12.3%, respectively). Sepsis trended down from 2007 to 2010, after which comparable NTDB data were not available. ARDS incidence in mechanically ventilated adult trauma patients has decreased significantly in recent years. We theorize this is likely attributable to improved critical care strategies. Unlike ARDS incidence, mortality in this patient population has not improved despite these advancements.

Venomous snakebites are fairly common in the United States and can present with a wide range of symptoms. A 48-year-old man presented after Eastern Diamondback rattlesnake envenomation. His hospital course was complicated by right leg compartment syndrome and delayed recurrent coagulopathy, requiring multiple doses of Crotalidae Polyvalent Immune Fab (CroFab) antivenom and transfusions. Thromboelastography was used as an adjunct to standard coagulation studies in monitoring his delayed recurrent coagulopathy.

Balloon occlusion of the aorta was first described by C.W. Hughes in 1954, when it was used as a tamponade device for three wounded soldiers during the Korean War suffering from intra-abdominal hemorrhage. Currently, the device is indicated in trauma patients as a surrogate for resuscitative thoracotomy. Brenner et al. reported a case series describing the use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in advanced hemorrhagic shock. Their conclusion was that “it is a feasible method for proximal aortic control.” We describe the novel use of REBOA before retroperitoneal hematoma exploration in a hemodynamically unstable patient. Reported is a 19-year-old blunt trauma victim where REBOA was successfully deployed as a means for proximal arterial control before a Zone 1 retroperitoneal hematoma exploration. The source of the patient's hemorrhagic shock was multifactorial: grade V hepatic injury, retrohepatic inferior vena cava laceration, and right renal vein avulsion with Zone 1 retroperitoneal hematoma. Immediate return of perfusion pressure, as systolic pressures increased from 50 to 150 mm Hg. Hemodynamic improvements were accompanied by decreased transfusion and vasopressor requirements. In addition, the surgeons were able to enter the retroperitoneal hematoma under controlled conditions. REBOA is an attractive new tool to gain proximal aortic control in select patients with hemorrhagic shock. It is less morbid, possibly more efficient, and appears to be more effective than resuscitative thoracotomy. REBOA is certainly feasible for proximal aortic control before retroperitoneal exploration, and should be considered in select patients.

The purpose of this study was to evaluate the effect of body mass index (BMI) on mortality after traumatic injury. The records of patients from 2012 to 2015 were retrospectively reviewed. The patients were stratified into the following groups based on admission BMI (kg/m²): underweight (UW) (BMI <19), ideal weight (IW) (BMI = 19–24.9), overweight (OW) (BMI = 25–29.9), obese (OB) (BMI = 30–39.9), and morbid obese (MO) (BMI >40). The groups were well matched with no significant differences in demographics and Injury Severity Score. Morality for the IW group was compared with the remaining BMI groups. A total of 6049 patients were identified. In comparison with IW group, the UW mortality was significantly higher (IW vs UW, 4.1% vs 8.8%, P = 0.001); however, the there was no significant difference with remaining groups. There was also no significant difference in mortality between IW and the remaining groups for patients that went directly to the operating room or for patients that had penetrating trauma (stab wounds and gunshot wounds). However, for blunt trauma, the mortality was significantly higher for UW (IW vs UW, 4.3% vs 9.4%, P = 0.001), no different for IW vs OW (4.3% vs 3.7%, P = 0.3), and significantly lower for IW vs OB (4.3% vs 2.8%, P = 0.04) and for IW vs MO (4.3% vs 1.0%, P = 0.03). After traumatic injuries, it is the underweight patients (BMI <19) and not the obese, that are at a significantly higher risk for overall mortality; this difference is especially evident after blunt trauma where obesity may actually confer a protective role.

To determine the incidence and severity of all-terrain vehicle crashes (ATVCs) compared with motorcycle crashes (MCCs) in all critically injured patients. Prospective data were retrospectively reviewed on 1840 patients involved in ATVCs and MCCs admitted to a rural level one trauma center over 16 years. ATVC patients (n = 655) were younger (25 vs 38, P < 0.0001), more likely female (20% vs 11%, P < 0.001), less severely injured (13.5 vs 16, P < 0.0001), had similar Glasgow Coma Score (13.3 vs 13.4, p = NS), less helmet use (6% vs 69%, P < 0.0001), more closed head injuries (59.7% vs 54.3%, P < 0.05), more facial injuries (16.9% vs 12.5%, P < 0.05), and lower mortality rate (2.8% vs 5.9%, P < 0.01) compared with MCC patients (n = 1172). Pediatric patients involved in ATVC were more common (29.8% vs 4.8%, P < 0.001), had decreased helmet use (12% vs 59%, P < 0.001) and decreased mortality (3.5% vs 14.3%, P < 0.01). Further injury prevention efforts regarding helmet use and increased regulations regarding ATVCs are needed to decrease the morbidity associated with these recreational vehicles.

Consent and conversion rates of potential organ donors in the United States need to be maximized to match the number of individuals awaiting organ donation. Studies to date have not focused on characteristics of centers with better outcomes. We performed an 8-year (2006–2014) retrospective study of our local organ procurement organization database. We categorized hospitals in our region as academic centers versus nonacademic centers, trauma centers versus nontrauma centers, and large (≥400 beds) centers versus small (<400 beds) centers. We also compared trauma centers with Level I designation to all other centers. Primary outcomes included consent and conversion rates for potential organ donors. There were 22,732 referrals to our organ procurement organization that resulted in 1,057 eligible deaths. When comparing academic to nonacademic hospitals, academic hospitals had higher consent (71% vs 59%, P < 0.0001) and conversion (73% vs 64%, P = 0.008) rates. Level I trauma centers had better consent and conversion rates when compared to all other hospitals, 73 versus 55 per cent and 76 versus 61 per cent respectively, P < 0.0001 for both. The small, academic, trauma centers had the highest consent and conversion rates, 77 and 78 per cent, respectively, P < 0.0001 for both. Hospital characteristics such as academic involvement, Level I trauma designation, and size impact consent and conversion rates for potential organ donors. Small (<400 bed), academic, trauma centers have the highest consent rates and conversion rates. Factors for success in these institutions should be examined and applied to assist in improving donor rates across all types of hospitals.

Invasive pleomorphic lobular carcinoma (IPLC) is defined to be an uncommon and different subtype of classical invasive lobular carcinoma (ILC). This special variant is characterized by significant cytological atypia and pleomorphism which differs from the cytological uniformity of ILC. IPLC has been shown to have some poor prognostic factors such as axillary node metastasis and higher histological grade which may lead to poor clinical courses including a short relapse time, increased risk of recurrence and a decreased survival. The aim of this study is to investigate the clinicopathological characteristics and prognosis of IPLC in comparison with ILC and also to evaluate if IPLC is a different clinical entity compared to ILC. A total number of 4418 breast cancer patients treated between 1996 and 2015 in Hacettepe University Cancer Institute, were retrospectively analyzed. Among 4418 patients, 210 were diagnosed with ILC and 23 patients diagnosed with pure IPLC. In this present study, clinicopathological characteristics, disease free survival (DFS) and overall survival (OS) of patients with ILC and IPLC were compared. This study design is one of the rare face to face comparison of pure IPLC and ILC. Patients with IPLC had an increased rate of higher histologic grade, extracapsular extension, lymphovascular invasion and lower percentage of hormone positivity than those of patients with ILC. During the follow-up time, IPLC group experienced 4 cases (17.3%) of recurrence, 5 cases (21.7%) of death and 2 cases (8.7%) of progression in 3 metastatic patients compared to that of 27 cases (12.9%) of recurrence, 29 cases (13,8%) of death and 14 cases (6.7%) of progression in 19 metastatic patients in the ILC group. Patients with IPLC had a worse DFS and OS duration than patients with ILC (P = 0.02 for OS, P = 0.04 for DFS). In conclusion, IPLC is a different and a special breast cancer subtype. This study suggests that IPLC is a distinct clinical entity with an advanced stage and more aggressive clinical course. Patients with IPLC reveal poorer prognostic factors such as higher histological grade, relative lower percentages of hormone positivity, and increased rate of recurrences resulting in poor clinical outcomes and worse survival. Nowadays, it is observed that current treatment methods for IPLC do not seem as successful as in ILC and failed to be effective. Thence, individual therapies including more aggressive surgery and adjuvant or neoadjuvant chemotherapy even in the earlier stages of breast cancer should be performed for this distinct variant.

The Affordable Care Act has placed unplanned patient readmissions under more scrutiny than ever. Geriatric patients, in particular, suffer a disproportionate amount of complications from any kind of hospitalization, including readmissions. This study seeks to identify risk factors in this population that predispose them to an unplanned readmission within 30 days after index surgery. The National Surgical Quality Improvement Program database was used to select patients 65 years and older, who underwent general surgery procedures in 2012. Patient demographics, comorbidities, complications, and readmissions were analyzed. A Cox regression survivorship model was used for multivariate analysis. A total of 7712 patients were reviewed; 617 patients (8.0%) had an unplanned readmission within 30 days of their operation. Cox regression revealed five different independent predictors of unplanned readmission within 30 days. They are age [P = 0.009, hazard ratio (HR) = 1.016, 95% confidence interval (CI) = 1.01–1.03], American Society of Anesthesiologists Class >2 (P = 0.037, HR = 1.22, CI = 1.024–1.475), operation time (minutes) (P = 0.001, HR = 1.001, CI = 1.00–1.002), any complication (P = 0.03, HR = 1.449, CI = 1.33–1.852), and deep vein thrombosis (P = 0.03, HR = 1.87, CI = 1.31–3.85). Using Cox regression to adjust for patient length of stay, age, American Society of Anesthesiologists class, any complication, operation time, and venous thromboembolism all independently increased the rate of unplanned readmissions. Patients who suffer any complication or a venous thromboembolism postoperatively are at a particularly high risk of readmission. These patients should be targeted for increased inpatient monitoring and included in preventable readmission programs after discharge.

With increasing life expectancy, the elderly are participating in recreational activities traditionally pursued by younger persons. Elderly patients have many reasons for worse outcomes after trauma, one of which may be the rising use of anticoagulant and/or antiplatelet medications. This study aimed to determine whether preinjury use of these agents yielded worse outcomes in geriatric patients injured during high-impact recreational activities. The National Trauma Data Bank was reviewed from 2007 to 2010 for patients ≥65 years admitted to Level I or II trauma centers with ICD-9 E-codes for specific mechanisms of injury. These included motorcycles, bicycles, snowmobiles, all-terrain vehicles, equestrian, water and alpine skiing, snowboarding, and others. Patients with preinjury bleeding disorder (BD), including warfarin and clopidogrel use, were compared with controls via a coarsened exact matching analysis. BD patients (294) were compared with 3929 controls. Although increased in BD patients, no significant mortality differences were observed in unmatched or matched analyses. BD patients yielded greater hospital length of stay (5 vs 4 days, P = 0.020) with increased odds of receiving five units or more of blood (7.0% vs 2.1%, odds ratio = 4.7, P < 0.001) and of deep vein thrombosis (7.6% vs 3.8%, odds ratio = 2.1, P = 0.018). Elderly patients with BD, including warfarin or clopidogrel use, do not seem to have significantly increased mortality after injury during specified recreational activities. BD patients had greater hospital length of stay, transfusion requirements, and deep vein thrombosis rates. These findings may inform counseling for those taking such medications as to the potential for adverse outcomes.

This study was conducted to determine the utility of multiple imaging studies (CT angiography, magnetic resonance angiography, and/or conventional angiography), in addition to duplex ultrasonography (DU), in evaluating patients with carotid stenosis. A retrospective case series was conducted of patients with carotid stenosis who underwent DU alone or DU plus additional imaging. Concordance between DU and additional imaging and the effect on treatment plan was evaluated. Two hundred patients with carotid stenosis were evaluated. Sixty-four had DU plus additional imaging. Sixty-two of the patients (96.9%) had no change in treatment due to additional imaging. Only 2 of the 64 patients (3.1%) with additional imaging had a change in treatment plan. In conclusion, additional imaging, beyond DU, is rarely necessary for treatment planning in patients with carotid disease.

Outpatient thyroidectomy has become slowly accepted with various published reports predominantly examining partial or subtotal thyroidectomy. Concerns regarding the safety of outpatient total and completion thyroidectomy remain, especially with regard to vocal fold paralysis, hypocalcemia, and catastrophic hematoma. We aimed to evaluate the safety of outpatient thyroid surgery in a large cohort by retrospectively comparing outcomes in those who underwent outpatient (n = 251) versus inpatient (n = 291) completion or total thyroidectomy between February 2009 and February 2015. Outpatient completion and total thyroidectomy had lower rates of temporary hypocalcemia (6% vs 24.4%; P < 0.001) and no significant difference in rates of return to emergency department (1.2% vs 1.4%), hematoma formation (0.8% vs 0.7%), temporary (2% vs 4.1%) or permanent (0.4% vs 0.7%) vocal fold paralysis, or permanent hypocalcemia (0.4% vs 0%) compared with the inpatient group. Outpatients requiring calcium replacement had shorter duration of postoperative calcium supplementation (44.4 ± 59.3 days vs 63.3 ± 94.4 days; P < 0.001). Our data demonstrate similar safety in outpatient and inpatient total and completion thyroidectomy.

Laparoscopic inguinal herniorrhaphy (LIH) has a relatively high risk of urinary retention. Bladder dysfunction may delay discharge after LIH. We hypothesized that filling the bladder before Foley catheter removal decreases time to discharge (TTD) after LIH. A secondary aim was to determine incidence of postoperative urinary retention (POUR) after bladder fill (BF). We reviewed a consecutive series of total extraperitoneal and transabdominal preperitoneal LIH procedures performed by a single surgeon at our institution from 2010 to 2013. All patients were catheterized during LIH, and selected patients received a 200-mL saline BF before Foley catheter removal. Patients were required to void >250 mL before discharge. TTD and incidence of POUR were compared between the BF and no-BF groups. A total of 161 LIH cases were reviewed. BF was performed in 89/161 (55%) of cases. TTD was significantly shorter in the BF versus the no-BF group (222 vs 286 minutes, respectively; P < 0.01). Patient and operative characteristics were similar between the BF and no-BF groups (P > 0.05). Incidence of POUR in the BF and the no-BF group was 10.1 and 16.7 per cent, respectively; however, this difference was not significant (P = 0.22). No postoperative urinary tract infection occurred in either group. In conclusions, postoperative BF significantly reduces TTD after LIH. Further studies may help to determine whether shorter postanesthesia care unit time and lower POUR rates associated with BF can lower LIH procedural costs and increase patient satisfaction.

In this study, we aimed to determine factors that cause appendix perforations and to identify the role of physicians and patients in contributing to the cause of these perforations. This study was conducted between April 2010 and May 2015 and included 64 patients with perforated appendicitis. Patients’ medical records were examined for factors that might have contributed to perforation, and the roles of patients and physicians in perforation appendicitis were evaluated. The perforation rate of patients with appendicitis was 16.0 per cent. The average duration from symptom onset to hospital admission was 4.4 days (29 patients were admitted to hospital within two days, 35 were admitted later). In total, 38 patients had visited a different hospital before admission. Furthermore, six out of 26 patients who had not visited any other hospital had consumed analgesics. Factors contributing to appendix perforation included misdiagnosis at the patient's initial visit (56.0%), delayed admission to hospital (11.0%), and use of analgesics (9.0%). The cause of perforation was mostly physician-related in children and adults, and patient-related in older adults.

We assessed the effectiveness of the implementation of an institutional massive transfusion protocol (MTP) for resuscitation with a 1:1:1 transfusion ratio of packed red blood cell (PRBC), fresh frozen plasma, and platelet units. In a Level I trauma center database, all trauma admissions (2004–2012) that received massive transfusions (≥10 units PRBCs in the first 24 hours) were reviewed retrospectively. Demographic data, transfusion ratios, and outcomes were compared before (PRE) and after (POST) MTP implementation in May 2008. Age, sex, and mechanism of injury were similar between 239 PRE and 208 POST trauma patients requiring massive transfusion. Transfusion ratios of fresh frozen plasma:PRBC and platelet:PRBC increased after MTP implementation. Among survivors, MTP implementation shortened hospital length of stay from 31 to 26 days (P = 0.04) and intensive care unit length of stay from 31 to 26 days (P = 0.02). Linear regression identified treatment after (versus before) implementation of MTP as an independent predictor of decreased ventilator days after adjusting for age, Glasgow Coma Scale, and chest Abbreviated Injury Score (P < 0.0001). Modest improvement in ratios likely does not account for all significant improvements in outcomes. Implementing a standardized protocol likely impacts automation, efficiency, and/or timeliness of product delivery.

Presently, trauma guidelines recommend epidural analgesia as the optimal modality of pain relief from rib fractures. They are not ideally suited for elderly trauma patients and have disadvantages including bleeding risk. The paravertebral analgesic pump (PVP) eliminates such disadvantages and includes ease of placement in the trauma setting. This study compares pain control in patients treated by EPI versus PVP. This is a retrospective, historical cohort study comparing two methods of pain management in the trauma setting. Before 2010, patients who had epidural catheters (EPI) placed for pain control were compared with patients after 2010 in which the PVP was used. All patients had multiple rib fractures as diagnosed by CT scan. Analysis was adjusted for age, number of fractures, and comorbid conditions. Multiple linear regression analysis was conducted to compare average reported pain. A total of 110 patients, 31 PVP and 79 epidural catheters, were included in the study. Overall mean age was 65 years. The mean Injury Severity Score was 12.0 (EPI) and 11.1 (PVP). Mean number rib fractures was 4.29 (EPI) and 4.71 (PVP). PVP was associated with a 30 per cent greater decrease in pain than that seen with EPI (6.0–1.9 vs 6.4–3.4). After controlling for age, Injury Severity Score, and number of rib fractures, there were no differences in intensive care unit or total length of stay (P = 0.35) or in pain score (3.76 vs 3.56, P = 0.64). In conclusion, the PVP compares well with epidural analgesia in older trauma patients yet is safe, well tolerated, and easily inserted.

We delineated the incidence of trauma patient pulmonary embolism (PE) and risk conditions by performing a systematic literature review of those at risk for deep vein thrombosis (DVT). The PE proportion was 1.4 per cent (95% confidence interval = 1.2–1.6) in at-risk patients. Of 10 conditions, PE was only associated with increased age (P < 0.01) or leg injury (P < 0.01; risk ratio = 1.6). As lower extremity DVT (LEDVT) proportions increased, mortality proportions (P = 0.02) and hospital stay (P = 0.0002) increased, but PE proportions did not (P = 0.13). LEDVT was lower with chemoprophylaxis (CP) (4.9%) than without CP (19.1%; P < 0.01). PEwas lower withCP (1.0%) than without CP (2.2%; P = 0.0004). Mortality was lower with CP (6.6%) than without CP (11.6%; P = 0.002). PE was similar with (1.2%) and without (1.9%; P = 0.19) mechanical prophylaxis (MP). LEDVT was lower with MP (8.5%) than without MP (12.2%; P = 0.0005). PE proportions were similar with (1.3%) and without (1.5%; P = 0.24) LEDVTsurveillance. Mortality was higher with LEDVTsurveillance (7.9%) than without (4.8%; P < 0.01). A PE mortality of 19.7 per cent (95% confidence interval = 18–22) 3 a 1.4 per cent PE proportion yielded a 0.28 per cent lethal PE proportion. As PE proportions increased, mortality (P = 0.52) and hospital stay (P = 0.13) did not. Of 176 patients with PE, 76 per cent had no LEDVT. In trauma patients at risk for DVT, PE is infrequent, has a minimal impact on outcomes, and death is a black swan event. LEDVTsurveillance did not improve outcomes. Because PE was not associated with LEDVT and most patients with PE had no LEDVT, preventing, diagnosing, and treating LEDVT may be ineffective PE prophylaxis.

Trials of enhanced recovery programs suggest that multimodality pain regimens improve outcomes after colorectal surgery. We sought to determine whether patients receiving postoperative multimodality pain regimens would have shorter lengths of stay without an associated increase in readmission rate as compared to those receiving opioid-based pain regimens. Retrospective cohort study of adults who underwent elective colorectal surgery between January 1, 2006, and December 31, 2012, in a national hospital network participating in the Premier Perspective database. Patients were grouped into multimodality or opioid-based using postoperative medication charges. Primary outcome measures included length of stay and 30-day readmission rate. Among 91,936 patients, 38 per cent received multimodality pain regimens and 61 per cent received opioid-based regimens. After adjustment for patient and surgical characteristics, there was no difference in length of stay or cost, odds of readmission were 1.2 (95% confidence interval = 1.2–1.3, P < 0.001), and odds of mortality were 0.8 (95% confidence interval = 0.6–0.9, P < 0.001) in the multimodality group compared to nonopioid sparing. Our results were consistent in secondary analyses using propensity matching. Fewer than half of patients undergoing elective colorectal surgery in our cohort received multimodality pain regimens, and receipt of these medications was associated with mixed benefits in terms of length of stay, readmission, and mortality.

The purpose of this study was to investigate the relationship between the serum parathormone (PTH) levels measured after completion of hemithyroidectomy on the first side during total thyroidectomy and the postoperative hypocalcemia. The patients were divided into two groups, as those who demonstrated a decrease in PTH levels measured after completion of hemithyroidectomy of the first side (Group 1, n = 43) and those who did not demonstrate a decrease in PTH levels (Group 2, n = 24). The serum PTH levels were measured just before the incision (PTH_i), when the hemithyroidectomy stage had been completed (PTH_ht), at the end of the operation (PTH_tt), and at the postoperative 24th hour (PTH_24hr). The serum total calcium (Ca²¹) levels were also measured. The median percentage differences in PTH_tt levels based on basal PTH_i levels of Groups 1 and 2 were -60.6 and -15.7 per cent, respectively, P = 0.001. The frequency of postoperative biochemical hypocalcemia was higher in Group 1, P < 0.05. It was determined that a 10 per cent or higher decrease in PTH_ht levels in Group 1 could predict biochemical hypocalcemia at the postoperative 24th hour. In conclusions, postoperative hypocalcemia is seen more frequent in patients with a decrease of PTH_ht during total thyroidectomy. A decrease of 10 per cent in PTH_ht levels measured after ipsilateral lobectomy and a 62 per cent or higher decrease in PTH_tt levels measured in the end of the total thyroidectomy could be helpful for prediction of postoperative hypocalcemia in these patients.