The American Surgeon™

Corticosteroids play an important role in responding to physiologic stress in the human body. However, its application in critical care remains heavily debated. The purpose of this study was to identify patient characteristics associated with receiving stress-dose steroids during the intensive care unit stay after traumatic injury and its effect on in-hospital mortality. Patients admitted to the University of Virginia trauma center between January 1, 2011, and December 31, 2015, were identified using our Trauma Registry. Stress dose steroids were defined as 100 mg IV hydrocortisone every eight hours. Patients who received stress-dose steroids were identified using the Clinical Data Repository. Patient characteristics associated with increased likelihood of receiving stress-dose steroids during admission were age >65, diabetes mellitus, congestive heart failure, burn injuries, Injury Severity Score >15, lower blood pressure (141/80 vs 125/76 mm Hg), and higher heart rate (87 vs 94/min). Patients who received stress-dose steroids were found to have increased mortality but not after controlling for the aforementioned patient factors associated with increased likelihood of receiving stress-dose steroids. The use of stress-dose steroids in critically ill patients with refractory hypotension does not appear to affect in-hospital mortality.

Pneumatosis intestinalis (PI) identified on computed tomography (CT) suggests an underlying pathology including bowel ischemia. Patients receiving tube feeds can develop PI, potentially requiring surgical intervention. We identify clinical factors in PI to predict those that may be safe to observe versus those that need immediate intervention. We retrospectively reviewed patients from a single institution from 2008 to 2016 with CT findings of PI and an enteric feeding tube. Patients who had not received tube feeds within one week of the CT were excluded. We analyzed clinical, operative, and outcome data to differentiate benign from pathologic outcomes. P values < 0.05 were set as significant. Forty patients were identified. We classified 24 as benign (no intervention) and 16 as pathologic (requiring intervention). A pathologic outcome was demonstrated for free fluid on CT [odds ratio (OR) = 5.00, confidence interval (CI) 1.23-20.30, P = 0.03)], blood urea nitrogen (BUN) elevation (OR = 8.27, CI 1.53-44.62, P = 0.01), creatinine (Cr) elevation (OR = 5.00, CI 1.27-19.62, P = 0.02), BUN/Cr ratio >30 (OR = 8.57, CI 1.79-40.98, P = 0.006), and vomiting/ feeding intolerance (OR = 9.38, CI 1.64-53.62, P = 0.01). Bowel function within 24 hours of the CT, bowel dilatation (small ≥ 3 cm; large ≥6 cm), and lactic acidemia were not significant. Peritonitis was only seen in pathologic states, but this did not reach statistical significance (P = 0.06). This represents the largest single-center retrospective analysis of tube feeding-induced PI to date. The presence of free fluid on CT, BUN and Cr elevation, BUN/Cr >30, vomiting/feeding intolerance and peritonitis were predictive of a pathologic etiology of PI.

Accurate localization of parathyroid adenomas allows for minimally invasive parathyroidectomy. This results in a shorter length of stay and increased patient satisfaction. Preoperative Technetium (^99mTc) sestamibi scans accurately localize parathyroid adenomas in 70 to 85 per cent of cases. If a patient has a negative scan, it is logical to believe that with a preoperative sestamibi injection, the gamma probe may fail to help find an adenoma. We hypothesized that the gamma probe would not be useful intraoperatively for patients with primary hyperparathyroidism (PHPTH) and a negative sestamibi scan. We retrospectively reviewed the cases of parathyroidectomy at our institution from 2010 to 2016. We selected patients with PHPTH and negative sestamibi scan. In all cases, an attempt was made to find adenomas intraoperatively with the gamma probe. A frozen section was obtained as well as intraoperative parathyroid hormone levels to confirm removal of hyperfunctioning parathyroid tissue. There were 132 parathyroidectomies of which 22 had PHPTH and a negative sestamibi scan. One case was excluded because of insufficient documentation of the intraoperative use of the gamma probe. In 19 of the 21 patients analyzed, the gamma probe successfully identified the adenoma in the operating room (sensitivity, 90.5%). In two patients, the gamma probe did not aid in localization. There were no false positives. In all cases, the parathyroid resected was confirmed by frozen section. The intraoperative parathyroid hormone levels dropped >50 per cent in all but three cases, two of which corresponded to those cases where the gamma probe did not help. Even in patients with negative sestamibi scans, intraoperative use of the gamma probe after preoperative sestamibi injection is effective in localizing parathyroid adenomas.

The role of decompressive craniectomy (DC) for severe traumatic brain injury (STBI) remains controversial. The purpose of this study was to identify factors that are indicators of survival and improved functional outcome in patients who undergo DC for STBI. A retrospective review of STBI patients who underwent DC was performed at four trauma centers during a 45-month period. Data collected included age, gender, mechanism of injury, Injury Severity Score (ISS), admission Glasgow Coma Scale (GCS), time from admission to DC, mortality, and extended Glasgow Outcome Score before discharge. Sixty-nine STBI patients were treated with DC during the study period. A higher initial GCS, lower ISS, and longer time to DC were all statistically significant for improved survival after DC. A younger age, higher initial GCS, and lower ISS were all statistically significant for a favorable functional outcome after DC. Patients with a higher initial GCS and lower ISS are more likely to survive DC and have a favorable functional outcome, whereas a longer time to DC was indicative of improved survival after DC.

The Prevalence of ventricular assist devices (VADs) is increasing as advanced cardiac therapies progress. These patients commonly require non-cardiac surgical procedures (NCS), although data are scant regarding the safety, timing, and operations that may safely be performed. We aim to describe our experience with VAD patients undergoing NCS. We retrospectively reviewed records on patients who underwent NCS after VAD implantation between 2013 and 2015 at a single Joint Commission–accredited VAD institution. Data collection included demographics, ischemic cardiomyopathy or nonischemic cardiomyopathy, operative details, and perioperative anticoagulation management and outcomes. Seventy-two NCS were performed by general surgeons, thoracic surgeons, plastic surgeons, urologists, vascular surgeons, ENTs, and other services. Procedures were similarly varied, including video-assisted thoracoscopy with decortications or lung biopsy, tracheostomies, percutaneous endoscopic gastrostomies, exploratory laparotomies, and wound debridements and/or closures. The ten deaths in the study group were judged not to be directly related to NCS. Eleven cases had postoperative bleeding and two cases had postoperative thrombosis, including one pump thrombosis. Based on our results, VAD is not an absolute contraindication to NCS, and a variety of NCS procedures can safely be performed. Further study should focus on quantifying and mitigating the risk that VADs bring to NCS.

This is a 10-year retrospective chart review evaluating the potential impact of the most recent American Cancer Society mammography screening guidelines which excludes female patients aged 40 to 44 years from routine annual screening mammography. Instead they recommend screening mammography starting at age 45 with the option to begin screening earlier if the patient desires. The institutional cancer registry was systematically searched to identify all women aged 40 to 44 years treated for breast cancer over a 10-year period. These women were separated into two cohorts: screening mammography detected cancer (SMDC) and nonscreening mammography detected cancer (NSMDC). Statistical analysis of the cohorts was performed for lymph node status (SLN), five-year disease-free survival, and five-year overall survival. Women with SMDC had a significantly lower incidence of SLN positive cancer than the NSMDC group, 9 of 63 (14.3%) versus 36 of 81 (44 %; P < 0.001). The five-year disease-free survival for both groups was 84 per cent for SMDC and 80 per cent for NSMDC; this was not statistically significant. The five-year overall survival was statistically significant at 94 per cent for the SMDC group and 80 per cent for the NSMDC group (P < 0.05). This review demonstrates the significance of mammographic screening for early detection and treatment of breast cancer. Mammographic screening in women aged 40 to 44 detected tumors with fewer nodal metastases, resulting in improved survival and reaffirming the need for annual mammographic screening in this age group.

Brain death is known to be associated with physiologic derangements but their incidence is poorly described. Knowledge of the changes that occur during brain death is important for management of the potential organ donor. Thus, we sought to characterize the pathophysiology that occurs during brain death in patients with traumatic injuries. All brain-dead patients over a 10-year period were identified from the trauma registry at a level 1 urban trauma center. Patient demographics, injury characteristics, and clinical data for defining organ dysfunction were reviewed for the 24 hours surrounding brain-death declaration. Three hundred and seventy-three patients were identified. Mean age was 37 years (617.2). Seventy-five per cent were male. Major mechanism of injury was blunt trauma in 66 per cent. Median injury severity score was 34 (IQR 25–43) with a median head abbreviated injury scale score of 5. The most common physiological disturbance was hypotension with 91 per cent of subjects requiring vasopressors. Thrombocytopenia and acidosis both had an incidence of 79 per cent. The next most common disturbances were hypothermia and moderate-to-severe respiratory dysfunction in 62 per cent. Myocardial injury was seen in 91 per cent but only 5.7 per cent of patients manifested severe cardiac dysfunction with an ejection fraction of <35. Diabetes insipidus was diagnosed in 50 per cent of patients. Interestingly, coagulopathy was noted in only 61.3 per cent, and hyperglycemia was seen in 36 per cent despite widespread belief that these occur universally during brain death. This is the first and largest study to characterize the incidence of pathophysiological disturbances following brain death in humans. Appropriate management of these dysfunctions is important for support of potential brain-dead organ donors.

Post-traumatic fluid management is a widely debated topic. No best-practice consensus exists. Adverse outcomes such as acute kidney injury or volume overload are common. Continuous renal replacement therapy (CRRT) is an adjunct therapy for severe acute renal failure and volume overload, but is costly and not without risk. Hemodynamic transesophageal echocardiography (hTEE) is widely accepted as a reliable way to monitor volume status of intensive care unit (ICU) patients. Although data exist evaluating hTEE and CRRT independently, there is a lack of research mutually inclusive of the two. We hypothesized that the use of hTEE is associated with less need for CRRT. Retrospective review of a level I trauma center from 2009 to 2015 identified patients that required CRRT. In 2013, we implemented a protocol using hTEE in trauma patients with significant resuscitation needs. We compared CRRTuse before and after implementation of the protocol (pre- and post-hTEE). Multivariate analysis using two sample t tests and χ² test of the odds ratio (O.R.) was completed on variables such as injury severity score (ISS), acute kidney injury network (AKIN), days of CRRT, ICU length of stay (LOS), and hospital LOS. A total of 5037 and 6699 trauma patients were evaluated in the pre- and post-hTEE groups, respectively. Mean ISS was 22 and 28 for pre- and post-hTEE, respectively (P value 0.19). Mean AKIN was 2.7 for both groups. Mean days on CRRT was eight before hTEE and seven after hTEE (P value 0.7); 23 patients required CRRT pre-hTEE, and 15 required CRRT post-hTEE (P value 0.01 O.R. 2.4). Given, the odds of CRRT pre-hTEE are more than twice that of CRRT post-hTEE; we conclude that the use of hTEE is associated with a reduction of CRRT.

The newly characterized modified frailty index (mFI) is a robust predictor of postoperative outcomes for surgical patients. The present study investigates the optimal cutoff for mFI specifically in older gastrointestinal (GI) cancer patients undergoing surgery. All patients more than 60 years old who underwent surgery for a GI malignancy (esophagus, stomach, colon, rectum, pancreas, liver, and bile duct) were identified in the 2005 to 2012 National Surgical Quality Improvement Program, Participant Use Data File (NSQIP PUF). Patients undergoing emergency procedures, of American Society of Anesthesiologists (ASA) five status, or diagnosed with preoperative sepsis were excluded. Logistic regression modeling and 10-fold cross validation were used to identify an optimal mFI cutoff. A total of 41,455 patients (mean age 72, 47.4% female) met the eligibility criteria. Among them, 19.0 per cent (n = 7891) developed a major postoperative complication and 2.8 per cent (n = 1150) died within 30 days. A random sampling by a cancer site was performed to create 90 per cent training and 10 per cent test sample datasets. Using 10-fold cross validation, logistical regression models evaluated the association between mFI and endpoints of 30-day mortality and major morbidity at various cutoffs. Optimal cutoffs for 30-day mortality and major morbidity were mFI ≥ 0.1 and ≥0.2, respectively. After adjusting for age, sex, ASA, albumin ≥3g/dl, and body mass index ≥ 30 kg/m², mFI ≥ 0.1 was associated with increased mortality (odds ratio (OR) 1.49, 1.30–1.71 95% confidence interval (CI), P < 0.001) and mFI ≥ 0.2 was associated with increased morbidity (OR 1.52, 1.39–1.65 95% CI, P < 0.001). For older GI cancer patients, a very low mFI was a predictor of poor postoperative outcomes with an optimal cutoff of two or more mFI characteristics.

Surgeons perceive that some surgical transfers are futile, but the incidence and risk factors of futile transfer are not quantified. Identifying futile interfacility transfers could save cost and undue burdens to patients and families. We sought to describe the incidence and factors associated with futile transfers. We conducted a retrospective cohort study from 2009 to 2013 including patients transferred to a tertiary referral center for general or vascular surgical care. Futile transfers were defined as resulting in death or hospice discharge within 72 hours of transfer without operative, endoscopic, or radiologic intervention. One per cent of patient transfers were futile (27/ 1696). Characteristics of futile transfers included older age, higher comorbidity burden and illness severity, vascular surgery admission, Medicare insurance, and surgeon documentation of end-stage disease as a factor in initial decision-making. Among futile transfers, 82 per cent were designated as do not resuscitate (vs 9% of nonfutile, P < 0.01), and 59 per cent received a palliative care consult (vs 7%, P < 0.01). A small but salient proportion of transferred patients undergo deliberate care de-escalation and early death or hospice discharge without intervention. Efforts to identify such patients before transfer through improved communication between referring and accepting surgeons may mitigate burdens of transfer and facilitate more comfortable deaths in patients’ local communities.

Breast conserving therapy (BCT), lumpectomy followed by radiotherapy, is an effective treatment for a majority of breast cancers. According to the National Comprehensive Cancer Network, mammographic imaging should be completed at least six months after completion of radiation. This study evaluates the clinical significance and financial cost of postoperative breast imaging within one year of BCT. Patients treated with BCT between 2014 and 2016 at an academic center were identified retrospectively. The medical records were reviewed to identify the timing and type of the first imaging study after BCT. This study evaluated the clinical significance and the cost of postoperative imaging. A total of 128 patients were included into the study. Seventy-six patients received mammograms 3 to 12 months after BCT. Six of the 76 postoperative mammograms required additional imaging/intervention for a total of seven additional imaging studies and three procedures, all of which revealed benign findings. None of these patients had physical examination findings that were of clinical concern. The total cost of postoperative imaging and procedures performed less than a year after BCT was estimated to be $32,506. Postoperative imaging performed on breast cancer patients less than a year after BCT proved to be of no medical benefit and revealed no additional significant pathology. The mammographic surveillance in this study did not lead to the diagnosis of recurrent malignancy or second primary lesions and placed additional financial burden on the patient population. This study demonstrates that breast imaging within a year after BCT had no clinical impact and resulted in increased cost of care.

This study seeks to determine whether uninsured breast cancer patients are more likely to present with advanced disease relative to insured patients. We retrospectively reviewed newly diagnosed breast cancer patients over a 27-month period. Patients were sorted based on insurance status at diagnosis. Demographic and tumor-specific data were collected and analyzed using non-parametric testing. We identified 276 breast tumors in 260 patients. Out of the 260 patients, 71 patients (27.3%) were uninsured and were more likely to be black (P < 0.05), present with a breast-specific complaint rather than an abnormal mammogram (P < 0.05), and present with more advanced disease (52% stage II or worse vs 26.6% in the insured population; P < 0.01). Percentage of invasive carcinoma and tumor biology were independent of insurance status. Insured patients were more likely to receive surgery as first therapy (76.5 vs 46.0%, P < 0.01), whereas uninsured patients were more likely to receive chemotherapy suggesting multimodality treatment. Uninsured patients had a longer time to therapy initiation (56.0 days vs 44.5 days, P < 0.05). Our study confirms that uninsured patients present with higher stage disease are more likely to have breast-specific complaints and are more likely to require chemotherapy as first-line treatment confirming the under-utility of screening mammography within our uninsured patients.

The purpose of this review was to evaluate outcomes relating to parastomal hernia repair. Data from the Americas Hernia Society Quality Collaborative were used to identify patients undergoing parastomal hernia repair from 2013 to 2016. Parastomal hernia repairs were compared with other repairs using Pearson's test and Wilcoxon test with a P value <0.05 considered significant. Parastomal hernia repairs were performed in 311 patients. Techniques of repair include open in 85 per cent and laparoscopic in 15 per cent. Mesh was used in 92 per cent with keyhole in 34 per cent, flat mesh in 33 per cent, and Sugarbaker in 25 per cent. Mesh types were permanent synthetic in 79 per cent, biologic in 13 per cent, absorbable synthetic in 6 per cent, and hybrid synthetic/biologic in 2 per cent. Most common location for mesh was sublay in 84 per cent followed by onlay in 14 per cent and inlay in 2 per cent with 59 per cent of patients undergoing a myofascial release. Ostomy disposition included ostomy left in situ (47%), moved to a new site (18%), taken down (22%), and rematured in same location in (13%). Outcomes related to parastomal hernia repair included 10 per cent surgical site infection, 24 per cent surgical site occurrence, and 12 per cent surgical site occurrences requiring procedural interventions with a 13 per cent readmission rate and 6 per cent reoperation rate. When comparing parastomal hernias with other ventral hernia repairs, parastomal hernias had a significantly higher surgical site infection, surgical site occurrence, surgical site occurrences requiring procedural intervention, readmission, reoperation rate, and length of stay, and were less commonly performed laparoscopically (P < 0.05). Most parastomal hernias are being repaired open with synthetic mesh in the sublay position. Less favorable outcomes of parastomal hernia repair when compared with other ventral hernia repairs are likely related to the complexity of parastomal hernia repair.

Prospective studies have shown equal outcomes after mastectomy or breast conservation in patients with invasive breast cancer; however, many of these studies excluded elderly patients. We identified patients in their eighties and nineties with clinical stage 0 to II breast cancer undergoing mastectomy or lumpectomy with or without radiation from the prospective sentinel lymph node database at Wake Forest Baptist Health and analyzed their treatment and survival. Of 92 patients, 24 (26.1%) underwent mastectomy, 22 (23.9%) lumpectomy with radiation, and 46 (50.0%) lumpectomy alone. Significant differences were noted in tumor size (P = 0.018), nodal status (P = 0.013), and stage (P = 0.011) between the groups. Only 7.6 per cent of patients had chemotherapy, whereas 51.1 per cent took antiestrogen therapy. Recurrence occurred in 11 patients. In univariate analysis, overall survival did not differ by surgery. Age was the only factor that increased risk of death (HR = 1.19, P = 0.028). In this age group, neither tumor factors nor the type of local treatment significantly influenced overall survival. Octogenarians and nonagenarians with early-stage breast cancer undergoing breast-conserving surgery with or without radiation have equivalent survival to patients having a mastectomy.

The aim of the study was to quantify nutritional losses related to pre- and postoperative fasts in critically ill intubated patients and to explore whether shorter fasts are safe and appropriate in this population. A retrospective review of mechanically ventilated adults undergoing surgery more than 24 hours after admission to a Level I trauma center over 15 months was done, which yielded 132 procedures and 81 unique patients. Ninety per cent of preoperative periods and 43 per cent of postoperative periods were affected by nonmedical barriers to feeding. Eighty-two per cent of gastrically fed nonemergent cases were fasted for longer than the 6-hour American Society of Anesthesiologists guideline, whereas 91 per cent of emergent cases had shorter fasts. There were no anesthetic complications, placing an upper limit of 6 per cent on the rate of aspiration for fasts shorter than six hours (95% confidence). Forty-three per cent of cases did not resume tube feeds within 90 minutes postoperatively, and only 37 per cent had a documented justification for delay. Intubated patients were frequently fasted preoperatively for longer than recommended and postoperatively for longer than medically indicated. No complications were observed with shorter-than-guideline fasts. This strengthens the evidence that “standard” preoperative fasting is unnecessary and deleterious in many critically ill intubated patients. New protocols and national guidelines are needed to ensure adequate nutrition.

Timing of chest tube (CT) removal after transition from suction to water-seal (WS) varies when treating traumatic simple pneumothoraces (PTXs). Longer periods of WS may identify slow-occurring PTXs reducing CT replacement, whereas shorter periods may expedite patient disposition and have associated cost savings. Prior studies support the need for an interval of WS. We compare durations of WS, looking at rates of CT reinsertion. A 10-year retrospective review on trauma patients with a simple PTX requiring a CT was performed. WS duration of 1 to 8 hours (short - SG) versus 18 to 36 hours (long - LG) were compared. Univariate analysis and multivariate logistic regression were used. Of the 2000 patient charts reviewed, 209 met the criteria, with 43 in the SG and 166 in the LG. Patient demographics and mechanism of injury were similar. There was no difference in CT replacement [6.9% (SG) vs 4.8% (LG), P 0.59]. Logistic regression revealed an increase in CT replacement if the patient ever had positive pressure ventilation (OR 4.1, CI 1.1–17, P 0.04) and if returned to suction from WS (OR 6.3, CI 1.2–28, P 0.03). Short intervals of WS do not increase CT reinsertion while decreasing the total time and morbidity associated with CT.

Parastomal hernias (PHs) cause significant morbidity in patients with permanent ostomies, and several laparoscopic and open repair techniques have been described. We report our experience with open retromuscular repair of PHs using permanent synthetic mesh. A prospectively maintained database was retrospectively reviewed to identify patients undergoing PH repair. Primary outcomes are surgical site occurrence, surgical site infection (SSI), and hernia recurrence. Variables were analyzed using Pearson's χ² test or Fisher's exact test. Values of P < 0.05 were considered significant. Forty-six patients underwent retromuscular PH repair with permanent synthetic mesh. There were 26 patients with colostomies and 20 with ileostomies. All the patients were repaired using a keyhole retromuscular technique and direct passage of stoma through mesh. Transversus abdominis release was performed in 65.2 per cent of cases. Permanent synthetic polypropylene mesh was used in all cases. Surgical site occurrence occurred in 47.8 per cent of patients, SSI in 17.4 per cent, and hernia recurrence in 21.7 per cent. Resiting the stoma yielded the highest rate of SSI (40%) compared with leaving the stoma in situ (11.8%) or rematuring the stoma (0%; P = 0.011). Open keyhole retromuscular PH repair of PH with permanent synthetic mesh is safe, effective, and durable.

Esophageal perforation is a complex clinical entity that has multiple etiologies and variability in presentation, making it challenging to diagnose and treat. The mortality of esophageal perforation has improved because therapies have evolved. Whereas primary repair is the standard of care, multiple treatments may be employed successfully. We retrospectively reviewed all cases of suspected or confirmed esophageal perforation that were admitted to the thoracic surgery service at our institution between January 2011 and June 2016. We reviewed the charts of 61 patients. Twenty-three underwent primary repair, 13 underwent stent placement, 12 underwent drainage, 12 underwent medical management, and one underwent exclusion and diversion. All patients were included in the final analysis except the singular patient who underwent diversion. Overall mortality was 4.9 per cent. None of the studied variables were found to be associated with mortality (P > 0.05). Factors associated with choice of treatment were age (P < 0.0005), Charlson Index (P = 0.032), etiology (P < 0.0005), and location (P = 0.005). The application of different management options is based on a thorough understanding time course, patient anatomy, severity of presentation, and underlying disease process.

Robotic surgery (RS) is a novel treatment for rectal cancer resection (RCR); however, this technology is not widely accessible. The objective of this study is to evaluate the utilization of RS in RCR compared with open and laparoscopic techniques and to assess the quality of resection. RCR from 2010 to 2012 were identified using the National Cancer Database and placed into categories: open, laparoscopic, and robotic. A total of 23,857 patients who received open, laparoscopic, and robotic RCR were included (n = 14,735 (61.8%); 7,185 (30.1%); 1,937 (8.1%), respectively). Patients over 70 had a lower likelihood of robotic RCR. Patients with insurance were 2 times more likely to have robotic RCR. Patients at an academic/research program were more likely to undergo RS compared with a community cancer program (OR 3.6, 95% CI [2.79, 4.78]; P < 0.0001). Length of stay (LOS) was longer in open (7.9 ± 7.1) versus laparoscopic (6.6 ± 6.3) or robotic (6.8 ± 6.4) RCR (P < 0.0001). Although there was an increased likelihood of positive surgical margins with open RCR (OR 1.3, 95% CI [1.09, 1.66]; P < 0.0001), there was no difference in robotic and laparoscopic techniques. Younger insured patients at academic/research affiliated hospitals have a higher likelihood of receiving robotic RCR. Compared with open RCR, robotic RCR have a lower likelihood of positive surgical margins and shorter LOS.

Peripherally inserted central venous catheters (PICCs) are now commonly used for central access in the intensive care unit (ICU) setting; however, there is a paucity of data evaluating the complication rates associated with these lines. We performed a retrospective review of all PICCs placed in the inpatient setting at our institution during a 1-year period from January 2013 to December 2013. These were divided into two groups: those placed at the bedside in the ICU and those placed by interventional radiology in non-ICU patients. Data regarding infectious and thrombotic complications were collected and evaluated. During the study period, 1209 PICC line placements met inclusion criteria and were evaluated; 1038 were placed by interventional radiology in non-ICU patients, and 171 were placed at the bedside in ICU patients. The combined thrombotic and central line associated blood stream infection rate was 6.17 per cent in the non-ICU group and 10.53 per cent in the ICU group (P = 0.035). The thrombotic complication rate was 5.88 per cent in the non-ICU group and 7.60 per cent in the ICU group (P = 0.38), whereas the central line associated blood stream infection rate was 0.29 per cent in the non-ICU group and 2.92 per cent in the ICU group (P = 0.002). This study seems to suggest that PICC lines placed at the bedside in the ICU setting are associated with higher complication rates, in particular infectious complications, than those placed by interventional radiology in non-ICU patients. The routine placement of PICC lines in the ICU settings needs to be reevaluated given these findings.

Enhanced Recovery Protocols (ERPs) have been shown to lead to quicker recovery in colorectal surgery, with reduced postoperative length of stay (LOS). ERPs could potentially be improved with an expanded preoperative component reflecting current evidence. We hypothesize that an ERP with an expanded preoperative component will reduce LOS consistent with or exceeding that seen with traditional ERPs. Our ERP was implemented in June of 2014. Data was collected for two full years from July 2014 through June 2016. The protocol was employed in colorectal cases, both elective and emergent. Data from ERP cases were compared with contemporaneous controls that did not go through the ERP. Patients who underwent colorectal procedures and participated in the ERP with the expanded preoperative component had an average LOS of 5.33 days, whereas controls stayed for an average of 7.93 days (P value, <0.01). ERP cases also experienced fewer read-missions and complications, although statistical significance could not be established. The results demonstrate that an ERP with an enhanced preoperative component significantly reduces LOS and potentially decreases the rate of readmissions and total complications.