The American Surgeon™

The optimal follow-up protocol for patients undergoing thoracic endovascular aortic repair (TEVAR) for traumatic thoracic aortic injury remains unclear. The objective of this study was to assess follow-up patterns in such patients and present an approach to improve long-term follow-up in this cohort. The University of Louisville Trauma Registry was queried for patients who underwent TEVAR for traumatic thoracic aortic injuries between 2006 and 2016. Demographic, injury-specific, perioperative, and outcome measures were recorded for each patient. Follow-up evaluation and duration of follow-up were captured. Follow-up imaging was reviewed for any evidence of vascular complications. A total of 56 patients underwent TEVAR for traumatic thoracic aortic injury. Median age was 48 (range 18–86). Injury mechanism was largely blunt trauma (55 (98%)). Median injury severity score was 34 (range 17–43). Median length of stay was 12.5 days (range 1–40 days), and 51 patients (91%) survived to discharge. Of these, 30 (54%) made at least one follow-up appointment, and 21 of those 30 (70%) received a follow-up CT scan. Median time to last follow-up was one month (range 0–48 months), with 12 patients (21%) having follow-up beyond two months. No patients demonstrated any evidence of vascular complications on imaging at last follow-up. Despite the increased use of TEVAR to treat traumatic aortic injuries, limited follow-up data exist to predict the long-term outcomes of such interventions. Development of statewide or regional databases may help better track outcomes and identify late complications.

Patients often receive axillary ultrasound-biopsy (AUS-B) before clinical evaluation. One positive biopsy in the absence of palpable disease rarely indicates additional nodal involvement, but it eliminates patients from being managed by the American College of Surgeons Oncology Group Z0011 trial criteria. To determine which patients may benefit from AUS-B, we analyzed whether characteristics on AUS were associated with large-volume axillary disease and, thus, the need for axillary lymph node (LN) dissection. A retrospective review identified patients who met Z0011 criteria and underwent AUS. Clinicopathologic and ultrasound characteristics were compared between patients with ≤2 versus ≥3 positive LNs. Two hundred and seven patients with cT1-2N0 tumors underwent preoperative AUS and breast-conserving surgery. On multivariate analysis, three AUS combinations were associated with ≥3 positive LNs: cortical thickness (CT) > 4 mm + loss of fatty hilum + round shape (P = 0.0218), CT > 4 mm + loss of fatty hilum (P = 0.0211), and CT > 4 mm + round shape (P = 0.0155). Preoperative axillary LN biopsy in patients with a single abnormal LN characteristic on AUS may be unnecessary because a positive finding will eliminate management according to Z0011 criteria. Cortical thickness >4 mm combined with any other abnormal characteristic was associated with ≥3 positive LNs, supporting the performance of AUS-B in this population.

The incidence and causes of failed paraesophageal hernia repairs (PEHR) remain poorly understood. Our study aimed to evaluate long-term clinical outcomes after reoperative fundoplication as compared with initial PEHR. A prospectively maintained institutional hernia-specific database was queried for PEHR between 2008 and 2017. Patients with prior history of PEHR were categorized as “redo” paraesophageal hernia (RPEH). Primary outcomes included postoperative morbidity, mortality, symptom resolution, and hernia recurrence. A total of 402 patients underwent minimally invasive PEHR (Initial PEH = 305, RPEH = 97). Redo PEHR had more prevalent preoperative nausea/vomiting (50.6% vs 34.1%, P < 0.007) and weight loss (24.1% vs 13.5%, P < 0.02). RPEH had had longer mean operative time (256.4 ± 91.2 vs 190.3 ± 59.9 minutes, P < 0.0001) and higher rate of conversion to open (10.3% vs 0.67%, P < 0.0001); however, no difference was noted in postoperative complications, hernia recurrence, or mortality between cohorts. Laparoscopic revision of prior PEHR in symptomatic patients can be safely performed with favorable outcomes compared with initial PEHR. Despite redo procedures seeming to be more technically demanding (as noted by longer operative time and higher conversion rates), outcomes are similar and overall resolution of symptoms is achieved in most patients.

Surgical site infections (SSI) are common complications after open ventral hernia repair (OVHR), potentially requiring further intervention. Antibiotic lavage before abdominal closure has been shown to lower the incidence in intra-abdominal and soft tissue SSI. A retrospective review of OVHR was performed with mesh at Greenville Health System Hernia Center between 2008 and 2017. Patients were divided into three groups, receiving no antibiotic irrigation (Grp 1, n = 260), gentamicin alone (Grp 2, n = 263), or gentamicin 1 clindamycin (G 1 C) irrigation (Grp 3, n = 299). Differences in categorical variables among the three groups were tested using chi-squared or Fischer's exact test (for n < 5). Analysis of continuous variables was performed using analysis of variance or Kruskal-Wallis test for differences in length of stay. Logistic regression was performed using all clinically relevant variables to determine the effects of irrigation on SSI. Incidence of surgical site occurrence was significantly lower after G 1 C irrigation (Grp 1, 28.1%; Grp 2, 35.4%; Grp 3, 19.7%; P < 0.001). Incidence of SSI was significantly lower after G 1 C irrigation, but not G alone (Grp 1, 16.5%; Grp 2, 15.2%; and Grp 3, 5.4%; P < 0.001). Multivariate logistic regression demonstrated significantly increased SSI with contaminated wounds (OR 2.96; 95% confidence interval (CI) 1.39–6.21), dirty wounds (OR 3.84; 95% CI 1.49–9.69), and chronic obstructive pulmonary disease (OR 3.70; 95% CI 2.16–6.38), as expected. Use of G 1 C was an independent predictor of decreased SSI (OR 0.33; 95% CI 0.16–0.67). Irrigation with a combined G 1 C antibiotic irrigation significantly reduces the incidence of surgical site infection after OVHR with mesh.

Procedures and outcomes for pediatric esophageal foreign body removal were analyzed. Traditional methods of battery removal were compared with a magnetic tip orogastric tube (MtOGT). A single institution retrospective review from 1997 to 2014 of pediatric patients with esophageal foreign bodies was performed. Balloon extraction with fluoroscopy (performed in 173 patients with 91% success), flexible endoscopy (92% success in 102 patients), and rigid esophagoscopy (95% in 38 patients) had excellent success rates. A MtOGT had 100 per cent success in six disc battery patients, when other methods were more likely to fail, and was the fastest. Power analysis suggested 20 patients in the MtOGT group would be needed for significant savings in procedural time. Thirty-two per cent of all foreign bodies and 95 per cent of batteries had complications (P = 0.002) because of the foreign body. Overall, 1.2 per cent had severe complications, whereas 10 per cent of batteries had severe complications (P = 0.04). Each technique if applied appropriately can be a reasonable option for esophageal foreign body removal. Magnetic tip orogastric tubes used to extract ferromagnetic objects like disc batteries had the shortest procedure time and highest success rate although it was not statistically significant. Disc batteries require emergent removal and have a significant complication rate.

Epiphrenic diverticula are pulsion-type outpouchings of the distal esophagus associated with motility disorders. They can present with chronic symptoms of dysphagia, regurgitation, reflux, and aspiration. A prospectively collected surgical outcomes database was queried for patients who underwent surgical treatment of epiphrenic diverticula at a single institution between August 1997 and August 2018. Patient demographics, presenting symptoms, operative intervention, and perioperative data were retrospectively reviewed. Twenty-seven patients with a symptomatic epiphrenic diverticulum were identified. Abnormal esophageal motility was diagnosed in 16 patients (59.2%), most commonly achalasia (29.6%). All patients had a minimally invasive (26 laparoscopic, one thoracoscopic) diverticulectomy with no conversions to open required. Concurrent myotomy was performed in 88.9 per cent patients and anti-reflux procedure in 85.2 per cent patients. There was minimal morbidity with no esophageal leaks, mortalities, or recurrent diverticula noted after 35.8 months of follow-up. Dysphagia was the most common persistent symptom and occurred in 11.1 per cent; overall resolution of symptoms was achieved with surgery in 89.9 per cent of patients. As minimally invasive techniques have advanced, laparoscopic diverticulectomy seems to be an excellent surgical approach for symptomatic epiphrenic diverticula. Long-term resolution of symptoms was achieved in most patients, with a very low complication rate.

The demand for organs for kidney transplantation (KTX) compels the use of high-risk donation after circulatory death donors (DCDs) and extended criteria donors (ECDs). Many deceased donors receive prehospital CPR, but the literature does not address CPR as a benefit to graft survival. We hypothesized that donor prehospital CPR correlates with improved graft survival with high-risk DCD/ECD kidneys. We retrospectively analyzed KTX recipients and their donor data from 2008 to 2013. A total of 646 cadaveric donors (498 SCDs, 55 DCDs, and 93 ECDs) facilitated 910 KTX. There were 223 KTX performed from 148 high-risk DCDs/ECDs (31 with CPR and 117 without CPR). The mean age of high-risk DCDs/ECDs with CPR was 44.94 versus 53.45 years without CPR (P = 0.005). The recipients of high-risk DCDs/ECDs revealed no significant difference in body mass index, length of stay, discharge Cr, CIT, or DGF with and without CPR. Graft survival at three years was significant with 0/50 failures from high-risk DCDs/ECDs with CPR versus 16/173 without CPR (P = 0.026). Our findings are limited as a single-center retrospective study; however, the result of significant three-year graft survival in high-risk DCDs/ECDs with CPR suggests that prehospital donor CPR should be further investigated for its contribution to the relative quality of the donor.

Multiple studies have shown the detrimental effect of miscommunication during transitions of care. The aim of this study is to determine whether a certain method of “sign-out” can improve information transmission and thereby reduce medical errors. Surgical interns underwent a 90-minute training session before starting residency in five previously verified methods of sign-out. They were randomly assigned to six groups (five methods and a control group). They were then given seven simulated patient charts with varying levels of medical complexity. They were then instructed to “sign-out” the patients to randomly selected colleagues. The control group did not use any of the previously taught methods and passed on information in a manner of their choosing. None of the methods consistently results in excellent transitions of care. Patient information values ranged from 26 to 40 (depending on complexity). Major points were consistently missed by all methods, but this may have been a component of the time constraint placed on this study. The “SIGNOUT?” method resulted in superior data transmission when compared with the control group (P = 0.0401). The only method that seemed to be significantly inferior was the “9Ds” method (P = 0.0610). The “SIGNOUT?” method leads to the largest amount of relevant information transmitted to the incoming team. There was no statistically significant difference among the other methods. Improvement in “sign-out” modalities and training may improve transmission of relevant patient information, but larger studies are needed to verify the data seen in this small, single-site study.

Patients presenting with near-obstructing colon lesions requiring segmental colectomy may benefit from intraoperative colonoscopy (IOC) after primary anastomosis for a more timely and accurate diagnosis of synchronous lesions. The aim of this study is to demonstrate the feasibility and safety of this technique. A retrospective cohort study of patients undergoing single-stage segmental colectomy and anastomosis at a single tertiary care institution from 2011 to 2013 was performed. One Hundred and sixty-eight consecutive patients underwent segmental colectomy and primary anastomosis of which 78 (46%) were unable to receive preoperative colonoscopy (POC) because of near-obstructing lesions and received IOC after the anastomosis. IOC detected synchronous adenomatous polyps in 24.4 per cent, diverticular disease in 19 per cent, and colitis/proctitis in 2.5 per cent. The IOC group was not significantly different from the POC group with regard to overall morbidity (31% vs 39% P = 0.45), anastomotic leakage (1.3% vs 0%, P = 0.46), or wound infection (5.1% vs 1.1%, P = 0.18). Operation time was 19 minutes longer in the intra-operative group, but overall length of hospital stay was not significantly different (6.4 ± 2.9 days vs 7.3 ± 4.6 days). In patients unable to receive POC because of partial obstruction, IOC after primary anastomosis is both feasible and safe for detecting proximal synchronous lesions.

Antithrombotic (anticoagulant [AC] and antiplatelet [AP]) drugs have been associated with mortality in geriatric patients with intracranial hemorrhage (ICH). It is unclear whether trauma team activation (TTA) in this cohort impacts outcome. Patients ≥65 years with a Glasgow Coma Scale of ≥13 and ICH over four years were included and were divided into three groups according to type of drug: group 1, AC with or without AP; group 2, AP only and; group 3, no AC or AP. The Rotterdam score was used to characterize the severity of CT findings. The primary outcome was inhospital mortality or transition to comfort measures. The secondary outcome was need for neurosurgical intervention within 48 hours. Logistic regression analysis was performed to evaluate for predictors of each outcome. Of 419 patients, 20.5, 50.4, and 29.1 per cent belonged to groups 1, 2, and 3, respectively, with TTA occurring in 39.5, 18.0, and 32.0 per cent of the respective groups. Within each group, there were no differences for the primary and secondary outcomes whether or not TTA was triggered. TTA patients had shorter times to CT (median, 20 minutes versus 80 minutes, P < 0.0001) and to administration of reversal agents (median, 105 minutes versus 255 minutes, P < 0.0001). Age, head-Abbreviated Injury Score, and the Rotterdam score were predictors for both outcomes by multivariable analysis, whereas antithrombotic drug use and TTA were not. In awake elderly patients on antithrombotic drugs found to have ICH, TTA expedited evaluation and treatment but was not associated with mortality benefit.

Approximately 18 billion dollars is spent annually on preoperative testing. The purpose of this study was to determine whether implementation of an algorithm aimed at minimizing pre-operative tests resulted in decreased costs without compromising care. We performed a pre–post trial comparing January 2016 to April 2016 with May 2016 to July 2017. In May 2016, an algorithm was instituted in which laboratories were canceled based on an algorithm that incorporated patient and procedural factors. Total number of laboratories canceled before orthopedic, urologic, or general surgical procedures was documented. Case cancellations during this time were recorded. There were 22,175 laboratories during the study time frame. There was a significant decrease of 2.4 per cent in expected laboratories in the post-intervention group. There was an overall cost savings of $33,032.00. The per cent of patients who were seen in preoperative testing clinic and still needed medical optimization decreased after algorithm implementation (3.3% vs 2.1% P < 0.01). No cases were canceled because of lack of laboratory information. An algorithm for selective preoperative laboratory testing provides overall cost savings. Decreasing the number of unnecessary laboratories ordered reduced case cancellations. Instituting an algorithm for preoperative laboratory testing is cost-effective without compromising care.

The purpose of this study was to use natural language processing of physician documentation to predict mortality in patients admitted to the surgical intensive care unit (SICU). The Multiparameter Intelligent Monitoring in Intensive Care III database was used to obtain SICU stays with six different severity of illness scores. Natural language processing was performed on the physician notes. Classifiers for predicting mortality were created. One classifier used only the physician notes, one used only the severity of illness scores, and one used the physician notes with severity of injury scores. There were 3838 SICU stays identified during the study period and 5.4 per cent ended with mortality. The classifier trained with physician notes with severity of injury scores performed with the highest area under the curve (0.88 ± 0.05) and accuracy (94.6 ± 1.1%). The most important variable was the Oxford Acute Severity of Illness Score (16.0%). The most important terms were “dilated” (4.3%) and “hemorrhage” (3.7%). This study demonstrates the novel use of artificial intelligence to process physician documentation to predict mortality in the SICU. The classifiers were able to detect the subtle nuances in physician vernacular that predict mortality. These nuances provided improved performance in predicting mortality over physiologic parameters alone.

Postoperative iatrogenic diaphragmatic hernias have been reported sparingly after several thoracic and abdominal surgeries. Although rare, a delay in diagnosis can lead to life-threatening cases of strangulation or perforation, as well as cardiovascular and respiratory insufficiency. This is a case of a 78-year-old female who developed acute obstructive symptoms secondary to herniation of the distal stomach through a defect in the central tendon of the diaphragm. The diaphragmatic defect was presumed to be iatrogenically acquired after Nissen fundoplication one year prior. Other etiologies were not as likely considering that she had never had any trauma to her chest or abdomen and had no history suggestive of a congenital nature for the diaphragmatic hernia. The hernia was successfully decompressed laparoscopically with the stomach having ischemic changes along the greater curvature, necessitating gastric wedge resection. The diaphragmatic defect, which was lengthened to reduce the edematous incarcerated stomach, was repaired primarily. The patient had an uneventful postoperative course. This case highlights the potential complication of incarcerated diaphragmatic hernia after Nissen fundoplication. Late diagnosis of iatrogenic diaphragmatic hernias is frequent because of nonspecific symptoms and surgery is indicated at the time of diagnosis.

Long-term outcomes in liver transplantation for acute liver failure (ALF) are poorly studied. The aim of the study was to identify psychosocial variables that affect adherence and late survival. Retrospective review of ALF liver transplant (LTx) patients between 1997 and 2017 (n = 47) was conducted. Psychosocial history, life stressors, and ability to participate in transplant were recorded. Survival was calculated using Kaplan-Meier and logistic regression. Eleven patients (31.5%) had poor adherence, four died, all from graft failure. Of 13 with fair and 12 with good adherence, two died, no adherence related. Poor adherence was associated with higher mortality (P = 0.04), but by Kaplan-Meier, their five- and 10-year survival was 78 and 54 per cent, versus fair and good adherence (five years, 83% P = 0.3). Participating in transplant decision improved survival (five years, 80%) versus not participating (five years, 61%; P = 0.03). Of 10 early deaths, three were neurologic and five of sepsis. Overall, one- and five-year survival was 78 and 69 per cent. ALF represents the nemesis of LTx programs. Psychosocial aspects pre-LTx, stressors, and poor adherence affected survival in this series. No improvement over two decades of ALF LTxs was observed. The ethics of transplanting these high-risk patients will be the subject of our future research.

The number of patients being treated surgically for gastroduodenal disease has decreased over the past five decades as a result of focus on medical treatment. However, perforated and bleeding peptic ulcer disease (PUD) continues to represent a significant percentage of patients who require emergency surgery. The aim of this study was to characterize these critically ill surgical patients treated for gastroduodenal disease in our hospital. A retrospective, single-center, consecutive cohort study of all patients identified from the hospital National Surgical Quality Improvement Program database who were admitted to our institution requiring emergent surgical intervention over the past two years was conducted. Of 423 patients, 33 (7.8%) had operative procedures for complications of PUD, of which 19 patients (57.6%) had perforation; nine patients (27.3%) had hemorrhage; one patient (3.0%) had both perforation and hemorrhage; two patients (6.1%) had distal gastrectomies for ulcers refractory to medical management alone, and two patients (6.1%) had gastrectomies for malignant gastric neoplasms. There is a significant population of patients who present with life-threatening complications of PUD, despite the decline in PUD worldwide. These patients are critically ill and require careful and diligent management for good outcomes.

The atypia of uncertain significance/follicular lesion of uncertain significance (AUS/FLUS) category of the Bethesda system for reporting thyroid cytopathology for fine needle aspiration biopsy (FNAB) has a predicted incidence of malignancy from 5 to 15 per cent. The literature has reported that suspicious ultrasound (SUS) characteristics can assist in predicting malignancy in thyroid biopsies. Some research suggests further subdivision of AUS/FLUS into nuclear atypia predominant or follicular predominant. We hypothesized that the rate of malignancy would be higher in AUS/FLUS biopsies with SUS characteristics and in the AUS/FLUS subset classified as nuclear atypia predominant. We performed a four-year retrospective analysis of patients who underwent FNAB classified as AUS/FLUS and who subsequently underwent thyroidectomy from October 2008–October 2012. A total of 3839 thyroid FNAB were performed over the four-year period, of which 342 received AUS/FLUS classification. Of these, we identified 119 patients who underwent thyroidectomy, of which 27 (23%) malignancies were identified. Reported cytology (nuclear atypia vs follicular predominant) did not differ between patients with and without carcinomas (P = 0.33). Suspicious ultrasound appearance failed to be significantly associated with an underlying carcinoma (P = 0.14); although, nearly 70 per cent of malignancies displayed SUS compared with 50 per cent within the benign group. Ultrasound seems to have no additional value in predicting malignancy in the AUS/FLUS categorization. Further subcategorization did not aid in risk stratification of this indeterminate category. This may suggest an expanded role for ancillary technologies such as molecular markers in this challenging Bethesda system for reporting thyroid cytopathology class. Further study of these findings is warranted.

Emergency general surgery (EGS) is defined as the urgent assessment and treatment of non-trauma, general surgical emergencies involving adults. Acute surgical emergencies often represent the most common reason for hospital admission with diagnoses, including bowel obstruction and appendicitis. EGS is a growing surgical subspecialty that includes both operative and nonoperative management of acutely ill patients. We sought to assess the burden of nonoperative care in EGS patients at our academic medical center. This study was conducted by retrospective analysis of prospectively collected data from patients entered into the Duke EGS Registry between July 1, 2016 and September 10, 2017. Fifty-six per cent (n = 771) of patients in the Duke EGS Registry (n = 1377) were managed nonoperatively as compared with 44 per cent (n = 606) who were managed operatively. Nonoperative management of disease represents a large subset of EGS and, therefore, needs further investigation to improve processes, outcomes, and standardization of care.

The purpose of this study was to evaluate the impact of management of venous injury on clinical outcomes in patients with combined lower extremity arterial and venous trauma. Patients with common and external iliac, common and superficial femoral, and popliteal artery injuries were identified. Patients who underwent vein repair and those who received vein ligation were compared. The analysis was repeated for those patients who required secondary intervention for their arterial injury and those who did not require secondary intervention. Seventy patients were identified with both arterial and venous injuries: 40 underwent vein ligation and 30 received vein repair. There was no difference in ischemic time between patients undergoing vein repair compared with ligation. Vein ligation did not produce a higher incidence of muscle debridement (10% vs 15%, P = 0.72), necessity for secondary intervention (10% vs 7.5%, P = 0.99), or amputation (3.3% vs 7.5%, P = 0.63). Patients who required secondary intervention had a greater degree of shock on presentation (packed red blood cells (PRBC), 13 units vs 6 units, P = 0.02) and were more likely to require muscle debridement (50% vs 9%, P = 0.02) and amputation (33% vs 3%, P = 0.03). Vein ligation did not impact muscle ischemia or success of arterial repair in patients with combined venous and arterial trauma in the lower extremities. Patient morbidity after extremity vascular trauma is most related to degree of shock.

To determine whether low-income status as demonstrated by insurance type has any association with aggressive tumor biology and breast cancer outcomes. Retrospective review of 535 women with new diagnosis of breast cancer from January 2009 to March 2013 was performed. There was no significant association between race and stage at diagnosis. Women with Medicaid/Charity coverage were diagnosed at more advanced stages, more likely to have triple-negative breast cancer (TNBC), and had longer time to treatment. Rate of TNBC was higher in black women and younger patients. There was no significant difference in breast cancer recurrence or survival by race, insurance type, age, or tumor biology. In multivariable analysis, only black race (P = 0.003) and Medicaid/Charity Insurance (P = 0.0008) were the most significant predictors of TNBC. Presentation of aggressive tumor biology and advanced stage is strongly associated with socio-economic factors as reflected by Medicaid funding and lack of insurance.

Although the overall rate of colorectal cancer (CRC) has remained stable, studies have shown an increase in the rate of CRC in young patients (<50) nationwide. We hypothesize that the rectal cancer (RC) rate in young people has increased in rural Appalachia. The goal is to provide insight into the future of RC epidemiology in underserved populations. This Institutional Review Board–approved retrospective study evaluated RC patients diagnosed in 2003 to 2016, and compared the ratio of early-onset RC to the state and national ratios using West Virginia State Cancer Registry, North American Association of Central Cancer Registries (NAACCR) and Surveillance, Epidemiology, and End Results Program Database. Demographics include age, gender, ethnicity, and county. We also evaluated cancer stage, family history, and comorbidities, including body mass index, smoking, and alcohol history. The rate of early-onset RC in our area is 1.5 times higher than the national rates. In our population, 100 per cent of patients were white with an equal gender distribution. Young patients with RC were noted to be more overweight than national rates. Young RC patients are more likely to have a first- or second-degree relative with cancer diagnosis. Smoking was strongly associated with young RC. Compared with national statistics, a higher proportion of young patients had Stage 1 or 2 disease which correlated with better survival. The rate of early-onset RC in the Tristate Appalachian area in West Virginia is higher than the national rate with risk factors including white ethnicity, obesity, diabetes mellitus, smoking, family history, and history of pelvic surgeries. It warrants further investigation and discussion of current CRC screening guidelines that begin at age 50.

Relationship between trauma center patient volume (TCV) and mortality remains inconclusive. Our aim was to determine the relationship between TCVs and observed/expected (O/E) all-cause mortality. This is the first study to evaluate the relationship between trauma center (TC) volumes and O/E all-cause mortality with no exclusion. Review of prospectively collected data from 94 TCs using the National Sample Program from the National Trauma Data Bank 2013. TCs were stratified into five groups based on TCV: <701, 701 to 1200, 1201 to 1700, 1701 to 2200, and >2200 yearly patient encounters. Chi-square and coefficient of determination were used for data analysis with a statistical significance defined as P-value < 0.05. A total of 139,324 trauma patients with blunt and penetrating injuries were evaluated from the National Sample Program. Of which, 63.6 per cent were male, 70.6 per cent white, and the average age was 41 years. The data were stratified by TCV into five groups with average O/Es ranging from 0.69 to 0.86 (P > 0.05). The coefficient of determination between TCV and O/E was r = 0.14 and r² = 0.02. When controlling for Injury Severity Score, the correlation between mechanism of injury (blunt vs penetrating) and O/E mortality was r = 20.025. The group with the lowest average volumes had statistically significantly worse outcomes than the group with next higher volumes and also worse than the group with the highest volumes (Group 5, P = 0.04). Higher TC volumes correlated with higher injury severity and lower O/E mortality.

A multimodality approach to enhance recovery after bowel surgery is demonstrated to reduce complications and decrease patient length of stay (LOS). This study evaluates the factors that influence patient LOS within a formal enhanced recovery protocol. From January 2014 to December 2016, all consecutive patients admitted to one ward, who had undergone bowel resection and were enrolled in an enhanced recovery protocol, were evaluated prospectively. We entered every patient's data into the American College of Surgeons Risk Calculator (ACSRC) to compare predicted versus actual outcomes. Statistical analysis of clinical factors, patient participation, and outcomes compared with the overall LOS was performed. Of 670 bowel resections performed during the study period, a total of 127 (19%) patients met the criteria and were analyzed for comorbidities, type of surgery, complications, and participation in recovery protocols. The median length of stay (mLOS) for all patients was 4.0 days (1.8–24.6 days). Factors influencing mLOS included laparoscopic versus open surgery (P = 0.006), COPD (P = 0.003), missing 24 hours of ambulation (P < 0.001), use of patient-controlled analgesia (P = 0.011), and diagnosis of insulin-dependent diabetes mellitus (P = 0.041). Increasing the use of morphine equivalents (MEs) increased mLOS beyond the ACSRC estimate (P = 0.003). Developing a major complication increased mLOS by 8.5 times the ACSRC estimate. Conclusion: A multimodality approach to enhance surgical recovery after bowel surgery decreases the LOS. The surgical approach, participation in ambulation, insulin-dependent diabetes mellitus, and COPD influenced the overall LOS. Increasing use of morphine equivalents and developing a complication increased mLOS beyond the ACSRC preoperative risk estimates.