The American Surgeon™

Poor outcomes were most frequent in general surgery or oncological surgery patients who were older with chronic comorbidities. In contrast, outcomes among transplant surgery and obstetric patients were not signficantly altered by COVID-19. Surgical societies have released specialty specific guidelines on the managment of patients who require surgical care during the pandemic.

COVID-19 is associated with adverse outcomes and increased mortality in surgical patients. Data is currently limited, often restricted to single sites and smaller cohorts. As the sequelae of the virus is better understood, the revisions to the guidelines on managment of surgical patients may help improve outcomes.

Trauma centers with low observed:expected (O:E) mortality ratios are considered high performers; however, it is unknown whether improvements in this ratio are due to a small number of unexpected survivors with high mortality risk (big saves) or a larger number of unexpected survivors with moderate mortality risk (marginal gains). We hypothesized that the highest-performing centers achieve that status via larger numbers of unexpected survivors with moderate mortality risk.

We calculated O:E ratios for trauma centers in Pennsylvania for 2016 using a risk-adjusted mortality model. We identified high and low performers as centers whose 95% CIs did not cross 1. We visualized differences between these centers by plotting patient-level observed and expected mortality; we then examined differences in a subset of patients with a predicted mortality of ≥10% using the chi-squared test.

One high performer and 1 low performer were identified. The high performer managed a population with more blunt injuries (97.2% vs 93.6%, P < .001) and a higher median Injury Severity Score (14 vs 11, P < .001). There was no difference in survival between these centers in patients with an expected mortality of <10% (98.0% vs 96.7%, P = .11) or ≥70% (23.5% vs 10.8%, P = .22), but there was a difference in the subset with an expected mortality of ≥10% (77.5% vs 43.1%, P < .001).

Though patients with very low predicted mortality do equally well in high-performing and low-performing centers, the fact that performance seems determined by outcomes of patients with moderate predicted mortality favors a “marginal gains” theory.

Increased prevalence of patients on anticoagulants and the advent of new therapies raise concern over how these patients fare if they sustain a traumatic injury. We investigated the role of prehospitalization anticoagulation therapy in trauma-related mortality and postacute disposition.

A retrospective analysis was performed on patients who sustained traumatic injury identified in the 2017 National Trauma Data Bank (NTDB). Patients with and without anticoagulation therapy were analyzed to identify differences in demographics, injury type, Injury Severity Score (ISS), and trauma outcomes including hospital length of stay, ER, final hospital disposition, and mortality. Logistic regression was used to correlate anticoagulation to mortality and facility discharge.

Of the 1 000 596 patients included, 73 602 (7%) patients were on anticoagulants at the time of their trauma. Increased age was the strongest predictor for anticoagulation therapy (odds ratio 5.54, 95% CI 5.44-5.63), but being female and white were also independent predictors of anticoagulation (P < .001). Patients on anticoagulants had a significantly longer length of stay (5.11 days; 95% CI 5.06-5.15) than those who were not (4.37 days, 95% CI 4.36-4.39), were 2.20 times more likely to die (95% CI 2.12-2.28, P < .001), and were 2.77 times more likely to be discharged to a facility (95% CI 2.73-2.81, P < .001). Anticoagulation remained a significant predictor of worse trauma outcomes even when accounting for age and ISS in multivariate analysis.

Anticoagulation preceding trauma-related admission is associated with higher mortality and an increased likelihood of the need for a posthospital care facility.

Ulcerative colitis (UC) is a chronic inflammatory intestinal disorder that can be managed surgically with a proctocolectomy. Minimally invasive techniques such as laparoscopic or robotic-assisted surgery are available based on the surgeon’s preference and familiarity. To date, there is a paucity of literature evaluating the safety of these techniques in comparison to the open approach in patients with UC.

We surveyed the National Surgical Quality Improvement Program (NSQIP) database to select patients with the diagnosis of UC who underwent either robotic, laparoscopic, or open proctocolectomy between 2012 and 2017. A total of 2129 patients were included in the study. The 30-day postoperative outcomes were compared using multivariable logistic regression models after adjusting for confounding variables. The confounding variables were defined as any preoperative variable that was associated with the type of procedure.

The 30-day postoperative outcomes reported in the NSQIP database were reviewed for each of the treatment groups (open, laparoscopic, and robotic). The anastomotic leak rate was significantly higher in the open group (P = .022). The robotic and laparoscopic groups had significantly fewer occurrences of postoperative ileus (P = .0006) and wound infections (P < .0001). There were significantly more strokes, cardiac events, and pulmonary events in the open surgical group. Operative time was significantly shorter in the open group (P < .0001). Reintervention rates were not significantly different among the groups.

Minimally invasive proctocolectomy has significantly fewer postoperative complications compared with open proctocolectomy for UC. There is no significant difference in the postoperative outcomes between robotic-assisted and laparoscopic proctocolectomy.

While the use of the failure-to-rescue (FTR) metric, or death after complication, has expanded beyond elective surgery to emergency general surgery (EGS), little is known about the trajectories patients take from index complication to death.

We conducted a retrospective cohort study of EGS operations using the National Surgical Quality Improvement Project (NSQIP) dataset, 2011-2017. 16 major complications were categorized as infectious, respiratory, thrombotic, cardiac, renal, neurologic, or technical. We tabulated common combinations of complications. We then use logistic regression analyses to test the hypotheses that (1) increase in the number and frequency of complications would yield higher FTR rates and (2) secondary complications that span a greater number of organ systems or mechanisms carry a greater associated FTR risk.

Of 329 183 EGS patients, 69 832 (21.2%) experienced at least 1 complication. Of the 11 195 patients who died following complication (16.0%), 8205 (63.4%) suffered more than 1 complication. Multivariable regression analyses revealed an association between the number of complications and mortality risk (odds ratio [OR] 2.37 for 2 complications vs 1, P < .001). There was a similar increase in mortality with increased complication accrual rate (OR 3.29 for 0.2-0.4 complications/day vs <0.2, P < .001). Increasing the number of types of complication were similarly associated with mortality risk.

While past FTR analyses have focused primarily on index complication, a broader consideration of ensuing trajectory may enable identification of high-risk cohorts. Efforts to reduce mortality in EGS should focus on attention to those who suffer a complication to prevent a cascade of downstream complications culminating in death.

Incisional hernias (IH) are iatrogenically created in 400 000 new patients annually. Without repair, IH-associated complications can result in major illness and death. The health disparities literature suggests that under-represented patients present more frequently with surgical emergencies. The health disparities associated with IH remain relatively unstudied.

Inpatient admission data were obtained from the Healthcare Cost and Utilization Project National Inpatient Sample for 2012-2014. Patients with IH International Classification of Diseases ninth revision were included. Analyses were completed using survey specific procedures (SAS v.9.4). Type of admission within groups was compared via Rao-Scott chi-square tests. The probability of an elective admission was modeled via SurveyLogistic Procedure.

Of 39 296 cases, 38.5% IH admissions were urgent or emergent (nonelective). The proportion of nonelective admission was statistically higher (P < .0001) in patients >65 (40.9%) and females (40.3%). Among insurance types, self-paying patients had the highest proportion of nonelective admissions (64.3%). Racial disparities remained significant after adjusting for age, sex, and insurance. Compared with white patients, the odds of an admission being nonelective were significantly higher for black (odds ratio [OR] [95% CI]: 1.65 [1.53-1.77]], Hispanic (OR [95% CI]: 1.39 [1.28-1.51]), and other (OR [95% CI]: 1.2 [1.06-1.37]) patients.

These data show that multiple at-risk patient populations are significantly more likely to require urgent admission for IH-related complications. These include older, female, non-white, and uninsured patients. Systematic efforts to ameliorate these disparities should be developed.

An invitation to speak at a national meeting represents the advancement of one’s career and indicates acceptance and the attention of the scientific community. Studies have revealed gender disparities across medical and surgical society meetings. The purpose of our study was to assess the current trend of women surgeon speakers at major national trauma surgery conferences during the last 4 years (ie, 2016-2019).

A retrospective analysis of conference programs of major trauma surgery association annual meetings including the American Association for the Surgery of Trauma (AAST), the Eastern Association for the Surgery of Trauma (EAST), and the Western Trauma Association (WTA) was conducted. Our primary outcome was the number and proportion of women surgeon speakers at each conference each year.

Twelve conference programs from three national trauma surgery association annual meetings were reviewed. A total of 2029 speakers were included; 608 (30%) of which were female and 1421 (70%) of which were male. The proportion of women speakers ranged from 22.3% to 41.4%. The number of women speakers increased each year from 2016 to 2019: (EAST: 25.2%-39.8%, P = .049; AAST: 27.1%-41.4%, P < .00001, and WTA: 27.8%-33.3%, P = . 0.573).

The number of women surgeon speakers at national trauma surgery conferences significantly increased from 2016 to 2019. The increase in women trauma surgeon speakers is encouraging and should be celebrated, but organizational leadership should take this information into account while extending invitations to surgeons for speaking opportunities and continue to promote diversity and inclusivity.

Data regarding the effect of conversion from minimally invasive surgery (MIS) to laparotomy in rectal cancer is limited. This study examines the impact of conversion from laparoscopic or robotic-assisted techniques to open resection on oncologic outcomes in a large population database.

The National Cancer Database from 2010 to 2016 was reviewed for all cases of invasive adenocarcinoma of the rectum or rectosigmoid junction managed surgically. Patients were divided into 3 cohorts by approach: laparoscopic/robotic (MIS), converted proctectomy (CP), and open proctectomy (OP). Kaplan–Meier estimation was used for unadjusted survival analysis, followed by adjusted multivariable Cox-Proportional Hazards regression. Secondary outcomes were analyzed by multivariable logistic regression.

The inclusion criteria identified 57 574 patients cases of adenocarcinoma of the rectum managed surgically. Of these patients, 23 579 (41.0%) underwent MIS, 3591 (6.2%) CP, and 30 404 (52.8%) OP. Five-year overall survival was greater in the MIS (70.4%) versus CP and OP (64.4% and 61.4%). No differences were detected for positive margins, 30-day, or 90-day mortality between CP and OP. MIS and CP approaches were significantly associated with increased odds of 12 or more regional lymph nodes examined and decreased overall mortality hazard compared with OP (all respective significant P < .05).

While similar odds of positive margins and short-term mortality is seen in patients whose procedure converts to laparotomy compared with planned laparotomy, both short-term and long-term oncologic benefit is seen in those who undergo a minimally invasive approach. Thus, a minimally invasive approach should be attempted for patients with rectal cancer.

The need to reverse the coagulation impairment caused by chronic antiplatelet agents in traumatic brain injury (TBI) patients with acute traumatic intracerebral hemorrhage (TICH) remains controversial. We sought to determine whether emergent platelet transfusion reduces the incidence of hemorrhage expansion, mortality, or need for neurosurgical intervention such as intracranial pressure (ICP) monitoring, burr holes, or craniotomy.

All adult blunt TICH patients (age ≥16 years) over a 4-year period were retrospectively reviewed. Patients with penetrating TBI, blunt TBI without TICH on admission computed tomography (CT), receiving warfarin, not on antiplatelet agents, or requiring immediate operative intervention were excluded. Patients were divided into 2 groups depending on whether they received a platelet transfusion: reversal group (RV) versus no reversal group (NR). Patient outcomes were analyzed using Mann-Whitney U and Fisher’s exact tests.

169 blunt TBI patients on chronic antiplatelet therapy were studied (102 RV group, 67 NR group). The groups were well matched with regard to age, Injury Severity Score, Abbreviated Injury Scale-head, Glasgow Coma Score, mechanism of injury, need for intubation, time to initial CT scan, and hospital length of stay. Immediate platelet transfusion did not alter the occurrence of TICH extension on follow-up CT (26% vs 21%, P = .71), TBI-specific mortality (9% vs 13%, P = .45), need for ICP monitor (2% vs 3%, P = 1.0), burr hole (1% vs 3%, P = .56), or craniotomy (1% vs 3%, P = .56).

Immediate platelet transfusion is unnecessary in blunt TBI patients on chronic antiplatelet therapy who do not require immediate craniotomy.

Approximately one-third of additional imaging for trauma consults results in the discovery of new injuries. No studies have addressed the perception of these findings in non-health care providers. Our hypothesis was that significant differences in perception of the importance of injuries would exist between health care providers (HCPs) and the general population.

Six standardized scenarios were developed detailing common new injury findings on additional imaging in trauma consults. Demographics as well as information regarding the significance of findings, potential for change in care, and the importance of patient notification were collected. Surveys were electronically distributed to HCPs in our system and the public. Data analysis was performed with generalized linear modeling.

A total of 339 public and 129 HCP surveys were returned. HCPs included attending staff, residents, and advanced care providers from a variety of specialties. Significant differences in perception were found in traumatic brain injury, spine fractures, and rib fractures, with HCPs rating most findings as less clinically important than the general population, while rating patient notification as more important. Perceived importance decreased with increased age in the general population. Increasing HCP age or length in practice did not significantly affect perception of clinical importance, except for rib fractures.

Differences in perception exist regarding the significance of additional injuries between HCPs and the general population. Perceptions of the general population also change with age. Decisions to pursue additional imaging in trauma patients should include consideration of these differences in perception to help support quality patient-centered care.

Acute care surgery patients are often unfasted at the time of surgery, presenting a unique opportunity to study the effects of fasting on the risk of pulmonary aspiration. We aimed to determine the relative risk of aspiration in patients who were fasted at the time of surgery according to guidelines versus those in an unfasted state.

A retrospective chart review of 100 patients who underwent appendectomy (n = 76) or exploratory laparotomy (n = 24) was conducted at a single institution in 2016-2017. Using the American Society of Anesthesiologists (ASA) Practice Guidelines for Preoperative Fasting, patients were stratified into study and control groups according to whether they were unfasted (nothing by mouth for <8 hours prior to surgery) or fasted (nothing by mouth for >8 hours prior to surgery). Data controlled for patients’ age, sex, body mass index (BMI), most recent hemoglobin A1c, presence of gastroesophageal reflux disease (GERD), and presence of hiatal hernia.

Of the 76 patients who underwent appendectomy, 15% were unfasted with a total of 0 aspiration events (P < .001). Of the 24 patients who underwent exploratory laparotomy, 42% were unfasted with a total of 0 aspiration events (P < .001). This yields a relative risk of pulmonary aspiration of 1.0 (absolute risk of 0) in both the study and control groups.

In an acute care surgery population including patients who were not fasted according to guidelines, there was no increase in the risk of pulmonary aspiration.

Epidemiological study; Level III.

Prehospital chest decompression can be a lifesaving procedure in severe chest trauma. Studies investigating prehospital chest decompression are mostly European where physicians are assigned to prehospital care units. This report is one of the first to compare demographics and outcomes in patients undergoing prehospital chest decompression by trained aeromedical nonphysician personnel to hospital chest decompression by physicians.

Prehospital tube thoracostomy (PTT) patients were identified from January 2014 to January 2019 and were matched in a 1:2 ratio based on age, Injury Severity Score (ISS), and chest Abbreviated Injury Score (AIS) to patients who underwent hospital tube thoracostomy (HTT) within 24 hours of admission.

Forty-nine PTT patients were matched to 98 HTT patients. PTT patients had lower admission Glasgow Coma Scale (GCS), a higher rate of pre-chest tube needle decompression, and higher level 1 trauma activation. PTT were placed sooner (21.9 vs 157.0 minutes, P < .001). Rates of tube malposition, organ injury, tube dislodgement, empyema, and hospital-acquired pneumonia over the course of hospital admission were not significantly different between the 2 groups. PTT patients had longer intensive care unit length of stay (LOS), but similar hospital LOS, and overall mortality.

This report demonstrates that PTT is performed sooner than hospital placed tubes. Complication rates associated with tube thoracostomy and patient outcomes were not statistically different between PTT and HTT groups.

Colorectal care bundles for surgical site infections (CRCB-SSIs) have been shown to reduce SSIs following elective colorectal surgery (CRS). There are limited data evaluating the effect of CRCB-SSI at Academic Disproportionate Share Hospitals (ADSH) with significant rates of urgent and emergent cases.

A CRCB-SSI was implemented in April 2016. We reviewed medical records of all patients undergoing colon resections between August 2015 and December 2017. Patients were divided into preimplementation and postimplementation groups. The primary endpoint was the SSI rate, and the secondary endpoint included types of SSI (superficial, deep, organ space). Univariable and multivariable analyses were performed. A subset analysis was performed in elective cases.

We analyzed a total of 417 patients. Of these, 116 (28%) and 301 (72%) patients were in the preimplementation and postimplementation groups, respectively. The rate of SSI decreased from 30.1% to 15.9% in the postimplementation group (P = .0012); however, it was not statistically significant after adjusting for baseline differences (relative risk [RR] 0.65; 95% CI 0.41-1.02).

The elective subset included 219 patients. The rate of SSI in this cohort decreased from 25% to 10.5% in the postimplementation group (P = .0012) and remained significant following multivariable analysis (RR 0.41, 95% CI 0.19- 0.88). There were no differences in the subtypes of SSI.

While the CRCB-SSI was effective in decreasing the postoperative SSI rate for elective cases, its effect on the overall patient population was limited. CRCB-SSIs are not enough to bring SSI rates to accepted rates in high-risk patients such as those seen at ADSH.

Older data indicate that less patients undergo surgery for complicated peptic ulcer disease (PUD). We evaluated contemporary trends in the surgical management and outcomes of patients with complicated PUD.

The National Inpatient Sample (2005-2014) was queried for patients with complicated PUD (hemorrhage, perforation, or obstruction). Trend analyses were used to evaluate changes in management and outcomes.

There were 1 570 696 admissions for complicated PUD during the study period. Majority (87.0%) presented with hemorrhage, 10.6% presented with perforation, and 2.4% had an obstruction. The average age was 67 years. Overall, admissions with complicated PUD decreased from 180 054 in 2005 to 150 335 in 2014. The proportion of patients managed operatively decreased from 2.5% to 1.9% in the hemorrhage group, 75.0% to 67.4% in the perforation group, and 26.0% to 20.2% in the obstruction group (all P-trend < .05). Overall, among patients managed operatively, the use of acid-reducing procedures decreased from 25.9% to 13.9%, mortality decreased from 11.9% to 9.4% (both P-trend < .001), while complications remained stable (10.4% to 10.3%, P-trend = .830).

There are fewer admissions with complicated PUD and more patients are treated nonoperatively. Despite subtle improvements, significant proportions of patients still die from complicated PUD indicating the need for improved preoperative optimization and postoperative care among these patients.

Hepatitis C virus (HCV) has historically been the most common cause of cirrhosis and hepatocellular carcinoma (HCC) in the United States. With improved HCV treatment, cirrhosis secondary to other etiologies is increasing. Given this changing epidemiology, our aim was to determine the impact of cirrhosis etiology on overall survival (OS) in patients with HCC.

All patients with cirrhosis and primary HCC from the US Safety Net Collaborative (2012-2014) database were included. Patients were grouped into “safety net” and “academic” based on where they received their care. The primary outcome was the OS.

1479 patients were included. The average age was 60 years and 78% (n = 1156) were male. 56% (n = 649) received care at academic and 44% (n = 649) at safety net hospitals. The median model for end-stage liver disease (MELD) was 10 (IQR 8-16). Median OS was 23 months. Etiology of cirrhosis was viral hepatitis 56% (n = 612), alcohol abuse 14% (n = 152), alcohol and hepatitis 23% (n = 251), and other 7% (n = 85). Patients with alcohol-related cirrhosis (alcohol alone or with hepatitis) were younger (59 vs 62 years), more likely to be male (86% vs 75%), treated at a safety net facility (45% vs 35%), uninsured (17% vs 13%), and had a higher MELD (median 12 vs 10) (all P < .003). They were less likely to have been screened for HCC within 1 year of diagnosis (20% vs 29%) and to receive treatment (69% vs 81%), and more likely to present with stage IV disease (21% vs 15%) (all P < .001). Patients with alcohol-related cirrhosis had decreased OS (5-year OS 24% vs 40%, P < .001), which persisted in a subset analysis of both academic and safety net populations.

Although not significant on MVA, alcohol-related cirrhosis is associated with all factors that correlate with decreased survival from HCC. Efforts must focus on this vulnerable patient population to optimize screening, treatment, and outcomes.

The purpose of this study was to evaluate the utilization of pelvic binders, the proper placement of binders, and to determine any differences in blood product transfusions between combat casualties with and without a pelvic binder identified on initial imaging immediately after the injury.

We conducted a retrospective review of all combat-injured patients who arrived at our military treatment hospital between 2010 and 2012 with a documented pelvic fracture. Initial imaging (X-ray or computed tomography) immediately after injury were evaluated by 2 independent radiologists. Young-Burgess (YB) classification, pelvic diastasis, correct binder placement over the greater trochanters, and the presence of a pelvic external fixator (ex-fix) was recorded. Injury severity score (ISS), whole blood, and blood component therapy administered within the first 24-hours after injury were compared between casualties with and without a pelvic binder.

39 casualties had overseas imaging to confirm and radiographically classify a YB pelvic ring injury. The most common fracture patterns were anteroposterior (53%) and lateral compression (28%). 49% (19/39) did not have a binder or ex-fix identified on initial imaging or in any documentation after injury. Ten patients had a binder, with 30% positioned incorrectly over the iliac crest. ISS (34 ± 1.6) was not statistically different between the binder and the no-binder group. Pubic symphysis diastasis was significantly lower in the binder group (1.4 ± 0.2 vs 3.7 ± 0.5, P < .001). There was a trend toward decreased 24-hour total blood products between the binder and no-binder groups (75 ± 11 vs 82 ± 13, P = .67). This was due to less cryoprecipitate in the binder group (6 ± 2 vs 19 ± 5, P = .01).

Pelvic binder placement in combat trauma may be inconsistent and an important area for continued training. While 24-hour total transfusions do not appear to be different, no-binder patients received significantly more cryoprecipitate.