Does practice make perfect? The impact of hospital and surgeon volume on complications after intra-abdominal procedures.

BACKGROUND: There is increasing interest in the regionalization of surgical procedures. However, evidence on the volume-outcome relationship for emergency intra-abdominal surgery is not well-synthesized. This systematic review and meta-analysis summarize evidence regarding the impact of hospital and surgeon volume on complications. METHODS: We identified cohort studies assessing the impact of hospital/surgeon volume on postoperative complications after emergency intra-abdominal procedures, with data collected after the year 2000 through a literature search without language restriction in the PubMed, Web of Science, and Cochrane databases. A weighted overall complication rate was calculated, and a random effect regression model was used for a summary odds ratio. A sensitivity analysis with the removal of studies contributing to heterogeneity was performed (PROSPERO: CRD42022358879). RESULTS: The search yielded 2,153 articles, of which 9 cohort studies were included and determined to be good quality according to the Newcastle Ottawa Scale. These studies reported outcomes for the following procedures: cholecystectomy, colectomy, appendectomy, small bowel resection, peptic ulcer repair, adhesiolysis, laparotomy, and hernia repair. Eight studies (2,358,093 patients) with available data were included in the meta-analysis. Low hospital volume was not significantly associated with higher complications. In the sensitivity analysis, low hospital volume was significantly associated with higher complications when appropriate heterogeneity was achieved. Low surgeon volume was associated with higher complications, and these findings remained consistent in the sensitivity analysis. CONCLUSION: We found that hospital and surgeon volume was significantly associated with higher complications in patients undergoing emergency intra-abdominal surgery when appropriate heterogeneity was achieved.

Timing matters: Early versus late rib fixation in patients with multiple rib fractures and pulmonary contusion.

BACKGROUND: Recent literature has shown that surgical stabilization of rib fractures benefits patients with rib fractures accompanied by pulmonary contusion; however, the impact of timing on surgical stabilization of rib fractures in this patient population remains unexplored. We aimed to compare early versus late surgical stabilization of rib fractures in patients with traumatic rib fractures and concurrent pulmonary contusion. METHODS: We selected all adult patients with isolated blunt chest trauma, multiple rib fractures, and pulmonary contusion undergoing early (<72 hours) versus late surgical stabilization of rib fractures (≥72 hours) using the American College of Surgeons Trauma Quality Improvement Program 2016 to 2020. Propensity score matching was performed to adjust for patient, injury, and hospital characteristics. Our outcomes were hospital length of stay, acute respiratory distress syndrome, unplanned intubation, ventilator days, unplanned intensive care unit admission, intensive care unit length of stay, tracheostomy rates, and mortality. We then performed sub-group analyses for patients with major or minor pulmonary contusion. RESULTS: We included 2,839 patients, of whom 1,520 (53.5%) underwent early surgical stabilization of rib fractures. After propensity score matching, 1,096 well-balanced pairs were formed. Early surgical stabilization of rib fractures was associated with a decrease in hospital length of stay (9 vs 13 days; P < .001), decreased intensive care unit length of stay (5 vs 7 days; P < .001), and lower rates of unplanned intubation (7.4% vs 11.4%; P = .001), unplanned intensive care unit admission (4.2% vs 105%, P < .001), and tracheostomy (8.4% vs 12.4%; P = .002). Similar results were also found in the subgroup analyses for patients with major or minor pulmonary contusion. CONCLUSION: These findings suggest that in patients with multiple rib fractures and pulmonary contusion, the early implementation of surgical stabilization of rib fractures could be beneficial regardless of the severity of pulmonary contusion.

Development of a Comprehensive Trauma Training Curriculum for the Resource-Limited Environment.

OBJECTIVE: The goal of this project was to create a multitiered trauma training curriculum that was designed specifically for the low-resource setting. DESIGN: We developed 2 courses designed to teach principles and skills necessary for trauma care. The first course, "Emergency Ward Management of Trauma (EWMT)," is designed to teach interns the initial assessment and stabilization of trauma patients in the emergency ward. The second course for mid-level surgical residents, "Surgical Techniques and Repairs in Trauma for the Low-resource Environment" (STaRTLE), is a cadaver-based operative trauma course designed to teach surgical exposures and techniques. The courses were rolled out at Mbarara Regional Referral Hospital in the low-income country of Uganda. Precourse and postcourse tests and surveys were administered. SETTING: This study took place at Mbarara Regional Referral Hospital (MRRH). This is a hospital in southwest Uganda with a subspecialty care, a medical school, nursing school, and multiple residency programs. PARTICIPANTS: Students in the EWMT course were interns at MRRH. After 1 year of training, most of these interns will become medical officers as the only provider at a district hospital in Uganda. The students in the STARTLE course were second-year residents in the general surgery program at MRRH. RESULTS: Scores on knowledge based tests improved significantly with both courses. Survey results from the EWMT course suggest that participants feel better prepared to care for the injured patient (median Likert [IQR]: 5.0 [5.0-5.0]) and that their practice improved (5.0 [5.0-5.0]). Similarly, following the STaRTLE course we found participants felt significantly more comfortable with performing 20 of the 22 operative procedures taught. CONCLUSIONS: These courses represent a feasible, cost-effective, and resource appropriate trauma education curriculum that if standardized and implemented may improve trauma care and outcomes in the resource-limited setting.