BMI and VTE Risk in Emergency General Surgery, Does Size Matter? : An ACS-NSQIP Database Analysis.

BACKGROUND: Venous thromboembolism (VTE) is a preventable cause of morbidity and mortality. Emergency general surgery (EGS) patients comprise 7% of hospital admissions in America with a reported rate of VTE of 2.5%. Of these, >69% required hospital readmission, making VTE the second most common cause for readmission after infection in EGS patients. We hypothesize a correlation between body mass index (BMI) and VTE in EGS patients. METHODS: The American College of Surgeons National Surgery Quality Improvement Database (NSQIP) was queried from January 2015 to December 2016. 83 272 patients met inclusion criteria: age ≥18 and underwent an EGS procedure. Patients were stratified by BMI. Descriptive statistics were used for demographic and numerical data. Categorical comparisons between covariates were completed using the chi-square test. Continuous variables were compared using Student's t-test, Mann Whitney U-test, or Kruskal-Wallis H test. RESULTS: 83 272 patients met the inclusion criteria. 1358 patients developed VTE (903 deep vein thrombosis (DVT) only, 335 pulmonary embolism (PE) only, and 120 with DVT and PE). Morbidly obese patients were 1.7 times more likely to be diagnosed with a PE compared with normal BMI (P = .004). Increased BMI was associated with the co-diagnosis of PE and DVT (P = .027). Patients with BMI <18.5 were 1.4 times more likely to experience a VTE compared with normal BMI (P = .018). Patients with a VTE were 3.2 times more likely to die (P < .001) and less likely to be discharged home (P < .001). DISCUSSION: Our study found that obese and underweight EGS patients had an increased incidence of VTE. Risk recognition and chemoprophylaxis may improve outcomes in this population.

Impact of Laparoscopy on Training: Are Open Appendectomy and Cholecystectomy on the Brink of Extinction?

The operative experience of present-day surgical residency training has evolved as a result of the contributions of laparoscopic surgery. Some traditional open procedures are now more descriptive and less of a familiarity to many general surgery residents (GSRs). The aim of this study was to investigate how open operative experience compares with laparoscopy for GSRs. A retrospective, multicenter, consecutive cohort study of all patients undergoing surgical intervention involving the appendix and gallbladder identified from the ACS-NSQIP database over a 2.5-year period. All GSR postgraduate year-level operative experience was recorded. Of 777 procedures, 13 laparoscopic appendectomy conversions to open (4.3%) by Rocky-Davis (15%) or lower midline (84.6%) incisions were performed versus 285 that remained laparoscopic (95.6%). Fifty (10.4%) open cholecystectomies (38 open + 10 conversions + 2 common bile duct (CBD) exploration), 27 (5.6%) laparoscopic cholecystectomies with cholangiogram, and 402 (83.9%) laparoscopic cholecystectomies were performed. Twenty-nine different GSRs participated in procedures. Eighty-five (10.9%) operations were performed with multi-postgraduate year levels. Surgical residents have an unequal operative experience for case-specific open procedures. A competency-based system to demonstrate a resident's hands-on surgical skills is fundamental to residency training and should be considered for specific types of low-volume open surgical cases.

Gastroduodenal Surgery: A Persistent and Continuing Challenge.

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.

Rapid Source-Control Laparotomy: Is There a Mortality Benefit in Septic Shock?

BACKGROUND: In the 1990s, damage control laparotomy (DCL) became a proved approach to treat intra-abdominal injuries caused by trauma. In the ensuing two decades, this approach has been applied to non-traumatic abdominal processes as well. Although the benefits of DCL are clear, the benefit of rapid source-control laparotomy (RSCL) for non-traumatic abdominal diseases is much less clear. However, two recent cohort analyses identified significant increases in the mortality rate with RCSL compared with primary fascial closure (PFC). The purpose of this study was to assess the efficacy of RSCL in patients with septic shock. METHODS: The 2015 National Surgical Quality Improvement Project (NSQIP) database was queried for 11 International Statistical Classifications of Diseases (ICD)-10 codes associated with septic shock. Collected data included age, gender, body mass index (BMI), wound class, American Society of Anesthesiologists (ASA) class, operative time, number of risk factors, and presence or absence of post-operative pneumonia. The risk factors were diabetes mellitus, alcohol or tobacco abuse, blood dyscrasias, disseminated cancer, and cardiac, gastrointestinal, pulmonary, hepatobiliary, or renal dysfunction. The primary outcomes were rate of re-operation, prevalence of post-operative pneumonia, hospital length of stay (LOS), and death by 30 days. RESULTS: The RSCL and PFC cohorts were each comprised of 56 patients matched for propensity scores for ICD-10 code. There were no significant differences in wound or ASA class, BMI, gender, or number of risk factors between the two cohorts. The operative time for RSCL was significantly shorter than for PFC (median 84 vs. 128 min, respectively; p = 0.002). There was no significant difference in re-operation rate, prevalence of post-operative pneumonia, LOS, or mortality rate between the two cohorts. CONCLUSIONS: Although this analysis showed no clear advantage to RSCL in the management of septic shock, it may be a means to salvage certain patients. The best way to assess the relative value of RSCL is a prospective trial.

Multidisciplinary team approach to traumatic spinal cord injuries: a single institution's quality improvement project.

BACKGROUND: A stepwise multidisciplinary team (MDT) approach to the injured trauma patient has been reported to have an overall benefit, with reduction in mortality and improved morbidity. Based on clinical experience, we hypothesized that implementation of a dedicated Spinal Cord Injury Service (SCIS) would impact outcomes of a patient specific population on the trauma service. METHODS: The trauma center registry was retrospectively queried, from January 2011 through December 2015, for patients presenting with a spinal cord injury. In 2013, a twice weekly rounding SCIS MDT was initiated. This new multidisciplinary service, the post-SCIS, was compared to the 2011-2012 pre-SCIS. The two groups were compared across patient demographics, mechanism of injury, surgical procedures, and disposition at discharge. The primary outcome was mortality. Secondary endpoints also included the incidence of complications, hospital length of stay (HLOS), ICU LOS, ventilator free days, and all hospital-acquired infectious complications. Logistic regression and Student's t test were used to analyze data. RESULTS: Ninety-five patients were identified. Of these patients, 41 (43%) pre-SCIS and 54 (57%) post-SCIS patients were compared. Mean age was 46.9 years and 79% male. Overall, adjusted mortality rate between the two groups was significant with the implementation of the post-SCIS (p = 0.033). In comparison, the post-SCIS revealed shorter HLOS (23 vs 34.8 days, p = 0.004), increased ventilator free days (20.2 vs 63.3 days, p < 0.001), and less nosocomial infections (1.8 vs 22%, p = 0.002). While the post-SCIS mean ICU LOS was shorter (12 vs 17.9 days, p = 0.089), this relationship was not significant. CONCLUSIONS: The application of an SCIS team in addition to the trauma service suggests that a structured coordinated approach can have an expected improvement in hospital outcomes and shorter length of stays. We believe that this clinical collaboration provides distinct specialist perspectives and, therefore, optimizes quality improvement. Level of evidence Epidemiologic study, level III.

Rapid Source-Control Laparotomy: Is There a Mortality Benefit?

BACKGROUND: The purpose of this study was to determine the influence rapid source-control laparotomy (RSCL) has on the mortality rate in non-trauma patients with intra-abdominal infection. The hypothesis was that RSCL reduces deaths and hospital lengths of stay (LOS) in patients compared with definitive repair and primary fascial closure (PFC). METHODS: The International Classification of Diseases-10 codes for sepsis, gastric and duodenal ulcer perforation or hemorrhage, incisional or ventral hernia with obstruction, intestinal volvulus, ileus with obstruction, diverticulitis with perforation or abscess, vascular disorder of intestine, non-traumatic intestinal perforation, peritoneal abscess, and unspecified peritonitis were used to query the 2015 National Surgical Quality Improvement Project (NSQIP) database for all patients treated with either RSCL or PFC. The two groups of patients were compared on the basis of LOS and deaths. Collected data included age, gender, body mass index (BMI), site classification, American Society of Anesthesiologists (ASA) class, operative time, number of risk factors, and pre-operative septic state. RESULTS: After adjusting for the aforementioned variables, propensity score-matched cohorts (n = 210 in each cohort) were used to evaluate the influence of incision closure type on LOS and mortality rate. The odds of death (31.4% vs. 21.4%) with RSCL was 1.78 (95% confidence interval 1.08-2.95; p = 0.02) times that of PFC. Closure type was not significantly associated with an increased LOS (median 14 vs. 11 days; p = 0.35). CONCLUSIONS: This retrospective cohort analysis demonstrated that RSCL is associated with higher odds of death in general surgical patients with intra-abdominal infection. There is a need for further studies to delineate what, if any, physiologic parameters indicate a need for RSCL.

Effectiveness of suspension seats in maintaining performance following military high-speed boat transits.

OBJECTIVE: The aim of this study was to investigate whether suspension seats (SS) fitted to rigid inflatable boats (RIB) could help maritime boarding teams maintain running performance during the high-risk posttransit phase. BACKGROUND: High-speed RIB transits have been reported to cause reductions in the running performance of boarding teams posttransit. METHOD: In this experiment, two pairs of teams completed a 3-hr transit in either calm or rough seas (calm, 5 vs. 5; rough, 6 vs. 6) in an RIB fitted with either fixed (FS) or Suspension seats (SS). Exhaustive shuttle run distance was measured pre- and immediately posttransit. Transit heart rate and perceived exertion (RPE) were measured and deck and seat pan acceleration recorded; the latter were reported as impacts count and peak magnitude. RESULTS: Distance run was reduced for the FS teams following both transits (calm,-250 m,-20%, p < .07; rough, -398 m, -26%, p < .05), whereas it was unchanged for the SS teams. All transit heart rates and RPE indicated light exertion levels. Seat pan impacts were similarly reduced during the calm transit (FS, -42%; SS, -30%); however, during the rough transit, the SS was more than twice as effective (FS, -32%; SS, -71%). Peak impact magnitudes were reduced by the SS (calm, -38%; rough, -57%) and amplified by the FS (calm, +3%; rough, +28%). CONCLUSION: Suspension seats effectively maintained posttransit running performance by reducing magnitude of the vertical shocks imposed on the passengers. APPLICATION: High-speed RIB transits followed immediately by high-intensity activity are intrinsic to contemporary maritime operations; suspension seats can maintain post-transit physical performance, thereby enhancing safety and operational effectiveness.

Physiological consequences of military high-speed boat transits.

The purpose of this study was to investigate the consequences of a high-speed boat transit on physical performance. Twenty-four Royal Marines were randomly assigned to a control (CON) or transit (TRAN) group. The CON group sat onshore for 3 h whilst the TRAN group completed a 3-h transit in open-boats running side-by-side, at 40 knots in moderate-to-rough seas, with boat deck and seat-pan acceleration recorded. Performance tests (exhaustive shuttle-run, handgrip, vertical-jump, push-up) were completed pre- and immediately post-transit/sit, with peak heart rate (HRpeak) and rating of perceived exertion (RPE) recorded. Serial blood samples (pre, 24, 36, 48, 72 h) were analyzed for creatine kinase (CK) activity. The transit was typified by frequent high shock impacts, but moderate mean heart rates (<45% HRpeak). The TRAN group post-transit run distance (-219 m, P < 0.01) and vertical-jump height (5%, P < 0.05) were reduced, the CON group showed no change. The TRAN group post-transit test RPE increased (P < 0.05), however, HRpeak was similar for each group (98%). Post-transit CK activity increased in the TRAN group up to 72 h (P < 0.01) and also, but less markedly, in the CON group (24 and 48 h, P < 0.05). Post-transit run and jump performances were reduced despite mean transit heart rates indicating low energy expenditure. The greater TRAN CK activity suggests muscle damage may have been a contributory factor. These findings have operational implications for Special Forces/naval/police/rescue services carrying out demanding, high-risk physical tasks during and immediately after high-speed boat transits.

Survey of spatial disorientation in military pilots and navigators.

BACKGROUND: The direction of future spatial disorientation (SD) research and training is shaped primarily by the outcome of formal investigation of aircraft accidents and incidents. However, another source of vital information is aircrews' experience of SD that does not result in reported incidents. METHODS: A short postal SD survey was distributed to 5 Naval Air Squadrons, 22 Joint Helicopter Command Units, and 7 Royal Air Force stations in the United Kingdom. There were 752 questionnaires, including responses from 562 pilots and 149 navigators, that were returned. RESULTS: Analysis was conducted primarily on the pilot data. The most frequently experienced SD episodes were "the leans" (by 92% of respondents), loss of horizon due to atmospheric conditions (82%), misleading altitude cues (79%), sloping horizon (75%), and SD arising from distraction (66%). In general, the frequency of SD episodes and ratings of severity of the worst ever SD episode were positively related to flying experience (p < 0.05). Overall, pilots who had received in-flight SD training reported more episodes of SD than those who had not participated in this training (p < 0.05). Differences in types of SD experienced were found between aircraft categories, e.g., more episodes of SD during night vision goggle use were reported by rotary-wing pilots compared with fast-jet aviators (p < 0.05). CONCLUSIONS: This preliminary survey has shown that SD is still a significant hazard of military flying. Overall, this study shows that the postal questionnaire is a useful tool for assessing how SD training and experience may benefit the recognition of situations that may cause SD. However, it is difficult to access those situations where aircrew were truly disorientated.