Meshing around: high-risk hernias and infected mesh.

Open laparotomy carries a risk up to 20% for an incisional hernia, making repair one of the most common operations performed by general surgeons in the USA. Despite a multitude of mesh appliances and techniques, no size fits all, and there is continued debate on what is the best mesh type, especially in high-risk patients with contaminated hernias. Infected mesh carries a significant burden to the patient, the surgeon and overall healthcare costs with medical legal implications. A stepwise approach that involves optimization of patient comorbidities, patient selective choice of mesh and technique is imperative in mitigating outcomes and recurrence rates. This review will focus on the avoidance of mesh infection and the selection of mesh in patients with contaminated wounds.

High-grade liver injuries with contrast extravasation managed initially with interventional radiology versus observation: A secondary analysis of a WTA multicenter study.

BACKGROUND: High-grade liver injuries with extravasation (HGLI â€‹+ â€‹Extrav) are associated with morbidity/mortality. For low-grade injuries, an observation (OBS) first-strategy is beneficial over initial angiography (IR), however, it is unclear if OBS is safe for HGLI â€‹+ â€‹Extrav. Therefore, we evaluated the management of HGLI â€‹+ â€‹Extrav patients, hypothesizing IR patients will have decreased rates of operation and mortality. METHODS: HGLI â€‹+ â€‹Extrav patients managed with initial OBS or IR were included. The primary outcome was need for operation. Secondary outcomes included liver-related complications (LRCs) and mortality. RESULTS: From 59 patients, 23 (39.0%) were managed with OBS and 36 (61.0%) with IR. 75% of IR patients underwent angioembolization, whereas 13% of OBS patients underwent any IR, all undergoing angioembolization. IR patients had an increased rate of operation (13.9% vs. 0%, p â€‹= â€‹0.049), but no difference in LRCs (44.4% vs. 43.5%) or mortality (5.6% vs. 8.7%) versus OBS patients (both p â€‹> â€‹0.05). CONCLUSION: Over 60% of patients were managed with IR initially. IR patients had an increased rate of operation yet similar rates of LRCs and mortality, suggesting initial OBS reasonable in appropriately selected HGLI â€‹+ â€‹Extrav patients.

The silver lining of the pandemic in surgical education: virtual surgical education and recommendations for best practices.

Virtual education is an evolving field within the realm of surgical training. Since the onset of the COVID-19 pandemic, the application of virtual technologies in surgical education has undergone significant exploration and advancement. While originally developed to supplement in-person curricula for the development of clinical decision-making, virtual surgical education has expanded into the realms of clinical decision-making, surgical, and non-surgical skills acquisition. This manuscript aims to discuss the various applications of virtual surgical education as well as the advantages and disadvantages associated with each education modality, while offering recommendations on best practices and future directions.

Evaluation of Abdominal Emergencies.

Early primary assessment and abdominal examination can often be enough to triage the patient with abdominal pain into those with less severe underlying pathologic condition from those with more acute findings. A focused history of the patient can then allow the clinician to develop their differential diagnosis. Once the differential diagnoses are determined, diagnostic imaging and laboratory findings can help confirm the diagnosis and allow for expeditious treatment and intervention.

Marijuana Legalization and Rates of Crashing Under the Influence of Tetrahydrocannabinol and Alcohol.

OBJECTIVE: To determine if statewide marijuana laws impact upon the detection of drugs and alcohol in victims of motor vehicle collisions (MVC). METHODS: A retrospective analysis of data collected at trauma centers in Arizona, California, Ohio, Oregon, New Jersey, and Texas between 2006 and 2018 was performed. The percentage of patients testing positive for marijuana tetrahydrocannabinol (THC) was compared to the percentage of patients driving under the influence of alcohol (blood alcohol level >0.08 g/dL) that were involved in an MVC. RESULTS: The data were analyzed to evaluate the trends in THC and alcohol use in victims of MVC, related to marijuana legalization. The change in incidence of THC detection (percentage) over the time period where data were available are as follows: Arizona 9.5% (0.4 to 9.9), California 5.4% (20.8 to 26.2), Ohio 5.9% (6.7 to 12.6), Oregon 3% (3.0 to 6.0), New Jersey 2.3% (2.7 to 5.0), and Texas 15.3% (3.0 to 18.3). Alcohol use did not change over time in most states. There did not appear to be a relationship between the legalization of marijuana and the likelihood of finding THC in patients admitted after MVC. In fact, in Texas, where marijuana remains illegal, there was the largest change in detection of THC. CONCLUSIONS: There was no apparent increase in the incidence of driving under the influence of marijuana after legalization. In addition, the changes in marijuana legislation did not appear to impact alcohol use.

An observation-first strategy for liver injuries with "blush" on computed tomography is safe and effective.

INTRODUCTION: The management of liver injuries in hemodynamically stable patients is variable and includes primary treatment strategies of observation (OBS), angiography (interventional radiology [IR]) with angioembolization (AE), or operative intervention (OR). We aimed to evaluate the management of patients with liver injuries with active extravasation on computed tomography (CT) imaging, hypothesizing that AE will have more complications without improving outcomes compared with OBS. METHODS: This is a prospective, multicenter, observational study. Patients who underwent CT within 2 hours after arrival with extravasation (e.g., blush) on imaging were included. Exclusion criteria included cirrhosis, nontraumatic hemorrhage, transfers from outside facilities, and pregnancy. No hemodynamic exclusion criteria were used. The primary outcome was liver-specific complications. Secondary outcomes include length of stay and mortality. Angioembolization patients were compared with patients treated without AE. Propensity score matching was used to match based on penetrating mechanism, liver injury severity, arrival vital signs, and early transfusion. RESULTS: Twenty-three centers enrolled 192 patients. Forty percent of patients (n = 77) were initially OBS. Eleven OBS patients (14%) failed nonoperative management and went to IR or OR. Sixty-one patients (32%) were managed with IR, and 42 (69%) of these had AE as an initial intervention. Fifty-four patients (28%) went to OR+/- IR. After propensity score matching (n = 34 per group), there was no difference in baseline characteristics between AE and OBS. The AE group experienced more complications with a higher rate of IR-placed drains for abscess or biloma (22% vs. 0%, p = 0.01) and an increased overall length of stay ( p = 0.01). No difference was noted in transfusions or mortality. CONCLUSION: Observation is highly effective with few requiring additional interventions. Angioembolization was associated with higher rate of secondary drain placement for abscesses or biloma. Given this, a trial of OBS and avoidance of empiric AE may be warranted in hemodynamically stable, liver-injured patient with extravasation on CT. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.

Infection after penetrating brain injury-An Eastern Association for the Surgery of Trauma multicenter study oral presentation at the 32nd annual meeting of the Eastern Association for the Surgery of Trauma, January 15-19, 2019, in Austin, Texas.

BACKGROUND: Fatality rates following penetrating traumatic brain injury (pTBI) are extremely high and survivors are often left with significant disability. Infection following pTBI is associated with worse morbidity. The modern rates of central nervous system infections (INF) in civilian survivors are unknown. This study sought to determine the rate of and risk factors for INF following pTBI and to determine the impact of antibiotic prophylaxis. METHODS: Seventeen institutions submitted adult patients with pTBI and survival of more than 72 hours from 2006 to 2016. Patients were stratified by the presence or absence of infection and the use or omission of prophylactic antibiotics. Study was powered at 85% to detect a difference in infection rate of 5%. Primary endpoint was the impact of prophylactic antibiotics on INF. Mantel-Haenszel χ and Wilcoxon's rank-sum tests were used to compare categorical and nonparametric variables. Significance greater than p = 0.2 was included in a logistic regression adjusted for center. RESULTS: Seven hundred sixty-three patients with pTBI were identified over 11 years. 7% (n = 51) of patients developed an INF. Sixty-six percent of INF patients received prophylactic antibiotics. Sixty-two percent of all patients received one dose or greater of prophylactic antibiotics and 50% of patients received extended antibiotics. Degree of dural penetration did not appear to impact the incidence of INF (p = 0.8) nor did trajectory through the oropharynx (p = 0.18). Controlling for other variables, there was no statistically significant difference in INF with the use of prophylactic antibiotics (p = 0.5). Infection was higher in patients with intracerebral pressure monitors (4% vs. 12%; p = <0.001) and in patients with surgical intervention (10% vs. 3%; p < 0.001). CONCLUSION: There is no reduction in INF with prophylactic antibiotics in pTBI. Surgical intervention and invasive intracerebral pressure monitoring appear to be risk factors for INF regardless of prophylactic use. LEVEL OF EVIDENCE: Therapeutic, level IV.

Predicting success: A comparative analysis of student performance on the surgical clerkship and the NBME surgery subject exam.

BACKGROUND: The National Board of Medical Examiners surgery shelf is a well-established terminal measure of student medical knowledge. No study has explored the correlation between intraclerkship quizzes and shelf exam performance. METHODS: Weekly quiz and National Board of Medical Examiners scores were collected from 156 third-year students who participated in a 12-week surgical clerkship from 2015 to 2017. Kruskal-Wallis, Wilcoxon rank sum, and linear regression analysis was completed. RESULTS: Trauma/Burns, Esophagus/Anorectal, and Wound/Intensive Care Unit quiz content corresponded with increased National Board of Medical Examiners performance with ß-coefficients of 1.57 (P < .001), 1.42 (P < .001), 1.38 (P < .001), respectively. Wound/Intensive Care Unit and Cardio/Vascular content corresponded with decreased likelihood of scoring < 70 points on the National Board of Medical Examiners (OR: 0.75 (P = .03), and 0.68 (P = .02)). Aggregate quiz scores stratified by academic block were 67 (IQR 64-69.5), 77 (IQR 74.5-80), 76.5 (IQR of 67-89.5), 83 (IQR of 76-85) corresponding to academic blocks 1, 2, 3, and 4, respectively (P < .001). CONCLUSION: Modeling National Board of Medical Examiners outcomes as a function of weekly quizzes taken during a 12-week surgery clerkship is a viable concept.

Trauma Surgeons' Perspective on Gun Violence and a Review of the Literature.

Background In the United States, there is a constant debate between the proponents of the right to bear arms and those desiring to reduce the epidemic of gun violence. We sought to capture the trauma surgeons' perspective on gun control. Methods We presented an on-line based survey to the members of the American Association for the Surgery of Trauma (AAST). Survey questions were chosen to reflect the popular media poll questions as well as trauma-specific perspectives. We compared the trauma surgeons' perspectives to that of the general populace from a poll conducted by the New York Times (NYT). Results A total of 120 trauma surgeons responded to the survey. The age group ranged from 34 to 82 years, and the median age was 51. Most respondents were male (64%, n = 67) and worked at a Level I trauma center (80%, n = 96) in an academic setting (67%, n = 80). About half of the responding surgeons owned a household firearm (40%; n = 48 of the AAST members vs. 47%; n = 521 of the general populace). Sixty-one percent of the trauma surgeons (n = 73) and 53% (n = 588) of the NYT respondents favor stricter gun control laws. While 80% (n = 888) of the NYT respondents felt that mental health screening and treatment would decrease gun violence, only 56% (n = 67) of surgeons felt that mental health screening would be beneficial. The majority (90%, n = 999) of the NYT poll respondents favor a law restricting the sale of guns only by licensed dealers. Only (66%, n = 79) of the trauma surgeons were in agreement with the stricter gun sale legislation by licensed dealers. Conclusion Trauma surgeons appear to share similar views with the general American populace regarding gun violence and injury control.

Natural history and clinical implications of nondepressed skull fracture in young children.

BACKGROUND: Head injury is the most common cause of neurologic disability and mortality in children. Previous studies have demonstrated that depressed skull fractures (SFs) represent approximately one quarter of all SFs in children and approximately 10% percent of hospital admissions after head injury. We hypothesized that nondepressed SFs (NDSFs) in children are not associated with adverse neurologic outcomes. METHODS: Medical records were reviewed for all children 5 years or younger with SFs who presented to our Level I trauma center during a 4-year period. Data collected included patient demographics, Glasgow Coma Scale (GCS) score at admission, level of consciousness at the time of injury, type of SF (depressed SF vs. NDSF), magnitude of the SF depression, evidence of neurologic deficit, and the requirement for neurosurgical intervention. RESULTS: We evaluated 1,546 injured young children during the study period. From this cohort, 563 had isolated head injury, and 223 of them had SF. Of the SF group, 163 (73%) had NDSFs, of whom 128 (78%) presented with a GCS score of 15. None of the NDSF patients with a GCS score of 15 required neurosurgical intervention or developed any neurologic deficit. Of the remaining 35 patients with NDSF and GCS score less than 15, 7 (20%) had a temporary neurologic deficit that resolved before discharge, 4 (11%) developed a persistent neurologic deficit, and 2 died (6%). CONCLUSION: Children 5 years or younger with NDSFs and a normal neurologic examination result at admission do not develop neurologic deterioration. LEVEL OF EVIDENCE: Epidemiological study, level III.