Airway risk associated with patients in halo fixation.

Background: The halo fixation device introduces a significant obstacle for clinicians attempting to secure a definitive airway in trauma patients with cervical spine injuries. The authors sought to determine the airway-related mortality rate of adult trauma patients in halo fixation requiring endotracheal intubation. Methods: This study was a retrospective chart review of patients identified between 2007 and 2012. Only adult trauma patients who were intubated while in halo fixation were included in the study. Results: A total of 46 patients underwent 60 intubations while in halo. On five occasions, (8.3%) patients were unable to be intubated and required an emergent surgical airway. Two (4.4%) of the patients out of our study population died specifically due to airway complications. Elective intubations had a failure rate of 5.8% but had no related permanent morbidity or mortality. In contrast to that, 25% of non-elective intubations failed and resulted in the deaths of two patients. The association between mortality and non-elective intubations was statistically highly significant (P = 0.0003). Conclusion: The failed intubation and airway-related mortality rates of patients in halo fixation were substantial in this study. This finding suggests that the halo device itself may present a major obstacle in airway management. Therefore, heightened vigilance is appropriate for intubations of patients in halo fixation.

SAGES white paper on the current state of community practice surgeons: re-discovering the value of our community practice surgeons.

BACKGROUND: The Community Practice (CP) surgeon is the first point of access to surgical care globally and performs the majority of procedures in the USA. CP surgeons include those of various practice models, locations and communities, education and training, and much more. It is a diverse group that drives quality, access to care, research, and innovation. The SAGES CP Committee was formed to better define the role and highlight the contribution of the CP surgeon, as well as advocate for the position of CP surgeons in our society. METHODS: In 2018, a survey was distributed to the SAGES membership asking members to self-identify as either a Community Surgeon or Academic Surgeon. RESULTS: The majority (71%) of SAGES members surveyed self-identified as "Community Surgeons." This was in stark contrast to the distribution of Community versus Academic Surgeons in SAGES leadership (25% versus 75%, respectively). CONCLUSION: By better defining the characteristics and role of the CP, SAGES will be better informed on how to effectively engage with this large group within the society and increase its representation within the leadership. The CP Committee met on a biannual basis over a period of two years focusing on assessing their role in the SAGES organization. The committee members created the following initial goals: (1) define in a broad sense the characteristics of a CP Surgeon, (2) discuss and characterize the value of the CP surgeons, (3) highlight past and future areas of contributions of the group, and (4) delineate ways to engage and represent this subgroup. This manuscript is a culmination of the work of this committee while also serving as a way to support the initiatives and direction of SAGES leadership.

The Development and Natural History of Hiatal Hernias: A Study Using Sequential Barium Upper Gastrointestinal Series.

OBJECTIVE: The aim of this study was to use barium upper gastrointestinal series (UGI) to evaluate the development and natural history of a hiatal hernia. SUMMARY OF BACKGROUND DATA: Hiatal hernias are common but the natural history of sliding and paraesophageal type hernias is poorly understood. METHODS: We reviewed UGI reports from 1987 to 2017 using a word scanning software program to identify individuals that had a hiatal hernia. Only those with at least 2 UGI studies 5 or more years apart were selected. The studies were then reviewed. RESULTS: There were 89 individuals that met inclusion criteria. Twenty-one people had no hiatal hernia on initial UGI and over a median of 99 months a sliding hiatal hernia (SHH) developed in 16 and a PEH developed in 5 people. A SHH was present on initial UGI in 55 people and at a median of 84 months subsequent UGI showed the SHH was stable in 11 (20%), increased in size in 30 (55%), and changed to a PEH in 14 people (25%). In 13 people a PEH was present on initial UGI and over a median of 97 months it was stable in 5 and increased in size in 8 people (62%). CONCLUSIONS: We showed that both SHH and PEH can develop over time and that the majority of both increased in size on follow-up UGI study. Further, 25% of SHH became a PEH over time. Recognizing an increase in size or change in type of a hiatal hernia may be clinically relevant to help understand changing or worsening symptoms in an individual.

Outcomes of Paraesophageal Hernia Repair: Analysis of the Veterans Affairs Surgical Quality Improvement Program Database.

BACKGROUND: While there have been many outcome studies on paraesophageal hernia repair in the civilian population, there is sparse recent data on the veteran population. This study analyzes the mortality and morbidities of veterans who underwent paraesophageal hernia repair in the Veterans Affairs Surgical Quality Improvement Program database. METHODS: Veterans who underwent paraesophageal hernia repair from 2010 to 2017 were identified using Current Procedural Terminology codes. Multivariable analysis was used to compare laparoscopic and open, including abdominal and thoracic approaches, groups. The outcomes were postoperative complications and mortality. RESULTS: There were 1607 patients in the laparoscopic group and 366 in the open group, with 84.1% men and mean age of 61 years. Gender and body mass index did not influence the type of surgical approach. The mortality rates at 30 and 180 days were 0.5% and 0.7%, respectively. Postoperative complications, including reintubation (2.2%), pneumonia (2.0%), intubation > 48 h (2.0%), and sepsis (2.0%) were higher in the open group (15.9% versus 7.2%, p < 0.001). The laparoscopic group had a significantly shorter length of stay (4.3 versus 9.6 days, p < 0.001) and a lower percentage of return to surgery within 30 days (3.9% versus 8.2%, p < 0.001) than the open group. The ratio of open versus laparoscopic paraesophageal hernia repairs varied significantly by different Veterans Integrated Services Network regions. CONCLUSIONS: Veterans undergoing laparoscopic paraesophageal hernia repair experience similar outcomes as patients in the private sector. Veterans who underwent laparoscopic paraesophageal hernia repair had significantly less complications compared to an open approach even after adjusting for patient comorbidities and demographics. The difference in open versus laparoscopic practices between various regions requires further investigation.

Outcomes and Trends in Colorectal Surgery in U.S. Veterans: A 10-year Experience at a Tertiary Veterans Affairs Medical Center.

Introduction: The past decade has witnessed numerous advances in colorectal surgery secondary to minimally invasive surgery, evidence-based enhanced recovery programs, and a growing emphasis on patient-centered outcomes. The purpose of this study is to benchmark outcomes and experiences of patients undergoing colorectal surgery at a tertiary Veterans Affairs Medical Center for a 10-year period. Materials and Methods: Veterans who underwent nonemergent colorectal procedures between 2008 and 2018 were identified using targeted Current Procedural Terminology (CPT) codes and the Computerized Patient Record System. Patient outcomes were captured using the Veterans Affairs Surgical Quality Improvement Program and focused on length of stay and aggregate postoperative morbidity profiles. SAS® Version 9.4 (SAS Institute Inc., Cary, NC) was used for all data analysis with P < .05 used to indicate significance. Results: In total, 327 patients underwent colon/rectal resection at our medical center. Of whom 95% of patients were male and the average age was 66 years. The median length of stay after surgery was 8 days. Within the 30-day postoperative period, the composite morbidity score was 24.1%: most notable being superficial surgical site infections (6.5%), wound dehiscence (4.6%), and pneumonia (3.1%). Over the course of the study period, the laparoscopic approach increased in utilization, with 22.2% of cases performed laparoscopically in 2008 that rose to 61.1% in 2018. Conclusion: Cataloging this decade of practice provides a foundation for future changes in the field of colorectal surgery and in the treatment of veterans. Understanding historical outcomes should help identify areas for ongoing process improvement and guide targeted approaches to quality metrics.

Awareness of residents' technical ability can affect margin status in breast conserving operations.

PURPOSE: The current study was performed to determine if awareness of the potential affect of residents could affect margin status. METHODS: Retrospective review of all patients who underwent lumpectomy from July 2006 to May 2017 was evaluated. The effect of surgical residents' participation and their technical ability was evaluated to determine the effect on margin status. Logistic regression analysis was performed to determined factors which affect margin status. RESULTS: Of 444 patients, 14% of patients had positive margins. The positive margin rate was lower during the second time period after the effect of technical ability of the residents was known 12% versus 19% (p = 0.10). Greater participation by the attending surgeon (32% vs. 21%) occurred in the second time period. In multivariate logistic regression analysis, operations done by residents with satisfactory technical skills or attending surgeon were less likely to have positive margins than those done by residents with unsatisfactory technical skills (OR 0.19, 95% CI 0.10-0.38; p = 0.0001). With mean follow-up of 48 months, 1.4% had local recurrences as a first event. CONCLUSIONS: Technically ability of residents appears to affect margin status after lumpectomy. Increased intervention by the attending surgeon can improve this outcome.

Closed therapy of thoracic and lumbar vertebral body fractures in trauma patients.

BACKGROUND: The failure rate for the closed/non-surgical treatment of thoracic and lumbar vertebral body fractures (TLVBF) in trauma patients has not been adequately evaluated utilizing computed tomography (CT) studies. METHODS: From 2007 to 2008, consecutive trauma patients, who met inclusion criteria, with a CT diagnosis of acute TLVBF undergoing closed treatment were assessed. The failure rates for closed therapy, at 3 months post-trauma, were defined by progressive deformity, vertebral body collapse, or symptomatic/asymptomatic pseudarthrosis. The Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification was utilized to classify the fractures (groups A1 and non-A1 fractures) and were successively followed with CT studies. RESULTS: There were 54 patients with 91 fractures included in the study; 66 were A1 fractures, and 25 were non-A1 fractures. All had rigid bracing applied with flat and upright X-ray films performed to rule out instability. None had sustained spinal cord injuries. Thirteen patients (24%) failed closed therapy [e.g. 13 failed fractures (14%) out of 91 total fractures]. Five failed radiographically only (asymptomatic), and eight failed radiographically and clinically (symptomatic). A1 fractures had a 4.5% failure rate, while non-A1 fractures failed at a rate of 40%. CONCLUSION: Failure of closed therapy for TLVBF in the trauma population is not insignificant. Non-A1 fractures had a much higher failure rate when compared to A1 fractures. We recommend close follow-up particularly of non-A1 fractures treated in closed fashion using successive CT studies.

Goal directed enoxaparin dosing provides superior chemoprophylaxis against deep vein thrombosis.

INTRODUCTION: Optimal enoxaparin dosing for deep venous thrombosis (DVT) prophylaxis remains elusive. Prior research demonstrated that trauma patients at increased risk for DVT based upon Greenfield's risk assessment profile (RAP) have DVT rates of 10.8% despite prophylaxis. The aim of this study was to determine if goal directed prophylactic enoxaparin dosing to achieve anti-Xa levels of 0.3-0.5IU/ml would decrease DVT rates without increased complications. MATERIALS AND METHODS: Retrospective review of trauma patients having received prophylactic enoxaparin and appropriately timed anti-Xa levels was performed. Dosage was adjusted to maintain an anti-Xa level of 0.3-0.5IU/ml. RAP was determined on each patient. A score of ≥5 was considered high risk for DVT. Sub-analysis was performed on patients who received duplex examinations subsequent to initiation of enoxaparin therapy to determine the incidence of DVT. RESULTS: 306 patients met inclusion criteria. Goal anti-Xa levels were met initially in only 46% of patients despite dosing of >40mg twice daily in 81% of patients; however, with titration, goal anti-Xa levels were achieved in an additional 109 patients (36%). An average enoxaparin dosage of 0.55mg/kg twice daily was required for adequacy. Bleeding complications were identified in five patients (1.6%) with three requiring intervention. There were no documented episodes of HIT. Subsequent duplex data was available in 197 patients with 90% having a RAP score >5. Overall, five DVTs (2.5%) were identified and all occurred in the high-risk group. All patients were asymptomatic at the time of diagnosis. CONCLUSION: An increased anti-Xa range of 0.3-0.5IU/ml was attainable but frequently required titration of enoxaparin dosage. This produced a lower rate of DVT than previously published without increased complications.

Computed tomographic imaging interpretation improves fetal outcomes after maternal trauma.

BACKGROUND: Computed tomography (CT) has been validated to identify and classify placental abruption following blunt trauma. The purpose of this study was to demonstrate improvement in fetal survival when delivery occurs by protocol at the first sign of class III fetal heart rate tracing in pregnant trauma patients with a viable fetus on arrival and CT evidence of placental perfusion 50% or less secondary to placental abruption. METHODS: This is a retrospective review of pregnant trauma patients at 26 weeks' gestation or greater who underwent abdominopelvic CT as part of their initial evaluation. Charts were reviewed for CT interpretation of placental pathology with classification of placental abruption based upon enhancement (Grade 1, >50% perfusion; Grade 2, 25%-50% perfusion; Grade 3, <25% perfusion), as well as need for delivery and fetal outcomes. RESULTS: Forty-one patients met inclusion criteria. Computed tomography revealed evidence of placental abruption in six patients (15%): Grade 1, one patient, Grade 2, one patient, and Grade 3, four patients. Gestational ages ranged from 26 to 39 weeks. All patients with placental abruption of Grade 2 or greater developed concerning fetal heart tracings and underwent delivery emergently at first sign. Abruption was confirmed intraoperatively in all cases. Each birth was viable, and Apgar scores at 10 minutes were greater than 7 in 80% of infants, all of whom were ultimately discharged home. The remaining infant was transferred to an outside facility. CONCLUSIONS: Delivery at first sign of nonreassuring fetal heart rate tracings in pregnant trauma patients (third trimester) with placental abruption of Grade 2 or greater can lead to improved fetal outcome. LEVEL OF EVIDENCE: Therapeutic/care management study, level III.

Enhanced cytotoxicity of optimized liposomal genistein via specific induction of apoptosis in breast, ovarian and prostate carcinomas.

Clinical use of genistein against cancer is limited by its extremely low aqueous solubility, poor bioavailability and pharmacokinetics. Based on structural analogy with steroidal compounds, liposomal vehicle compositions were designed and optimized for maximum incorporation of genistein's flavonoid structure. Model conventional and stealth liposomes of genistein (GenLip)--incorporating unsaturated phospholipids and cholesterol--have demonstrated enhanced drug solubilization (over 350-folds > aqueous drug solution), shelf-life stability, and extended release profile. Owing to effective cellular delivery, preservation of genistein's antioxidant activity was confirmed through marked neutralization of peroxides via GenLip, in both quantitative and microscopic fluorescent-probe oxidation assays. Furthermore, significant broad-spectrum anticancer efficacy of GenLip, in murine and human cancer cell lines (p < 0.05-0.001), was achieved in a concentration and time-dependent manner--approx. 5-7 lower IC50 values versus all non-incorporated drug controls. Indicative of key pro-apoptotic activity, GenLip produced DNA laddering, with 1/3 of free drug solution content, and resulted in the highest induction level of P53-independent apoptotic pathway markers, compared to all treatments, in our assays (namely, mitochondrial polarization, and caspase-3/7 enzymes). Our proof-of-principle pharmaceutical design of genistein-loaded liposomes shows optimal loading capacity and physico-chemical properties, which improved cellular delivery and specific pro-apototic effectiveness of incorporated drug, against various cancers.