Levi Procter

General surgical operative duration is associated with increased risk-adjusted infectious complication rates and length of hospital stay.

BACKGROUND Studies of specific procedures have shown increases in infectious complications with operative duration. We hypothesized that operative duration is independently associated with increased risk-adjusted infectious complication (IC) rates in a broad range of general surgical procedures. STUDY DESIGN We queried the American College of Surgeons National Surgical Quality Improvement Program database for general surgical operations performed from 2005 to 2007. ICs (wound infection, sepsis, urinary tract infection, and/or pneumonia) and length of hospital stay (LOS) were evaluated versus operative duration (OD, ie, incision to closure). Multivariable regression adjusted for 38 patient risk variables, operation type and complexity, wound class and intraoperative transfusion. We also analyzed isolated laparoscopic cholecystectomies in patients of American Society of Anesthesiologists class 1 or 2, without intraoperative transfusion and with a clean or clean-contaminated wound class. RESULTS In 299,359 operations performed at 173 hospitals, unadjusted IC rates increased linearly with OD at a rate of close to 2.5% per half hour (chi-square test for linear trend, p < 0.001). After adjustment, IC risk increased for each half hour of OD relative to cases lasting <or=1 hour, almost doubling at 2.1 to 2.5 hours (odds ratio = 1.92; 95% CI, 1.82 to 2.03; p < 0.001). In isolated laparoscopic cholecystectomy, IC rates increased linearly with OD (n = 17,018, chi-square test for linear trend, p < 0.001) with rates for 1.1 to 1.5 hour cases (1.4%) doubling those lasting <or=0.5 hour (0.7%). Across all procedures, adjusted LOS increased geometrically with operative duration at a rate of about 6% per half hour (coefficient for natural log transformed LOS = 0.059 per half hour; 95% CI, 0.058 to 0.060; p < 0.001). CONCLUSIONS Operative duration is independently associated with increased ICs and LOS after adjustment for procedure and patient risk factors.

An acute care surgery rotation contributes significant general surgical operative volume to residency training compared with other rotations.

BACKGROUND Surgical resident rotations on trauma services are criticized for little operative experience and heavy workloads. This has resulted in diminished interest in trauma surgery among surgical residents. Acute care surgery (ACS) combines trauma and emergency/elective general surgery, enhancing operative volume and balancing operative and nonoperative effort. We hypothesize that a mature ACS service provides significant operative experience. METHODS A retrospective review was performed of ACGME case logs of 14 graduates from a major, academic, Level I trauma center program during a 3-year period. Residency Review Committee index case volumes during the fourth and fifth years of postgraduate training (PGY-4 and PGY-5) ACS rotations were compared with other service rotations: in total and per resident week on service. RESULTS Ten thousand six hundred fifty-four cases were analyzed for 14 graduates. Mean cases per resident was 432 ± 57 in PGY-4, 330 ± 40 in PGY-5, and 761 ± 67 for both years combined. Mean case volume on ACS for both years was 273 ± 44, which represented 35.8% (273 of 761) of the total experience and exceeded all other services. Residents averaged 8.9 cases per week on the ACS service, which exceeded all other services except private general surgery, gastrointestinal/minimally invasive surgery, and pediatric surgery rotations. Disproportionately more head/neck, small and large intestine, gastric, spleen, laparotomy, and hernia cases occurred on ACS than on other services. CONCLUSIONS Residents gain a large operative experience on ACS. An ACS model is viable in training, provides valuable operative experience, and should not be considered a drain on resident effort. Valuable ACS rotation experiences as a resident may encourage graduates to pursue ACS as a career.

An acute care surgery service generates a positive contribution margin in an appropriately staffed hospital.

BACKGROUND Acute care surgery (ACS) includes trauma, surgical critical care, and emergent general surgery. There is a national shortage of institutions that can provide for patients needing access to emergency surgical care. Inability to fund ACS surgeons can be a barrier. We hypothesize that an ACS service, in an appropriately staffed hospital, generates a positive contribution margin (CM). STUDY DESIGN Fiscal data for 2009 were retrospectively reviewed at the University of Kentucky, a Level I trauma center with an ACS service. Contribution margin (ie, net revenue minus direct costs) and mean length of stay were calculated for all patients admitted to the ACS service. Inpatient data were stratified by trauma vs general surgery, emergent vs elective, and by payor mix. RESULTS Annual CM associated with the 5 ACS faculty was

Nonopioid management of acute pain associated with trauma: Focus on pharmacologic options.

21,799,000. Trauma generated higher CM than general surgery. General surgery had a greater CM, more if emergent than if elective (

In vitro transfusion of red blood cells results in decreased cytokine production by human T cells.

9,500 vs

Abdominal Wall Hernias and Biomaterials

5,500; p < 0.01). Self-payment was lower with emergent general surgery vs trauma (20% vs 25%; p = 0.02). CONCLUSIONS Acute care surgery generates a positive CM. Emergent general surgery generates a greater CM than elective general surgery because of increased case mix index. These data suggest that hospital subsidization of acute care surgeons is financially feasible and might address the surgical workforce shortage and the critical problem of access to emergency surgical services.

Emergent Surgical Management of Ventral Hernias

Despite the prevalence of acute pain in the trauma setting and known complications of its improper management, including risk of chronic pain, delayed recovery, and poorer quality of life, recent survey data suggest little has changed in the overall management of pain in the acute setting during the

Strangulated appendix after transabdominal preperitoneal (TAPP) inguinal hernia repair.

BACKGROUND Transfusion-related immunomodulation consists of both proinflammatory and anti-inflammatory responses after transfusion of blood products. Stored red blood cells (RBCs) suppress human T-cell proliferation in vitro, but the mechanism remains unknown. We hypothesized that cytokine synthesis by T cells may be inhibited when stored RBCs are present and that suppression between fresh and stored RBCs would be different. METHODS Purified human T cells were stimulated to proliferate with anti-CD3/anti-CD28 and then exposed to stored or fresh RBCs. Cells were placed in culture for 5 days. Cell culture supernatants were analyzed for the production of typical T-cell cytokines using multianalyte ELISArray kits. RESULTS Stimulated T cells proliferated. RBC exposure markedly suppressed this proliferation. Interleukin 10, interleukin 17a, interferon &ggr;, tumor necrosis factor &agr;, and granulocyte macrophage colony-stimulating factor were increased in response to stimulation but depressed in the presence of stored RBCs. The use of fresh RBCs also resulted in depression of these cytokines when compared with stimulated T cells with no RBCs; however, this depression was less pronounced. CONCLUSION T-cell activation is associated with both proinflammatory and anti-inflammatory cytokine release, comparable with patterns seen in trauma and acute injury. All of these responses are depressed by an exposure to stored RBCs. Decreased levels of these cytokines after RBC transfusion represents a potential contributor to the immunosuppressive complications seen in trauma patients after transfusion. This provides insight for future mechanistic studies to delineate the role of RBC transfusion in transfusion-related immunomodulation.

Minimizing opioid use after acute major trauma

Hernia is derived from the Latin word meaning “rupture or protrusion”. A hernia is the protrusion of tissue or an organ through a defect or weakness in the surrounding walls. Abdominal wall hernias occur at sites lacking a covering with overlapping aponeuroses and fascia. Hernias can be present at birth (congenital), develop spontaneously over time or as a result of surgery or trauma. Areas on the ventral abdominal wall prone to hernia formation are located at the arcuate line, epigastric, inguinal and umbilical hernias. Iatrogenic hernias on the abdominal wall occur at sites of surgical incisions (incisional hernias).

Morbid obesity and diverticulitis: Results from the ACS NSQIP dataset

The emergency care of ventral hernias is complex. The key to improved morbidity and mortality is operating on these patients prior to progressing to strangulation. The type of operation depends on many factors, including location of the hernia, patient’s physiology, imaging findings, and prior repairs with or without mesh. The operations can be open, laparoscopic, or a combination of both. The use of laparoscopy has a significant role in assessing bowel viability and repair. Dealing with large ventral hernias in a damage control surgery should focus on sepsis source control and abdominal closure. In these patients, definitive and complex abdominal wall closures with non-biologic prosthesis should be avoided. The goal is survival and planning a formal abdominal wall construction in the future with a non-biologic prosthesis. This chapter will review these topics.