Faculty Bibliography

OBJECTIVES/OBJECTIVE:Laryngotracheal trauma is poorly studied and associated with serious morbidity and mortality. This study reports features associated with laryngotracheal fractures, and factors associated with laryngeal fracture repair. STUDY DESIGN/METHODS:edition encodings. Demographic, diagnostic and procedure characteristics were analyzed with univariate chi-squared analysis and multivariate logistic regression. RESULTS:We extracted 635 cases of laryngotracheal injury, with a median Injury Severity Score of 16 (IQR: 10 - 25). Most were caused unintentionally (65.7%), followed by assault (28.8%). Blunt trauma (79.5%) was more common than penetrating trauma (20.0%). These trends were upheld in the subgroup of repaired fractures, which made up 12.6% (80/635) of cases. The median length of hospital stay was 6 days (IQR: 3 - 13) in all fractures and 10 days (IQR: 6 - 14) in the subgroup of repaired fractures, while the median length of ICU stay was 4 days (IQR: 2 - 9) in all fractures and 4.5 (IQR: 6 - 14.3) in the subgroup of repaired fractures. Cut/pierce injuries (OR: 4.7, P < 0.001) and ISS (OR: 0.97, pP = 0.026) significantly affected rate of laryngeal fracture repair. CONCLUSION/CONCLUSIONS:Laryngotracheal fractures are uncommon but serious injuries. Our results show that penetrating causes of injuries have the shortest time to repair, and that a higher ISS score is negatively associated with repair.

Introduction Surgical site infections (SSIs) continue to be a challenging issue among patients undergoing pancreatectomy. Anecdotally, the use of negative pressure wound therapy (NPWT) following pancreatectomy for cancer has been associated with decreased SSIs. The objective of this study was to compare the postoperative outcomes of NPWT and non-NPWT for incisional wound care following distal pancreatectomy or pancreatoduodenectomy for pancreatic diagnoses using a national surgical database. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was queried from 2005 to 2019 for patients undergoing distal pancreatectomy or pancreaticoduodenectomy for pancreatic diagnoses using primary Current Procedural Terminology (CPT) codes. The primary outcome was surgical site infection rates between NPWT and non-NPWT patient groups. Secondary outcomes include sepsis, septic shock, readmission, and reoperation. Outcomes of interest were compared using multivariate logistic regression. Results A total of 54,457 patients underwent pancreatectomy with 131 receiving NPWT. Multivariate analysis, while accounting for patient characteristics, including wound classification, showed no difference in postoperative superficial SSI, deep SSI, sepsis, septic shock, or readmission between the NPWT and non-NPWT groups. Organ space SSI was higher in the NPWT group (21% vs 12%, p=0.001). Reoperation related to procedure was also high in the NPWT group (14% vs 4.3%, p<0.001). Conclusion The use of NPWT in distal pancreatectomies and pancreatoduodenectomies is associated with increased organ space SSIs and reoperation rates, with no difference in superficial SSI, deep SSI, or readmission. This large sample study shows no significant benefit of using NPWT incisional wound care after pancreatectomy.

PURPOSE:Work-relative-value-units (wRVUs) are a core metric of faculty effort but do not account for the additional work associated with intraoperative teaching. This study introduces and assesses an indexed effort, wRVU per minute (wRVU index). We hypothesize that there is a significant decrease in the calculated wRVU index among teaching cases. METHODS:We queried the ACS-NSQIP database for 7 core Emergency General Surgery procedures and records were stratified into teaching vs non-teaching, and emergent vs non-emergent procedures. We utilized multivariable generalized linear models to determine factors associated with increased operative time and decreased wRVU index. RESULTS:Data were available for 953,967 cases from 2005 to 2010. For all cases, teaching vs non-teaching, the median wRVU index was 0.16 vs 0.21 (p ​< ​0.001). There was a positive association between teaching cases and decreased wRVU index for all cases. CONCLUSION:The wRVU index was 24% lower for teaching cases when compared to non-teaching cases despite controlling for patient-specific factors. This finding highlights the need for further evaluation of the current wRVU framework.

INTRODUCTION/UNASSIGNED:Ischemic colitis is a common manifestation of intestinal ischemia and is potentially a surgical emergency. Although such surgical emergencies were historically approached via open exploration, it is uncertain if there is a role for minimally invasive techniques. This study compares open vs laparoscopic colectomy techniques in the management of ischemic colitis. METHODS/UNASSIGNED:Using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database, patients with ischemic colitis undergoing colectomy from 2005 to 2019 were compared. The primary outcome of interest was 30-day mortality. Additional outcomes of interest were procedure related readmission, procedure related reoperation, length of stay, surgical site infections (SSI), septic shock, and other complications. Outcomes of interest were compared using multivariate logistic regression. RESULTS/UNASSIGNED:=<0.001) were significantly decreased using a laparoscopic approach. DISCUSSION/UNASSIGNED:30-day postoperative mortality was significantly lower using a laparoscopic. Patients that had a laparoscopic colectomy had shorter hospital stays. While patients that underwent laparoscopic procedures tended to be less sick, multivariate analysis showed decreased rates of sepsis and surgical site infections compared to open colectomies when correcting for these factors. CONCLUSION/UNASSIGNED:Laparoscopic colectomy may be a better surgical approach for patients with ischemic colitis compared to open colectomy.

Introduction It has been suggested that hernia repair with concomitant cholecystectomy increases the risk of postoperative complications due to potential mesh contamination. This study compares postoperative outcomes and complications between patients who underwent ventral hernia repair (VHR) with and without concomitant cholecystectomy (CCY). Methods Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, from 2005 to 2019, we queried patients who underwent ventral hernia repairs using the current procedural terminology (CPT) codes 49652-49657 (laparoscopic) and 49560-49566 (open), with or without cholecystectomy. The ACS NSQIP is a prospective, systematic study of patients who underwent major general surgical procedures aggregating data from over 200 hospitals. Cases involving additional concomitant procedures were excluded. Primary outcomes of interest were 30-day mortality, length of stay, readmission, return to operating room (OR), and postoperative complications. The odds ratio for primary outcomes was calculated using multivariable binomial logistic regression to control for patient risk factors. Results In total, 167586 cases were identified, 165,758 ventral hernia repairs alone, and 1,828 ventral hernia repairs with concomitant cholecystectomy. There was no difference in 30-day mortality, length of stay, readmission, return to the operating room, or postoperative complications between groups. Patients who underwent simultaneous VHR/CCY when compared to those who had VHR alone, had no differences in the rate of surgical site infections (1.86% vs. 1.97%, P = 0.57) or sepsis (0.82% vs. 0.41%, P = 0.10).  Conclusion In a large national sample, there is no significant difference in postoperative outcomes, specifically infection-related complications, when comparing VHR along with concurrent VHR/CCY. Our findings suggest no increased risks for patients undergoing concurrent ventral hernia repair and cholecystectomy. Hence, surgeons might consider this combined approach to offer the best value-based care, especially when it could eliminate the need for a second operation and the risk of infection is low. Prospective studies with more procedural-specific information for hernia repairs and indications for cholecystectomy are needed however it is likely safe to perform both procedures during the same setting in cholecystectomy cases lacking signs of acute infection.

INTRODUCTION/UNASSIGNED:Gallstone ileus is an uncommon etiology of intestinal obstruction, although many cases require surgical repair. There is no consensus regarding the necessity of concomitant cholecystectomy. (CCY) at the time of index surgery. This study aimed to evaluate the outcomes of gallstone ileus in patients with and without CCY. METHODS/UNASSIGNED:Using the ACS NSQIP database from 2005 to 2019, we included patients who underwent surgical management of gallstone ileus (enterolithotomy) with or without CCY. The primary outcomes of interest were surgical site infection (SSI) and 30-day mortality. Additional outcomes of interest included readmissions related to the procedure, length of hospital stay (LOS), return to the operating room, and sepsis. Demographics were evaluated using univariate analysis, whereas outcomes of interest were analyzed using multivariate logistic regression. RESULTS/UNASSIGNED: = 0.08), but this was not statistically significant. No concomitant CCY was associated with increased SSI rates, readmissions related to the procedure, 30-day mortality, or sepsis. CONCLUSION/UNASSIGNED:Surgical management of gallstone ileus with or without CCY has similar short-term postoperative outcomes.

INTRODUCTION:Bullying is a notable problem in surgery, creating a hostile environment for surgeons and trainees, and may negatively affect patient care. However, specific details regarding bullying in orthopaedic surgery are lacking. The primary aim of this study was to determine the prevalence and nature of bullying within orthopaedic surgery in the United States. METHODS:A deidentified survey was developed using the survey created by the Royal College of Australasian Surgeons and the validated Negative Acts Questionnaire-Revised survey tool. This survey was distributed to orthopaedic trainees and attending surgeons in April 2021. RESULTS:Of the 105 survey respondents, 60 (60.6%) were trainees and 39 (39.4%) were attending surgeons. Although 21 respondents (24.7%) stated they had been bullied, 16 victims (28.1%) did not seek to address this behavior. Perpetrators of bullying were most commonly male (49/71, 67.2%) and the victims' superior (36/82, 43.9%). Five bullying victims (8.8%) reported the behavior, despite 46 respondents (92.0%) stating that their institution has a specific policy against bullying. CONCLUSION:Bullying behavior occurs in orthopaedic surgery, with perpetrators being most commonly male and the victims' superiors. Despite the fact that an overwhelming majority of institutions have policies against bullying, the reporting of such behavior is lacking.