Background: The authors assessed the rate of short-term satisfaction (30 days) following laparoscopic sleeve gastrectomy in patients suffering from morbid obesity in their center and assessed the predictors of improved level of satisfaction from the surgery. Methods: Patients who had laparoscopic sleeve gastrectomy performed at our facility in the period from January 2021 to December 2023 were evaluated in this retrospective cohort analysis. Two medical professionals examined the patient data. Patients with insufficient information were not included in the research. The following information was gathered: mean arterial pressure, age, gender, co-morbidity, BMI, OSA, and GERD. Additionally, the preoperative Hb concentration, HbA1C, and serum TSH levels were measured. The duration of hospital stays, the time required for amblution, and the time required for oral fluid intake were also documented. Results: Our university hospitals had performed laparoscopic sleeve gastrectomy on 193 morbidly obese patients; 24 individuals were eliminated, and the remaining 169 candidates were subdivided into two groups: group A (111 pleased candidates) and group B (58 unsatisfied candidates). The 30-day satisfaction rate was 65.68%. Reduced age (coefficient: -0.0063, Odds ratio: 1.429, and P= 0.034), increased BMI (coefficient: 0.0269, Odds ratio: 0.637, and P= 0.0002), female gender (coefficient: 0.414, Odds ratio: 0.000, and P= 0.003), and increased severity of preoperative OSA (coefficient: 0.264, Odds ratio: 77.048, and P= 0.001) all with significant increase in the level of satisfaction, according to an analysis of the predicted factors of patient satisfaction. Conclusion: For morbidly obese individuals, the short-term satisfaction following laparoscopic sleeve gastrectomy can surpass 65%. This is associated with younger age, female gender, higher BMI, more severe OSA, and a poor cardiac history.

Background Mortality for patients with pelvic fracture with hemorrhagic shock ranges from 21% to 57%. ResQFoam administered intra-abdominally has previously been shown to provide a survival benefit in large-animal models of abdominal exsanguination. It also significantly decreased mortality in models of retroperitoneal hemorrhage with complex pelvic fracture when deployed in the preperitoneal space. We hypothesized that percutaneously administered ResQFoam into the abdominal cavity could decrease mortality in exsanguinating pelvic hemorrhage.Methods Using non-coagulopathic Yorkshire swine, the injury model consisted of a unilateral, closed-cavity retroperitoneal vascular hemorrhage (with intraperitoneal communication) combined with a complex pelvic fracture. After the injury, animals received fluid resuscitation alone (control, n=14), fluid resuscitation with ResQFoam deployed in the preperitoneal pelvic space (n=10), or fluid resuscitation with ResQFoam deployed intra-abdominally (n=10). Hemodynamic monitoring was continued for 3 hours or until death.Results Intra-abdominal and preperitoneal use of ResQFoam provided a similar significant survival benefit compared with controls. The median survival times for the intra-abdominal and preperitoneal ResQFoam groups were 87 and 124 min, respectively, compared with 17 min for the control group (p=0.008 and 0.002, respectively). The survival rate at 3 hours was 40% for both ResQFoam groups compared with 0% in controls (p=0.020). There was no significant difference in the median survival time or overall survival curves between the two ResQFoam groups (p=0.734 and p=0.975, respectively). Both ResQFoam groups stabilized mean arterial pressure and significantly reduced hemorrhage rate. The average hemorrhage rate in control animals was 4.9±4.6 g/kg/min compared with 0.6±0.6 g/kg/min and 0.5±0.5 g/kg/min in the intra-abdominal (p=0.008) and preperitoneal (p=0.002) ResQFoam groups, respectively.Conclusions Similar survival benefit and hemorrhage control were achieved with ResQFoam in the treatment of exsanguinating pelvic hemorrhage with complex pelvic fracture whether it was administered preperitoneally or intra-abdominally. Thus, ResQFoam can be administered intra-abdominally to treat either abdominal or pelvic hemorrhage.Level of evidence Not applicable (animal study).

Background: The authors noticed during their practice that most of patients scheduled for laparoscopic cholecystectomy (LC) owing to acute cholecystitis are associated with increased intraoperative blood pressure especially during manipulation on the gallbladder which may increase the risk of bleeding. A retrospective analysis was carried out to estimate the risk and the potential risk factors of intraoperative hypertension. Methods: A retrospective analysis of the data of patients who underwent LC for acute cholecystitis in our university hospitals from June 2022 to December 2023. The patients’ documents and records were revised with exclusion of patients with incomplete data. The data of age, gender, ASA class, BMI, co-morbidities, preoperative CRP, preoperative TLC, preoperative temperature, and preoperative bilirubin were collected and reported. The data of duration of surgery, time for devascularization of the gallbladder, and the changes in the blood pressure were also recorded. Results: Seventy-three patients underwent LC for acute cholecystitis during the study period, 44 (60.27%) of them developed intraoperative hypertension with statistically significant difference between the patients who did not develop intraoperative hypertension in BMI (p=0.0003), preoperative CRP (p=0.008), preoperative TLC (p=0.001), duration of surgery (p=0.034), and time to devascularization of the gallbladder (p=0.027). The regression analysis revealed an increased risk of intraoperative hypertension with decreased age (p=0.0191), increased BMI (p=0.034), and increased preoperative TLC (p=0.038). Conclusions: The risk of intraoperative hypertension during LC for acute cholecystitis increased with decreased age, increased BMI, and increased preoperative TLC.

This multicentre retrospective study was conducted in 3 university hospitals in Egypt between April 2020 and June 2022. The aim was to assess the relation between Coronavirus Disease-19 (COVID-19) and ischemic priapism. Forty-three ischemic priapism patients were diagnosed and divided into two groups (30 in group I with ischemic priapism only, and 13 in group II with both ischemic priapism and COVID-19). Further sub-classification of COVID-19 patients according to the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection severity was done. Cavernosal aspiration was successful in 25 patients (83.3%) in group I and 12 (92.3%) in group II. Long term follow-up proved moderate to severe erectile dysfunction in 6 patients (20.0%) and 1 (7.7%) in group I and II, respectively. All those with severe erectile dysfunction were managed by distal shunt and prepared for penile prosthesis placement. The median duration of ischemic priapism was significantly longer in patients with severe erectile dysfunction [19 vs. 7 h, P = 0.01]. There was no statistically significant difference between both groups regarding patients’ age (p = 0.8), required priapism management (p = 0.4), priapism recurrence (p = 0.1), and erectile dysfunction severity (p = 0.5). Ischemic priapism in COVID-19 patients can occur not only in severe, but also in mild or even asymptomatic cases. COVID-19 did not influence the ischemic priapism treatment protocol and post-treatment erectile function. COVID-19 and ischemic priapism seem to have a coincidence relation rather than a causal.

BACKGROUND Mortality for pelvic fracture patients presenting with hemorrhagic shock ranges from 21% to 57%. The objective of this study was to develop a lethal and clinically relevant pelvic hemorrhage animal model with and without bony fracture for evaluating therapeutic interventions. ResQFoam is a self-expanding foam that has previously been described to significantly decrease mortality in large-animal models of abdominal exsanguination. We hypothesized that administration of ResQFoam into the preperitoneal space could decrease mortality in exsanguinating pelvic hemorrhage. METHODS Two pelvic hemorrhage models were developed using noncoagulopathic swine. Pelvic hemorrhage model 1: bilateral, closed-cavity, major vascular retroperitoneal hemorrhage without bony pelvic fracture. After injury, animals received no treatment (control, n = 10), underwent preperitoneal packing using laparotomy pads (n = 11), or received ResQFoam (n = 10) injected into the preperitoneal space. Pelvic hemorrhage model 2: unilateral, closed-cavity, retroperitoneal hemorrhage injury (with intraperitoneal communication) combined with complex pelvic fracture. After injury, animals received resuscitation (control, n = 12), resuscitation with preperitoneal packing (n = 10) or with ResQFoam injection (n = 10) into the preperitoneal space. RESULTS For model 1, only ResQFoam provided a significant survival benefit. The median survival times were 50 minutes and 67 minutes for preperitoneal packing and ResQFoam, compared with 6 minutes with controls (p = 0.002 and 0.057, respectively). Foam treatment facilitated hemodynamic stabilization and resulted in significantly less hemorrhage (21.5 ± 5.3 g/kg) relative to controls (31.6 ± 5.0 g/kg, p < 0.001) and preperitoneal packing (32.7 ± 5.4 g/kg, p < 0.001). For model 2, both ResQFoam and preperitoneal packing resulted in significant survival benefit compared with controls. The median survival times were 119 minutes and 124 minutes for the preperitoneal packing and ResQFoam groups, compared with 4 minutes with controls (p = 0.004 and 0.013, respectively). CONCLUSION Percutaneous injection of ResQFoam into the preperitoneal space improved survival relative to controls, and similar survival benefit was achieved compared with standard preperitoneal pelvic packing. The technology has potential to augment the armamentarium of tools to treat pelvic hemorrhage.

OBJECTIVES To assess the risk of azoospermia development and the value of sperm retrieval in post-pubertal testicular torsion (TT).MATERIALS AND METHODS This prospective study included patients with post-pubertal TT. Surgical exploration was urgently per-formed with either orchiopexy or orchiedectomy and contralateral orchiopexy. With the intention of cryopreservation, all cases underwent conventional testicular sperm extraction. Patients were fol-lowed-up after 1, 3, and 6 months with semen analysis and hormonal assay (FSH, LH and testoster-one). Sperm retrieval rate (SRR), azoospermia rate and changes in hormonal profile were evaluated.RESULTS The study included 62 patients with a median (IQR) age of 19 (18-20.7) years and duration of tes-ticular torsion of 32.5 (18.3-48) hours. Testicular salvage was successful in 20 (32.3%) while orchiedectomy was performed on 42 patients. The duration of torsion [OR, 95% CI = 0.75 (0.61-0.93), P = .008] was the independent predictor of testicular salvage. Successful SR was achieved in 58 patients (93.5%); (40 from the affected testis and 18 from the contralateral side). After 6 months, 21 patients (33.8%) developed azoospermia [19 (45.2%) in orchidectomy group and 2 (10%) in orchiopexy group, P = .006]. Abnormal contralateral testis was the independent predic -tor of azoospermia [OR, 95% CI = 92(8.4-101.5), P < .001]. Azoospermia patients showed a statis-tically significant increase in FSH and LH and decrease in testosterone level as compared to the non-azoospermia group (P < .001).CONCLUSION Azoospermia is not rare in post-pubertal TT patients; therefore, SR at time of intervention seems to be a good option for them to preserve their fertility potentials. UROLOGY 171: 121-126, 2023.& COPY; 2022 Elsevier Inc.

INTRODUCTION:Synthetic mid-urethral slings (MUSs) are the gold standard treatment for female stress urinary incontinence (SUI). Recently, there have been reports of serious adverse events with synthetic tapes such as urethral erosion, vaginal erosion, and mesh infection. Tension-free vaginal flap (TVF) operation has been proven to be successful as a natural alternative to synthetic slings. We propose our novel technique, the transobturator tension-free vaginal flap (TO-TVF), utilizing native vaginal tissue and being suspended via transobturator route.METHODS:This prospective study was conducted on 72 female patients with SUI, presenting at Alexandria University Hospital. Patients were randomized into 2 groups, group 1: 37 patients subjected to TO-TVF and group 2: 35 patients to conventional transobturator tape (TOT). In TO-TVF, a rectangular vaginal wall flap is created. A polypropylene monofilament mesh is sutured to each edge of the vaginal flap. This is inserted like conventional outside-in TOT. Patients were subjected to PGI and UDI-6 questionnaires and urodynamic study before and 6 months postoperatively.RESULTS:Both groups showed comparable and significant improvements in questionnaires. Mean operative time for TO-TVF and conventional TOT was 26.31 ± 5.2 min and 21.8 ± 3.1 min, respectively. Cure rate was 89% in group 1 and 91.4% in group 2, which was not statistically significant. No significant intraoperative complications were encountered. We had no cases of vaginal or urethral erosion in both groups.CONCLUSIONS:TO-TVF is a cost-effective, feasible, safe, and effective surgical alternative to synthetic MUS. Synthetic mesh tissue anchoring properties are maintained for better adjustment of tension. However, long-term follow-up on a large cohort of patients is still needed.

Introduction: Proximal hypospadias (PPH) repair is a challenge. Dilemma exists whether to do it in single or staged repair. Staged repair is our adopted procedure which was recently modified by Snodgrass into staged tubularized autograft repair (STAG), in which attention was given to ventral straightening of the penis together with some other technical details. Herein, we report our experience with STAG in a cohort of primary posterior hypospadias. Patients and methods: In the period from 2011 to 2018 we operated 43 primary posterior hypospadias. Two principal surgeons (HB, MY) and multiple assistants operate children the same way, and data are recorded in a prospectively designed data base. In all children, inner prepuce graft was utilized, when curvature is more than 30 degrees, plate transection with or without ventral corporotomies were adopted. Results: Forty-three children with PPH and ventral curvature more than 30 degrees underwent first stage with median age 12 months (6-132 IQR16). Penile curvature was corrected by plate transection in 27 children (62.8%), ventral corporotomies in 16 children (37.2%). Graft take was successful in 90.7%, 4 children needed revision of fibrotic graft. Second stage was completed in 37 children, success was 56.8%, 21.6% fistula, 24.3% glanular dehiscence. Overall success after third surgery to correct complications was 78.4%. In a mean follow up of 3.2 years, we had recurrence of curvature in 2 children taking success rate to 72.9%. No meatal stenosis, no diverticulum, no stricture, no urethral dehiscence was encountered. Cosmetic appearance was excellent in follow up. Conclusion: STAG achieves proper straightening of the penis and allows for reconstruction of a good urethra, yet urethrocutaneous fistula and glanular dehiscence remain the main complications. Follow up is important to address results of ventral corporotomies. Type of study: Therapeutic. (c) 2020 Elsevier Inc. All rights reserved.

Objective: The International Patterns of Opioid Prescribing study compares postoperative opioid prescribing patterns in the United States (US) versus the rest of the world. Summary of Background Data: The US is in the middle of an unprecedented opioid epidemic. Diversion of unused opioids contributes to the opioid epidemic. Methods: Patients >= 16 years old undergoing appendectomy, cholecystectomy, or inguinal hernia repair in 14 hospitals from 8 countries during a 6-month period were included. Medical records were systematically reviewed to identify: (1) preoperative, intraoperative, and postoperative characteristics, (2) opioid intake within 3 months preoperatively, (3) opioid prescription upon discharge, and (4) opioid refills within 3 months postoperatively. The median/range and mean/standard deviation of number of pills and OME were compared between the US and non-US patients. Results: A total of 4690 patients were included. The mean age was 49 years, 47% were female, and 4% had opioid use history. Ninety-one percent of US patients were prescribed opioids, compared to 5% of non-US patients (P < 0.001). The median number of opioid pills and OME prescribed were 20 (0-135) and 150 (0-1680) mg for US versus 0 (0-50) and 0 (0-600) mg for non-US patients, respectively (both P < 0.001). The mean number of opioid pills and OME prescribed were 23.1 +/- 13.9 in US and 183.5 +/- 133.7 mg versus 0.8 +/- 3.9 and 4.6 +/- 27.7 mg in non-US patients, respectively (both P < 0.001). Opioid refill rates were 4.7% for US and 1.0% non-US patients (P < 0.001). Conclusions: US physicians prescribe alarmingly high amounts of opioid medications postoperatively. Further efforts should focus on limiting opioid prescribing and emphasize non-opioid alternatives in the US.

Objective: To compare the presentation, management, and outcomes of appendicitis in pregnant and non-pregnant females of childbearing age (18-45 years). Methods: This was a post-hoc analysis of a prospectively collected database (January 2017-June 2018) from 28 centers in America. We compared pregnant and non-pregnant females' demographics, clinical presentation, laboratory data, imaging findings, management, and clinical outcomes. Results: Of the 3,597 subjects, 1,010 (28%) were of childbearing age, and 41 were pregnant: The mean age of the pregnant subjects was 30 +/- 8 years at a median gestational age of 15 (range 10-23) weeks. The two groups had similar demographics and clinical presentation, but there were differences in management and outcomes. For example, in pregnant subjects, abdominal ultrasound scans (US) plus magnetic resonance imaging (MRI) was the most frequently used imaging method (41%) followed by MRI alone (29%), US alone (22%), computed tomography (CT) (5%), and no imaging (2%). Despite similar American Association for the Surgery of Trauma Emergency General Surgery Clinical and Imaging Grade at presentation, pregnant subjects were more likely to be treated with antibiotics alone (15% versus 4%; p = 0.008). Pregnant subjects were less likely to have simple appendicitis and were more likely to have complicated (perforated or gangrenous) appendicitis or a normal appendix. With the exception of index hospital length of stay, there were no significant differences between the groups in clinical outcomes at index hospitalization or at 30 days. Conclusion: Almost 1 in 20 women of childbearing age presenting with appendicitis is pregnant. Appendicitis most commonly affects women in early to mid-pregnancy. Compared with non-pregnant women of childbearing age, pregnant women presenting with appendicitis undergo non-operative management more often and are less likely to have simple appendicitis. Compared with non-pregnant patients, they have similar clinical outcomes at both index hospitalization and 30 days after discharge.

Hematuria is a critical symptom that should properly be investigated. One of the rare causes is renal papillary hypertrophy. Literature review revealed only few reported cases. Biopsy in reported cases has shown hyperplasia of renal papillae with normal histology. We report a case of bilateral renal papillary hypertrophy in a 32 years old female presented with intermittent gross hematuria. Computed tomgraphy urography, cystoscopy and selective cytology did not show any positive findings. Retrograde flexible uretero-renoscopy showed enlarged renal papillae protruding into upper and middle calyces of both kidneys with clots and active bleeding in some. Holmium:YAG Laser ablation of hypertrophic papillae showed an effective minimally invasive management of the condition.

BACKGROUND: A minimally invasive step-up (MIS) approach has been associated with reduced morbidity compared with open surgical necrosectomy (OSN) for treatment of necrotizing pancreatitis. We sought to determine whether transitioning from an OSN to an MIS-based approach would result in reduced mortality. MIS interventions included percutaneous drainage, endoscopic transgastric necrosectomy, video-assisted retroperitoneal debridement, sinus tract endoscopic necrosectomy, or a combination of techniques, with selective use of OSN. STUDY DESIGN: We conducted an observational cohort study with retrospective comparison at a single tertiary referral center (2006 through 2019). Eighty-eight patients were treated with OSN and 91 were treated with an MIS-based approach. Baseline characteristics and clinical outcomes were compared between groups. The primary end point was 90-day mortality. RESULTS: There was no difference in baseline characteristics. Ninety-day mortality was 2% with MIS compared with 10% with OSN (p = 0.03). One-year mortality was 3% with MIS compared with 15% with OSN (p = 0.012). The rate of organ failure was lower with MIS (30% vs 45%; p = 0.029), but there was a higher bleeding rate (19% vs 9%; p = 0.064). In the MIS group, 9% were treated with percutaneous drainage, 32% with endoscopic transgastric necrosectomy, 8% with video-assisted retroperitoneal debridement, 15% with sinus tract endoscopic necrosectomy, and 27% with a combination of techniques. CONCLUSIONS: Adoption of a multidisciplinary MIS-based approach to necrotizing pancreatitis resulted in a 5-fold decrease in mortality compared with OSN. (C) 2020 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy II (PD11)1 Apr 2020PD11-06 EVALUATION OF LAPAROENDOSCOPIC SINGLE SITE SURGERY VERSUS MINILAPAROSCOPY IN RADICAL NEPHRECTOMY: PROSPECTIVE RANDOMIZED COMPARATIVE STUDY Ahmed Abouelkhair*, Aly Abdel Karim, Ahmed Eid, and Wally Mahfouz Ahmed Abouelkhair*Ahmed Abouelkhair* More articles by this author , Aly Abdel KarimAly Abdel Karim More articles by this author , Ahmed EidAhmed Eid More articles by this author , and Wally MahfouzWally Mahfouz More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000845.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We aimed to present the first prospective randomized comparison between laparoendoscopic single-site surgery (LESS) and minilaparoscopy (ML) radical nephrectomy for treatment of renal neoplasms. METHODS: Between January 2016 and January 2018, 30 patients were allocated and blindly randomized to either LESS radical nephrectomy (LESS RN, n=15) or ML radical nephrectomy (ML RN, n=15). Both cohorts were compared regarding demographic data, peri- and postoperative characteristics, and visual analogue pain scale (VAS). Cosmetic outcome was assessed after 6 months using patient scar assessment scale (PSAS) and observer scar assessment scale (OSAS). RESULTS: Mean operative time was 142.7±16.3 and 97.60±25.6 minutes in LESS and ML groups, respectively (P< 0.05). Mean estimated blood loss was 70.67±43.67 and 56±23.54 mL in both groups, respectively (P > 0.05). Mean VAS was 2.07±0.26 and 2.27±0.46 in both groups, respectively (P= 0.07). Mean PSAS and OSAS was 6.53±6.53 and 7.00±0.93 vs 9.8±2 and 9.73±1.67 in both groups, respectively (P< 0.05). There were no intraoperative complications, conversions to open surgery, or to conventional laparoscopy in both groups. No additional port was used in LESS RN. There was no significant difference in the postoperative complications according to the Clavien-Dindo system nor in hospital stay in both groups. CONCLUSIONS: Both LESS RN and ML RN are valid options for treatment of renal neoplasms. They have comparable results in terms of blood loss, complication rate, VAS and hospital stay. However, LESS is associated with longer operative time and better cosmesis Source of Funding: none © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e255-e256 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ahmed Abouelkhair* More articles by this author Aly Abdel Karim More articles by this author Ahmed Eid More articles by this author Wally Mahfouz More articles by this author Expand All Advertisement PDF downloadLoading ...

Background: More than 145,500 abdominal abscesses occur annually in the U.S. Percutaneous catheter drainage (PCD) is the primary treatment for clinically significant intra-abdominal collections (IACs), but only approximately 90% of all IACs are treatable with PCD. This leaves a significant number of patients facing long courses of management, including multiple interventions. Minimally invasive debridement techniques are now employed regularly for the treatment of infected necrosis caused by acute pancreatitis. We describe the use of minimally invasive videoscopic debridement techniques employed as part of a "step-up" approach to resolve IACs of other etiologies that are unresponsive to PCD. Methods: Data of all patients undergoing this procedure at a tertiary referral academic center from 2015 to 2017 after failure of different PCD techniques were analyzed retrospectively. Results: Four men and two women, mean age 54.6 years (range 26-70 years), with refractory IACs (mean drainage time 91.3 days; mean number of drainage procedures 4.6) following a variety of surgical interventions and inflammatory conditions underwent either video-assisted retroperitoneal debridement or sinus tract endoscopic debridement with a rigid or flexible endoscope. Technical success was achieved in all cases, and clinical success was observed in five cases. No immediate procedural complications were detected. The mean hospital stay and post-procedure drainage times were 5.5 and 25.2 days, respectively. There were no recurrent IACs. Conclusion: Minimally invasive debridement techniques can safely resolve IACs refractory to standard PCD techniques. Employment of these techniques as part of a step-up approach may reduce the morbidity and duration of drainage for the thousands of patients treated annually who have refractory IACs, whatever their etiology.

BACKGROUND The decision to emergently operate on nonagenarian patients (NONAs) can be complex due to the uncertainty about outcomes and goals of care at this advanced age. We sought to study: (1) the outcomes and predictors of mortality for NONAs undergoing emergency general surgery (EGS) and (2) the accuracy of ACS-NSQIP mortality risk calculator in this special population. METHODS Using the 2007 to 2015 ACS-NSQIP database, we included all patients older than 90 years of age who underwent an emergent operation with a Current Procedural Terminology (CPT) code for “digestive system.” Multivariable logistic regression analyses were performed to identify independent predictors of 30-day mortality. NONAs' mortality rates for different combinations of risk factors were also studied and compared to the ACS-NSQIP calculator-predicted mortality rates. RESULTS Out of a total of 4,456,809 patients, 4,724 NONAs were included. The overall 30-day patient mortality and morbidity rates were 21% and 45%, respectively. In multivariable analyses, several independent predictors of 30-day mortality were identified, including recent history of weight loss, history of steroid use, smoking, functional dependence, hypoalbuminemia and sepsis or septic shock. The mortality among NONAs with a history of steroid use and a recent history of weight loss was 100%. Similarly, the mortality of NONAs with recent history of weight loss who presented with preoperative septic shock was 93%. The ACS-NSQIP calculator significantly and consistently underestimated the risk of mortality in all NONAs undergoing EGS. CONCLUSION Most NONAs undergoing EGS survive the hospital stay and the first 30 postoperative days, even in the presence of significant preexisting comorbidities. However, the combination of recent weight loss with either steroid use or septic shock nearly ensures mortality and should be used in the discussions with patients and families before a decision to operate is made. The ACS-NSQIP surgical risk calculator should be used with caution in these high-risk patients. LEVEL OF EVIDENCE Prognostic study, level III.

Sorena Keihani, M.D., Bryn E. Putbrese, Douglas M. Rogers, Chong Zhang Raminder, Nirula Xian, Luo-Owen, Kaushik Mukherjee, Bradley J. Morris, Sarah Majercik, Joshua Piotrowski, Christopher M. Dodgion, Ian Schwartz, Sean P. Elliott, Erik S. DeSoucy, Scott Zakaluzny, Brenton G. Sherwood, Bradley A. Erickson, Nima Baradaran, Benjamin N. Breyer, Cameron N. Fick, Brian P. Smith, Barbara U. Okafor, Reza Askari, Brandi Miller, Richard A. Santucci, Matthew M. Carrick, Jurek F. Kocik, Timothy Hewitt, Frank N. Burks, Marta E. Heilbrun, Jeremy B. Myers (J Trauma Acute Care Surg. 2019;86(6):974Y982)

BACKGROUND:Physician assistants (PAs) often have been embedded in academic medical centers to help ensure an adequate patient care workforce while supporting compliance with work-hour restrictions for residents and fellows (also called trainees). Limited studies have explored the effect of PAs on trainee learning. This qualitative study explored, from the perspective of physician faculty and PAs, how PAs working in the clinical learning environment can enhance or hinder trainee learning.METHODS:Using purposive sampling, 12 PAs and 12 physician faculty members in one US teaching hospital were selected for semistructured interviews. Data collection and analysis were characterized by an iterative process. Data analysis was informed by principles of conventional content analysis.RESULTS:Participants identified various ways in which PAs may affect trainee learning, intrinsically linked to the roles PAs assume in the clinical learning environment: clinician, teammate, and clinical teacher. Trainee learning may be enhanced because learning time can be optimized by having PAs in the clinical learning environment. Trainees can learn about PAs and how to collaborate with them, and PAs can enculturate and provide clinical instruction to trainees. Trainee learning may be hindered if learning opportunities for trainees go to PAs, trainees feel intimidated by experienced PAs, or trainees become too dependent on PAs.CONCLUSIONS:Our findings demonstrate enhancements and hindrances to trainees' learning linked to three key roles PAs perform in the clinical learning environment. These findings can inform how PAs are integrated into teaching services. Further investigation is needed to understand how PAs can balance their professional roles to foster effective collaborative practice and learning.

BACKGROUND:The Emergency Surgery Score (ESS) was validated recently as an accurate and user-friendly post-operative mortality risk calculator specific for Emergency General Surgery (EGS). ESS is calculated by adding one to three integer points for each of 22 pre-operative variables (demographics, co-morbidities, and pre-operative laboratory values); increasing scores accurately and gradually predict higher mortality rates. We sought to evaluate whether ESS can predict the occurrence of post-operative infectious complications in EGS patients.PATIENTS AND METHODS:Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2007-2015, all EGS patients were identified by using the "emergent" ACS-NSQIP variable and a concomitant surgery Current Procedural Terminology code for "digestive system." Patients with any missing ESS variables or those who died within 72 hours from the surgical procedure were excluded. A composite variable, post-operative infection, was created and defined as the post-operative occurrence of one or more of the following: superficial, deep incisional or organ/space surgical site infection, surgical site disruption, pneumonia, sepsis, septic shock, or urinary tract infection. ESS was calculated for all included patients, and the correlation between ESS and post-operative infection was examined using c-statistics.RESULTS:Of a total of 4,456,809 patients, 90,412 patients were included. The mean age of the population was 56 years, 51% were female, and 70% were white; 22% developed one or more post-operative infections, most commonly sepsis/septic shock (12.2%), surgical site infection (9%), and pneumonia (5.7%). The ESS gradually and consistently predicted infectious complications; post-operative infections developed in 7%, 24%, and 49% of patients with an ESS of 1, 5, and 10, respectively. The c-statistics for overall post-operative infection, post-operative sepsis/septic shock, and pneumonia were 0.73, 0.75, and 0.80, respectively.CONCLUSION:The ESS accurately predicts the occurrence of post-operative infectious complications in EGS patients and could be used for pre-operative clinical decision-making as well as quality benchmarking of infection rates in EGS.

INTRODUCTION AND AIM:Children with neuropathic lower urinary tract dysfunction usually suffer from associated bowel dysfunction, urinary tract infection and vesicoureteral reflux. This work aimed to highlight the impact of bowel management on bladder dynamics. PATIENTS AND METHODS:In the period from January 2011 to January 2013, 30 patients, 21 girls and 9 boys with neuropathic lower urinary tract dysfunction were studied. All suffered from urinary tract and bowel dysfunctions. All children were on urological treatment. They had their bowel managed by assurance and psychological support, dietary modification, retrograde or antegrade enemas and maintenance therapy. They were evaluated initially and on follow up by history, physical examination, ultrasound, urodynamics, Wexener score and bowel control chart. RESULTS:Mean age was 8.3 ± 3.47 years (range from 4 to 18). There was a significant decrease in bowel dysfunction (Wexener score decreased from 12.67 ± 1.54 to 10.17 ± 1.76, p = 0.00), rectal diameter (decreased from 34.83 ± 5.91 to 27.90 ± 5.32 mm, p = 0.00), and frequency of UTI (p = 0.00). Detrusor leak point pressure decreased from 37.33 ± 24.95 to 30 ± 17.35 cmH2O, (p = 0.42). The cystometric capacity increased from 136.63 ± 45.69 to 155.17 ± 39.29 ml. (p = 0.001). Reflux and kidney function improved but was not statistically significant (p = 0.25 and p = 0.066 respectively). CONCLUSION:Management of bowel dysfunction is of utmost importance in the treatment of children with neuropathic bladder dysfunction. It has a positive effect on lower urinary tract function and decreasing the incidence of complications. This is a LEVEL III prospective study.