BackgroundFor many years, robotic surgery has been an option for various elective surgical procedures. Though robotic surgery has not traditionally been the first choice for acute surgical patients, recent work has shown promise in broader applications. However, there are limited data regarding how to establish an institutional robotics program for higher acuity patients. This project aimed to map a pathway for the creation of an acute care surgery robotic program at a large academic medical center.MethodsVarious stakeholders were gathered jointly with our surgical faculty: anesthesia, operating room leadership, surgical technologists, circulating nurses, Central Sterile Supply, and Intuitive Surgical Inc. representatives. Staff underwent robotics training, and surgical technologists were trained as bedside first assistants. Nontraditional robotic operating rooms were allocated for coordinated placement of appropriate cases, and pre-made case carts were arranged with staff to be available at all hours. A workflow was created between surgical faculty and staff to streamline add-on robotic cases to the daily schedule.ResultsSix faculty and two fellows are now credentialed in robotics surgery, and additional surgeons are undergoing training. Numerous staff have completed training to perform operative assistant duties. The operating capacity of robotic acute care surgeries has more than doubled in just one year, from 77 to 172 cases between 2022 and 2023, respectively. Two add-on cases can be accommodated per day. Select patients are being offered robotic surgeries in the acute surgical setting, and ongoing efforts are being made to create guidelines for which patients would best benefit from robotic procedures.ConclusionsLaunching a successful robotic surgery program requires a coordinated, multidisciplinary effort to ensure seamless integration into daily operations. Additional assistance from outside technology representatives can help to ensure comfort with procedures. Further studies are needed to determine the acute patient population that may benefit most from robotic surgery.

Hackenberger, Paige N. MD; Eiferman, Daniel MD; Janis, Jeffrey E. MD Author Information

Nicholson, Emily; Gerlach, Anthony; Elefritz, Jessica; Thompson, Molly; Phelps, Megan; Thomas, Sheela; Eiferman, Daniel; Wehner, Rebecca Author Information

Srivatsa, Shachi MD; Chawla, Mehak BS MBA; Hernandez, Marlene Alejandra; Mallampalli, Grace M BSN; Eiferman, Daniel Scott MD, FACS Author Information

BACKGROUND:Nutrition support professionals are tasked with estimating energy requirements for critically ill patients. Estimating energy leads to suboptimal feeding practices and adverse outcomes. Indirect calorimetry (IC) is the gold standard for determining energy expenditure. However, access is limited, so clinicians must rely on predictive equations.METHODS:A retrospective chart review of critically ill patients who underwent IC in 2019 was conducted. The Mifflin-St Jeor equation (MSJ), Penn State University equation (PSU), and weight-based nomograms were calculated using admission weights. Demographic, anthropometric, and IC data were extracted from the medical record. Data were stratified by body mass index (BMI) classifications, and relationships between estimated energy requirements and IC were compared.RESULTS:Participants (N = 326) were included. Median age was 59.2 years, and BMI was 30.1. The MSJ and PSU were positively correlated with IC in all BMI classes (all P < 0.001). Median measured energy expenditure was 2004 kcal/day, which was 1.1-fold greater than PSU, 1.2-fold greater than MSJ, and 1.3-fold greater than weight-based nomograms (all P < 0.001).CONCLUSION:Despite the significant relationships between measured and estimated energy requirements, the significant fold-differences suggest that using predictive equations leads to significant underfeeding, which may result in poor clinical outcomes. Clinicians should rely on IC when available, and increased training in the interpretation of IC is warranted. In the absence of IC, the use of admission weight in weight-based nomograms could serve as a surrogate, as these calculations provided the closest estimate to IC in participants with normal weight and overweight, but not obesity.

Background Wound class in hernia repairs impacts surgical technique and outcomes. Hernia recurrence and complications are high when dirty wounds are treated in one stage. We hypothesize patients who undergo intentionally staged repairs are less likely to have adverse outcomes and associated costs. Methods Patients were identified by retrospective chart review. Patient characteristics and outcome variables were collected. An economic analysis of cost variables was performed using medical records and published meta-analyses. Results There were 8 patients in the staged repairs group and 10 patients in the control group. Length of stay was 14.9 days (±8.8), and 8.7 days (±6.4), respectively. Rate of hernia recurrence within 1 year was 14.3% and 37.5%. Rate of mesh infection at 30 days was 0% and 10%. Compared to controls, delayed-immediate repairs had a nearly 2-fold index surgical cost. Discussion Although there is an increased cost associated with delayed-immediate repairs, this cost may be offset by the decreased infection, seroma, dehiscence, enterocutaneous fistula formation, and hernia recurrence rate that necessitates future interventions. Further data collection is required to determine if clinical and economic benefit is seen long-term.

BACKGROUND:Acute kidney injury (AKI) is a serious postoperative complication of abdominal wall reconstruction that can significantly impact outcomes of these patients. This study examines AKI following abdominal wall hernia repair to determine incidence and risk factors and outline potential mitigation strategies. METHODS:Using a single institution IRB-approved prospective database, patients undergoing complex abdominal wall reconstruction from 2013 to 2021 were identified. Patients with AKI were compared to controls and preoperative and intraoperative characteristics were evaluated. Multivariate analysis was utilized to identify factors associated with development of AKI. RESULTS:297 patients were reviewed, 21.2 % (n = 63 patients) had AKI. Patients with AKI had a greater decrease in postoperative GFR to preoperative GFR (40.5% vs 18.3%, p <0.0001). Factors associated with AKI included ASA score >2 (odds ratio (OR) = 2.10, [1.50; 5.12], p = 0.02), HTN (OR = 2.05, [1.05; 4.0], p = 0.04), higher baseline Cr (OR = 5.98, [2.56; 13.98], p <0.0001), and diabetes (OR = 0.135, [0.0275; 0.666], p = 0.01). Operative time was longer in patients who developed AKI [average 400 min (range: 278-510 min) vs 310 min (range: 260-374 min), p = 0.04] and was an independent predictor of developing AKI (OR = 319.59, [137.25; 744.65], p <0.0001). DISCUSSION:Preoperative identification of patients with medical comorbidities undergoing elective complex abdominal wall reconstruction continues to be imperative to improve outcomes. This study demonstrates that perioperative management for high risk patients requires flexibility, including potential adjustments to enhanced recovery after surgery protocols in order to adequately address the risks for AKI.

Background This article seeks to be a collection of evidence and experience-based information for health care providers around the country and world looking to build or improve an abdominal core health center. Abdominal core health has proven to be a chronic condition despite advancements in surgical technique, technology, and equipment. The need for a holistic approach has been discussed and thought to be necessary to improve the care of this complex patient population. Methods Literature relevant to the key aspects of building an abdominal core health center was thoroughly reviewed by multiple members of our abdominal core health center. This information was combined with our authors’ experiences to gather relevant information for those looking to build or improve a holistic abdominal core health center. Results An abundance of publications have been combined with multiple members of our abdominal core health centers members experience’s culminating in a wide breadth of information relevant to those looking to build or improve a holistic abdominal core health center. Conclusions Evidence- and experience-based information has been collected to assist those looking to build or grow an abdominal core health center.

Introduction: Opioid addiction frequently occurs after exposure to prescribed pain medica -tions. Trauma patients are likely to receive opioids due to injuries and surgeries resulting in high levels of pain. Multimodal analgesia has been shown to decrease opioid consumption postoperatively. A multimodal analgesia order set was implemented with the goal of increasing prescription of multimodal analgesia contributing to decreased overall opioid use. We hypothesized that the multimodal order set would be associated with significantly less opioid utilization without affecting pain scores. Methods: This single-center retrospective cohort analysis included non-intensive care unit trauma patients. Patients were propensity-matched by the year of treatment. Oral morphine equivalents and pain scores were compared before and after implementation of the order set. The primary objective was to evaluate differences in oral morphine equiv-alents 24 h prior to discharge before and after implementation of the multimodal analgesia order sets.Results: One hundred and fourteen patients in the preimplementation group and 121 pa-tients in the postimplementation group met inclusion criteria. Oral morphine equivalents did not differ significantly between the cohorts, 21.3 [0-53.5] OME in 2018 versus 18.8 [0-56.3] in 2020 (P = 0.85). Pain scores 24 h prior to discharge, 6 [4-8] versus 5.7 [3.5-7] (P = 0.4), did not differ significantly between groups despite more operations in the 2020 cohort.Conclusions: Implementation of a multimodal order set was not associated with significant reduction in the amount of opioids used in non-intensive care unit trauma patients. However, pain scores were unchanged despite an increased number of procedures per-formed suggesting that multimodal analgesia sets may be a useful tool to aid in decreasing opioid utilization after traumatic injuries.(c) 2022 Elsevier Inc. All rights reserved.

Traumatic brain injury (TBI) can lead to significant neuropsychiatric problems and neurodegenerative pathologies, which develop and persist years after injury. Neuroinflammatory processes evolve over this same period. Therefore, we aimed to determine the contribution of microglia to neuropathology at acute [1 d postinjury (dpi)], subacute (7 dpi), and chronic (30 dpi) time points. Microglia were depleted with PLX5622, a CSF1R antagonist, before midline fluid percussion injury (FPI) in male mice and cortical neuropathology/inflammation was assessed using a neuropathology mRNA panel. Gene expression associated with inflammation and neuropathology were robustly increased acutely after injury (1 dpi) and the majority of this expression was microglia independent. At 7 and 30 dpi, however, microglial depletion reversed TBI-related expression of genes associated with inflammation, interferon signaling, and neuropathology. Myriad suppressed genes at subacute and chronic endpoints were attributed to neurons. To understand the relationship between microglia, neurons, and other glia, single-cell RNA sequencing was completed 7 dpi, a critical time point in the evolution from acute to chronic pathogenesis. Cortical microglia exhibited distinct TBI-associated clustering with increased type-1 interferon and neurodegenerative/damage-related genes. In cortical neurons, genes associated with dopamine signaling, long-term potentiation, calcium signaling, and synaptogenesis were suppressed. Microglial depletion reversed the majority of these neuronal alterations. Furthermore, there was reduced cortical dendritic complexity 7 dpi, reduced neuronal connectively 30 dpi, and cognitive impairment 30 dpi. All of these TBI-associated functional and behavioral impairments were prevented by microglial depletion. Collectively, these studies indicate that microglia promote persistent neuropathology and long-term functional impairments in neuronal homeostasis after TBI.SIGNIFICANCE STATEMENTMillions of traumatic brain injuries (TBIs) occur in the United States alone each year. Survivors face elevated rates of cognitive and psychiatric complications long after the inciting injury. Recent studies of human brain injury link chronic neuroinflammation to adverse neurologic outcomes, suggesting that evolving inflammatory processes may be an opportunity for intervention. Here, we eliminate microglia to compare the effects of diffuse TBI on neurons in the presence and absence of microglia and microglia-mediated inflammation. In the absence of microglia, neurons do not undergo TBI-induced changes in gene transcription or structure. Microglial elimination prevented TBI-induced cognitive changes 30 d postinjury (dpi). Therefore, microglia have a critical role in disrupting neuronal homeostasis after TBI, particularly at subacute and chronic timepoints.

George, Emily BS; Mackenzie Renshaw, Savannah BS; Gupta, Anand MBBS, MPH; VS. Manilchuk, Andrei MD, FACS; Scott Eiferman, Daniel MD, FACS; Collins, Courtney MD, FACS; Kumar Narula, Vimal MD, FACS; Poulose, Benjamin MD, MPH, FACS Author Information

Animal models are critical for determining the mechanisms mediating traumatic brain injury-induced (TBI) neuropathology. Fluid percussion injury (FPI) is a widely used model of brain injury typically applied either midline or parasagittally (lateral). Midline FPI induces a diffuse TBI, while lateral FPI induces both focal cortical injury (ipsilateral hemisphere) and diffuse injury (contralateral hemisphere). Nonetheless, discrete differences in neuroinflammation and neuropathology between these two versions of FPI remain unclear. The purpose of this study was to compare acute (4-72 h) and subacute (7 days) neuroinflammatory responses between midline and lateral FPI. Midline FPI resulted in longer righting reflex times than lateral FPI. At acute time points, the inflammatory responses to the two different injuries were similar. For instance, there was evidence of monocytes and cytokine mRNA expression in the brain with both injuries acutely. Midline FPI had the highest proportion of brain monocytes and highest IL-1β/TNFα mRNA expression 24 h later. NanoString nCounter analysis 7 days post-injury revealed robust and prolonged expression of inflammatory-related genes in the cortex after midline FPI compared to lateral FPI; however, Iba-1 cortical immunoreactivity was increased with lateral FPI. Thus, midline and lateral FPI caused similar cortical neuroinflammatory responses acutely and mRNA expression of inflammatory genes was detectable in the brain 7 days later. The primary divergence was that inflammatory gene expression was greater and more diverse subacutely after midline FPI. These results provide novel insight to variations between midline and lateral FPI, which may recapitulate unique temporal pathogenesis.

Introduction: Helicopter transport is a resource intensive and expensive method for transportation of patients by helicopter. The primary objective of this study was to evaluate the appropriateness of helicopter transport determined by procedural care within 1-h of transfer at an urban level I trauma center. Methods: All trauma patients transported by helicopter from January 2015-December 2017 to an urban level I trauma center from referring hospitals or the scene were retrospectively analyzed. A subgroup analysis was performed evaluating patients that required a procedure or operation within 1-h of transport compared with the remainder of the patient cohort who were transported via helicopter. Results: A total of 1590 patients were transported by helicopter. Thirty-nine percent of patients (n = 612) were admitted directly to the floor from the trauma bay and 16% (n = 249) of patients required only observation or were discharged home after helicopter transfer. Approximately one-third of the entire study cohort (36%, n = 572) required any procedure, with a median time to procedure of 31.5 h (interquartile range 54.4). Only 13% (n = 74) required a procedure within 1-h of helicopter transport. The average distance (in miles) if the patient had been driven by ground transport rather than helicopter was 67.0 miles (SD +/- 27.9) and would take an estimated 71.5 min (+/- 28.4) for patients who required a procedure within 1-h compared with 61.6 miles (SD +/- 30.9) with an estimated 66.1 min (SD +/- 30.8) for the remainder of the cohort (P value 0.899 and 0.680, respectively). Conclusions: This analysis demonstrates that helicopter transport was not necessary for the vast majority of trauma patients transported via helicopter. (C) 2020 Elsevier Inc. All rights reserved.

Background: The devastating effects of the opioid epidemic are well documented. We implemented a surgeon/pharmacist opioid reduction initiative at an academic medical center that incorporated multimodal pain therapy in an attempt to reduce total inpatient opioids prescribed. We hypothesized that less opioids would be used postoperatively without affecting pain scores or length of stay. Methods: This single-center observational cohort analysis included patients admitted to the acute general surgical service and had one of 10 emergent general surgical (nontrauma) procedures. Patients who underwent surgery before the opioid reduction initiative were compared with patients who underwent surgery postinitiative. The primary objective was to evaluate differences in daily oral morphine equivalents and average pain scores in patients before and after implementation of the surgeon/pharmacist initiative. Results: Eighty-three patients in the preopioid reduction initiative group and 92 patients in the postopioid reduction initiative group met inclusion criteria. Oral morphine equivalents were significantly different at 24 h before discharge when comparing across both year (P = 0.032) and number of procedures (P = 0.013). Our results showed decreased opioid utilization in the postopioid reduction initiative group on all observed postoperative days with unaffected pain scores. Conclusions: An opioid reduction initiative showed promise in lowering the number of opioids used during inpatient admission without affecting pain scores in emergent general surgical procedures. This initiative can be easily reproduced at other institutions to help combat the opioid epidemic. (C) 2020 Elsevier Inc. All rights reserved.

BACKGROUND:Emergency general surgery can have a profound impact on the functional status of even previously independent patients. The role and influence of discharging a patient to a skilled nursing facility, however, remains largely unknown. METHODS:We queried the American College of Surgeons National Surgical Quality Improvement Program for community-dwelling adults who underwent 1 of 7 emergency general surgery procedures and were discharged home or to a skilled nursing facility from 2012 to 2016. Propensity score matching and multivariable regression analyses were performed to determine the relationship between discharge disposition and outcomes. RESULTS:Overall, 140,922 patients met the inclusion criteria. The majority were discharged home (95.9%). After applying 1:1 propensity score matching, in comparison to patients discharged home, individuals discharged to a skilled nursing facility had a greater odds of respiratory (odds ratio 2.32; 95% confidence interval, 1.59-3.38) and septic complications (odds ratio 1.63, 95% confidence interval 1.12-2.36) after discharge. Furthermore, following surgery, individuals discharged to a skilled nursing facility had a greater odds of 30-day readmission (odds ratio 1.14; 95% confidence interval, 1.01-1.29), and death within 30 days of the procedure (odds ratio 2.07; 95% confidence interval, 1.65-2.61). CONCLUSION:After accounting for patient severity and perioperative course, discharge to a skilled nursing facility is an independent risk factor for death, readmission, and postdischarge complications.

Learning Objectives: Clostridium difficile infection (CDI) accounts for up to 25% of episodes of antibiotic-associated diarrhea and is the most common cause of healthcare-associated diarrhea. Rectal vancomycin irrigation (PRV) is a therapeutic option; however evidence is limited for use post-colectomy. The objective of this study is to describe the impact of PRV in patients who underwent colectomy for toxic C. difficile colitis. Methods: This was a retrospective, single-center, observational study of adult patients who underwent colectomy for CDI between January 1, 2011 and December 31, 2016. Patients who received PRV post-colectomy were compared to those who did not (no-PRV) with a primary outcome of all-cause hospital mortality. Secondary efficacy outcomes included intensive care unit (ICU) and hospital length of stay (LOS), ventilator-free days at day 28 post-colectomy, proctitis or pseudomembranes, re-initiation of CDI therapy, and normalization of infectious signs and symptoms at CDI therapy completion. The primary safety outcome was rectal stump blowout. Continuous variables are reported as median [IQR] and were analyzed using the Mann-Whitney U test. Nominal data are reported as percent and were analyzed using either the chi-squared or Fisher’s exact test as appropriate. Results: A total of 50 patients were included (38 PRV; 12 no-PRV). Baseline demographics were similar between groups, however significantly more PRV patients were admitted with sepsis/septic shock (18.4 vs. 0%, p<0.01). Duration of PRV therapy post-colectomy was 5 [4–8] days. No difference was observed between PRV and no-PRV groups for the primary outcome of all-cause mortality (39.5 vs 33.3%, p>0.99). There was no significant difference between groups for hospital LOS, but there was a trend toward longer ICU LOS for PRV patients (9.5 [5–17] vs. 2.5 [1.5–13.5] days, p=0.050). There were no differences in the remaining secondary efficacy outcomes. No episodes of rectal stump blowout were observed in either group. Conclusions: As there were no significant clinical benefits observed with PRV, these results do not support routine recommendation of rectal vancomycin irrigations. However, as no episodes of rectal stump blowout were observed, they suggest this therapy may be a safe option for patients with severe CDI requiring colectomy.

Background Vascularized lymph node transfer (VLNT) is a well-established method for the surgical management of refractory extremity lymphedema. Generally, donor lymph nodes are harvested from the axilla, groin, or supraclavicular area. However, these sites offer their own disadvantages and introduce risk for inducing lymphedema at the surgical donor site. In our experience, the jejunal mesentery can be an excellent source of lymph nodes without the risk of donor site lymphedema. Long term complications are unknown for this procedure; we report our experience, complication rates, and lessons learned. Methods A retrospective review was performed for all patients at our institution undergoing surgical treatment of lymphedema using jejunal mesenteric VLNT from February 2015 to February 2018. Demographic data, length of follow up, and surgical complications were reviewed. Results Twenty-nine patients have undergone jejunal VLNT at our institution during the three-year study period, with a total of 30 transfers. Five patients had a concurrent omental lymph node transfer. Average length of follow up was 17.6 months (range 1.0-36.8 months). There was one flap loss in this time frame (3.3%). Four patients developed hernias post-operatively (13.8%), and three had nonoperative small bowel obstructions (10.3%). One patient had a postoperative wound infection at the abdominal incision (3.4%). Conclusions Jejunal VLNT can be an effective option for surgical treatment of lymphedema, without the risk of postoperative donor site lymphedema. Patients and surgeons should be aware of the risks of hernia and small bowel obstruction with this method compared to other lymph node sources.

BACKGROUND Clostridioides difficile infection (CDI) accounts for as many as 25% of episodes of antibiotic-associated diarrhea and is the most common cause of healthcare-associated diarrhea. Rectal vancomycin irrigation is a therapy option; however, evidence is limited for its value post-colectomy. The objective of this study was to describe outcomes of patients who underwent total colectomy for fulminant C. difficile colitis and received rectal vancomycin post-operatively. METHODS This was a single-center retrospective chart review of adult patients who underwent total colectomy for fulminant CDI. Efficacy outcomes were all-cause in-hospital death, intensive care unit (ICU) and hospital length of stay, ventilator-free days at day 28 post-procedure, development of proctitis or pseudomembranes, need for re-initiation of CDI therapy, and normalization of infectious signs and symptoms at completion of CDI therapy. The primary safety outcome was the incidence of rectal stump blowout. RESULTS Of the 50 patients included, 38 (76%) received treatment with rectal vancomycin at the discretion of the surgeon. The Sequential Organ Failure Assessment score on the day of the procedure was higher in the rectal vancomycin group; however, this difference did not reach statistical significance. No difference was observed between the groups in the primary outcome of all-cause death. There was no significant difference between the groups for hospital length of stay, but there was a trend toward longer ICU length of stay for patients who received rectal vancomycin (9.5 days vs. 2.5 days; p = 0.05). No differences in the remaining secondary efficacy outcomes were observed. No episodes of rectal stump blowout were observed in either group. CONCLUSIONS This study aimed to add to the limited data on the use of rectal vancomycin irrigation post-colectomy for toxic C. difficile colitis. Although our results do not support routine use of rectal vancomycin irrigation, they suggest that this therapy is not harmful if providers are considering its use for severe infections refractory to alternative treatment.