ABSTRACT BACKGROUND Andexanet Alfa (AA) is the only FDA approved reversal agent for apixaban and rivaroxaban (DOAC). There are no studies comparing its efficacy with 4-Factor Prothrombin Complex Concentrate (PCC). This study aimed to compare PCC to AA for DOAC reversal, hypothesizing non-inferiority of PCC. METHODS We performed a retrospective, non-inferiority multicenter study of adult patients admitted from July 1, 2018 to December 31, 2019 who had taken a DOAC within 12 hours of injury, were transfused red blood cells (RBCs) or had traumatic brain injury, and received AA or PCC. Primary outcome was PRBC unit transfusion. Secondary outcome with ICU length of stay. MICE imputation was used to account for missing data and zero-inflated poisson regression was used to account for an excess of zero units of RBC transfused. 2 Units difference in RBC transfusion was selected as non-inferior. RESULTS Results: From 263 patients at 10 centers, 77 (29%) received PCC and 186 (71%) AA. Patients had similar transfusion rates across reversal treatment groups (23.7% AA vs 19.5% PCC) with median transfusion in both groups of 0 RBC. According to the Poisson component, PCC increases the amount of RBC transfusion by 1.02 times (95% CI: 0.79-1.33) compared to AA after adjusting for other covariates. The averaged amount of RBC transfusion (non-zero group) is 6.13. Multiplying this number by the estimated rate ratio, PCC is estimated to have an increase RBC transfusion by 0.123 (95% CI: 0.53-2.02) units compared to AA. CONCLUSION PCC appears non-inferior to AA for reversal of DOACs for RBC transfusion in traumatically injured patients. Additional prospective, randomized trials are necessary to compare PCC and AA for the treatment of hemorrhage in injured patients on DOACs. LEVEL OF EVIDENCE Therapeutic/Care Management, Level III

Introduction: Historically, colon resection was recommended after one episode of complicated diverticulitis. However, current trends favor a more individualized approach. This review examines elective sigmoidectomy for complicated diverticulitis as well as robotic approaches for diverticular disease.Methods: The literature was reviewed for timely (post 2000) and relevant articles regarding robotics and diverticulitis. The articles included large prospective series, retrospective analysis, meta-analyses and randomized controlled trials.Results: Primary anastomosis with or without protective ileostomy has emerged as an alternative to the Hartman's procedure in emergent or urgent surgery in patients without significant comorbidities. Elective sigmoidectomy after an episode of complicated diverticulitis should be decided on a case-by-case basis considering patient characteristics, continued subacute symptoms, complications from the disease, and chance of recurrence episodes.Conclusions: There are several variations techniques for robotic sigmoidectomy outlined in this article, and familiarity with all can help depending on the logistics of the case. Minimally invasive colectomy provides superior patient satisfaction and outcomes.

Akkari, Riad; Devlin, Joseph; Markie, Robert; Yamane, David; Al-mashat, Mustafa Author Information

BACKGROUND:Recently, open abdominal aortic aneurysm (AAA) repair (OSR) has become less common and will often be reserved for patients with more complex aortic anatomy. Despite improvements in patient management, the reduced surgical volume has raised concerns for potentially worsened outcomes in the contemporary era (2014-2019) compared with an earlier era in which OSR was more widely practiced (2005-2010). In the present study, we compared the 30-day outcomes of open AAA repair between these two eras. METHODS:The American College of Surgeons National Quality Improvement Program general database was queried for open AAA repair using the Current Procedural Terminology and International Classification of Diseases, 9th and 10th, codes. The cases were stratified into two groups by operation year: 2005 to 2010 (early) and 2014 to 2019 (contemporary). In each era, the cases were further divided into elective and ruptured groups. The 30-day outcomes, including mortality, major morbidity, postoperative sepsis, and unplanned reoperation, were compared between the contemporary and early eras in the elective and ruptured groups. Preoperative variables with a P value <.25 were adjusted for in the multivariate analysis. RESULTS:In the contemporary and early eras, 3749 and 3798 patients had undergone elective OSR and 1148 and 907 had undergone ruptured OSR, respectively. These samples were of similar sizes owing to the National Quality Improvement Program sampling process and our relatively strict inclusion criteria. In the contemporary era, fewer patients were elderly and fewer were smokers or had hypertension or dyspnea in the elective and rupture cohorts. More patients had had American Society of Anesthesiologists class >3 in the elective contemporary era (39% vs 24%; P < .0001). The contemporary elective repair group demonstrated increased 30-day mortality (3.7% vs 3.2%; adjusted odds ratio [aOR], 1.36; P = .006), major adverse cardiac events (5.7% vs 3.4%; aOR, 1.87; P < .0001), and bleeding requiring transfusion (58.5% vs 13.7%; aOR, 8.96; P < .0001). The incidence of pulmonary complications (12.1% vs 15.2%; aOR, 0.80; P = .02) and sepsis (3.7% vs 8.4%; aOR, 0.47; P < .0001) had decreased in the contemporary era, with a similar rate of unplanned reoperations (8.4% vs 7.7%; aOR, 1.16; P = .09). The incidence of renal complications in the contemporary era had increased, with a statistically significant difference. However, the absolute increase of <0.5% was likely not clinically relevant (5.5% vs 5.1%; aOR, 1.23; P = .049). In the ruptured cohort, contemporary repair was associated with increased 30-day mortality (41.4% vs 40%; aOR, 1.53; P < .0001), major adverse cardiac events (25.8% vs 12.8%; aOR, 2.49; P < .0001), and bleeding requiring transfusion (88.2% vs 27%; aOR, 23.03; P < .0001). The incidence of pulmonary complications (36.9% vs 48.1%; aOR, 0.67; P < .0001), sepsis (14.6% vs 23%; aOR, 0.75; P = .03), and unplanned reoperations (18.1% vs 22.7%; aOR, 0.74; P = .008) had decreased in the contemporary OSR group. No differences were detected in the incidence of renal complications. CONCLUSIONS:The 30-day mortality has worsened after open AAA repair in the elective and rupture settings despite the improvements in perioperative management over the years. These complications likely stem from increased bleeding events and major cardiac events, which were increased in the contemporary era.