Publications by authors named "David A Spain"

157 Publications

Factors Associated With General Surgery Residents' Operative Experience During the COVID-19 Pandemic.

JAMA Surg 2021 Apr 30. Epub 2021 Apr 30.

Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California.

Importance: The suspension of elective operations in March 2020 to prepare for the COVID-19 surge posed significant challenges to resident education. To mitigate the potential negative effects of COVID-19 on surgical education, it is important to quantify how the pandemic influenced resident operative volume.

Objective: To examine the association of the pandemic with general surgical residents' operative experience by postgraduate year (PGY) and case type and to evaluate if certain institutional characteristics were associated with a greater decline in surgical volume.

Design, Setting, And Participants: This retrospective review included residents' operative logs from 3 consecutive academic years (2017-2018, 2018-2019, and 2019-2020) from 16 general surgery programs. Data collected included total major cases, case type, and PGY. Faculty completed a survey about program demographics and COVID-19 response. Data on race were not collected. Operative volumes from March to June 2020 were compared with the same period during 2018 and 2019. Data were analyzed using Kruskal-Wallis test adjusted for within-program correlations.

Main Outcome And Measures: Total major cases performed by each resident during the first 4 months of the pandemic.

Results: A total of 1368 case logs were analyzed. There was a 33.5% reduction in total major cases performed in March to June 2020 compared with 2018 and 2019 (45.0 [95% CI, 36.1-53.9] vs 67.7 [95% CI, 62.0-72.2]; P < .001), which significantly affected every PGY. All case types were significantly reduced in 2020 except liver, pancreas, small intestine, and trauma cases. There was a 10.2% reduction in operative volume during the 2019-2020 academic year compared with the 2 previous years (192.3 [95% CI, 178.5-206.1] vs 213.8 [95% CI, 203.6-223.9]; P < .001). Level 1 trauma centers (49.5 vs 68.5; 27.7%) had a significantly lower reduction in case volume than non-level 1 trauma centers (33.9 vs 63.0; 46%) (P = .03).

Conclusions And Relevance: In this study of operative logs of general surgery residents in 16 US programs from 2017 to 2020, the first 4 months of the COVID-19 pandemic was associated with a significant reduction in operative experience, which affected every PGY and most case types. Level 1 trauma centers were less affected than non-level 1 centers. If this trend continues, the effect on surgical training may be even more detrimental.
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http://dx.doi.org/10.1001/jamasurg.2021.1978DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8087976PMC
April 2021

Scoping review of traumatic hemothorax: Evidence and knowledge gaps, from diagnosis to chest tube removal.

Surgery 2021 Apr 19. Epub 2021 Apr 19.

Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA; Surgeons Writing About Trauma, Stanford University, Stanford, CA.

Background: Traumatic hemothorax is a common injury that invites diagnostic and management strategy debates. Evidence-based management has been associated with improved care efficiency. However, the literature abounds with long-debated, re-emerging, and new questions. We aimed to consolidate up-to-date evidence on traumatic hemothoraces, focusing on clinical conundra debated in literature.

Methods: We conducted a scoping review of 21 clinical conundra in traumatic hemothorax diagnosis and management according to PRISMA-ScR guidelines. Experimental and observational studies evaluating patients (aged ≥18 years) with traumatic hemothoraces were identified through database searches (PubMed, EMBASE, Web of Science, Cochrane Library; database inception to Sep, 26 2020) and bibliography reviews of selected articles. Three reviewers screened and selected articles using standardized forms.

Results: We screened 1,440 articles for eligibility, of which 71 met criteria for synthesis. The review comprises 6 sections: (1) Presumptive antibiotics before tube thoracostomy; (2) Initial diagnostic and intervention decisions; (3) Chest tubes; (4) Retained hemothoraces; (5) Delayed hemothoraces; and (6) Chest tube removal). The 21 conundra across these sections follow the format of a question, our recommendation based on interpretation of available evidence, and succinct rationale. Rationale sections detail knowledge gaps and opportunities for future research.

Conclusion: Even practices engrained into surgical dogma, such as obtaining chest x-rays after inserting or removing chest tubes and mandating operation for patients who develop chest tube output above a certain threshold, deserve re-evaluation. Some knowledge gaps require rigorous future investigation; sound clinical judgment can likely supplement others.
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http://dx.doi.org/10.1016/j.surg.2021.03.030DOI Listing
April 2021

COVID-19 Impact on Surgical Resident Education and Coping.

J Surg Res 2021 Feb 11;264:534-543. Epub 2021 Feb 11.

Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Stanford, California; Department of Surgery, Stanford University School of Medicine, Stanford, California. Electronic address:

Background: Healthcare systems and surgical residency training programs have been significantly affected by the novel coronavirus disease 2019 (COVID-19) pandemic. A shelter-in-place and social distancing mandate went into effect in our county on March 16, 2020, considerably altering clinical and educational operations. Along with the suspension of elective procedures, resident academic curricula transitioned to an entirely virtual platform. We aimed to evaluate the impact of these modifications on surgical training and resident concerns about COVID-19.

Materials And Methods: We surveyed residents and fellows from all eight surgical specialties at our institution regarding their COVID-19 experiences from March to May 2020. Residents completed the survey via a secure Qualtrics link. A total of 38 questions addressed demographic information and perspectives regarding the impact of the COVID-19 pandemic on surgical training, education, and general coping during the pandemic.

Results: Of 256 eligible participants across surgical specialties, 146 completed the survey (57.0%). Junior residents comprised 43.6% (n = 61), compared to seniors 37.1% (n = 52) and fellows 19.3% (n = 27). Most participants, 97.9% (n = 138), anticipated being able to complete their academic year on time, and 75.2% (n = 100) perceived virtual learning to be the same as or better than in-person didactic sessions. Participants were most concerned about their ability to have sufficient knowledge and skills to care for patients with COVID-19, and the possibility of exposure to COVID-19.

Conclusions: Although COVID-19 impacted residents' overall teaching and clinical volume, residency programs may identify novel virtual opportunities to meet their educational and research milestones during these challenging times.
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http://dx.doi.org/10.1016/j.jss.2021.01.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7877215PMC
February 2021

ACQUISITION OF MEDICAID AT THE TIME OF INJURY: AN OPPORTUNITY FOR SUSTAINABLE INSURANCE COVERAGE.

J Trauma Acute Care Surg 2021 Mar 27. Epub 2021 Mar 27.

Department of Surgery, Stanford University School of Medicine, Stanford, CA Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE) Stanford University School of Medicine, Stanford, CA.

Introduction: Uninsured trauma patients are at higher risk of mortality, limited access to postdischarge resources and catastrophic health expenditure. Hospital Presumptive Eligibility (HPE), enacted with the 2014 Affordable Care Act, enables uninsured patients to be screened and acquired emergency Medicaid at the time of hospitalization. We sought to identify factors associated with successful acquisition of HPE insurance at the time of injury, hypothesizing that patients with higher injury severity (ISS>15) would be more likely to be approved for HPE.

Methods: We identified Medicaid and uninsured patients aged 18-64 years old with a primary trauma diagnosis (ICD-10) in a large level I trauma center between 2015-2019. We combined trauma registry data with review of electronic medical records, to determine our primary outcome, HPE acquisition. Descriptive and multivariate analyses were performed.

Results: Among 2,320 trauma patients, 1,374 (59%) were already enrolled in Medicaid at the time of hospitalization. Among those uninsured at arrival, 386 (40.8%) acquired HPE before discharge, and 560 (59.2%) remained uninsured. HPE patients had higher injury severity score (ISS > 15: 14.8% vs. 5.7%, p < .001), longer median length of stay (LOS) (2 [IQR: 0,5] vs. 0 [0,1] days, p < .001), were more frequently admitted as inpatients (64.5% vs. 33.6%, p < .001) and discharged to post-acute services (11.9% vs. 0.9%, p < .001). Patient, hospital and policy factors contributed to HPE non-approval. In adjusted analyses, Hispanic ethnicity (vs. non-Hispanic whites: aOR 1.58, p = .02) and increasing ISS (p ≤ .001) were associated with increased likelihood of HPE approval.

Conclusion: The time of hospitalization due to injury is an underutilized opportunity for intervention, whereby uninsured patients can acquire sustainable insurance coverage. Opportunities to increase HPE acquisition merit further study nationally across trauma centers. As administrative and trauma registries do not capture information to compare HPE and traditional Medicaid patients, prospective insurance data collection would help to identify targets for intervention.

Level Of Evidence: Epidemiologic, level III.
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http://dx.doi.org/10.1097/TA.0000000000003195DOI Listing
March 2021

Situating Artificial Intelligence in Surgery: A Focus on Disease Severity.

Ann Surg 2020 09;272(3):523-528

Department of Surgery, Stanford University, Stanford, CA.

Objectives: Artificial intelligence (AI) has numerous applications in surgical quality assurance. We assessed AI accuracy in evaluating the critical view of safety (CVS) and intraoperative events during laparoscopic cholecystectomy. We hypothesized that AI accuracy and intraoperative events are associated with disease severity.

Methods: One thousand fifty-one laparoscopic cholecystectomy videos were annotated by AI for disease severity (Parkland Scale), CVS achievement (Strasberg Criteria), and intraoperative events. Surgeons performed focused video review on procedures with ≥1 intraoperative events (n = 335). AI versus surgeon annotation of CVS components and intraoperative events were compared. For all cases (n = 1051), intraoperative-event association with CVS achievement and severity was examined using ordinal logistic regression.

Results: Using AI annotation, surgeons reviewed 50 videos/hr. CVS was achieved in ≤10% of cases. Hepatocystic triangle and cystic plate visualization was achieved more often in low-severity cases (P < 0.03). AI-surgeon agreement for all CVS components exceeded 75%, with higher agreement in high-severity cases (P < 0.03). Surgeons agreed with 99% of AI-annotated intraoperative events. AI-annotated intraoperative events were associated with both disease severity and number of CVS components not achieved. Intraoperative events occurred more frequently in high-severity versus low-severity cases (0.98 vs 0.40 events/case, P < 0.001).

Conclusions: AI annotation allows for efficient video review and is a promising quality assurance tool. Disease severity may limit its use and surgeon oversight is still required, especially in complex cases. Continued refinement may improve AI applicability and allow for automated assessment.
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http://dx.doi.org/10.1097/SLA.0000000000004207DOI Listing
September 2020

Heterogeneity in managing rib fractures across non-trauma and level I, II, and III trauma centers.

Am J Surg 2021 Feb 16. Epub 2021 Feb 16.

Division of General Surgery, Department of Surgery, Stanford University, USA; Surgeons Writing About Trauma, Stanford University, USA.

Background: We aimed to elucidate management patterns and outcomes of high-risk patients with rib fractures (elderly or flail chest) across non-trauma and trauma centers. We hypothesized highest-capacity (level I) centers would have best outcomes for high-risk patients.

Methods: We queried the 2016 National Emergency Department Sample to identify adults presenting with rib fractures. Multivariable regression assessed ED and inpatient events across non-trauma and level III/II/I trauma centers.

Results: Among 504,085 rib fracture encounters, 46% presented to non-trauma centers. Elderly patients with multiple rib fractures had stepwise increase in inpatient admission odds and stepwise decrease in pneumonia odds at higher-capacity trauma centers compared to non-trauma centers. Among patients with flail chest, odds of undergoing surgical stabilization (SSRF) increased at trauma centers. Undergoing SSRF was associated with reduced mortality but remained underutilized.

Conclusion: Half of patients with rib fractures present to non-trauma centers. Nationwide care-optimization for high-risk patients requires further effort.
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http://dx.doi.org/10.1016/j.amjsurg.2021.02.013DOI Listing
February 2021

Nationwide cost-effectiveness analysis of surgical stabilization of rib fractures by flail chest status and age groups.

J Trauma Acute Care Surg 2021 03;90(3):451-458

From the Department of Surgery (J.C., L.T., D.A.S., J.D.F.), Division of General Surgery, Department of Epidemiology and Population Health (J.C.), Surgeons Writing About Trauma (J.C., B.M., R.T., L.T., D.A.S., J.D.F.), and School of Medicine (B.M., R.T.), Stanford University, Stanford, California; Department of Surgery, Chulalongkorn University (W.L.), Bangkok, Thailand; and Stanford Health Policy (J.A.S., J.D.G.-F.), Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, California.

Background: Surgical stabilization of rib fracture (SSRF) is increasingly used to manage patients with rib fractures. Benefits of performing SSRF appear variable, and the procedure is costly, necessitating cost-effectiveness analysis for distinct subgroups. We aimed to assess the cost-effectiveness of SSRF versus nonoperative management among patients with rib fractures younger than 65 years versus 65 years or older, with versus without flail chest. We hypothesized that, compared with nonoperative management, SSRF is cost-effective only for patients with flail chest.

Methods: This economic evaluation used a decision-analytic Markov model with a lifetime time horizon incorporating US population-representative inputs to simulate benefits and risks of SSRF compared with nonoperative management. We report quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios. Deterministic and probabilistic sensitivity analyses accounted for most plausible clinical scenarios.

Results: Compared with nonoperative management, SSRF was cost-effective for patients with flail chest at willingness-to-pay threshold of US $150,000/QALY gained. Surgical stabilization of rib fracture costs US $25,338 and US $123,377/QALY gained for those with flail chest younger than 65 years and 65 years or older, respectively. Surgical stabilization of rib fracture was not cost-effective for patients without flail chest, costing US $172,704 and US $243,758/QALY gained for those younger than 65 years and 65 years or older, respectively. One-way sensitivity analyses showed that, under most plausible scenarios, SSRF remained cost-effective for subgroups with flail chest, and nonoperative management remained cost-effective for patients older than 65 years without flail chest. Probability that SSRF is cost-effective ranged from 98% among patients younger than 65 years with flail chest to 35% among patients 65 years or older without flail chest.

Conclusions: Surgical stabilization of rib fracture is cost-effective for patients with flail chest. Surgical stabilization of rib fracture may be cost-effective in some patients without flail chest, but delineating these patients requires further study.

Level Of Evidence: Economic/decision, level II.
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http://dx.doi.org/10.1097/TA.0000000000003021DOI Listing
March 2021

Concomitant Sternal Fractures: Harbinger of Worse Pulmonary Complications and Mortality in Patients With Rib Fractures.

Am Surg 2021 Jan 31:3134821991978. Epub 2021 Jan 31.

Division of General Surgery, Department of Surgery, 6429Stanford University, CA, USA.

Background: Sternal and rib fractures are common concomitant injuries. However, the impact of concurrent sternal fractures on clinical outcomes of patients with rib fractures is unclear. We aimed to unveil the pulmonary morbidity and mortality impact of concomitant sternal fractures among patients with rib fractures.

Methods: We identified adult patients admitted with traumatic rib fractures with vs. without concomitant sternal fractures using the 2012-2014 National Inpatient Sample (NIS). After 2:1 propensity score matching and adjustment for residual imbalances, we compared risk of pulmonary morbidity and mortality between patients with vs. without concomitant sternal fractures. Subgroup analysis in patients with flail chest assessed whether sternal fractures modify the association between undergoing surgical stabilization of rib fractures (SSRF) and pulmonary morbidity or mortality.

Results: Of 475 710 encounters of adults admitted with rib fractures, 24 594 (5%) had concomitant sternal fractures. After 2:1 propensity score matching, patients with concomitant sternal fractures had 70% higher risk (95% CI: 50-90% higher, < 0.001) of undergoing tracheostomy, 40% higher risk (30-50% higher, <.001) of undergoing intubation, and 20% higher risk of respiratory failure (10-30% higher, <.001) and mortality (10-40% higher, =.007). Subgroup analysis of 8600 patients with flail chest showed concomitant sternal fractures did not impact the association between undergoing SSRF and any pulmonary morbidity or mortality.

Conclusion: Concomitant sternal fractures are associated with increased risk for pulmonary morbidity and mortality among patients with rib fractures. However, our findings are limited by a binary definition of sternal fractures, which encompasses heterogeneous injury patterns with likely variable clinical relevance.
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http://dx.doi.org/10.1177/0003134821991978DOI Listing
January 2021

A Review of "Will Future Surgeons Be Interested in Trauma Care? Results of a Resident Survey" (1992).

Authors:
David A Spain

Am Surg 2021 Feb 27;87(2):191-194. Epub 2021 Jan 27.

Department of Surgery, 6429Stanford University, Stanford, CA, USA.

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http://dx.doi.org/10.1177/0003134820988821DOI Listing
February 2021

Outcomes after Surgery among Patients Diagnosed with One or More Multi-Drug-Resistant Organisms.

Surg Infect (Larchmt) 2021 Jan 20. Epub 2021 Jan 20.

Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA.

Infections with multi-drug-resistant organisms (MDROs) may be difficult to treat and prolong patient hospitalization and recovery. Multiple MDRO coinfections may increase the complexity of clinical management. However, association between multiple MDROs and outcomes of patients who undergo surgery is unknown. We performed a retrospective, cross-sectional analysis of the 2016 National Inpatient Sample for identified by International Classification of Disease, 10th Revision Clinical Modification (ICD-10-CM) diagnosis codes associated with multi-drug-resistant organisms: methicillin-resistant (MRSA), vancomycin-resistant (VRE), multi-drug-resistant gram-negative bacilli, and infection (CDI). Admitted patients with diagnosis codes for MDROs were cross-matched with codes for common general surgery procedures. Outcomes of interest included length of stay and mortality. Weighted univariable and multivariable analyses accounting for the survey methodology were performed. Of 1,550,224 patients undergoing surgery in 2016, 39,065 (3%) admissions were diagnosed with an MDRO and 1,176 (0.1%) were associated with dual MDROs diagnoses. Patients diagnosed with one MDRO were hospitalized three times longer (17.3 days; 95% confidence interval [CI], 16.8-17.7) and patients diagnosed with two MDROs five times longer (31.6 days; 95% CI, 27.0-36.2; p < 0.0001) than undiagnosed patients (6.1 days; 95% CI, 6.1-6.1; all p < 0.0001). On multivariable analysis, the strongest predictor of mortality was a diagnosis of two MDRO infections (odds ratio [OR], 4.8; 95% CI, 3.16-7.21; p < 0.0001). The second strongest predictor was diagnosis of single MDRO infection (OR, 2.9; 95% CI, 2.64-3.20; p < 0.0001). Presence of an MDRO was associated with increased odds of mortality and length of stay in admitted surgical patients. Interventions to reduce MDRO infection among surgical patients may reduce hospital length of stay and mortality.
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http://dx.doi.org/10.1089/sur.2020.400DOI Listing
January 2021

The impact of trauma systems on patient outcomes.

Curr Probl Surg 2021 Jan 5;58(1):100840. Epub 2020 Jun 5.

Stanford University, Stanford, CA. Electronic address:

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http://dx.doi.org/10.1016/j.cpsurg.2020.100840DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7274082PMC
January 2021

The impact of trauma systems on patient outcomes.

Curr Probl Surg 2021 Jan 10;58(1):100849. Epub 2020 Jun 10.

Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA. Electronic address:

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http://dx.doi.org/10.1016/j.cpsurg.2020.100849DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7286246PMC
January 2021

A multi-institutional study assessing general surgery faculty teaching evaluations.

Am J Surg 2020 Dec 25. Epub 2020 Dec 25.

Department of Surgery, University of Washington Medical Center, Seattle, WA, USA. Electronic address:

Background: Resident evaluation of faculty teaching is an important metric in general surgery training, however considerable variability in faculty teaching evaluation (FE) instruments exists.

Study Design: Twenty-two general surgery programs provided their FE and program demographics. Three clinical education experts performed blinded assessment of FEs, assessing adherence 2018 ACGME common program standards and if the FE was meaningful.

Results: Number of questions per FE ranged from 1 to 29. The expert assessments demonstrated that no evaluation addressed all 5 ACGME standards. There were significant differences in the FEs effectiveness of assessing the 5 ACGME standards (p < 0.001), with teaching abilities and professionalism rated the highest and scholarly activities the lowest.

Conclusion: There was wide variation between programs regarding FEs development and adhered to ACGME standards. Faculty evaluation tools consistently built around all suggested ACGME standards may allow for a more accurate and useful assessment of faculty teaching abilities to target professional development.
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http://dx.doi.org/10.1016/j.amjsurg.2020.12.030DOI Listing
December 2020

Prospectively Assigned AAST Grade versus Modified Hinchey Class and Acute Diverticulitis Outcomes.

J Surg Res 2021 03 25;259:555-561. Epub 2020 Nov 25.

Division of General Surgery, Department of Surgery, Stanford University, Stanford, California.

Background: The American Association for the Surgery of Trauma (AAST) recently developed a classification system to standardize outcomes analyses for several emergency general surgery conditions. To highlight this system's full potential, we conducted a study integrating prospective AAST grade assignment within the electronic medical record.

Methods: Our institution integrated AAST grade assignment into our clinical workflow in July 2018. Patients with acute diverticulitis were prospectively assigned AAST grades and modified Hinchey classes at the time of surgical consultation. Support vector machine-a machine learning algorithm attuned for small sample sizes-was used to compare the associations between the two classification systems and decision to operate and incidence of complications.

Results: 67 patients were included (median age of 62 y, 40% male) for analysis. The decision for operative management, hospital length of stay, intensive care unit admission, and intensive care unit length of stay were associated with both increasing AAST grade and increasing modified Hinchey class (all P < 0.001). AAST grade additionally showed a correlation with complication severity (P = 0.02). Compared with modified Hinchey class, AAST grade better predicted decision to operate (88.2% versus 82.4%).

Conclusions: This study showed the feasibility of electronic medical record integration to support the full potential of AAST classification system's utility as a clinical decision-making tool. Prospectively assigned AAST grade may be an accurate and pragmatic method to find associations with outcomes, yet validation requires further study.
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http://dx.doi.org/10.1016/j.jss.2020.10.016DOI Listing
March 2021

Surgical Stabilization of Rib Fracture to Mitigate Pulmonary Complication and Mortality: A Systematic Review and Bayesian Meta-Analysis.

J Am Coll Surg 2021 Feb 16;232(2):211-219.e2. Epub 2020 Nov 16.

Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA; Surgeons Writing About Trauma (SWAT), Stanford University, Stanford, CA.

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http://dx.doi.org/10.1016/j.jamcollsurg.2020.10.022DOI Listing
February 2021

Recurrent small bowel obstruction with intraluminal structures.

J Trauma Acute Care Surg 2021 01;90(1):e13-e15

From the Department of Surgery (B.J.S., K.E.K., D.A.S.), and Division of Gastroenterology and Hepatology (P.G.), Stanford University, Stanford, California.

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http://dx.doi.org/10.1097/TA.0000000000002956DOI Listing
January 2021

Intravenous lidocaine as a non-opioid adjunct analgesic for traumatic rib fractures.

PLoS One 2020 28;15(9):e0239896. Epub 2020 Sep 28.

Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA, United States of America.

Introduction: Pain management is the pillar of caring for patients with traumatic rib fractures. Intravenous lidocaine (IVL) is a well-established non-opioid analgesic for post-operative pain, yet its efficacy has yet to be investigated in trauma patients. We hypothesized that IVL is associated with decreased inpatient opioid requirements among patients with rib fractures.

Methods: We retrospectively evaluated adult patients presenting to our Level 1 trauma center with isolated chest wall injuries. After 1:1 propensity score matching patients who received vs did not receive IVL, we compared the two groups' average daily opioid use, opioid use in the last 24 hours of admission, and pain scores during admissions hours 24-48. We performed multivariable linear regression for these outcomes (with sensitivity analysis for the opioid use outcomes), adjusting for age as a moderating factor and controlling for hospital length of stay and injury severity.

Results: We identified 534 patients, among whom 226 received IVL. Those who received IVL were older and had more serious injury. Compared to propensity-score matched patients who did not receive IVL, patients who received IVL had similar average daily opioid use and pain scores, but 40% lower opioid use during the last 24 hours of admission (p = 0.002). Multivariable regression-with and without sensitivity analysis-did not show an effect of IVL on any outcomes.

Conclusion: IVL was crudely associated with decreased opioid requirements in the last 24 hours of admission, the time period associated with opioid use at 90 days post-discharge. However, we did not observe beneficial effects of IVL on multivariable adjusted analyses; we are conducting a randomized control trial to further evaluate IVL's opioid-sparing effects for patients with rib fractures.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0239896PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7521689PMC
November 2020

Splenectomy for benign and malignant hematologic pathology: Modern morbidity, mortality, and long-term outcomes.

Surg Open Sci 2020 Oct 16;2(4):19-24. Epub 2020 Aug 16.

Department of Surgery, Stanford University, Stanford, CA.

Background: The role of splenectomy to diagnose and treat hematologic disease continues to evolve. In this single-center retrospective review, we describe modern morbidity, mortality, and long-term outcomes associated with splenectomy for benign and malignant hematologic disorders.

Methods: We analyzed all nontrauma splenectomies performed for benign or malignant hematologic disorders from January 2009 to September 2018. Variables collected included demographics, preexisting comorbidities, laboratory results, intra- and postoperative features, and long-term follow-up. Outcomes of interest included postoperative complications, 30-day mortality, and overall mortality.

Results: We identified 161 patients who underwent splenectomy for hematologic disorders. Median age was 54 years (range 19-94), and 83 (52%) were female. Splenectomy was performed for 95 (59%) patients with benign hematologic disorders and for 66 (41%) with malignant conditions. Most splenectomies were laparoscopic (76%), followed by laparoscopic hand assisted (11%), open (8%), and laparoscopic converted to open (6%). Median follow-up was 761 days (interquartile range: 179-2025 days). Major complications occurred in 21 (13%) patients. Three (2%) patients died within 30 days; 16 (9%) died more than 30 days after operation, none from surgical complications, with median time to death of 438 days (interquartile range: 231-1497 days). Among malignant cases, only preoperative thrombocytopenia predicted death (odds ratio = 5.8, 95% confidence interval = 1.1-31.8, P = .04). For benign cases, increasing age was associated with inferior survival (odds ratio = 2.3, 95% confidence interval = 1.0-5.1, P = .05).

Conclusion: Splenectomy remains an important diagnostic and therapeutic option for patients with benign and malignant hematologic disorders and can be performed with a low complication rate. Despite considerable burden of comorbid disease in these patients, early postoperative mortality was uncommon.
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http://dx.doi.org/10.1016/j.sopen.2020.06.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7479208PMC
October 2020

Prospective study of short-term quality-of-life after traumatic rib fractures.

J Trauma Acute Care Surg 2021 01;90(1):73-78

From the Division of General Surgery (J.C., G.C., J.D.J., D.A.S.), Department of Surgery, Department of Epidemiology and Population Health (J.C.), Surgeons Writing About Trauma (S.K., N.A.H., G.C., R.S., J.D.J., D.A.S.), and School of Medicine (S.K., R.S.), Stanford University, Stanford, California.

Background: Postdischarge convalescence after traumatic rib fractures remains unclear. We hypothesized that patients with rib fractures, even as an isolated injury, have associated poor quality of life (QoL) after discharge.

Methods: We prospectively enrolled adult patients at our level I trauma center with rib fractures between July 2019 and January 2020. We assessed QoL at 1 and 3 months after discharge using the Trauma-specific Quality-of-Life (T-QoL; 43-question survey evaluating five QoL domains on a 4-point Likert scale, where 4 indicates optimal and 1, worst QoL) and supplementary questionnaires. We used generalized estimating equations to assess T-QoL score trends over time and effect of age, sex, injury pattern, self-perceived injury severity, and Injury Severity Score.

Results: We enrolled 139 patients (108 completed the first and 93 completed both surveys). Three months after discharge, 33% of patients were not working at preinjury capacity, and 7% were still using opioid analgesia. Suffering rib fractures mostly impacted recovery and resilience (T-QoL score, mean [robust standard error] at 1 month, 2.7 [0.1]; 3 months, 3.0[0.1]) and physical well-being domains (1 month, 2.5 [0.1]; 3 months, 2.9[0.1]). Quality of life improved over time across all domains. Compared with patients who perceived their injuries as mild/moderate, patients who perceived their injuries as severe/very severe reported worse T-QoL scores across all domains. In contrast, Injury Severity Score did not affect QoL. Patients 65 years or older (-0.6 [0.1]) and women (-0.6 [0.2]) reported worse functional engagement compared with those 65 years or older and men, respectively.

Conclusion: We found that patients with traumatic rib fractures experience suboptimal QoL after discharge. Quality of life improved over time, but even 3 months after discharge, patients reported challenges performing activities of daily living, slower-than-expected recovery, and not returning to work at preinjury capacity. Perception of injury severity had a large effect on QoL. Patients with rib fractures may benefit from close short-term follow-up.

Level Of Evidence: Prognostic and epidemiological, level III.
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http://dx.doi.org/10.1097/TA.0000000000002917DOI Listing
January 2021

Using a virtual platform for personal protective equipment education and training.

Med Educ 2020 11 10;54(11):1071-1072. Epub 2020 Sep 10.

Department of Surgery, Division of General Surgery, Stanford University, Stanford, CA, USA.

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http://dx.doi.org/10.1111/medu.14321DOI Listing
November 2020

Pulmonary contusions in patients with rib fractures: The need to better classify a common injury.

Am J Surg 2021 01 31;221(1):211-215. Epub 2020 Jul 31.

Department of Surgery, Division of General Surgery, Stanford University, United States; Surgeons Writing about Trauma, Stanford University, United States.

Background: Pulmonary contusions are common injuries. Computed tomography reveals vast contused lung volume spectrum, yet pulmonary contusions are defined dichotomously (unilateral vs bilateral). We assessed whether there is stepwise increased risk of pulmonary complications among patients without, with unilateral, and with bilateral pulmonary contusion.

Methods: We identified adults admitted with rib fractures using the largest US inpatient database. After propensity-score-matching patients without vs with unilateral vs bilateral pulmonary contusions and adjusting for residual confounders, we compared risk for pneumonia, ventilator-associated pneumonia (VAP), respiratory failure, intubation, and mortality.

Results: Among 148,140 encounters of adults with multiple rib fractures, 19% had concomitant pulmonary contusions. Matched patients with pulmonary contusions had increased risk of pneumonia 19% [95%CI:16-33%], respiratory failure 40% [95%CI: 31-50%], and intubation 46% [95%CI: 33-61%]. Delineation showed bilateral contusions, not unilateral contusions, attributed to increased risk of complications.

Conclusions: There is likely a correlation between contused lung volume and risk of pulmonary complications; dichotomously classifying pulmonary contusions is insufficient. Better understanding this correlation requires establishing the clinically significant contusion volume and a correspondingly refined classification system.
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http://dx.doi.org/10.1016/j.amjsurg.2020.07.022DOI Listing
January 2021

Lessons from Epidemics, Pandemics, and Surgery.

J Am Coll Surg 2020 12 21;231(6):770-776. Epub 2020 Aug 21.

Department of Surgery, Stanford Hospital and Clinics, Stanford University, Stanford, CA.

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http://dx.doi.org/10.1016/j.jamcollsurg.2020.08.736DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7441012PMC
December 2020

Hospital Readmission After Climbing-Related Injury in the United States.

Wilderness Environ Med 2020 Sep 13;31(3):298-302. Epub 2020 Aug 13.

Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA.

Introduction: Rock climbing and mountaineering may result in injury requiring hospital admission. Readmission frequency after climbing-related injury is unknown. The aim of this study was to assess readmission frequency, morbidity, and mortality after admission for climbing-related injury.

Methods: We performed a retrospective analysis of the 2012 to 2014 national readmission database, a nationally representative sample of all hospitalized patients. Rock climbing, mountain climbing, and wall climbing injuries were identified using International Classification of Diseases-Ninth Revision-Clinical Modification codes (E004.0). Outcomes evaluated included readmission frequency, morbidity, mortality, inpatient admission, and costs. Adjusted analyses accounting for survey methodology were performed. Data are presented as mean±SD.

Results: A weighted-estimate 1324 inpatient admissions were associated with a climbing-related injury. Most patients were aged 18 to 44 y (64%), and 68% (n=896) were male. Isolated extremity injures were more common than other injuries (49%, n=645). Sixty-five percent (n=856) underwent a major operative procedure. Less than 1% of all climbing-related visits resulted in death. Within 6 mo of the index hospitalization, 2% (n=23) of the patients had at least 1 readmission, with a time to readmission of 9.9±6.6 (95% CI 4.5-15.4) d. Only female sex was associated with increased odds of readmission (odds ratio=5.5; 95% CI 1.5-20.1; P=0.01).

Conclusions: There is a very low frequency of readmissions after being admitted to the hospital for climbing-related injury. A considerable opportunity to describe the long-term burden of climbing-related injury exists, and further research should be done to assess injury burden treated in the outpatient setting.
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http://dx.doi.org/10.1016/j.wem.2020.05.005DOI Listing
September 2020

Mortality After General Surgery Among Hospitalized Patients With Hematologic Malignancy.

J Surg Res 2020 12 13;256:502-511. Epub 2020 Aug 13.

Department of Surgery, Stanford University, Stanford, California.

Background: Hospitalized patients with hematologic malignancies (HMs) may require abdominal operations for complications of malignancy, treatment sequelae, or unrelated abdominal pathology. We determined predictors of mortality after emergency general surgery for patients with HM using national-level data.

Materials And Methods: We analyzed the 2010-2014 National Inpatient Sample for International Classification of Disease, Ninth Revision, Clinical Modification codes for HM and abdominal operations, comparing adult patient encounters with abdominal operations with HM to those without HM. Multivariate logistic regression was performed to identify predictors of mortality.

Results: Of the 7.9 million adult inpatient encounters where abdominal surgery was performed, 82,187 (1%) had concomitant diagnoses of HM. Mortality among patient encounters with HM was significantly higher than without HM (9.0% versus 2.0%; P < 0.0001). Patient encounters with HM and surgery and a diagnosis of acute abdominal pain had mortality rates as high as 41%. The median standardized risk ratio for death after the top 25 general surgery procedures was 2.9 (interquartile range: 2.2-3.8) among patients with HM. In adjusted analyses, odds of mortality among patients with HM undergoing surgery were increased by concomitant acute abdominal pain diagnosis (odds ratio [OR] = 2.6; P < 0.0001), coagulopathy (OR = 2.0; P < 0.0001), aplastic anemia (OR = 1.7; P < 0.0001), peripheral vascular disease (OR = 1.4; P = 0.001), and weight loss (OR = 1.3; P < 0.0001).

Conclusions: Although uncommon, surgery on patients with HM is associated with mortality rates nearly five times higher than the general surgical population. Patients with HM requiring surgical intervention may be at particularly high odds of death and postoperative complications.
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http://dx.doi.org/10.1016/j.jss.2020.07.006DOI Listing
December 2020

Placement of Surgical Feeding Tubes Among Patients With Severe Traumatic Brain Injury Requiring Exploratory Abdominal Surgery : Better Early Than Late.

Am Surg 2020 Jun;86(6):635-642

6429 Division of General Surgery, Department of Surgery, Stanford University, CA, USA.

Objectives: The purpose of this study was to identify trauma patients who would benefit from surgical placement of an enteral feeding tube during their index abdominal trauma operation.

Methods: We performed a retrospective analysis of all patients admitted to 2 level I trauma centers between January 2013 and February 2018 requiring urgent exploratory abdominal surgery.

Results: Six-hundred and one patients required exploratory abdominal surgery within 24 hours of admission after trauma activation. Nineteen (3% of total) patients underwent placement of a feeding tube after their initial exploratory surgery. On multivariate analysis, an intracranial Abbreviated Injury Scale ≥4 (odds ratio [OR] = 9.24, 95% CI 1.09-78.26, = .04) and a Glasgow Coma Scale ≤8 (OR = 4.39, 95% CI 1.38-13.95, = .01) were associated with increased odds of requiring a feeding tube. All patients who required a feeding tube had an Injury Severity Score ≥15. While not statistically significant, patients with an open surgical feeding tube compared with interventional radiology/percutaneous endoscopic gastrostomy placement had lower median intensive care unit length of stay, fewer ventilator days, and shorter median total hospital length of stay.

Conclusions: Trauma patients with severe intracranial injury already requiring urgent exploratory abdominal surgery may benefit from early, concomitant placement of a feeding tube during the index abdominal operation, or at fascial closure.
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http://dx.doi.org/10.1177/0003134820923302DOI Listing
June 2020

Understanding Health Care Utilization and Mortality After Emergency General Surgery in Patients With Underlying Liver Disease.

Am Surg 2020 Jun;86(6):665-674

6429 Department of Surgery, Division of General Surgery, Stanford University Medical Center, Stanford, CA, USA.

Background: Mortality and complications are not well defined nationally for emergency general surgery (EGS) patients presenting with underlying all-cause liver disease (LD).

Study Design: We analyzed the 2012-2014 National Inpatient Sample for adults (aged ≥ 18 years) with a primary EGS diagnosis. Underlying LD included International Classification of Diseases, Ninth Revision, Clinical Modification codes for alcoholic and viral hepatitis, malignancy, congenital etiologies, and cirrhosis. The primary outcome was mortality; secondary outcomes included complications, operative intervention, and costs.

Results: Of the 6.8 million EGS patients, 358 766 (5.3%) had underlying LD. 59.1% had cirrhosis, 6.7% had portal hypertension, and 13.7% had ascites. Compared with other EGS patients, EGS-LD patients had higher mean costs ($12 847 vs $10 234, < .001). EGS-LD patients were less likely to have surgery (26.1% vs 37.0%, < .001) but for those who did, mortality was higher (4.8% vs 1.8%, < .001). Risk factors for mortality included ascites (adjusted odds ratio [aOR] = 2.68, < .001), dialysis (aOR = 3.44, < .001), sepsis (aOR = 8.97, < .001), and respiratory failure requiring intubation (aOR = 10.40, < .001). Odds of death increased in both surgical (aOR = 4.93, < .001) and non-surgical EGS-LD patients (aOR = 2.56, < .001).

Conclusions: Underlying all-cause LD among EGS patients is associated with increased in-hospital mortality, even in the absence of surgical intervention.
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http://dx.doi.org/10.1177/0003134820923304DOI Listing
June 2020

The Research Agenda for Stop the Bleed: Beyond Focused Empiricism in Prehospital Hemorrhage Control.

JAMA Netw Open 2020 07 1;3(7):e209465. Epub 2020 Jul 1.

Department of Surgery, Stanford University, Stanford, California.

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http://dx.doi.org/10.1001/jamanetworkopen.2020.9465DOI Listing
July 2020

Pain Scores in Geriatric vs Nongeriatric Patients With Rib Fractures.

JAMA Surg 2020 09;155(9):889-891

Division of General Surgery, Department of Surgery, Stanford University, Stanford, California.

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http://dx.doi.org/10.1001/jamasurg.2020.1933DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7330821PMC
September 2020

Safety of Foregoing Operation for Small Bowel Obstruction in the Virgin Abdomen: Systematic Review and Meta-Analysis.

J Am Coll Surg 2020 09 20;231(3):368-375.e1. Epub 2020 Jun 20.

Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA; Students and Surgeons Writing About Trauma, Stanford University, Stanford, CA.

Our objective was to assess the safety of foregoing surgery in patients without abdominopelvic surgery history presenting with small bowel obstruction (SBO). Classic dogma has counseled early surgical intervention for SBO in the virgin abdomen-patients without abdominopelvic surgery history-given their presumed higher risk of malignant or potentially catastrophic etiologies compared with those who had undergone previous abdominal operations. The term virgin abdomen was coined before widespread use of CT, which now elucidates many SBO etiologies. Despite recent efforts to re-evaluate clinical management standards, the prevalence of SBO etiologies in the virgin abdomen and the current management landscape (nonoperative vs operative) in these patients remain unclear. Our random-effects meta-analysis of 6 studies including 442 patients found the prevalence of malignant etiologies in patients without abdominopelvic surgery history presenting with SBO varied from 7.7% (95% CI 3.0 to 14.1) to 13.4% (95% CI 7.6 to 20.3) on sensitivity analysis. Most malignant etiologies were not suspected before surgery. De novo adhesions (54%) were the most common etiology. More than half of patients underwent a trial of nonoperative management, which often failed. Subgroups of patients likely have variable risk profiles for underlying malignant etiologies, yet no study had consistent follow-up data and we did not find convincing evidence that foregoing operative management altogether in this population can be generally recommended.
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http://dx.doi.org/10.1016/j.jamcollsurg.2020.06.010DOI Listing
September 2020