Background As non-operative management of appendicitis gains popularity, vigilance for appendiceal tumors becomes increasingly important. We hypothesized that among patients presenting with acute appendicitis, those with advanced age, multiple comorbidities, atypical presentation, and complicated appendicitis would be more likely to have underlying appendiceal tumors. Methods We performed a 4-year retrospective cohort analysis of 677 consecutive adult patients who underwent appendectomy for appendicitis at our tertiary care center. Patients with an appendiceal tumor on their final pathology report were compared to patients with no tumor. Conditions present on admission were used to create a multivariate logistic regression model to predict appendiceal tumor. Risk factors were reported as odds ratio (OR) [95% confidence interval]. Model strength was assessed by area under the receiver operating characteristic curve (AUROC). Results Seventeen patients (2.5%) had an appendiceal tumor. Within this group, fourteen underwent immediate appendectomy, two initially had non-operative management but failed to improve on antibiotics and underwent appendectomy during the initial admission, and one had successful non-operative management and elective appendectomy 19 days after discharge. Four variables contributed to the multivariate model to predict the presence appendiceal tumor: age ≥50 (OR 3.6 [1.1–11.4]), outpatient steroid/immunosuppressant use (OR 12.1 [2.0–72.5]), the absence of migratory right lower quadrant pain (OR 4.7 [1.2–18.1]), and the appearance of a phlegmon on CT scan (OR 7.0 [1.6–30.2]); model AUROC: 0.860 [0.705–0.969]. Conclusions For patients presenting with acute appendicitis, conditions present on admission may predict underlying appendiceal tumor. Patients with advanced age, multiple comorbidities, atypical presentation, and complicated appendicitis should be considered for appendectomy during the index admission or at earliest convenience if non-operative management is necessary. Level of evidence level III prognostic study

Therapeutic study, level III.

Over the last decade, chronic critical illness (CCI) has emerged as an epidemic in intensive care unit (ICU) survivors worldwide. Advances in ICU technology and implementation of evidence-based care bundles have significantly decreased early deaths and have allowed patients to survive previously lethal multiple organ failure (MOF). Many MOF survivors, however, experience a persistent dysregulated immune response that is causing an increasingly predominant clinical phenotype called the persistent inflammation, immunosuppression, and catabolism syndrome (PICS). The elderly are especially vulnerable; thus, as the population ages the prevalence of this CCI/PICS clinical trajectory will undoubtedly grow. Unfortunately, there are no proven therapies to prevent PICS, and multimodality interventions will be required. The purpose of this review is to: (1) discuss CCI as it relates to PICS, (2) identify the burden on healthcare and poor outcomes of these patients, and (3) describe possible nutrition interventions for the CCI/PICS phenotype.

BACKGROUND Differentiating between partial adhesive small bowel obstruction (aSBO) likely to resolve with medical management and complete obstruction requiring operative intervention remains elusive. We implemented a standardized protocol for the management of aSBO and reviewed our experience retrospectively. METHODS Patients with symptoms of aSBO were admitted for intravenous fluid resuscitation, bowel rest, nasogastric tube decompression, and abdominal examinations every 4 hours. Laboratory values and a computed tomography scan of the abdomen and pelvis with intravenous contrast were obtained. Patients with peritonitis or computed tomography scan findings suggesting bowel compromise were taken to the operating room for exploration following resuscitation. All other patients received 80 mL of Gastroview (GV) and 40 mL of sterile water via nasogastric tube. Abdominal plain films were obtained at 4, 8, 12, and 24 hours. If contrast did not reach the colon within 24 hours, then operative intervention was performed. RESULTS Over 1 year, 91 patients were admitted with aSBO. Sixty-three patients received GV, of whom 51% underwent surgery. Twenty-four patients went directly to the operating room because of clinical or imaging findings suggesting bowel ischemia. Average time to surgery was within 1 day for the no-GV group and 2 days for the GV group. Patients passing GV to the colon within 5 hours of administration had a 90% rate of resolution of obstruction. There was a direct relationship between the duration of time before passing GV to the colon and hospital length of stay (HLOS) (r2 = 0.459). Patients who received GV and did not require surgery had lower HLOS (3 days vs. 11 days, p < 0.0001). CONCLUSION The GV protocol facilitated early recognition of complete obstruction. Administration of GV had diagnostic and therapeutic value and did not increase HLOS, morbidity, or mortality. LEVEL OF EVIDENCE Therapeutic study, level V. Epidemiologic study, level V.

Background Temporary abdominal closure (TAC) following damage control surgery (DCS) for injured patients has been generalized to septic patients. However, direct comparisons between these populations are lacking. We hypothesized that patients with intra-abdominal sepsis would have different resuscitation requirements and lower primary fascial closure rates than trauma patients. Study Design We performed a three year retrospective cohort analysis of patients managed with TAC for trauma (n=77) or intra-abdominal sepsis (n=147). All patients received negative pressure wound therapy (NPWT) TAC with intention for planned relaparotomy and sequential abdominal closure attempts at 24-48 hour intervals. Results At presentation, trauma patients had higher rates of hypothermia (31% vs. 18%), severe acidosis (27% vs. 14%), and coagulopathy (68% vs. 48%), and septic patients had higher vasopressor infusion rates (46% vs. 27%). Forty-eight hours after presentation, septic patients had persistently higher vasopressor infusion rates (37% vs. 17%), and trauma patients had received more red blood cell transfusions (6.0 vs. 0.0 units), fresh frozen plasma (5.0 vs. 0.0 units), and crystalloid (8,290 vs. 7,159 ml). Among patients surviving to discharge, trauma patients had higher primary fascial closure (PFC) rates (90% vs. 76%). For trauma patients, independent predictors of failure to achieve PCF were ≥2.5 L NPWT output at 48 hours, ≥10 L crystalloid administration at 48 hours, and ≥10 U PRBC+FFP at 48 hours. For septic patients, relaparotomy within 48 hours predicted successful PFC; requirement for ≥3 diagnostic/therapeutic laparotomies predicted failure to achieve PFC. Conclusions Traumatic injury and intra-abdominal sepsis are associated with distinct pathophysiologic insults, resuscitation requirements, and outcomes. Failure to achieve primary fascial closure in trauma patients was attributable to the triad of hypothermia, acidosis, and coagulopathy; failure to achieve fascial closure in septic patients was dependent upon operative course. Indications and optimal techniques for TAC may differ between these populations. Level of Evidence level IV – therapeutic, and level III – prognostic

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Background The prognosis for patients with severe acute lower intestinal bleeding (ALIB) may be assessed by complex artificial neural networks (ANNs) or user-friendly regression-based models. Comparisons between these modalities are limited, and predicting the need for surgical intervention remains elusive. We hypothesized that ANNs would outperform the Strate rule to predict severe bleeding and would also predict the need for surgical intervention. Methods We performed a 4-y retrospective analysis of 147 adult patients who underwent endoscopy, angiography, or surgery for ALIB. Baseline characteristics, Strate risk factors, management parameters, and outcomes were analyzed. The primary outcomes were severe bleeding and surgical intervention. ANNs were created in SPSS. Models were compared by area under the receiver operating characteristic curve (AUROC) with 95% confidence intervals. Results The number of Strate risk factors for each patient correlated significantly with the outcome of severe bleeding (r = 0.29, P < 0.001). However, the Strate model was less accurate than an ANN (AUROC 0.66 [0.57–0.75] versus 0.98 [0.95–1.00], respectively) which incorporated six variables present on admission: hemoglobin, systolic blood pressure, outpatient prescription for Aspirin 325 mg daily, Charlson comorbidity index, base deficit ≥5 mEq/L, and international normalized ratio ≥1.5. A similar ANN including hemoglobin nadir and the occurrence of a 20% decrease in hematocrit was effective in predicting the need for surgery (AUROC 0.95 [0.90–1.00]). Conclusions The Strate prediction rule effectively stratified risk for severe ALIB, but was less accurate than an ANN. A separate ANN accurately predicted the need for surgery by combining risk factors for severe bleeding with parameters quantifying blood loss. Optimal prognostication may be achieved by integrating pragmatic regression-based calculators for quick decisions at the bedside and highly accurate ANNs when time and resources permit.

Background: To standardize care and promote early fascial closure among patients undergoing emergent laparotomy and temporary abdominal closure (TAC), we developed a protocol addressing patient selection, operative technique, resuscitation strategies, and critical care provisions. We hypothesized that primary fascial closure rates would increase following protocol implementation with no difference in complication rates. Study Design:We performed a retrospective cohort analysis of 138 adult trauma and emergency general surgery patients who underwent emergent laparotomy and TAC, comparing protocol patients (n=60) to recent historic controls (n=78) that would have met protocol inclusion criteria. The protocol includes low volume 3% hypertonic saline resuscitation, judicious wound vacuum fluid replacement, and early relaparotomy with sequential fascial closure. Demographics, baseline characteristics, illness severity, resuscitation course, operative management, and outcomes were compared. The primary outcome was fascial closure.Results: Baseline characteristics, including age, ASA class and postoperative lactate levels were similar between groups. Within 48 hours of initial laparotomy and TAC, protocol patients received significantly lower total intravenous fluid resuscitation volumes (9.7 vs. 11.4 L, p=0.044) and exhibited higher serum osmolarity (303 vs. 293 mosm/kg, p=0.001). The interval between abdominal operations was significantly shorter following protocol implementation (28.2 vs. 32.2 hours, p=0.027). The incidence of primary fascial closure was significantly higher in the protocol group (93% vs. 81%, p=0.045, number needed to treat: 8.3). Complication rates were similar between groups.