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Splenic angioembolization (SAE) is increasingly used in the management of splenic injuries in adults, although its value in pediatric trauma is unclear. We sought to assess outcomes related to splenectomy vs SAE. The National Trauma Data Bank was queried for patients 0 to 15 years of age from 2007 to 2011. Subgroup analysis of splenectomy vs SAE was performed for high-grade injuries using propensity analysis and inverse probability weighting. Of 11,694 children presenting with splenic trauma, over 90% were treated nonoperatively. Adjusted analysis of high-grade injuries included 265 children who underwent splenectomy and 199 who underwent SAE. The Injury Severity Score, number of transfusions, and complications rates were not significantly different between the 2 groups. Overall adjusted mortality for children with high-grade injuries was 13.4% following splenectomy and 10.0% following SAE (P = .31) Patients undergoing SAE for high-grade splenic trauma have comparable morbidity and mortality with splenectomy. •Splenectomy was compared with splenic angioembolization for management of splenic trauma in children.•Less than 10% of the children require intervention for splenic injury.•There was no difference in transfusion rates or postprocedural complications.•Mortality rates between the 2 groups were not statistically different.

Background Several single-center reports suggest that vascular resection (VR) during pancreaticoduodenectomy (PD) for patients with pancreatic adenocarcinoma is feasible without affecting early postoperative mortality or morbidity. Our objective is to review the outcomes associated with VR during PD using a large multicenter data source. Methods A retrospective cohort analysis was performed using the National Surgical Quality Improvement Program Participant User Files for 2005–2009. All patients undergoing PD for a postoperative diagnosis of malignant neoplasm of the pancreas were included. Forward stepwise multivariate regression analysis was used to determine the association between VR during PD and 30-day postoperative mortality and morbidity after adjustment for patient demographics and comorbidities. Results 3,582 patients were included for analysis, 281 (7.8 %) of whom underwent VR during PD. VR during PD was associated with significantly greater risk-adjusted 30-day postoperative mortality [5.7 % with VR versus 2.9 % without VR, adjusted odds ratio (AOR) 2.1, 95 % confidence interval (CI) 1.22–3.73, P  = 0.008] and overall morbidity (39.9 % with VR versus 33.3 % without VR, AOR 1.36, 95 % CI 1.05–1.75, P  = 0.02). There was no significant difference in risk-adjusted postoperative mortality or morbidity between those patients undergoing VR by the primary surgical team versus those patients undergoing VR by a vascular surgical team. Conclusions Contrary to the findings of several previously published single-center analyses, the current study demonstrates increased 30-day postoperative morbidity and mortality in PD with VR when compared with PD alone.

Key Clinical Message If patient anatomy or disease does not allow for a traditional or partial cholecystectomy, an omental pedicle plug may be a viable option to limit the risk of postoperative uncontrolled bile leak from the cystic duct and to control patient symptoms.

The American Board of Surgery In-Training Examination (ABSITE) offers annual assessment of resident medical knowledge. We sought to determine if ongoing end-of-rotation evaluations by faculty of residents' medical knowledge correlate with ABSITE performance. Retrospective cross-sectional study was conducted over 3 years at 2 institutions. Faculty rated residents' clinical knowledge as part of a global summative evaluation. The intraclass correlation coefficient and convergent validity between faculty evaluations and ABSITE performance were assessed. A total of 1,562 faculty evaluations were completed for about 147 residents. There was poor agreement among faculty for each resident, with intraclass correlation coefficients of less than 0.2. Spearman's correlation coefficient was calculated for evaluations and ABSITE scores and were found to be weakly correlative at one institution and not correlated at all at the other. Finally, evaluations across quartiles of resident ABSITE scores were examined and show no correlation. Faculty evaluations of resident medical knowledge correlate poorly with resident ABSITE performance, and should not be used as an ongoing predictive tool. •We examine evaluation tools at 2 general surgery residency programs.•Faculty evaluations do not correlate well with one another.•Faculty evaluations of medical knowledge correlate weakly with ABSITE scores.

Although black patients with acute appendicitis have been shown to be less likely than whites to undergo laparoscopic appendectomy, it is unknown whether they suffer increased complications after surgical management of acute appendicitis. A retrospective analysis of all patients undergoing appendectomy for acute appendicitis from 2005 through 2009, using the National Surgical Quality Improvement Program database, was conducted. Rates of serious and overall morbidity were compared between blacks and whites, with adjustment for preoperative risk factors, the severity of appendicitis, and surgical approach. Blacks were more likely than whites to suffer serious postoperative complications (4.8% vs 3.3%; adjusted odds ratio vs whites, 1.39; 95% confidence interval, 1.16–1.67; P = .0002) or any complication (8.4% vs 6.0%; adjusted odds ratio vs whites, 1.31; 95% confidence interval, 1.14–1.50; P = .0007). Racial disparities in postoperative outcomes exist for even a procedure as ubiquitous as appendectomy. More research is needed to determine the underlying reasons for these disparities.

Background Complex, oncologic surgery is an important component of resident education. Our objective was to evaluate the impact of resident participation in oncologic procedures on overall 30-day morbidity and mortality. Methods A retrospective cohort analysis was performed using the National Surgical Quality Improvement Program Participant User Files for 2005–2009. Colorectal, hepatopancreaticobiliary, and gastroesophageal oncology procedures were included. Multivariate logistic regression was used to assess the impact of trainee involvement on 30-day morbidity and mortality after adjusting for potential confounders. Results A total of 77,862 patients were included for analysis, 53,885 (69.2 %) involving surgical trainees and 23,977 (30.8 %) without trainees. The overall 30-day morbidity was significantly higher in the trainee group [27.2 vs. 21 %, adjusted odds ratio (AOR) 1.19, 95 % confidence interval (CI) 1.15–1.24, p  < 0.0001)]; however, there was significantly lower 30-day postoperative mortality in the trainee group (1.9 vs. 2.1 %, AOR 0.87, 95 % CI 0.77–0.98, p  = 0.02) and significantly lower failure-to-rescue rate (defined as mortality rate among patients suffering one or more postoperative complications) (5.9 vs. 7.6 %, AOR 0.79, 95 % CI 0.68–0.90, p  = 0.001). The overall 30-day morbidity was highest in the PGY 5 level (29 %) compared to 24 % for PGY 1 or 2 and 23 % for PGY 3 (AOR per level increase 1.05, 95 % CI 1.03–1.07, p  < 0.0001). Conclusions Trainee participation in complex, oncologic surgery is associated with significantly higher rates of 30-day postoperative complications in NSQIP-participating hospitals; however, this effect is countered by overall lower 30-day mortality and improved rescue rate in preventing death among patients suffering complications.

Objective The routine use of venous thromboembolism (VTE) chemoprophylaxis after hepatic surgery remains controversial due to the relatively low incidence of this complication and the significant risk of perioperative bleeding. The objective of our analysis was to identify perioperative predictors of postoperative VTE in patients undergoing resection. Methods All patients from the American College of Surgeons National Surgical Quality Improvement Program Participant User File from 2005 to 2009 who underwent hepatic resection were included for analysis. Forward stepwise multivariate logistic regression models were used to determine perioperative variables that are significantly associated with VTE after hepatic surgery. Results The overall incidence of VTE after hepatic resection was 2.9 %. Significant predictors of VTE after hepatic resection included preoperative mechanical ventilation, male gender, operative time > 3 h, age ≥ 70 years, intraoperative transfusion, and extended hepatectomy. Several non-VTE postoperative complications were also associated with subsequent VTE, including prolonged mechanical ventilation, need for early reoperation, and postoperative bleeding. Conclusions Many perioperative factors, including extended hepatectomy as well as several postoperative non-VTE complications, are associated with an increased risk of VTE after hepatic resection. Knowledge of these factors may assist surgeons in deciding which patients merit more aggressive prophylaxis against this complication.

Our objective was to study outcomes associated with open inguinal herniorrhaphy performed under locoregional (LR) versus general anesthesia (GA). National Surgical Quality Improvement Program (NSQIP) data from 2005 to 2009 was queried to capture patients undergoing initial unilateral inguinal herniorrhaphy. We excluded patients with incarcerated/strangulated hernia or those undergoing a concomitant procedure. Outcomes were anesthesia and operative times, postoperative admission, and 30-day morbidity. Using the entire NSQIP sample, forward stepwise multivariate regression analysis was used to compare outcomes between patients receiving LR versus GA after adjustment for patient demographics and comorbid diagnoses. Outcomes were also compared for a smaller subgroup of patients propensity-matched for receiving LR anesthesia. A total of 25,213 patients were analyzed (16,282 GA and 8,931 LR). Patients in the LR group had a higher incidence of comorbid illnesses and were more likely to have an American Society of Anesthesiologists classification ≥ 3. Multivariate analyses demonstrated that LR anesthetic is associated with shorter anesthetic and operative times and a lower hospital admission rate. Comparison using a propensity-matched cohort for undergoing LR anesthesia confirms that these patients had significantly shorter anesthesia (32 vs 38 min, P < 0.0001) and operative times (53.3 vs 57.2 min, P < 0.0001), as well as a significantly reduced rate of postoperative admission (5.9% vs 10.9%, P < 0.0001) and 30-day morbidity (0.9% vs 1.3%, P < 0.05). Our analysis of NSQIP suggests that, compared with general anesthesia, the locoregional technique is associated with shorter anesthesia and operative times, reduced need for postoperative hospital admission, and a small but significant reduction in postoperative morbidity.

Race- and insurance-based disparities exist in the utilization of high-volume hospitals for complex surgery. Retrospective analysis of the Nationwide Inpatient Sample from 1988 through 2005 was performed to examine hospital volume trends for eight procedures. Ordered logistic regression analyses were performed to determine temporal trends in the utilization of high-volume hospitals by minority and Medicaid-insured patients compared with white patients and those with private insurance or Medicare. Black patients are increasing their utilization of higher-volume hospitals, but not at a rate sufficient to overcome existing disparities relative to the utilization of such hospitals by white patients. Meanwhile, disparities in the utilization of higher-volume hospitals are increasing for Hispanics and patients who are primarily insured through Medicaid. Existing racial and insurance-based disparities in the utilization of high-volume surgical care will persist or become even more pronounced without active intervention from health care policymakers.

Introduction Recent data suggests that the previously demonstrable relationship between hospital volume and outcomes for liver transplant procedures may no longer exist. Furthermore, to our knowledge, no study has been published examining whether individual surgeon volume is associated with outcomes in liver transplantation. Materials and methods The Nationwide Inpatient Sample database was used to obtain early clinical outcome and resource utilization data for liver transplant procedures performed in the USA from 1988 through 2003. The relationship between surgeon and hospital volume and early clinical outcomes was analyzed with and without adjustment for certain confounding variables such as patient age and presence of co-morbid disease. Results The in-hospital mortality rate, major postoperative complication rate, and length of hospital stay after liver transplantation did not differ significantly based on hospital procedural volume. These outcome variables did, however, exhibit a statistically significant inverse relationship with individual surgeon volume of liver transplant procedures. A significant relationship between procedure volume and outcomes for liver transplantation cannot be demonstrated at the level of transplant center, but does appear to exist at the level of the individual transplant center. Conclusion Minimal volume requirements for individual liver transplant surgeons may be justified, pending validation of this volume–outcomes relationship using a clinical data source.