An Empirical National Assessment of the Learning Environment and Factors Associated With Program Culture Objectives: To empirically describe surgical residency program culture and assess program characteristics associated with program culture. Summary Background Data: Despite concerns about the impact of the learning environment on trainees, empirical data have not been available to examine and compare program-level differences in residency culture. Methods: Following the 2018 American Board of Surgery In-Training Examination, a cross-sectional survey was administered to all US general surgery residents. Survey items were analyzed using principal component analysis to derive composite measures of program culture. Associations between program characteristics and composite measures of culture were assessed. Results: Analysis included 7387 residents at 260 training programs (99.3% response rate). Principal component analysis suggested that program culture may be described by 2 components: Wellness and Negative Exposures. Twenty-six programs (10.0%) were in the worst quartile for both Wellness and Negative Exposure components. These programs had significantly higher rates of duty hour violations (23.3% vs 11.1%), verbal/physical abuse (41.6% vs 28.6%), gender discrimination (78.7% vs 64.5%), sexual harassment (30.8% vs 16.7%), burnout (54.9% vs 35.0%), and thoughts of attrition (21.6% vs 10.8%; all P < 0.001). Being in the worst quartile of both components was associated with percentage of female residents in the program (P = 0.011), but not program location, academic affiliation, size, or faculty demographics. Conclusions: Residency culture was characterized by poor resident wellness and frequent negative exposures and was generally not associated with structural program characteristics. Additional qualitative and quantitative studies are needed to explore unmeasured local social dynamics that may underlie measured differences in program culture.

The Hidden Burden of Mental Health Outcomes Following Firearm-related Injures Objectives: Examine the effect of different types of firearms on readmission due to acute stress disorder (ASD) and/or post-traumatic stress disorder (PTSD) in firearm-injury victims. Background: Survivors of firearm-related injuries suffer long-term sequelae such as disability, work loss, and deterioration in the quality of life. There is a paucity of data describing the long-term mental health outcomes in these patients. Methods: We performed a 5-year (2011–2015) analysis of the Nationwide Readmission Database. All adult patients with firearm injuries were stratified into 3 groups by firearm type: handgun, shotgun, and semiautomatic rifle. Outcome measures were the incidence and predictors of ASD/PTSD. Results: A total of 100,704 victims of firearm-related injuries were identified, of which 13.3% (n = 13,393) were readmitted within 6 months of index hospitalization, 6.7% (n = 8970) of these due to ASD/PTSD. Mean age was 34 ± 14 years, 88% were men. Of those readmitted due to ASD/PTSD, 24% (n = 2153) sustained a handgun-related injury on index hospitalization, 12% (n = 1076) shotgun, and 64% (n = 5741) semiautomatic gun (P = 0.039). On regression analysis, semiautomatic gun and shotgun victims had higher odds of developing ASD/PTSD upon readmission [odds ratio (OR): 2.05 (1.10–4.12) and OR: 1.41 (1.08–2.11)] compared to handgun. Female sex [OR: 1.79 (1.05–3.05)] and younger age representing those younger than 25 years [OR: 4.66 (1.12–6.74)] were also independently associated with higher odds of ASD/PTSD. Conclusions: Apart from the lives lost, survivors of semiautomatic rifle- and shotgun-related injuries suffer long-term mental health sequalae. These secondary and debilitating mental health outcomes are important considerations for capturing the overall burden of the disease.

Effect of Postoperative Permissive Anemia and Cardiovascular Risk Status on Outcomes After Major General and Vascular Surgery Operative Interventions Objectives: To determine the effect of postoperative permissive anemia and high cardiovascular risk on postoperative outcomes. Methods: The Veterans Affairs Surgical Quality Improvement Program and Corporate Data Warehouse databases were queried for patients who underwent major vascular or general surgery operations. The status of cardiovascular risk was assessed by calculating the Revised Cardiac Risk Index. Primary endpoint was a composite of mortality, myocardial infarction, acute renal failure, coronary revascularization, or stroke within 90 days postoperatively. Results: We analyzed 142,510 procedures performed from 2000 to 2015. Postoperative anemia was the strongest independent predictor of the primary endpoint whose odds increased by 43% for every g/dL drop in postoperative nadir Hb [95% confidence interval (95% CI): 41–45]. Cardiac risk status as described by the RCRI also independently predicted the primary endpoint, with an additive effect particularly evident at postoperative nadir Hb values below 10 gm/dL. Postoperative anemia, after age, was the second strongest independent predictor of long-term (12 years) mortality (hazard ratio: 1.18, 95% CI: 1.17–1.19). Conclusion: Postoperative anemia is strongly associated with postoperative ischemic events, 90-day mortality, and long-term mortality. Restrictive transfusion should be used cautiously after major general and vascular operations, particularly in patients at a high cardiovascular risk.

A Surgical Endovascular Trauma Service Increases Case Volume and Decreases Time to Hemostasis Objectives: The aim of this study was to evaluate the effect of a recently active endovascular trauma service (ETS) on case volume and time to hemostasis, as a complement to an existing interventional radiology (IR) service. Summary Background Data: Endovascular techniques are vital for trauma care, but timely access can be a challenge. There is a paucity of data on the effect of a multispecialty team for delivery of endovascular hemorrhage control. Methods: The electronic medical record of trauma patients undergoing endovascular procedures between 2013 and 2018 was queried for provider type (IR or ETS). Case volume and rates were expressed per 100 monthly admissions, normalizing for seasonal variation. Interrupted time series analysis was used to model the case rate pre- and post-introduction of the ETS. Admission-to-procedure-time data were collected for pelvic angioembolization as a marker of patients requiring emergency hemostasis. Results: During 6 years, 1274 admission episodes required endovascular interventions. Overall case volume increased from 2.7 to 3.6 at a rate of 0.006 (P = 0.734) after introduction of the ETS. IR case volume decreased from 3.3 to 2.6 at a rate of 0.03 (P = 0.063). ETS case volume increased at a rate of 0.048 (P < 0.001), which was significantly different from the IR trend (P < 0.001). Median (interquartile range) time-to-procedure (hours) was significantly shorter for pelvic angioembolization [3.0 (4.4) vs 4.3 (3.6); P < 0.001] when ETS was compared to IR. Conclusion: A surgical ETS increases case volume and decreases time to hemostasis for trauma patients requiring time sensitive interventions. Further work is required to assess patient outcome following this change.

Association of Overlapping, Nonconcurrent, Surgery With Patient Outcomes at a Large Academic Medical Center: A Coarsened Exact Matching Study Objective: Assess the safety of overlapping surgery before implementation of new recommendations and regulations. Background: Overlapping surgery is a longstanding practice that has not been well studied. There remains a need to analyze data across institutions and specialties to draw well-informed conclusions regarding appropriate application of this practice. Methods: Coarsened exact matching was used to assess the impact of overlap on outcomes amongst all surgical interventions (n = 61,524) over 1 year (2014) at 1 health system. Overlap was categorized as: any, beginning, or end overlap. Study subjects were matched 1:1 on 11 variables. Serious unanticipated events were studied including unplanned return to operating room, readmission, and mortality. Results: In all, 8391 patients (13.6%) had any overlap and underwent coarsened exact matching. For beginning/end overlap, matched groups were created (total matched population N = 4534/3616 patients, respectively). Any overlap did not predict unanticipated return to surgery (9.8% any overlap vs 10.1% no overlap; P = 0.45). Further, any overlap did not predict an increase in reoperation, readmission, or emergency room (ER) visits at 30 or 90 days (30D reoperation 3.6% vs 3.7%; P = 0.83, 90D reoperation 3.8% vs 3.9%; P = 0.84) (30D readmission 9.9% vs 10.2%; P = 0.45, 90D readmissions 6.9% vs 7.0%; P = 0.90) (30D ER 5.4% vs 5.6%; P = 0.60, 90D ER 4.8% vs 4.7%; P = 0.71). In addition, any overlap was not associated with mortality over the surgical follow-up period (90D mortality 1.7% vs 2.1%; P = 0.06). Beginning/end overlap had results similar to any overlap. Conclusion: Overlapping, nonconcurrent surgery is not associated with an increase in reoperation, readmission, ER visits, or unanticipated return to surgery.

Sex Disparity in Outcomes of Ruptured Abdominal Aortic Aneurysm Repair Driven by In-hospital Treatment Delays Objective: We sought to assess whether sex-related differences in timely repair of ruptured abdominal aortic aneurysm (rAAA) were associated with excess risk of early mortality in women. Summary Background Data: rAAA is a surgical emergency and timeliness of intervention affects outcomes. A door-to-intervention time of <90 minutes is recommended. Methods: All rAAA repairs in the Vascular Quality Initiative from 2003 to 2017 were reviewed. Patients were stratified by sex and time-delay cohorts. Univariate and multivariate analyses were performed. Results: There were 3719 rAAA repairs, of which 797 (21%) were performed in women. Sex did not affect repair type: open versus endovascular (21% females, each). Despite similar presentation delays [median 6 hours (inter quartile range, IQR: 3–16)], admission-to-intervention time was longer for women than men [median 1.5 hours (IQR 1–4] vs 1.2 hours (IQR 1–3), P=0.047]. Overall, 45% of patients had a >90-minute delay from admission to repair, with more women than men experiencing this delay (49% vs 44%, P=0.01). Neither were more likely to undergo transfer for treatment. After risk adjustment, female sex was associated with a 48% increase in 30-day mortality. Sex differences in mortality were no longer observed in patients with intervention delays of ≤90 minutes. In patients with >90-minute delays, a 77% increase in 30-day mortality of women over men was noted. Conclusions: Nearly half of rAAA patients have a door-to-intervention time longer than recommended societal guidelines. Sex differences in mortality after rAAA repair seem to be driven by in-hospital treatment delays.

Mitigating Racial and Sex Disparities in Access to Living Donor Kidney Transplantation: Impact of the Nation's Longest Single-center Kidney Chain Objective: In this study, we sought to assess likelihood of living donor kidney transplantation (LDKT) within a single-center kidney transplant waitlist, by race and sex, after implementation of an incompatible program. Summary Background Data: Disparities in access to LDKT exist among minority women and may be partially explained by antigen sensitization secondary to prior pregnancies, transplants, or blood transfusions, creating difficulty finding compatible matches. To address these and other obstacles, an incompatible LDKT program, incorporating desensitization and kidney paired donation, was created at our institution. Methods: A retrospective cohort study was performed among our kidney transplant waitlist candidates (n = 8895). Multivariable Cox regression was utilized, comparing likelihood of LDKT before (era 1: 01/2007–01/2013) and after (era 2: 01/2013–11/2018) implementation of the incompatible program. Candidates were stratified by race [white vs minority (nonwhite)], sex, and breadth of sensitization. Results: Program implementation resulted in the nation's longest single-center kidney chain, and likelihood of LDKT increased by 70% for whites [adjusted hazard ratio (aHR) 1.70; 95% confidence interval (CI), 1.46–1.99] and more than 100% for minorities (aHR 2.05; 95% CI, 1.60–2.62). Improvement in access to LDKT was greatest among sensitized minority women [calculated panel reactive antibody (cPRA) 11%–49%: aHR 4.79; 95% CI, 2.27–10.11; cPRA 50%–100%: aHR 4.09; 95% CI, 1.89–8.82]. Conclusions: Implementation of an incompatible program, and the resulting nation's longest single-center kidney chain, mitigated disparities in access to LDKT among minorities, specifically sensitized women. Extrapolation of this success on a national level may further serve these vulnerable populations.

Impact of Medicaid Expansion of the Affordable Care on the Outcomes of Lower Extremity Bypass for Patients With Peripheral Artery Disease in the Vascular Quality Initiative Database Objective: The aim of this study was to evaluate changes in the utilization and outcomes of surgery after Medicaid Expansion (ME) for patients with peripheral artery disease (PAD). Summary Background Data: Recent studies have demonstrated increased insurance coverage and improved care with the Affordable Care Act's (ACA) state expansion of Medicaid. Methods: Infrainguinal bypass procedures performed due to occlusive pathology in the Vascular Quality Initiative database between 2010 and 2017 were included. Primary outcomes including postoperative mortality and major adverse limb events (MALE) at 1-year of follow-up were analyzed using interrupted time-series analysis (ITS). Results: Out of 26,446 infrainguinal bypass procedures, 13,955 (52.8%) were included in this analysis. ME states witnessed an annual decrease in infrainguinal surgery for acute ischemia [annual change in post vs pre-ME period (95% confidence interval): −4.3% (−7.5% to −1.0%), P = 0.02] and an increase in revascularization for claudication [3.7% (1.7%–5.6%), P = 0.01]. Among nonacute cases, elective procedures increased in ME states [3.9% (0.1%–7.7%), P = 0.05] along with a significant annual decrease in in-hospital mortality [−0.4% (−0.8 to −0.02), P = 0.04) and MALE at 1 year of follow up [−9.0% (−20.3 to 2.3), P = 0.09]. These results were statistically significant after comparing them with the annual trend changes in states which did not adopt ME. Conclusions: The adoption of ME in 2014 was associated with significant increase in the use of infrainguinal bypass for nonsevere and elective cases, along with improved in-hospital mortality and MALE at 1 year. Longer follow-up is needed to evaluate the impact of ME on other aspects of care and longer term outcomes of PAD patients.

Management of Five Hundred Patients With Gut Failure at a Single Center: Surgical Innovation Versus Transplantation With a Novel Predictive Model Objective(s): To define the evolving role of integrative surgical management including transplantation for patients gut failure (GF). Methods: A total of 500 patients with total parenteral nutrition-dependent catastrophic and chronic GF were referred for surgical intervention particularly transplantation and comprised the study population. With a mean age of 45 ± 17 years, 477 (95%) were adults and 23 (5%) were children. Management strategy was guided by clinical status, splanchnic organ functions, anatomy of residual gut, and cause of GF. Surgery was performed in 462 (92%) patients and 38 (8%) continued medical treatment. Definitive autologous gut reconstruction (AGR) was achievable in 378 (82%), primary transplant in 42 (9%), and AGR followed by transplant in 42 (9%). The 84 transplant recipients received 94 allografts; 67 (71%) liver-free and 27 (29%) liver-contained. The 420 AGR patients received a total of 790 reconstructive and remodeling procedures including primary reconstruction, interposition alimentary-conduits, intestinal/colonic lengthening, and reductive/decompressive surgery. Glucagon-like peptide-2 was used in 17 patients. Results: Overall patient survival was 86% at 1-year and 68% at 5-years with restored nutritional autonomy (RNA) in 63% and 78%, respectively. Surgery achieved a 5-year survival of 70% with 82% RNA. AGR achieved better long-term survival and transplantation better (P = 0.03) re-established nutritional autonomy. Both AGR and transplant were cost effective and quality of life better improved after AGR. A model to predict RNA after AGR was developed computing anatomy of reconstructed gut, total parenteral nutrition requirements, cause of GF, and serum bilirubin. Conclusions: Surgical integration is an effective management strategy for GF. Further progress is foreseen with the herein-described novel techniques and established RNA predictive model.