Jose J Diaz

• MD, CPE, FACS, FCCM
• Chief Acute Care Surgery at University of South Florida

Background: Damage control laparotomy (DCL) is a well-established tool to stabilize critically ill surgical patients. Direct peritoneal resuscitation (DPR), whereby the open abdomen is continuously irrigated with glucose-based hypertonic dialysate, is a valuable adjunct that improves abdominal closure rates and decreases wound complications. Infect...

Antibiotics are recognized widely for their benefits when used appropriately. However, they are often used inap-propriately despite the importance of responsible use within good clinical practice. Effective antibiotic treatment is an essential component of universal healthcare, and it is a global responsibility to ensure appropriate use. Currently...

Background: Appropriate and timely care is essential in the management of severe acute pancreatitis (SAP). We hypothesized that transferred patients with SAP undergoing procedural intervention would have higher mortality compared to those managed directly at academic centers. Methods: This was a retrospective analysis of Maryland's statewide cla...

Background: Surgical Rescue (SR) is the recovery of patients with surgical complications. Patients transferred (TP) for surgical diagnoses to higher-level care or inpatients (IP) admitted to nonsurgical services may develop intra-abdominal infection (IAI) and require emergency surgery (ES). The aims were to characterize the SR population by the si...

Introduction: This study aimed to determine whether surgical stabilization of rib fractures (SSRF) is associated with worse outcomes in individuals with multicompartmental injuries. Materials and methods: A retrospective review of a prospective trauma registry was performed for adult blunt trauma patients (aged ≥ 18 y) with Injury Severity Score...

With the proliferation of surgical subspecialties and the public demand for specific expertise, the field of surgery has witnessed the extinction of the multitalented general surgeon over time. To mitigate this issue and ensure that effective and high-quality care is provided to the trauma, emergency general surgery (EGS), and critically ill patien...

We investigated whether the COVID-19 pandemic affected rates of interpersonal violence (IV). A retrospective study was performed using city-wide crime data and the trauma registry at one high-volume trauma center pre-pandemic [PP] (March-October 2019) and during the pandemic [PA] (March-October 2020). The proportion of trauma admissions attributabl...

Background Older adults (OAs; ≥ 65 years) comprise a growing population in the United States and are anticipated to require an increasing number of emergency general surgery procedures (EGSPs). The aims of this study were to identify the frequency of EGSPs and compare cost of care in OAs managed at teaching hospitals (THs) vs nonteaching hospitals...

Background: Data on duration of antibiotics in patients managed with an open abdomen (OA) due to intra-abdominal infection (IAI) are scarce. We hypothesized that patients with IAI managed with OA rather than closed abdomen (CA) would have higher rates of secondary infections (SIs) independent of the duration of the antibiotic treatment. Methods:...

Background The American Association for the Surgery of Trauma (AAST) has developed a grading system for emergency general surgery (EGS) conditions. We sought to validate the AAST EGS grades for patients undergoing urgent/emergent colorectal resection. Methods Patients enrolled in the “Eastern Association for the Surgery of Trauma Multicenter Color...

Background Knowledge on pancreatic pseudocyst (PP) management has mostly involved large database analysis, which limits understanding of a complex and heterogeneous disease. We aimed to review the clinical course and outcomes of PP and acute peripancreatic fluid collections (APFC) that require intervention at 1 high-volume center. Methods Retrospe...

Background: Emergency general surgery (EGS) is emerging as a distinct sub-specialty of acute care surgery but continues to exist without essential processes that drive modern trauma programs. An EGS-specific quality program was created with service-based Advanced Practice Provider (SB APP) administrative oversight, thus validating the need for a d...

Objectives The inherent complexity of the Emergency General Surgery (EGS) patient may preclude precise documentation at admission. To obviate lapses in documentation, an EGS tertiary survey (EGS-TS) was developed to enable early recognition of relevant omissions in documentation and clinical findings. We theorized that the creation of the EGS-TS wo...

Acute portal vein thrombosis complicated by mesenteric ischemia requires emergent treatment to address the compromised bowel as well as the portal vein thrombus. We report a novel hybrid approach to managing this disease process. The procedure we discuss entails exploratory laparotomy and small bowel resection by the acute care emergency surgery te...

Objectives Damage control laparotomy (DCL) remains an important tool in the trauma surgeon’s armamentarium. Inconsistency in reporting standards have hindered careful scrutiny of DCL outcomes. We sought to develop a core outcome set (COS) for DCL clinical studies to facilitate future pooling of data via meta-analysis and Bayesian statistics while m...

On January 2020, the WHO Director General declared that the outbreak constitutes a Public Health Emergency of International Concern. The world has faced a worldwide spread crisis and is still dealing with it. The present paper represents a white paper concerning the tough lessons we have learned from the COVID-19 pandemic. Thus, an international an...

Background Older adults (OAs) ≥ 65 years of age, representing the fastest growing segment in the United States, are anticipated to require a greater percentage of emergency general surgery procedures (EGSPs) with an associated increase in health care costs. The aims of this study were to identify the frequency of EGSP and charges incurred by OA com...

Background: Clostridioides difficile infection (CDI) can result in life-threatening illness requiring surgery. Surgical options for managing severe or fulminant, non-perforated C. difficile colitis include total abdominal colectomy with end ileostomy or creation of a diverting loop ileostomy with antegrade vancomycin lavage. Methods: The Surgical I...

Percutaneous dilatational tracheostomy (PDT) and percutaneous endoscopic gastrostomy (PEG) tube placements are routine procedures performed in the intensive care units (ICUs). They are performed to facilitate care and promote healing. They also help prevent complications from prolonged endotracheal intubation and malnutrition. In most cases, both a...

Abstract Objective Emergency general surgery (EGS) patients presenting with sepsis remain a challenge. The Surviving Sepsis Campaign recommends a 30 mL/kg fluid bolus in these patients, but recent studies suggest an association between large volume crystalloid resuscitation and increased mortality. The optimal amount of pre-operative fluid resuscit...

Background: The Surgical Infection Society (SIS) Guidelines for the treatment of complicated skin and soft tissue infections (SSTIs) were published in October 2009 in Surgical Infections. The purpose of this project was to provide a succinct update on the earlier guidelines based on an additional decade of data. Methods: We reviewed the previous g...

Objective: Emergency general surgery (EGS) patients presenting with sepsis remain a challenge. The Surviving Sepsis Campaign recommends a 30 mL/kg fluid bolus in these patients, but recent studies suggest an association between large volume crystalloid resuscitation and increased mortality. The optimal amount of pre-operative fluid resuscitation pr...

Background Hospital readmission is an important quality-of-care indicator. We sought to examine the rates and predictors of unplanned readmission for the high-risk non-trauma emergency laparotomy patient. Methods This is a post hoc analysis of a multicenter prospective observational study. Between April 2018 and June 2019, a total of 19 centers en...

Dementia is a terminal illness that leads to progressive cognitive and functional decline. As the elderly population grows, the incidence of dementia in hospitalized older adults increases and is associated with poor short-term and long-term outcomes. Delirium is associated with an accelerated cognitive decline in hospitalized patients with dementi...

Background The aim of this study was to determine the current utilization patterns of resuscitative endovascular balloon occlusion of aorta (REBOA) for hemorrhage control in nontrauma patients. Methods Data on REBOA use in nontrauma emergency general surgery patients from six centers, 2014-2019, was pooled for analysis. We performed descriptive an...

Background: The Emergency Surgery Score (ESS) was recently validated as an accurate mortality risk calculator for Emergency General Surgery. We sought to prospectively evaluate whether ESS can predict the need for respiratory and/or renal support (RRS) at discharge after emergent laparotomies (EL). Methods: This is a post-hoc analysis of a 19-ce...

Introduction: We sought to evaluate whether the Emergency Surgery Score (ESS) can accurately predict outcomes in elderly patients undergoing emergent laparotomy (EL). Methods: This is a post-hoc analysis of an EAST multicenter study. Between April 2018 and June 2019, all adult patients undergoing EL in 19 participating hospitals were prospective...

Thoracic trauma continues to cause at least 25% of traumatic deaths in the USA, and many of these injuries cause death within the first minutes to hours following trauma. Mortality of thoracic injuries is second only to head injuries. Many deaths are preventable by prompt diagnosis and treatment given the vital structures that reside within the tho...

Background Percutaneous drainage as the initial procedure for severe pancreatitis (SP) may not always be optimal. Our aim was to identify the characteristics of patients who failed percutaneous drainage and compare their outcomes with patients who underwent surgical intervention as the initial approach. Methods A retrospective review of a prospect...

Appendicitis is the most common general surgery problem in pregnant patients, but patients can present with vague symptoms making diagnosis difficult. Misdiagnosis and delayed diagnosis can lead to complications such as perforation, which can result in dire outcomes, including fetal and maternal demise. A high level of clinical suspicion should be...

Background: The Emergency Surgery Score (ESS) was recently developed and retrospectively validated as an accurate mortality risk calculator for Emergency General Surgery (EGS). We sought to prospectively validate ESS, specifically in the high-risk non-trauma emergency laparotomy (EL) patient. Methods: This is an EAST multicenter prospective obse...

The current morbidity of rib plating is due to the size of the incision required to perform an open procedure. We describe a minimally invasive laparoscopic approach to rib plating. A cadaver model was used to develop the surgical technique by performing both left and right posterior-lateral rib plating. A small incision was made over the auscultat...

Background: Despite the frequent occurrence of interhospital transfers in emergency general surgery (EGS), rates of transfer of complications are undescribed. Improved understanding of hospital transfer patterns has a multitude of implications, including quality measurement. The objective of this study was to describe individual hospital transfer...

The original article [1] contained a typo in author, Federico Coccolini’s name. This has now been corrected.

Differentiation between SBO that will resolve with supportive measures and those requiring surgery remains challenging. WSC administration may be diagnostic and therapeutic. The purpose of this study was to evaluate use of a SBO protocol using WSC challenge. A protocol was implemented at five tertiary care centers. Demographics, prior surgical hist...

Hospitalizations for peptic ulcer disease (PUD) have decreased since the advent of specific medical therapy in the 1980s. The authors' clinical experience at a tertiary center, however, has been that procedures to treat PUD complications have not declined. This study tested the hypothesis that despite decreases in PUD hospitalizations, the volume o...

Background: Severe complicated intra-abdominal sepsis (SCIAS) has high mortality, thought due in part to progressive bio-mediator generation, systemic inflammation, and multiple organ failure. Treatment includes early antibiotics and operative source control. At surgery, open abdomen management with negative-peritoneal-pressure therapy (NPPT) has...

Introduction: The overuse of temporary abdominal closure and second look (SL) laparotomy in emergency general surgery (EGS) cases has been questioned in the recent literature. In an effort to hopefully decrease the number of open abdomen (OA) patients, we hypothesize that reviewing our cases, many of these SL patients could be managed with single-...

Patients supported with venovenous extracorporeal membrane oxygenation are at risk for intra-abdominal hypertension and abdominal compartment syndrome. Flow through the return cannula may be compromised in these patients, resulting in inadequate support and end-organ malperfusion. Early decompressive laparotomy can mitigate these complications and...

The ACGME work hour restrictions facilitated increased utilization of service-based advanced practice providers (APPs) to offset reduced general surgery resident work hours. Information regarding attending surgeon perceptions of APP impact is limited. The aim of this survey was to gauge these perceptions with respect to workload, length of stay (LO...

Interhospital transfer of emergency general surgery (EGS) patients is a common occurrence. Modern individual hospital practices for interhospital transfers have unknown variability. A retrospective review of the Maryland Health Services Cost Review Commission database was undertaken from 2013 to 2015. EGS encounters were divided into three groups:...

Purpose of Review The following is a comprehensive review of the current practice of Vascular Surgery, highlighting the existing gaps in vascular surgical care and delivery and providing evidence-based suggestions for improvements moving forward. Recent Findings Recent data demonstrate that a shift of many vascular surgical procedures from extensi...

Penetrating traumatic diaphragmatic injuries in the hemodynamically stable patient are challenging to diagnosis and manage. The at-risk region of the body is between the fourth intercostal space or from the level of the nipples to the umbilicus abdomen. The 2 major modalities for diagnostic testing have been computed tomography (CT) scan or laparos...

Posterior component separation with transversus abdominis release and implantation of synthetic mesh in the retromuscular space is a durable type of repair for many large incisional hernias with recurrence rates consistently less than 10%. The purported advantage of biologic prostheses in contaminated fields has recently been challenged, and the co...

Background: Limited data exist for long-term outcomes after emergency general surgeries (EGSs) in the United States. This study aimed to characterize the incidence of inpatient readmissions and additional operations within 6 months of an EGS procedure. Methods: In this retrospective observational study, we identified adults (≥18 years old) under...

Background: We examined and compared APP versus surgical resident perceptions of the role of APPs in surgical subspecialty teams. Methods: Residents/first year surgical critical care fellows and inpatient service-specific APPs responded to a survey that examined perceptions about the APP-resident/fellow relationship. Statistical analysis compare...

The science of chest wall injury has continued to grow. The understanding of the mechanics of the chest wall and the various injury patterns has become better understood. This has allowed surgeons to study how to improve on the management of chest wall injury. The surge in technology on implant development had been significant in the last 10 years....

Background Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. Principles of treatment incl...

Background Hemorrhagic shock is the second leading cause of death in blunt trauma and a significant cause of mortality in non-trauma patients. The increased use of resuscitative endovascular balloon occlusion of the aorta (REBOA) as a bridge to definitive control for massive hemorrhage has provided promising results in the trauma population. We des...

Soft tissue diseases including necrotizing soft tissue infections are associated with high mortality and morbidity with hospital-acquired infection rates up to 76 per cent. Critically ill patients with soft tissue infections have increased metabolic requirements; however, the effect of early nutrition on inhospital morbidity including nosocomial in...

Background Severe complicated intra-abdominal sepsis (SCIAS) is a worldwide challenge with increasing incidence. Open abdomen management with enhanced clearance of fluid and biomediators from the peritoneum is a potential therapy requiring prospective evaluation. Given the complexity of powering multi-center trials, it is essential to recruit an in...

Blunt abdominal aortic injury is an infrequent occurrence after blunt trauma. The majority of these injuries result from deceleration forces sustained in motor vehicle collisions. Effects of these forces on the thoracic aorta are well described, but associated spinal compression or distraction can also lead to injury of the affixed abdominal aorta....

Introduction: Patients with acute vascular disease frequently need specialized management that may require transfer to a vascular referral center. While transfer may be medically necessary, it can delay definitive care and is an indicator of incorrect triage to the initial hospital. Regionalization of acute vascular care could improve patient tria...

Background The American College of Surgeons has developed a verification program for children’s surgery centers. Highly specialized hospitals may be verified as Level I, while those with fewer dedicated resources as Level II or Level III, respectively. We hypothesized that more specialized children’s centers would utilize more resources. Study Des...

The Global Alliance for Infections in Surgery appreciates the great effort of the task force who derived and validated the Sepsis-3 definitions and considers the new definitions an important step forward in the evolution of our understanding of sepsis. Nevertheless, more than a year after their publication, we have a few concerns regarding the use...

Infected pancreatic necrosis is a complex disease process associated with significant morbidity and mortality. For years, management relied on extensive open operations to remove the necrotic tissue. The operations, themselves, also had high mortality rates. Over the past 15 years, however, improvements in laparoscopy and other “minimally invasive”...

Laparoscopy has become standard of care for many surgical diseases. As experience has increased, the indications have extended to the trauma patient. Generally, it is only utilized as a screening tool in hemodynamically stable patients; however, there are certain injury patterns which can be successfully managed laparoscopically. If this approach i...

This text is designed to present a comprehensive, up to date and safe approach to managing emergency general surgery patients with a minimally invasive approach. This book bridges the gap between the minimally invasive surgery (MIS) expert who may not routinely be involved in the care of the acute care surgery patient and the ACS expert surgeon who...

The portion of the population over 65 years is expected to continue to increase until 2030. This population has increased healthcare utilization compared to younger adults and frequently requires unplanned surgical procedures. To optimally care for older adults undergoing emergency general surgery, a system-based, multidisciplinary team should be u...

Introduction Thoracic aortic injury is a leading cause of death after blunt trauma, but the effect of trauma system organization on outcomes is undefined. This was an analysis of thoracic aortic injury in a state with a comprehensive trauma system. Methods This was a retrospective study of thoracic aortic injury in Maryland between 2009 and 2014 u...

This declaration, signed by an interdisciplinary task force of 234 experts from 83 different countries with different backgrounds, highlights the threat posed by antimicrobial resistance and the need for appropriate use of antibiotic agents and antifungal agents in hospitals worldwide especially focusing on surgical infections. As such, it is our i...

Although seemingly disparate problems, patients with perforated peptic ulcers (PPU) and dislodged percutaneous endoscopic gastrostomies (PEGs) share several common features and the successful management of these patients requires considerable thought and attention to detail. Despite the development of potent medications to suppress gastric acid pro...

Acute necrotizing pancreatitis remains a significant problem with significant morbidity and mortality. Keys to management include proper diagnosis, admission to the intensive care unit, aggressive resuscitation, and a multidisciplinary approach for management options. The care team should include a designated surgeon, gastroenterologists with exper...

1. Surg Infect (Larchmt). 2017 Nov/Dec;18(8):846-853. doi: 10.1089/sur.2017.219. A Global Declaration on Appropriate Use of Antimicrobial Agents across the Surgical Pathway. [No authors listed] This declaration, signed by an interdisciplinary task force of 234 experts from 83 different countries with different backgrounds, highlights the threat...

Malnutrition among the critically ill is widely prevalent, resulting in impaired ventilator drive, prolonged ventilator dependence, impaired immunologic function, and increased risk of infection. The initiation of early nutrition therapy, specifically enteral nutrition, decreases the early loss of lean mass, provides calories, and improves patients...

Background: Patients managed non-operatively have been excluded from risk-adjusted benchmarking programs, including the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP). Consequently, optimal performance evaluation is not possible for specialties like emergency general surgery (EGS) where non-operative manag...

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in the emergency departments worldwide. The cornerstones of effective treatment of IAIs are early recognition, adequate source control, and appropriate antimicrobial therapy. Prompt resuscitation of patients with ongoi...

Background: Acute appendicitis is the most common abdominal surgical emergency in the United States, with a lifetime risk of 7%-8%. The treatment paradigm for complicated appendicitis has evolved over the past decade, and many cases now are managed by broad-spectrum antibiotics. We determined the role of non-operative and operative management in a...

Objective The paradigm of acute care surgery has revolutionized nonelective general surgery. Similarly, nonelective vascular surgery may benefit from specific management and resource capabilities. To establish the burden and scope of vascular acute care surgery, we analyzed the characteristics and outcomes of patients hospitalized for vascular surg...

“Damage control surgery” is a management approach to the injured or critically ill patient who is approaching physiologic exhaustion that aims to minimize or further worsen the lethal triad of acidosis, hypothermia, and coagulopathy. The patient’s overall management is divided into phases through which the surgeon must maneuver. At the minimum, the...

Necrotizing soft tissue infections (NSTI) have been recognized for millennia and continue to impose considerable burden on both patient and society in terms of morbidity, death, and the allocation of resources. With improvements in the delivery of critical care, outcomes have improved, although disease-specific therapies are lacking. The basic prin...

Background: Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendati...

Background: Data from the trauma patient population suggests handsewn anastomoses (HS) are superior to stapled (ST). A recent retrospective study in emergency general surgery (EGS) patients had similar findings. The aim of the current study is to evaluate HS and ST anastomoses in EGS patients undergoing urgent/emergent operations. Methods: The s...

Objective: Rare disease Background: Acute transverse myelitis (ATM) is an uncommon and often overlooked complication of certain bacterial and viral infections that can have a rapid onset and result in severe neurological deficits. Case Report: This case report describes a previously healthy 28-year-old woman who presented to the trauma center after...

Management of patients undergoing damage control laparotomy (DCL) involves many surgical, medical, and logistical factors. Ideal patient management optimizing fascial closure with regard to timing and closure techniques remains unclear. A retrospective review of patients undergoing DCL from 2000 to 2012 at an urban Level I trauma center was underta...

Prompt discharge after laparoscopic appendectomy (LA) is a marker of quality of care, fiscally desirable and feasible in select patients. Patients over 30 comprise a more heterogeneous cohort known to experience worse outcomes after LA. We aimed to identify easily available preoperative risk factors portending a postoperative length of stay ≥2 days...

Prompt discharge after laparoscopic appendectomy (LA) is a marker of quality of care, fiscally desirable and feasible in select patients. Patients over 30 comprise a more heterogeneous cohort known to experience worse outcomes after LA. We aimed to identify easily available preoperative risk factors portending a postoperative length of stay ≥2 days...

Acute pancreatitis is a common gastrointestinal disease that results in a significant physical, psychosocial, and financial toll [2, 3]. It has become the leading gastroenterology discharge diagnosis in the United States and its incidence appears to be increasing [2, 4, 5]. The cost of caring for these patients is greater than 2 billion dollars ann...

Introduction: Bariatric surgery is the most effective method for producing sustained weight loss, improving obesity-associated comorbidities and reducing inflammation in the morbidly obese population. The red cell distribution width (RDW) is a novel marker of inflammation that is usually reported as part of a complete blood count. In this study, w...

Background: In damage control laparotomy, operative principles include hemorrhage and contamination control. However, required components of initial damage control laparotomy are unknown, and nonemergency injury repair is sometimes delayed for resuscitation, angiography, or nonabdominal operations. The frequency and effects of delayed intervention...

Objective: To evaluate racial differences in the burden of aortic dissection. Design: Retrospective analysis of a comprehensive state-wide inpatient database. Setting: Acute care hospitals in the state of Maryland, 2009 - 2014. Participants: All hospitalized adults with aortic dissection (AD), stratified by race. Main outcome measures: Sta...