Abstract
Background
The “surgical soul” indicates a small spherical area at the head of pancreas with adjacent major vessels. Traumatic injuries to this area are known for the extreme complexity to manage. The aim of this study was to describe the characteristics and outcomes of patients with wounded surgical soul using a nationwide dataset.
Methods
We conducted a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program database (2013–2018). We included patients (age ≥16 years) with Abbreviated Injury Scale (AIS) ≥4 pancreatic and/or duodenal injuries with associated injuries to any of the following vessels: inferior vena cava (IVC), superior mesenteric artery/vein injury (SMA/SMV), portal vein (PV), renal vein (RV), and splenic vein (SV). Multivariate logistic regression was performed to identify factors associated with in-hospital mortality.
Results
A total of 219 patients were identified. Of those, 178 (81.3%) sustained penetrating trauma. Pancreatic injury accounted for 73.5% of all patients, 39.8% with duodenal injury, 45.2% with IVC injury, 11.0% with SMA injury, and 56.6% with PV/SMV/RV/SV injury. Liver (56.2%), colon (47.0%), and stomach (37.9%) were common associated injuries. The overall in-hospital mortality rate was 58% with most deaths occurring <48 hours. In the multivariate analysis, older age, systolic blood pressure <90 mm Hg, chest AIS>3, abdominal aortic injury, and packed red blood cell transfusion >10 units within 24 hours were factors associated with mortality.
Conclusions
Injuries to the surgical soul are rare but associated with a significant mortality risk. The surgical strategy should focus on early hemorrhage control to improve the likelihood of patient survival.
Level of evidence
Prognostic/epidemiological, level IV.
Keywords: abdominal injuries, pancreas, duodenum, Vascular System Injuries
WHAT IS ALREADY KNOWN ON THIS TOPIC
The surgical soul indicates a small spherical area around the head of pancreas with adjacent major vessels.
Scattered patient reports have described the management and outcome of patients with the wounded surgical soul.
WHAT THIS STUDY ADDS
The wounded surgical soul remains fundamentally a surgical disease which often requires multiple operations.
This nationwide study found that injuries to the surgical soul are associated with high mortality (58.0%), particularly within 48 hours.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE, OR POLICY
Surgical strategy for the wounded surgical soul should focus on early hemorrhage control to improve the likelihood of patient survival.
Background
Pancreatic or duodenal trauma is uncommon and the incidence ranges from 0.3% to 5%, accounting for less than 5% of all abdominal trauma.1,7 However, these injuries are associated with a disproportionately high risk of morbidity and mortality.1 8 9 One major reason is the complexity of anatomy in the injured area itself, particularly around the pancreatic head and second portion of the duodenum. According to the current Abbreviated Injury Scale (AIS), it is classified as the highest grade of pancreatic or duodenal injury (Grade IV or V) if massive disruption of this area is encountered or if the ampulla of Vater is involved.10
Additionally, the decision-making process in such severe trauma is often colored by the ongoing exsanguination and extremely deranged physiologic status, adding more uncertainty. Managing pancreaticoduodenal trauma with associated injuries to surrounding major vessels thus becomes one of the most troublesome challenges a trauma surgeon could face. The injury can be comprised of the pancreaticoduodenal complex and the confluence of superior mesenteric vein (SMV), splenic vein (SV), and portal vein (PV) centrally; laterally by the superior mesenteric artery (SMA); and posteriorly by renal vein (RV) and inferior vena cava (IVC) (figure 1).
Figure 1. (A) The circled area in the pancreaticoduodenal complex is often referred to as “surgical soul”. (B) Intraoperative findings of the wounded surgical soul. The second portion of the duodenum (asterisks) and the pancreatic head (stars) are both completely transected. An intravascular shunt is placed in the injured superior mesenteric vein (arrows).
This silver-dollar-sized (2.5–3.0 cm) area was coined as a “surgical soul” by Asher Hirshberg and Kenneth Mattox.11 Several surgical options would be applied to the injuries to the surgical soul, but none of those methods has been established to be a standard procedure.12,14 The rarity of this trauma adds an additional layer of complexity when attempting to compare different repair approaches. Therefore, we sought to elucidate the characteristics, outcomes, and risk factors for mortality in the very specific case of surgical soul wounds through use of a nationwide dataset. We hypothesized that the wounded surgical soul would be associated with increased risk of early hospital deaths, particularly in patients requiring massive blood transfusion.
Methods
We conducted a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) database. Patients (age >16 years) who sustained injuries to the surgical soul between 2013 and 2018 were included for the analysis. The wounded surgical soul was defined as AIS ≥4 pancreatic and/or AIS ≥4 duodenal injury with concomitant injuries to any of the following vessels (AIS ≥4): IVC, SMA, SMV, PV, RV, and SV (online supplemental table 1). Patients with prehospital cardiac arrest, no signs of life on arrival, or who died in the emergency department were excluded. The demographic data, vital signs on arrival, associated injuries, AIS of each body region, and Injury Severity Scores (ISS) were collected. Additionally, any therapeutic intervention such as laparotomy, resuscitative thoracotomy, resuscitative endovascular balloon occlusion of the aorta (REBOA), angioembolization, and blood transfusion was retrieved. In the patients who survived more than 48 hours, the use of endoscopic retrograde cholangiopancreatography (ERCP), percutaneous abdominal drainage including pancreatic cyst, and parenteral nutrition were reported (online supplemental table 2). The primary outcome was in-hospital mortality, and secondary outcomes were hospital complications.
Statistical analysis
Continuous variables were reported as medians with IQRs and compared using Mann-Whitney U test. Categorical variables were reported as counts with percentages. χ2 or Fisher’s exact test was used as appropriate to evaluate the differences between categorical variables. Among all the demographic data and injury characteristics, the rate of missing data ranged from 0.9% to 2.3%. No imputation was performed. Univariate analysis was performed to compare the characteristics of patients between those who survived the hospital stay and those who did not. The variables with p value <0.2 in the univariate analysis were then included in a multivariable logistic regression model to identify the independent factors associated with in-hospital mortality. The backward method was used to maintain confounders if they produced more than 10% change in the odds of association with the outcome of interest. In addition, we performed the sensitivity analysis in a subgroup of patients who sustained firearm injuries. P values of <0.05 were considered statistically significant. All statistical analyses were performed using SPSS V.28.0 (IBM Corp., Armonk, New York, USA). The study followed the Strengthening the Reporting of Observational Studies in Epidemiology guideline.
Results
Of 1,675,511 patients submitted to the ACS-TQIP between 2013 and 2018, 219 patients (0.013%) met our inclusion and exclusion criteria. The median age was 32, and 81.3% were penetrating trauma (table 1). Within 1 hour after arrival, 58.2% developed hypotension defined as systolic blood pressure <90 mm Hg. In addition to the grade IV/V pancreaticoduodenal injuries, most patients had associated injuries to adjacent major veins such as IVC (45.2%) or PV/SMV/SV/RV (56.6%) whereas only 11.0% had SMA injuries. Other major associated injuries were listed in table 2. In the abdomen, liver (56.2%), colon (47.0%), and stomach (37.9%) were the most commonly injured organs, whereas some patients sustained additional injuries to major intra-abdominal arteries including celiac trunk and its branches (26.9%) or abdominal aorta (7.8%). Blunt trauma patients were more likely to present with severe injuries (AIS >3) to other body regions such as the thorax (30.6% vs 10.7%, p=0.002) and head (8.3% vs 1.1%, p=0.035), with significantly higher ISS compared with penetrating trauma (34 vs 26, p<0.001).
Table 1. Patient characteristics.
| Variables | Total patients n=219 |
|---|---|
| Median age (IQR) | 32 (24–44) |
| Male sex (%) | 192 (87.7) |
| Blunt/penetrating trauma (%) | 36/178 (16.4/81.3) |
| Injury mechanism (%) | |
| Firearm | 164 (74.9) |
| Cut/pierce | 14 (6.4) |
| Transport accident | 29 (13.2) |
| Fall | 1 (0.5) |
| Other blunt mechanisms | 6 (2.7) |
| Median SBP (mm Hg, IQR) | 110 (89–131) |
| SBP <90 mm Hg within first hour (%)* | 128 (58.2) |
| Median pulse (IQR) | 107 (88–131) |
| Median GCS (IQR) | 14 (6–15) |
| Median ISS (IQR) | 26 (25–35) |
| Injured organs | |
| Pancreas (%) | 181 (82.6) |
| AIS 4/5 (%) | 87/74 (39.7/33.8) |
| Duodenum (%) | 127 (58.0) |
| AIS 4/5 (%) | 24/63 (11.0/28.8) |
| Combined pancreas/duodenum AIS ≥4 (%) | 29 (13.2) |
| Inferior vena cava (%) | 99 (45.2) |
| Superior mesenteric artery (%) | 24 (11.0) |
| PV/SMV/SV/RV (%) | 124 (56.6) |
Initial (<30 min after arrival) and/or lowest SBP (<1 hour after arrival) <90 mm Hg in the emergency department.
AIS, Abbreviated Injury Scale; GCS, Glasgow Coma Scale; ISS, Injury Severity Score; PV, portal vein; RV, renal vein; SBP, systolic blood pressure; SMV, superior mesenteric vein; SV, splenic vein.
Table 2. Associated organ injuries.
| Injured organs (%) | Total n=219 |
Blunt n=36 |
Penetrating n=178 |
P value* | ||
|---|---|---|---|---|---|---|
| All | Firearm n=164 |
Cut/pierce n=14 |
||||
| Liver | 123 (56.2) | 21 (58.3) | 98 (55.1) | 93 (56.7) | 5 (35.7) | 0.718 |
| Colon | 103 (47.0) | 16 (44.4) | 86 (48.3) | 81 (49.4) | 5 (35.7) | 0.672 |
| Stomach | 83 (37.9) | 4 (11.1) | 77 (43.3) | 74 (45.1) | 3 (21.4) | <0.001 |
| Kidney | 67 (30.6) | 6 (16.7) | 59 (33.1) | 4 (28.6) | 55 (33.5) | 0.050 |
| Jejunum/ileum | 60 (27.4) | 8 (22.2) | 52 (29.2) | 49 (29.9) | 3 (21.4) | 0.394 |
| Celiac trunk/branches | 59 (26.9) | 7 (19.4) | 51 (28.7) | 47 (28.7) | 4 (28.6) | 0.257 |
| Spleen | 40 (18.3) | 15 (41.7) | 25 (14.0) | 23 (14.0) | 2 (14.3) | <0.001 |
| Abdominal aorta | 17 (7.8) | 1 (2.8) | 16 (9.0) | 16 (9.8) | 0 (0) | 0.317 |
| Gallbladder | 17 (7.8) | 2 (5.6) | 15 (8.4) | 13 (7.9) | 2 (14.3) | 0.744 |
| Adrenal gland | 8 (3.7) | 4 (11.1) | 4 (2.2) | 4 (2.4) | 0 (0) | 0.029 |
| Chest AIS >3 | 30 (13.7) | 11 (30.6) | 19 (10.7) | 1 (0.6) | 1 (7.1) | 0.002 |
| Head AIS >3 | 5 (2.3) | 3 (8.3) | 2 (1.1) | 18 (11.0) | 1 (7.1) | 0.035 |
| Extremities AIS >3 | 26 (11.9) | 6 (16.7) | 20 (11.2) | 20 (12.2) | 0 (0) | 0.401 |
Blunt versus penetrating.
AIS, Abbreviated Injury Scale.
As shown in table 3, all patients underwent a laparotomy. Resuscitative thoracotomy and REBOA were performed in 4.1% and 3.2% of patients, respectively. The median packed red blood cell (PRBC) transfusion volume within 4 hours and 24 hours was 4,550 and 5,200 mL (IQR: 2,400–7,650 mL and 3,000–9,075 mL), respectively. The in-hospital mortality was 58.0%, with most deaths occurring within 48 hours after admission (81.9%). For patients who survived more than 48 hours, 68.5% (74/108) needed multiple operations. The rate of unplanned return to the operation room was remarkably high (17.4%). ERCP and percutaneous abdominal drainage were performed in 7.3% and 21.1% of the patients, respectively. Other common hospital complications included acute kidney injury (27.5%), deep vein thrombosis (21.1%), and severe sepsis (17.4%).
Table 3. Therapeutic interventions and patient outcomes.
| N=219 | |
|---|---|
| Laparotomy (%) | 219 (100.0) |
| 2* | 38/210 (18.1) |
| ≥3* | 45/210 (21.4) |
| Resuscitative thoracotomy (%) | 9 (4.1) |
| REBOA (%) | 7 (3.2) |
| Angioembolization (%) | 6 (2.7) |
| Median transfusion volume within 4 hours, mL (IQR) | |
| Packed red blood cell | 4,550 (2,400-7,650) |
| Plasma | 2,700 (1,400-4,270) |
| Platelet | 500 (225–825) |
| Median transfusion volume within 24 hours, mL (IQR) | |
| Packed red blood cell | 5,200 (3,000-9,075) |
| Plasma | 3,240 (1,644-6,000) |
| Platelet | 550 (225–1125) |
| In-hospital mortality (%) | |
| Total patients | 127/219 (58.0) |
| Subgroups | |
| Pancreas AIS 4/5 | 96/161 (59.6) |
| Duodenum AIS 4/5 | 51/87 (58.6) |
| Both pancreas and duodenum AIS 4/5 | 20/29 (69.0) |
| Associated IVC injuries (1) | 54/99 (54.5) |
| Associated SMA injuries (2) | 16/24 (66.7) |
| Associated SV/SMV/PV/RV injuries (3) | 72/124 (58.1) |
| Associated injuries: 2 of (1)/(2)/(3) | 13/24 (54.2) |
| Associated injuries: (1)+(2)+(3) | 1/2 (50.0) |
| Mortality within 48 hours (%) | 104/219 (47.5) |
| Hospital complications (%)† | |
| Acute kidney injury | 30 (27.5) |
| Unplanned return to operation room | 19 (17.4) |
| Deep vein thrombosis | 23 (21.1) |
| Pulmonary embolism | 3 (2.8) |
| Severe sepsis | 19 (17.4) |
| Surgical site infection | 18 (16.5) |
| Pneumonia | 12 (11.0) |
| Acute respiratory distress syndrome | 5 (4.6) |
| Endoscopic retrograde cholangiopancreatography† | 8 (7.3) |
| Abdominal percutaneous drainage† | 23 (21.1) |
| Parenteral nutrition† | 11 (10.1) |
| Median hospital LOS, days (IQR)† | 25.0 (13.0–47.8) |
| Median ICU LOS, days (IQR)† | 8.0 (5.0–21.5) |
| Median ventilator days (IQR)† | 5.0 (3.0–14.0) |
Only patients with the data on operative timing.
Only patients survived more than 48 hours were included.
AIS, Abbreviated Injury Scale; ICU, intensive care unit; IVC, inferior vena cava; LOS, length of stay; PV, portal vein; REBOA, resuscitative endovascular balloon occlusion of the aorta; RV, renal vein; SMA, superior mesenteric artery; SMV, superior mesenteric vein; SV, splenic vein.
Table 4 shows the differences in the characteristic between patients who survived and those who died in the hospital. In the multivariable logistic regression analysis, age (OR: 3.54, 95% CI 1.18 to 12.42), systolic blood pressure (SBP) <90 mm Hg within the first hour (OR: 3.44, 95% CI 1.68 to 7.25), chest AIS >3 (OR: 6.50, 95% CI 1.96 to 30.17), abdominal aortic injury (OR: 9.25, 95% CI 1.60 to 177.29), massive transfusion within 24 hours (defined as PRBC >10 units) (OR: 4.90, 95% CI 1.95 to 13.54) were significantly associated with in-hospital mortality. Similarly, the subgroup analysis in patients with firearm injuries showed that SBP <90 mm Hg within the first hour, chest AIS >3, and massive transfusion within 24 hours were significantly associated with in-hospital mortality (online supplemental table 3).
Table 4. Univariate and multivariate analysis for the in-hospital mortality.
| Variables | Survived n=92 |
Deceased n=127 |
P value | AOR* | 95% CI | Adjusted p value |
|---|---|---|---|---|---|---|
| Age >50 years (%) | 9 (9.9) | 25 (19.8) | 0.047 | 3.54 | 1.18 to 12.42 | 0.032 |
| Male sex (%) | 78 (84.8) | 114 (89.8) | 0.268 | |||
| Penetrating trauma (%) | 78 (87.6) | 100 (80.0) | 0.141 | |||
| SBP <90 mm Hg (%) | 40 (43.5) | 88 (69.3) | <0.001 | 3.44 | 1.68 to 7.25 | <0.001 |
| ISS | 25 (18–34) | 27 (25–36) | 0.002 | |||
| Pancreas AIS 4/5 (%) | 65 (70.7) | 96 (75.6) | 0.414 | |||
| Duodenum AIS 4/5 (%) | 36 (39.1) | 51 (40.2) | 0.878 | |||
| Inferior vena cava (%) | 45 (48.9) | 54 (42.5) | 0.348 | |||
| SMA (%) | 8 (8.7) | 16 (12.6) | 0.361 | |||
| PV/SMV/SV/RV (%) | 52 (56.5) | 72 (56.7) | 0.980 | |||
| Head AIS>3 (%) | 2 (2.2) | 3 (2.4) | 1 | |||
| Chest AIS>3 (%) | 4 (4.3) | 26 (20.5) | <0.001 | 6.50 | 1.96 to 30.17 | 0.006 |
| Liver (%) | 53 (57.6) | 70 (55.1) | 0.714 | |||
| Spleen (%) | 17 (18.5) | 23 (18.1) | 0.945 | |||
| Kidney (%) | 35 (38.0) | 32 (25.2) | 0.042 | 0.47 | 0.22 to 0.98 | 0.046 |
| Colon (%) | 38 (41.3) | 65 (51.2) | 0.148 | |||
| Jejunum/ileum (%) | 27 (29.3) | 33 (26.0) | 0.582 | |||
| Abdominal aorta (%) | 1 (1.1) | 16 (12.6) | 0.002 | 9.25 | 1.60 to 177.29 | 0.041 |
| Celiac trunk or branches (%) | 26 (28.3) | 33 (26.0) | 0.708 | |||
| PRBC>10 units within 24 hours (%) | 45 (52.3) | 97 (88.2) | <0.001 | 4.90 | 1.95 to 13.54 | 0.001 |
| ED thoracotomy (%) | 1 (1.1) | 8 (6.3) | 0.083 | |||
| REBOA (%) | 3 (3.3) | 4 (3.1) | 1.000 |
The parameters with adjusted ORs were those selected in the final logistic regression model.
AIS, Abbreviated Injury Scale; AOR, adjusted OR; ED, emergency department; ISS, Injury Severity Score; PRBC, packed red blood cell; PV, portal vein; REBOA, resuscitative endovascular balloon occlusion of the aorta; RV, renal vein; SBP, systolic blood pressure; SMA, superior mesenteric artery; SMV, superior mesenteric vein; SV, splenic vein.
Discussion
The present study showed that despite the advancement of resuscitation and critical care in these decades, the wounded surgical soul remained a difficult challenge with grave outcome. The difficulties come from a combination of the exsanguination often requiring massive blood transfusion and concomitant complex intra-abdominal injuries at initial stage, and from the high proportion of complications subsequently. It should be emphasized that the wounded surgical soul remains fundamentally a surgical disease associated with increased risk of mortality and morbidity.
Our results showed that the injuries to the surgical soul are predominantly caused by penetrating trauma (81.3%), and mostly by firearm injury. Similar results were also described in previous studies about pancreaticoduodenal injuries with associated abdominal vascular trauma (namely, to the PV, SMV, and IVC).1 9 12 15 16 Even in countries with a low penetrating trauma volume, there exists a significant association between penetrating mechanism and pancreaticoduodenal injuries.7 It is well known that most patients with pancreaticoduodenal trauma also have associated abdominal organ injuries. Schellenberg et al reported that 99% (70/71) of their pancreatic trauma patients had associated injuries in the abdomen.17 O’Reilly et al also reported 63.6% (735/1,155) of the pancreaticoduodenal trauma patients sustained additional intra-abdominal injuries.7 In the current study, being the nearest organs, the liver and colon appear to be most frequently involved. Although the details of radiographic images or operative findings are not collected in the TQIP, the significantly higher proportion of gastric injury in the penetrating group might allude to a common trajectory of firearm injury. Most of the blunt trauma patients in this study were involved in traffic accidents (29/36, 80.6%). Previous studies have shown that blunt trauma caused by traffic accidents—especially high-energy road crashes—is prone to involve multiple systems. Our findings were consistent with this observation, as higher ISS and more frequent chest and head involvement were found in blunt trauma compared with penetrating mechanisms.18 19
More than half of the patients with wounded surgical soul did not survive their hospitalization, and the majority of mortality was within 48 hours after admission. It is well known that uncontrolled hemorrhage and severe traumatic brain injury are the most common causes among early trauma death.20 Although the definite causes of death were not reported in the TQIP, given the relatively low incidence of severe traumatic brain injury in our study, exsanguination rather than severe traumatic brain injury probably played a more important role in the mortality following the wounded surgical soul. Similarly, Kao et al reported that among their pancreatic trauma patients, none of them died from pancreatic injury itself within 48 hours of the hospital stay.9 Phillips et al analyzed the National Trauma Data Bank and found that in penetrating pancreatic trauma patients with 24-hour mortality, nearly 70% had associated major vessel injuries.10 In other words, timely and adequate surgical control of catastrophic hemorrhage from the major vascular injuries is likely to be the key for successful management of patients with the wounded surgical soul. By performing the multivariate logistic regression analysis, we identified the following factors to be associated with in-hospital mortality: age, SBP <90 mm Hg within 1 hour after presentation, associated injuries to the chest (AIS >3), and concomitant abdominal injuries including colon and abdominal aorta. Associated high-grade injuries to the chest or abdominal aorta can certainly aggravate the difficulty for hemostasis.21 Although we found discrepancies in mortality between different combinations of vessels in the surgical soul (table 3), none of those vessels were shown to be independently associated with mortality. Of note, the SMV, PV, RV, and SV injuries could not be distinguished based on the current AIS coding system (online supplemental table 1); therefore, separating each vessel to assess its association with outcomes could not be performed in the present study.
There are several limitations to this study. First, we were unable to identify the cause of death in our study patients. Additionally, some patients might have died before they could undergo surgical interventions, whereas our data suggest that all patients with the wounded surgical soul received surgical interventions. This might be because we only included patients whose injuries were confirmed to meet the definition of “the wounded surgical soul”. Other diagnostic methods such as CT and postmortem examination are not routinely performed in these patients. Second, as operative procedures are recorded using the International Classification of Diseases, 10th Revision (ICD-10) in the TQIP, we were unable to report the details of surgical procedures performed for the wounded surgical soul (ie, some combination of multiple wounded major vessels and intra-abdominal organs). For example, although surgical options for high-grade pancreaticoduodenal injuries could include some of the most invasive procedures such as pancreaticoduodenectomy or pyloric exclusions, there are no specific ICD-10 codes for these procedures. Furthermore, damage control and staged operations are usually unavoidable for the wounded surgical soul, especially given the frequency of large-volume blood transfusions within 4 hours post-injury in our study population—making it almost impossible for them to receive all the necessary repair procedures during the initial operation. However, the limited information in the TQIP data impeded our ability to draw a clear picture regarding the actual interventions undertaken to deal through multiple operations. Additionally, the TQIP does not collect the data for common pancreatic complications (eg, pancreatic/duodenal fistula or pseudocyst). Although we reported data on the use of ERCP and percutaneous abdominal drainage, which are commonly performed for pancreatic complications, the actual complication rates after different types of surgical interventions for the wounded surgical soul remain unclear. In previous studies, the rate of these organ-specific complications ranged from 36% to 75% following high-grade pancreaticoduodenal injury.3 9 12 Lastly, the definitions of a few complications have had some minor changes over time in the TQIP. For example, the definitions of acute respiratory distress syndrome (ARDS) before and after 2015 were different, which might have affected the incidence of ARDS in our study cohort. Despite all the limitations, we think that the present study provided a more precise understanding of the current trends in acute management (eg, blood transfusion, resuscitative thoracotomy, adjunctive use of REBOA) and characteristics of associated injuries to the surrounding major vessels, given no other study had specifically focused on the group of patients with these devastating injuries.
Conclusions
As a special subgroup in pancreaticoduodenal trauma, the wounded surgical soul remains a great challenge to trauma surgeons due to its high mortality and morbidity. Additionally, the high proportion of associated injuries makes the injury more complicated and unpredictable. Although there is no consensus about the surgical procedures to be considered for the wounded surgical soul, our results suggest that early hemorrhagic control may increase the chance of hospital survival.
Supplementary material
Footnotes
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Not applicable.
Presented at: This article was presented at the Annual Scientific Meeting of the American College of Surgeons, Southern California Chapter, Santa Barbara, California, USA; January 22, 2023.
Data availability statement
Data are available upon reasonable request.
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Supplementary Materials
Data Availability Statement
Data are available upon reasonable request.