The effect of incremental increases in the number of packed red blood cell units transfused on perioperative outcomes in open abdominal aortic aneurysm repair.

INTRODUCTION: Despite abundant evidence in the surgical and critical care literature demonstrating inferior outcomes in transfused patients, liberal use of blood transfusion, particularly after the initial unit, remains common in vascular surgery. We therefore sought to investigate the incremental risk of each additional unit of blood transfused intraoperatively for patients undergoing elective open repair of abdominal aortic aneurysm (AAA) with regards to postoperative mortality and complications. METHODS: Patients in the Vascular Quality Initiative registry undergoing elective open infrarenal AAA repair from 2003 to 2020 were included. Exclusion criteria were age greater than 90, prior aortic surgery, concomitant iliac aneurysm, and concomitant additional major procedure. Multivariable logistic regression was used to calculate adjusted odds ratios for in-hospital mortality with incremental increases in packed red blood cells (pRBCs) given intraoperatively. Univariate analysis was performed for secondary outcomes including postoperative cardiac, respiratory, renal, and wound complications. RESULTS: Of 4608 patients who underwent elective open AAA repair, 796 patients (16.9%) underwent perioperative transfusion. The overall in-hospital mortality rate was 2.5%. Adjusting for relevant factors, there was an increase in the odds of in-hospital mortality of 24% for each additional unit transfused. Incremental increases in the number of units transfused were associated with significantly higher risk of postoperative myocardial infarction, congestive heart failure, pulmonary complications, renal failure, and wound complications. DISCUSSION: There appears to be an important increase in the odds of mortality for each additional unit transfused during infrarenal open AAA repair even when controlling for confounders.

Potentially Avoidable Admissions and Prolonged Hospitalization in Patients with Suspected Colon Cancer.

BACKGROUND: Suspicion of cancer in the Emergency Department (ED) may lead to potentially avoidable and prolonged admissions. We aimed to examine the reasons for potentially avoidable and prolonged hospitalizations after admissions from the ED for new colon cancer diagnoses (ED-dx). METHODS: A retrospective, single-institution analysis was conducted of patients with ED-dx between 2017 and 2018. Defined criteria were used to identify potentially avoidable admissions. Patients without avoidable admissions were examined for ideal length of stay (iLOS), using separate defined criteria. Prolonged length of stay (pLOS) was defined as actual length of stay (aLOS) being greater than 1 day longer than iLOS. RESULTS: Of 97 patients with ED-dx, 12% had potentially avoidable admissions, most often (58%) for cancer workup. Very little difference in demographic, tumor characteristics, or symptoms were found, except patients with potentially avoidable admissions were more functional (Eastern Cooperative Oncology Group [ECOG] score 0-1: 83% vs. 46%; p = 0.049) and had longer symptom duration prior to ED presentation {24 days (interquartile range [IQR] 7-75) vs. 7 days (IQR 2-21)}. Among the 60 patients who had necessary admissions but did not require urgent intervention, 78% had pLOS, most often for non-urgent surgery (60%) and further oncologic workup. The median difference between iLOS and aLOS was 12 days (IQR 8-16) for pLOS. CONCLUSIONS: Potentially avoidable admissions following Ed-dx were uncommon but were mostly for oncologic workup. Once admitted, the majority of patients had pLOS, most often for definitive surgery and further oncologic workup. This suggests a lack of systems to safely transition to outpatient cancer management.

Does the Hospital Day of Surgery for Endovascular Repair of Symptomatic Abdominal Aortic Aneurysms Affect Outcomes?

OBJECTIVE: Symptomatic abdominal aortic aneurysms (sAAA) are considered surgically urgent. Recent data suggest delaying surgery allows for medical optimization without affecting outcomes. We investigated the association of the hospital day of surgery with 30 day outcomes. METHODS: Patients with infrarenal sAAA undergoing endovascular aortic repair (EVAR) between 2011 and 2018 in the American College of Surgeons National Surgery Quality Improvement Project database were included. The primary outcome was 30 day mortality. Additional outcomes included myocardial infarction, pulmonary complications, length of stay, and discharge disposition. Days-to-surgery were classified as the day of presentation (D0), day 1, day 2, days 3 and 4, days 5 to 7 (D5), and day 8 or more (D8). RESULTS: A total of 804 patients were identified. D8 patients had higher proportions of dyspnea on exertion, chronic obstructive pulmonary disease, congestive heart failure, and history of dialysis. D0 surgery appeared protective of mortality (odds ratio [OR] 0.34, p=0.0132). Each additional day increased the mortality risk (OR 1.23, p<0.001) although not within the first 4 days. There was increased mortality for patients having surgery at D5 (7.7%) and D8 (23.8%) compared with repair earlier (1%-4%, p=0.03). Bivariable analysis revealed no significant differences in secondary outcomes. Multivariable modeling revealed increased mortality for D8 versus D0 (adjusted OR of 6.8, 95% confidence interval 1.7-26.5). CONCLUSIONS: While D0 appears to have the lowest risk of mortality, EVAR for sAAA up to 4 days may not be associated with increased mortality. Further research should determine delay etiologies and whether they improve operative planning and optimization without impacting morbidity and mortality.

The order of surgery and chemotherapy matters: Multimodality therapy and stage-specific differences in survival in gastric cancer.

BACKGROUND AND OBJECTIVES: Multimodality treatment improves survival for gastric cancer (GC). However, the effect of treatment sequence by stage remains unclear. We aim to compare outcomes between patients receiving neoadjuvant(neoadj) and adjuvant chemotherapy (adj). METHODS: Nonmetastatic GC patients with clinical stage ≥ T2N0 who underwent both resection and neoadj or adj were identified using the National Cancer Database (2005-2014). Multivariable Cox regression analyses were performed on propensity score-matched (PSM) cohorts stratified by stage to compare overall survival (OS). RESULTS: We identified 11 984 patients; 55% stage I (SI), 76% stage II (SII) and 57% stage III (SIII) received neoadj. Unadjusted analysis showed worse survival among SI neoadj patients (hazard ratio [HR] 1.195, confidence interval [CI] 1.04-1.38) and improved survival for SII (HR 0.93 CI 0.87-0.998) and SIII (HR 0.75, CI 0.68-0.84). After PSM, SI patients with neoadj had worse OS with increased risk of death compared to Adj (HR 1.186, CI 1.004-1.402). SII patients had no difference in OS (HR 0.98, CI 0.91-1.07) and SIII patients had improved OS (HR 0.78, CI 0.69-0.90). CONCLUSIONS: In patients who received surgery and chemotherapy, the benefit of neoadj was limited to SIII with worse survival for SI. A clinical trial to examine the optimal sequence of chemotherapy is warranted.

Assessing outcomes in laparoscopic vs open surgical management of adhesive small bowel obstruction.

BACKGROUND: Small bowel obstruction is typically managed nonoperatively; however, refractory small bowel obstructions or closed loop obstructions necessitate operative intervention. Traditionally, laparotomy has long been the standard operative intervention for lysis of adhesions of small bowel obstructions. But as surgeons become more comfortable with minimally invasive techniques, laparoscopy has become a widely accepted intervention for small bowel obstructions. The objective of this study was to compare the outcomes of laparoscopy to open surgery in the operative management of small bowel obstruction. METHODS: This is a retrospective analysis of operative small bowel obstruction cases at a single academic medical center from June 2016 to December 2019. Data were obtained from billing data and electronic medical record for patients with primary diagnosis of small bowel obstruction. Postoperative outcomes between the laparoscopic and open intervention groups were compared. The primary outcome was time to return of bowel function. Secondary outcomes included length of stay, 30-day mortality, 30-day readmission, VTE, and reoperation rate. RESULTS: The cohort consisted of a total of 279 patients with 170 (61%) and 109 (39%) patients in the open and laparoscopic groups, respectively. Patients undergoing laparoscopic intervention had overall shorter median return of bowel function (4 vs 6 days, p = 0.001) and median length of stay (8 vs 13 days, p = 0.001). When stratifying for bowel resection, patients in the laparoscopic group had shorter return of bowel function (5.5 vs 7 days, p = 0.06) and shorter overall length of stay (10 vs 16 days, p < 0.002). Patients in the laparoscopic group who did not undergo bowel resection had an overall shorter median return of bowel function (3 vs 5 days, p < 0.0009) and length of stay (7 vs 10 days, p < 0.006). When comparing surgeons who performed greater than 40% cases laparoscopically to those with fewer than 40%, there was no difference in patient characteristics. There was no significant difference in return of bowel function, length of stay, post-operative mortality, or re-admission laparoscopic preferred or open preferred surgeons. CONCLUSION: Laparoscopic intervention for the operative management of small bowel obstruction may provide superior clinical outcomes, shorter return of bowel function and length of stay compared to open operation, but patient selection for laparoscopic intervention is based on surgeon preference rather than patient characteristics.

Analysis of Outpatient Adherence in 45,237 Patients Referred by an Emergency Department to Surgical Clinics.

INTRODUCTION: This study examines referral patterns to surgical clinics from the emergency department and the impact of sociodemographic factors on adherence. METHODS: Patients from 2017 to 2021 were identified who had a referral placed to surgical specialties from the ED. The primary outcome was the proportion of patients who had a referral to surgery placed during an ED visit but who showed up to surgery clinic visit within 60 days of referral placement. Univariate and multivariate analysis was performed. RESULTS: Referrals were made for 45,237 patients overall and 4130 for general surgery specifically. 44% showed up to general surgery clinic visit. In univariate and multivariate analysis, those who showed up to clinic were older, tended to be female, had a lower social economic status, had Medicaid or Medicare insurance and had more comorbidities compared to those who did not show up. Asians and Hispanics were more likely to show up to clinic compared to Whites. CONCLUSIONS: Assigning navigators in the ED to follow-up with patients who are younger and healthier, with private insurances who have existing PCPs to ensure they follow up as advised is a potential targeted intervention to improve clinic adherence.

Evaluation of Survival and Postoperative Radiation Among Patients with Advanced Medullary Thyroid Carcinoma: An Analysis of the National Cancer Database.

BACKGROUND: This study compared survival between patients who had medullary thyroid cancer (MTC) treated with surgery alone and patients who underwent surgery and radiation (SRT). METHODS: Patients from the National Cancer Database (NCDB) with a diagnosis of stage 3 or 4 MTC, lymph node disease, and no distant metastases between 2008 and 2016 were studied. Kaplan-Meier analyses and log-rank statistics were used to estimate and compare overall survival between patients treated with surgery alone and those treated with SRT. Mutlivariable Cox proportional hazards models and propensity-matching were used to adjust for confounding and selection bias. RESULTS: Among 1370 patients, 1112 (81%) received surgery alone, and 258 (19%) received SRT. The hazard ratio for mortality in the SRT group was 1.784 (95% confidence interval [CI] 1.313-2.43) after multivariable adjustment for confounding variables. Furthermore, SRT remained associated with a higher mortality rate (p < 0.008) after propensity-matching in an effort to adjust for selection bias. CONCLUSIONS: This analysis of NCDB patients showed that SRT is associated with a significantly higher mortality rate among patients treated for stage 3 or 4 IV MTC with positive lymph node disease. Although this observation can be attributed to unmeasured confounders or selection bias, the cause for the profound survival differences deserves prospective evaluation, especially as adjuvant therapies for this disease continue to evolve.

Impact of tibial bypass conduit on long-term amputation-free survival and primary patency in the Vascular Quality Initiative.

OBJECTIVE: Much research remains focused on tibial bypass conduit selection. We sought to describe long-term amputation-free survival (AFS) and primary patency (PP) of patients undergoing tibial bypass by conduit type and configuration across several permutations in the Society for Vascular Surgery Vascular Quality Initiative. METHODS: Patients in the Vascular Quality Initiative registry undergoing elective first-time femoral- or popliteal-to-tibial bypass for occlusive disease involving rest pain or tissue loss were identified. Prior ipsilateral infrainguinal bypass or concomitant procedures were excluded. Outcomes of interest included patient AFS at 22 months and PP at 1 year (defined as freedom from revision, thrombectomy, or graft occlusion). RESULTS: A total of 4192 bypasses were identified. The majority utilized great saphenous vein (GSV) (76.2%), followed by polytetrafluoroethylene (10.6%), nonautologous biologic (6.5%), composite (3.3%), arm vein (2.8%), and small saphenous vein (0.6%). Compared with all prosthetic and composite bypasses, vein grafts had the best AFS (76.4%; P < .0001) and PP (68.1%; P = .041). Of the single segment vein conduits, GSV bypasses had the best PP (69.1%) and arm vein the worst (60.2%). AFS and PP were similar between single-segment GSV orientations. Single-segment GSV bypasses exhibited better PP than multiple segment bypasses (69.1% vs 54.6%; P = .0016). PP was significantly better for polytetrafluoroethylene compared with nonautologous biologic (68.4% vs 51.2%; P = .0039). PP did not significantly differ between vein cuff for prosthetic bypass compared with no vein cuff (69.1% vs 59.7%; P = .091). PP was not significantly different between single-segment GSV and prosthetic grafts with vein cuff (69.1% vs 69.1%; P = .51). There were no significant differences in AFS comparing arm vein, prosthetic bypass with vein cuff, or composite grafts (67.2% vs 63.8% vs 59.3%; P = .092), as well as in PP (60.2% vs 69.1% vs 54.8%; P = .14). CONCLUSIONS: Single-segment vein bypass was only marginally the most optimal conduit. Surprisingly, there may be more equipoise among conduit types, particularly in the absence of adequate GSV. Prosthetic grafts overall may not be as disadvantaged in the long term as initially thought, especially when compared with arm vein, as prosthetic bypass with vein cuff did not significantly differ in PP. Similarly, a composite conduit may not impact long-term outcomes. These data suggest that conduit choice may not impact outcomes to the degree previously thought and that other factors may have a greater impact than presumed, especially in conduit limited situations.

De Novo Renal Failure and Clinical Outcomes of Patients With Critical Coronavirus Disease 2019.

OBJECTIVES: To describe the characteristics and outcomes associated with concomitant renal and respiratory failure in patients with critical coronavirus disease 2019. DESIGN, SETTING, AND PATIENTS: This is a case series of patients from a U.S. healthcare system in New York City. All adult patients (≥ 18 yr) admitted to the hospital with positive coronavirus disease 2019 testing between March 10, 2020, and March 31, 2020, who required mechanical ventilatory support were included. Patients who remained hospitalized were followed through May 1, 2020. INTERVENTIONS: Renal replacement therapy included at least one session of dialysis, continued venovenous hemofiltration, or peritoneal dialysis. MEASUREMENTS AND MAIN RESULTS: Baseline characteristics, laboratory markers, 30-day in-hospital outcomes, ventilator days, and survival to discharge were included. Multivariate predictors for mortality and need for renal replacement therapy were identified. A total of 330 patients were included in this analysis and were most commonly greater than or equal to 70 years (40%), male (61%), Black or African American (41%), and Hispanic or Latino (38%). Renal replacement therapy was required in 101 patients (29%), most commonly among Blacks or African Americans (50%). Elevated d-dimer, C-reactive protein, and procalcitonin were associated with renal replacement therapy, compared with the nondialysis cohort. Overall, 243 patients (74%) died and 56 (17%) were discharged from the hospital, of which 9 (3%) required renal replacement therapy. Male sex (odds ratio, 2.0; 1.1-3.5; p = 0.020), Black race (odds ratio, 1.8; 1.0-3.1; p = 0.453), and history of hypertension (odds ratio, 2.7; 1.3-5.4; p = 0.005) were predictors for requiring renal replacement therapy. Risk factors for in-hospital mortality included age greater than or equal to 60 years (odds ratio, 6.2; 3.0-13.0; p < 0.0001), male sex (odds ratio, 3.0; 1.4-6.4; p = 0.004), and body mass index greater than or equal to 30 kg/m2 (odds ratio, 2.1; 1.0-4.4; p = 0.039). Concomitant renal failure in critical coronavirus disease 2019 was not a significant predictor of death (odds ratio, 2.3; 0.98-5.5; p = 0.057). CONCLUSIONS: This case series concludes that respiratory failure conveys significant mortality risk in patients with coronavirus disease 2019 and that survival with concomitant renal failure is rare.

Aortic Neck Dilatation Following Thoracic Endovascular Aortic Repair.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) has become a mainstay of treatment for a variety of thoracic aortic pathologies. Expansion of the proximal aortic neck after endovascular repair of abdominal aortic aneurysms has been demonstrated; however, dilatation of the proximal aortic neck after TEVAR has not been well described. We sought to describe remodeling of the proximal neck following TEVAR. METHODS: This is a retrospective, single institution review of patients who underwent TEVAR for thoracic aortic aneurysm (TAA) and dissection with aneurysmal degeneration from 2010 to 2019. Postoperative computed tomography scans were reviewed and aortic diameter was measured in orthogonal planes using 3-dimensional centerline reconstruction software. The primary outcome was change in aortic diameter at the proximal aortic neck as compared to the initial postoperative computed tomography scan. Clinical and operative data were analyzed to identify factors associated with significant neck dilatation. RESULTS: Of 87 patients who underwent TEVAR during the study period, 30 met inclusion criteria. Median follow up was 20.5 months. Median age was 67 years, and 15 patients (50%) were female. The proximal aortic neck experienced an overall increase over time in aortic diameter. Five mm distal to the graft showed the greatest rate of expansion, with a median increase of 1.3, 2.9, and 6.2 mm at one year, two years, and three years, respectively. When comparing patients who had mean expansion at this location of >2.0 mm/year to patients who did not, a higher percentage had dissection pathology (81.8% vs. 31.6%, P = 0.008), had graft placement at aortic landing zone 2 (36.4% vs. 5.3%, P = 0.028), and were smokers (100% vs. 52.6%, P = 0.006). Higher percent oversizing was shown to be associated with significant aortic neck dilatation for true aneurysms only. CONCLUSIONS: Aortic neck dilatation occurs over time for the majority of patients following TEVAR with the distal neck experiencing the highest rate of expansion. Dissection pathology, aortic landing zone 2, and smoking were found to be associated with a higher rate of neck dilatation.

A Propensity-Matched Analysis of Endovascular Intervention versus Open Nonautologous Bypass as Initial Therapy in Patients with Chronic Limb-Threatening Ischemia.

OBJECTIVES: Endovascular therapies are increasingly used in patients with complex multilevel disease and chronic limb-threatening ischemia (CLTI). Infrageniculate bypass with autologous vein conduit is considered the gold standard in these patients. However, many patients often lack optimal saphenous vein, leading to the use of nonautologous prosthetic conduit. We compared limb salvage and survival rates for patients with CLTI undergoing first time revascularization with either open nonautologous conduit or endovascular intervention. METHODS: We retrospectively reviewed consecutive patients undergoing first time endovascular or open surgical revascularization at our institution between 2009 and 2016. Patients were divided into endovascular intervention or open bypass with nonautologous conduit (NAC) cohorts. Primary endpoints were amputation-free survival (AFS), freedom from reintervention, primary patency, and overall survival. Propensity scoring was used to construct matched cohorts. Outcomes were evaluated using Kaplan-Meier and Cox Proportional Hazards models. RESULTS: A total of 125 revascularizations were identified. There were 65 endovascular interventions and 60 NAC bypasses. In unmatched analysis, there was an elevated risk of perioperative MI (7% vs. 0%, P = 0.05) and amputation (10% vs. 2%, P = 0.04) for the NAC groups compared to the endovascular group. In matched analysis, endovascular patients had a lower incidence of 30-day amputation (1.5% vs. 10% P = 0.04) and length of stay (median days, 1 vs. 9, P < 0.01) compared to the open cohort. While not statistically significant, the endovascular group trended towards increased rates of two-year AFS (76% vs. 65%, P = 0.07) compared to the NAC group. There was no significant difference in overall survival when the endovascular cohort was compared to NAC (85% vs. 77%, P = 0.29) patients. In matched Cox analysis, nonautologous conduit use was associated with an increased risk of limb loss (HR 2.03, 95% CI 0.94-4.38, P = 0.07) compared to endovascular revascularization. CONCLUSIONS: An "endovascular first" approach offers favorable perioperative outcomes and comparable AFS compared to NAC and may be preferable when autologous conduit is unavailable.

Extended screening guidelines for the diagnosis of abdominal aortic aneurysm.

BACKGROUND: The U.S. Preventive Services Task Force (USPSTF) guidelines are the most widely used criteria for screening for abdominal aortic aneurysms (AAA). However, when the USPSTF criteria are applied retrospectively to a group of patients who have undergone treatment for AAA, there are many patients who satisfy none of the AAA screening criteria. The more sensitive Society for Vascular Surgery (SVS) guidelines have expanded the criteria for screening for AAA with the hope of capturing a greater fraction of those individuals who can undergo treatment for their AAA before presenting with AAA rupture. We sought to identify the number of patients who would have been identified as having criteria for screening for AAA by both the USPSTF and SVS criteria, in a cohort of patients who have undergone treatment for AAA. METHODS: We assessed demographic, comorbidity, and perioperative complication data for all patients undergoing endovascular and open AAA repair in the Vascular Quality Initiative. Patients meeting each of the screening criteria were identified. Clinical factors and demographic variables were collected. RESULTS: We identified 55,197 patients undergoing AAA repair in the Vascular Quality Initiative, including 44,602 patients who underwent endovascular aneurysm repair (EVAR) and 10,595 patients undergoing open repair. Of these, the USPTF guidelines would have identified fewer than one-third of patients (32% EVAR and 33% open repair). Applying the SVS guidelines increased the number meeting criteria for screening by 6% and 12% for the EVAR and open repair cohorts, respectively. Finally, adoption of the expanded SVS guidelines (including the "weak recommendations") would have identified an additional 34% of EVAR patients and 21% of open AAA repair patients. Use of the expanded criteria would have resulted in 27% of patients undergoing EVAR and 33% of patients undergoing open AAA repair who would not have met any screening criteria. In EVAR patients not meeting the criteria, 52% were younger than 65 years had a history of heavy smoking. Of all those who did not meet screening criteria, ruptured AAA was twice as prevalent as those who met screening criteria (8.5% vs 4.4%; P ≤ .0001). CONCLUSIONS: Expanding established USPSTF screening guidelines to include the expanded SVS criteria may potentially double the number of patients identified with AAA. Smokers under the age of 65, and elderly patients 70 and older with no smoking history, represent two groups with AAA and potentially twice the risk of presenting with rupture.

Evaluation of Adrenal Vein Sampling Use and Outcomes in Patients With Primary Aldosteronism.

BACKGROUND: Primary aldosteronism (PA) occurs in 10%-20% of patients with resistant hypertension. Guidelines recommend adrenal vein sampling (AVS) to identify patients for surgical management. We evaluate the use of AVS in managing PA to better understand the selection and outcomes of medical versus surgical treatment. METHODS: A retrospective review was performed, and patients were divided into those who did (AVS) and did not have AVS (non-AVS). Demographics, aldosterone and renin levels, blood pressure, comorbidities, and antihypertensive medications were recorded. Reasons to defer AVS and medical versus surgical decision-making were examined and groups were compared. RESULTS: We included 113 patients; 39.8% (45/113) had AVS, whereas 60.2% (68/113) did not. Groups were similar in age, body mass index, and initial systolic blood pressure (SBP). In patients who underwent AVS, 31 of 45 (68.9%) had unilateral secretion and were referred for surgery, whereas 13 of 45 (28.9%) had bilateral secretion. Of the 31 referred for surgery, 26 underwent laparoscopic adrenalectomy, all cured; four refused surgery; and one counseled toward medical management by their physician. In 68 non-AVS patients, 6 (8.8%) underwent adrenalectomy without sampling and 2 with no clinical improvement. The remaining deferrals were because of normal or bilateral adrenal nodules on imaging (8/68, 11.8%); medical management due to poor surgical candidacy (12/68, 17.6%); patient refusal of intervention (13/68, 19.1%); or reasons not stated (28/68, 41.1%). At the follow-up, patients who underwent AVS had lower median SBP (135.4 mmHg versus 144.7 mmHg, P = 0.0241) and shorter follow-up (17.7 mo versus 54.0 mo, P < 0.0001). Surgically managed patients had biochemical resolution of PA with normalization of potassium levels (3.6 to 4.7mEq/L, P < 0.00001). CONCLUSIONS: AVS correctly selects patients for surgical management avoiding unnecessary surgery. However, despite guidelines, AVS is not always pursued as part of PA treatment, potentially excluding surgical candidates.

Protamine sulfate use during tibial bypass does not appear to increase thrombotic events or affect short-term graft patency.

OBJECTIVES: While the use of protamine sulfate as a heparin reversal agent has been extensively reviewed in patients undergoing carotid endarterectomy and coronary artery bypass grafting, there is a lack of literature on protamine's effects on lower extremity bypasses. The purpose of this study was to determine the risk of protamine sulfate dosing after tibial bypass on thrombotic or bleeding events, including early bypass failure. METHODS: We performed a retrospective review of our institutional database for patients undergoing primary distal peripheral bypass from January 2009 through December 2015 (contralateral bypass was considered to be a new primary bypass). Primary endpoints include composite thrombotic events (myocardial infarction, stroke, amputation at 30 days and patency less than 30 days) and composite bleeding events (bleeding or transfusion). RESULTS: A total of 152 tibial or peroneal bypasses in 136 patients with critical limb ischemia were identified. Of these, 78 (57.4%) patients received protamine sulfate intraoperatively and 58 (42.6%) did not. There were no differences in composite thrombotic or hemorrhagic outcomes. Protamine use had no effect on the rates of perioperative MI (9.0% versus 3.5%, p = 0.20), stroke (1.3% versus 1.7%, p = 0.83), or perioperative mortality (5.1% versus 3.5%, p = 0.64). There was no significant difference in composite post-operative bleeding events (20.7% versus 14.1%, p = 0.31) or composite thrombotic events (17.2% versus 18.0%, p = 0.91). Patients who received protamine undergoing bypass with non-autogenous conduit had significantly higher-recorded median operative blood loss (250 mL versus 150 mL, p = 0.0097) and median procedure lengths (265 min versus 201 min, p = 0.0229). No difference in 30-day amputation-free survival was noted (91.0% versus 91.4%, p = 0.94). Follow-up Kaplan-Meier estimation did not demonstrate a difference in 30-day patency (91.7% versus 88.5%, p = 0.52). CONCLUSIONS: Heparin reversal with protamine sulfate after tibial or peroneal bypass grafting is not associated with higher cardiovascular morbidity, bypass thrombosis, amputation, or mortality. Additionally, there was no statistically significant difference in post-operative bleeding or thrombosis complications for patients who did not receive protamine, although the findings are suggestive of a potential difference in a more adequately powered study. Our results suggest that protamine sulfate is safe for intraoperative use without increased risk of thrombotic complications or early tibial bypass graft failure.

Targeting the safe zone: A quality improvement project to reduce vascular access complications.

OBJECTIVE: The aim of this study was to assess the effectiveness of a quality improvement (QI) program in reducing vascular complications during cardiac catheterization. BACKGROUND: Vascular access complications during cardiac catheterization are associated with higher morbidity and mortality. We implemented a QI program focused on using micropuncture techniques and targeting the "safe zone," an area below the inferior border of the inferior epigastric artery and above the inferior border of the femoral head, for femoral artery puncture. METHODS: Our catheterization laboratory implemented a protocol that required all operators to use micro puncture technique during diagnostic and/or percutaneous coronary interventions and to document arteriotomy in the "safe zone." We also encouraged use of vascular ultrasound, radial artery approach, and increased use of vascular closure devices (VCDS). We analyzed data on 3120 patients (2013, pre-QI cohort) and 3222 patients (2014, QI cohort). Data on vascular complications were prospectively collected and compared with the rate of complications that occurred during the same time one year prior when the QI project was not in effect. RESULTS: Baseline characteristics of two cohorts of patients were similar. Compliance with the protocol was excellent. Appropriate documentation of the wire exiting the needle was observed in 95% of cases. VCD use increased from 35% in 2013 to 60% in 2014 (P < 0.001) There were no significant differences in the overall number of complications after implementation of the QI project (1.03% complications before QI implementation and 0.96% after QI implementation. P = 0.79) but there was an absolute reduction in the number of hematomas (0.77 vs. 0.40% in 2013 vs. 2014, respectively, P = 0.06) and of pseudoaneurysms (0.35 vs. 0.19% P = 0.20). Correlates of major vascular complications included), age > 75 years (HR 3.1, P < 0.0001), and PCI (vs. diagnostic cath). CONCLUSIONS: Micropuncture technique in association with "safe zone targeting "did not significantly reduce vascular complications in patients undergoing cardiac catheterization, but a trend toward decrease of hematomas and pseudoaneurysms was noted. Factors such as age and type of procedure (PCI vs. diagnostic) play a significant role in the occurrence of vascular complications. © 2017 Wiley Periodicals, Inc.

Poor Outcomes of Gastric Cancer Surgery After Admission Through the Emergency Department.

BACKGROUND: Outcomes after nonelective surgery for gastric cancer (GC) are poorly defined. Our objective was to compare outcomes of patients undergoing nonelective GC surgery after admission through the emergency department (EDSx) with patients receiving elective surgery or surgery after planned admission (non-EDSx) nationally. METHODS: The Nationwide Inpatient Sample (NIS) database was used to examine patients undergoing GC surgery between 2008 and 2012. Demographics and outcomes were compared between EDSx and non-EDSx. Multivariable logistic regression was used to examine predictors of discharge to home. RESULTS: Of 9279 patients, 1143 (12%) underwent EDSx. They were more likely to be female (42 vs. 35%), nonwhite (56 vs. 33%), aged ≥75 years (40 vs. 26%), in the lowest quartile for household income (31 vs. 25%), have one or more comorbidities (87 vs. 70%), treated at a nonteaching hospital (46 vs. 25%), and have a concomitant diagnosis of obstruction, perforation, or bleeding (30 vs. 6%). They had longer total length of stay (LOS; 16 vs. 9 days), longer median postoperative stays (10 vs. 9 days), higher in-hospital mortality (8 vs. 3%), and were less likely to be discharged home (63 vs. 82%). EDSx was more expensive ($125,300 vs. $83,604). EDSx was associated with a lower likelihood of discharge to home (odds ratio 0.52, 95% CI 0.43-0.62). CONCLUSIONS: Nationally, 12% of GC surgeries are performed after emergency department admission, which occurs more frequently in vulnerable populations and results in worse outcomes. Understanding factors leading to increased EDSx and developing strategies to decrease EDSx may improve GC surgery outcomes.

Correlation between preoperative endoscopic ultrasound and surgical pathology staging of gastric adenocarcinoma: A single institution retrospective review.

BACKGROUND: Recent evidence validates the effectiveness of neoadjuvant chemotherapy in the treatment of gastric adenocarcinoma. Endoscopic ultrasonographic (EUS) staging has been proposed as a useful adjunct in this setting. METHODS: We performed a retrospective review of patients treated at our institution for gastric adenocarcinoma between July 2005 and January 2014. We identified patients referred for EUS before surgery as part of a prospective treatment plan. Histopathologic staging was compared to EUS staging, with a focus on T- and N-stage. Agreement between the two modalities was examined using kappa-statistics. RESULTS: We identified 614 patients with biopsy-proven gastric adenocarcinoma; 145 underwent curative-intent surgery. Surgical pathology and EUS results were available from 69 patients. The accuracy of EUS for the evaluation of T- and N-stage was 44.9% and 56.5%, respectively. EUS demonstrated greater concordance with histopathology at evaluating T-stage (κ = 0.3469) than N-stage (κ = 0.1316). EUS underestimated T- and N-stage in 40.8% and 30.4% of patients, respectively. CONCLUSION: EUS seems to correlate poorly with pathology in the preoperative staging of gastric adenocarcinoma. In the majority of inaccurate cases, EUS underestimates T-stage and N-stage, limiting its utility in the neoadjuvant setting.

The value of FDG-PET in the staging of gastric adenocarcinoma: A single institution retrospective review.

BACKGROUND: The value of FDG-PET in the staging of gastric adenocarcinoma (GA) has been subject to debate. METHODS: We performed a retrospective review of GA patients between 2006 and 2014 and identified those who had a CT and FDG-PET before initiating treatment. CT and FDG-PET images were analyzed by a blinded body radiologist and nuclear physician, respectively. Disease stage was assessed, looking at primary tumor (PT), locoregional (LLN) and distant lymph node disease (DLN), and metastasis (M). RESULTS: We identified 608 patients who had biopsy-proven GA and 207 (34.0%) had a CT and FDG-PET as part of their staging work-up. Of these, imaging from 166 (27.3%) patients was available for review. CT identified PT, LLN, DLN, and M in 120 (72.3%), 84 (50.6%), 25 (15.1%), and 32 (19.3%) patients, respectively; while FDG-PET identified PT, LLN, DLN, and M in 125 (75.3%), 78 (47.0%), 41 (24.7%), and 27 (16.3%) of patients, respectively. FDG-PET up-staged 31 (18.7%) patients while it down-staged 17 (10.2%) patients. Of patients who were up-staged, 20 (64.5%) developed progressive disease. CONCLUSIONS: Our findings support the use of FDG-PET as a valuable adjunct to CT in the staging of GA, as it changed the stage in 48 (28.9%) patients. J. Surg. Oncol. 2016;113:640-646. © 2016 Wiley Periodicals, Inc.

Cardiac transplantation from infected donors: is it safe?

BACKGROUND: Transplantation of a cardiac allograft from an infected donor risks transmission of disease to the immunocompromised recipient. Such organs are often not utilized despite little supporting evidence. We sought to evaluate outcomes following cardiac transplant with the use of an infected allograft. METHODS: The UNOS/OPTN database was used to identify first time, adult heart transplant recipients from 1995 to 2009. Patients receiving allografts from blood culture positive donor (CPD) were compared to those who did not (NCPD). RESULTS: A total of 26,813 recipients were included. Nine hundred ninety-five (3.7%) received a heart from a CPD. Recipients of hearts from CPDs were more likely to be diabetic (24% vs. 20%, p = 0.01), hypertensive (42% vs. 38%, p = 0.02), status 1 (80% vs. 76%, p = 0.0021), have a BMI > 30 (19% vs. 16%, p = 0.001), on intra-aortic balloon pump (IABP) support (7% vs. 5%, p = 0.017), and worse functional status. Recipients with a CPD were more likely to be treated for a post-transplant infection (28% vs. 23%, p = 0.003) but not for an episode of rejection in the first year after transplantation (39% vs. 40%, p = 0.73). Receipt of a CPD allograft was not a multivariate predictor for mortality. CPD and NCPD survival was similar at one year (86% vs. 87%, p = 0.2585) and 15 years (34% vs. 36%, p = 0.0929). CONCLUSION: Use of allografts from CPD has no influence on survival despite the fact that these recipients tend to have a higher acuity and more comorbidities at the time of transplantation. Utilization of a heart from a donor with a confirmed blood stream infection should be carefully considered.