Volume and outcomes relationship in laparoscopic diaphragmatic hernia repair.

BACKGROUND: There is no published data regarding the relationship between hospital volume and outcomes in patients undergoing laparoscopic diaphragmatic hernia repair. We hypothesize that hospitals performing high case volume have improved outcomes compared to low-volume hospitals. MATERIALS AND METHODS: We reviewed the National Inpatient Sample (NIS) database between 2008 and 2012 for adults with the diagnosis of diaphragmatic hernia who underwent elective laparoscopic repair of diaphragmatic Hernia and/or Nissen fundoplication. Pediatric, emergent, and open cases were excluded. Main outcome measures included logistic regression analysis of factors predictive of in-hospital mortality and outcomes according to annual hospital case volume. RESULTS: A total of 31,228 laparoscopic diaphragmatic hernia operations were analyzed. The overall in-hospital mortality was 0.14%. Risk factors for higher in-hospital mortality included renal failure (AOR: 6.26; 95% CI: 2.48-15.78; p < 0.001), age>60 years (AOR: 5.06; 95% CI: 2.38-10.76; p < 0.001), and CHF (AOR: 3.80; 95% CI: 1.39-10.38; p = 0.009) while an incremental increase in volume of 10 cases/year (AOR: 0.89; 95% CI: 0.81-0.98; p = 0.019) and diabetes (AOR: 0.34; 95% CI: 0.12-0.93; p = 0.036) decreases mortality. There was a small but significant inverse relationship between hospital case volume and mortality with a 10% reduction in adjusted odds of in-hospital mortality for every increase in 10 cases per year. Using 10 cases per year as the volume threshold, low-volume hospitals (≤10 cases/year) had almost a twofold higher mortality compared to high-volume hospitals (0.23 vs. 0.12%, respectively, p = 0.02). CONCLUSIONS: There was a small but significant inverse relationship between the hospitals' case volume and mortality in laparoscopic diaphragmatic hernia repair.

Predicting islet yield in pediatric patients undergoing pancreatectomy and autoislet transplantation for chronic pancreatitis.

BACKGROUND/OBJECTIVE: Chronic pancreatitis (CP) in children is associated with significant morbidity and can lead to narcotic dependence. Total pancreatectomy (TP) may be indicated in refractory CP to relieve pain; simultaneous islet autotransplant (IAT) may prevent postsurgical diabetes. About half of pediatric patients are insulin independent 1 yr after IAT. Insulin independence correlates best with the number of islets available for transplantation (islet yield). Currently there is no known method to predict islet yield in a given patient. We assessed the ability of preoperative metabolic tests to predict islet yields in 10 children undergoing TP/IAT. DESIGN/METHODS: Hemoglobin A1c (HbA(1c)) and mixed meal tolerance tests (MMTT) were obtained prior to surgery in 10 patients age

Early hypothermia in severely injured trauma patients is a significant risk factor for multiple organ dysfunction syndrome but not mortality.

OBJECTIVE: To evaluate the relationship of early hypothermia to multiple organ failure and mortality in a prospectively-collected database of severely injured trauma patients. METHODS: This prospective observational study was performed at 7 level I trauma centers over a 16-month period. Severely injured trauma patients with signs of hypoperfusion (eg, base deficit, hypotension) and need for blood transfusion during their early hospital course were followed for 24 hours with near infrared spectroscopy-derived tissue oxygen saturation (StO2) and other variables for 28 days to evaluate outcomes including multiple organ dysfunction syndrome (MODS) and death. Early hypothermia was defined as the presence of a temperature <35°C [corrected] anytime within the first 6 hours of hospitalization. Comparisons between groups were made using the Wilcoxon Two-Sample test for continuous variables and either the Fisher exact or chi2 test for categorical variables. Multivariate logistic regression was utilized to understand the effect of hypothermia on outcome (MODS and mortality). RESULTS: Hypothermia was very common in this cohort of patients, present in 43% of patients enrolled (155/359). Hypothermic patients were 3 times more likely than normothermic patients to develop MODS (21% vs. 9%, P = 0.003). Hypothermic patients did not have an increased incidence of mortality (16% vs. 12%, P= 0.2826). Base deficit in hypothermic patients did not discriminate between patients who did or did not develop MODS (9.8 +/- 4.6 mEq/L vs. 9.4 +/- 4.4 mEq/L). In contrast, base deficit in hypothermic patients discriminated with respect to mortality (14.6 +/- 7.2 mEq/L versus 9.5 +/- 4.5 mEq/L; P 0.0021), but this effect was not observed in normothermic patients [corrected]. Significant predictors of MODS using multivariate analysis included minimum StO2 (P= 0.0014) and hypothermia (P = 0.0371). Predictors for mortality using multivariate analysis included minimum StO2 (P= 0.0021) and base deficit (P= 0.0454), but not hypothermia (P= 0.5289). Hypothermia remained a significant risk factor for MODS when systolic blood pressure, volume of fluid, and volume of blood infused were included in the multivariate model. CONCLUSION: Hypothermia is common in severely injured trauma patients (nearly half of patients in this series) and is a significant risk factor for MODS but not mortality. The predictive value of base deficit for development of MODS is blunted in the presence of hypothermia. A low StO2 value predicts MODS and mortality in trauma patients and is a durable measure in both normothermic and hypothermic patient groups.

The role of total pancreatectomy and islet autotransplantation for chronic pancreatitis.

Total pancreatectomy and islet autotransplantation are done for chronic pancreatitis with intractable pain when other treatment measures have failed, allowing insulin secretory capacity to be preserved, minimizing or preventing diabetes, while at the same time removing the root cause of the pain. Since the first case in 1977, several series have been published. Pain relief is obtained in most patients, and insulin independence preserved long term in about a third, with another third having sufficient beta cell function so that the surgical diabetes is mild. Islet autotransplantation has been done with partial or total pancreatectomy for benign and premalignant conditions. Islet autotransplantation should be used more widely to preserve beta cell mass in major pancreatic resections.

Impact of chronic steroid use on outcomes of colorectal surgery.

BACKGROUND: Steroid use has been recognized as a factor which has various effects on multiple organs. We aim to investigate the association between chronic steroid use and postoperative complications after colorectal surgery. METHODS: The National Surgical Quality Improvement Program database was used to examine the clinical data of patients undergoing colorectal resection during 2005 to 2013. Multivariate regression analysis was performed to investigate outcomes of patients with chronic steroid use. RESULTS: We sampled a total of 147,121 patients who underwent colorectal resection. Of these, 11,195 (7.6%) had a history of chronic steroid use. Patients who had chronic steroid use had a higher risk of preoperative sepsis (adjusted odds ratio [AOR]: 1.41, P < .01), hypoalbuminemia (AOR: 1.49, P < .01), bleeding disorders (AOR: 1.54, P < .01), and diabetes (AOR: 1.11, P = .01). Chronic steroid use was associated with a significant increase in the mortality and morbidity of patients (AOR: 1.56 and 1.25, respectively, P < .01). CONCLUSIONS: Patients with a chronic steroid use have a high risk of preoperative malnutrition, diabetes, bleeding disorders, and sepsis. A history of chronic steroid use was associated with a significant increase in the mortality and morbidity of patients.

Positive sterility cultures of transplant solutions during pancreatic islet autotransplantation are associated infrequently with clinical infection.

BACKGROUND: Chronic pancreatitis is a painful and often debilitating disease. Total pancreatectomy with intra-portal islet autotransplantation (TP-IAT) is a treatment option that allows for pain relief and preservation of beta-cell mass, thereby minimizing the complication of diabetes mellitus. Cultures of harvested islets are often positive for bacteria, possibly due to frequent procedures prior to TP-IAT, such as endoscopic retrograde cholangiopancreatography (ERCP), stenting, or other operative drainage procedures. It is unclear if these positive cultures contribute to post-operative infections. HYPOTHESIS: We hypothesized that positive cultures of transplant solutions will not be associated with increased infection risk. METHODS: We reviewed retrospectively the sterility cultures from both the pancreas preservation solution used to transport the pancreas and the final islet preparation for intra-portal infusion of patients who underwent TP-IAT between April 2006 and November 2012. Two hundred fifty-one patients underwent total, near-total, or completion pancreatectomy with IAT and had complete sterility cultures. All patients received prophylactic peri-operative antibiotics. Patients with positive pancreas preservation solution or islet sterility cultures received further antibiotics for 5-7 d. Patients' medical records were reviewed for post-operative infections and causative organisms. RESULTS: Of the 251 patients included, 151 (61%) had one or more positive bacterial cultures from the pancreas preservation solution or final islet product. Seventy-three of the 251 patients (29%) had an infectious complication. Thirty-four of the 73 (22%) patients with a post-operative infectious complication also had positive cultures. Only seven of 151 patients with positive cultures (4.7%) had an infectious complication caused by the same organism as that isolated from their pancreas or islet cell preparation. CONCLUSIONS: In autologous islet preparations, isolation solutions frequently have positive cultures, but this finding is associated infrequently with clinical infection.

Near-infrared spectroscopy-derived tissue oxygen saturation in battlefield injuries: a case series report.

BACKGROUND: Near-infrared spectroscopy technology has been utilized to monitor perfusion status in animal models of hemorrhagic shock and in human traumatic injury. To observe the effectiveness of such a device in a combat setting, an FDA-approved device was used in conjunction with standard resuscitation and therapy of wounded patients presenting to the 228th Combat Support Hospital (CSH), Company B, over a three-month period. MATERIALS AND METHODS: These observations were performed on patients presenting to the 228th CSH, Co B, at Forward Operating Base Speicher, outside of Tikrit, Iraq, between the dates of June 15 and September 11, 2005. We utilized the Inspectra 325 tissue oxygen saturation (StO2) monitor (Hutchinson Technology, Inc; Hutchinson, MN, USA) with the probe placed on the thenar eminence or on another appropriate muscle bed, and used to monitor StO2 during early resuscitation and stabilization of patients. RESULTS: During the above time period, 161 patients were evaluated at the CSH as a result of traumatic injury and the device was placed on approximately 40 patients. In most patients, StO2 readings of greater than 70% were noted during the initial evaluation. No further information was collected from these patients. In 8 patients, convenience samples of StO2 data were collected along with pertinent physiologic data. In these patients, StO2 levels of below 70% tracked with hypotension, tachycardia, and clinical shock resulted in increases in StO2 after resuscitation maneuvers. CONCLUSION: Near-infrared spectroscopy-derived StO2 reflected and tracked the resuscitation status of our patients with battlefield injuries. StO2 has significant potential for use in resuscitation and care of patients with battlefield injuries.

Evaluation of isolated rib lesions with radionuclide-guided biopsy.

BACKGROUND: Isolated rib lesions detected on bone scanning can pose a diagnostic challenge, particularly in patients with a known primary cancer. The purpose of our study was to assess the diagnostic value of radionuclide-guided rib biopsy with an intraoperative gamma probe. METHODS: We conducted a retrospective chart review of 10 patients who underwent an intraoperative gamma probe-guided rib biopsy. Rib defects were identified by radionuclide bone scan. Patients received an intravenous dose of technetium 99m methylene diphosphonate within 6 hours before surgery. The approximate location of the rib defect was scanned with a hand-held gamma probe intraoperatively; an excisional rib biopsy was performed in the area with the highest tracer activity. RESULTS: Median age was 54 years (range, 40 to 83) and median body mass index was 32.5 (range, 23 to 52). Seven patients had a known primary extraosseous cancer and 3 patients had no history of cancer. Seven patients had pain at the time of initial evaluation. The median operative time was 45 minutes, median operative blood loss was 25 mL, and median length of stay was 1 day. Complications occurred in 2 patients: a pneumothorax that did not require treatment and a delayed hemothorax that required tube thoracostomy. Rib biopsy was accurate in all 10 patients; metastatic disease was found in 5 of 7 cancer patients. Pain improved or resolved in 4 patients. CONCLUSIONS: The evaluation of isolated rib lesions using radionuclide-guided rib biopsy with an intraoperative hand-held gamma probe is accurate and potentially therapeutic. Thoracic surgeons and oncologists should be aware of this approach.

Islet autotransplant outcomes after total pancreatectomy: a contrast to islet allograft outcomes.

INTRODUCTION: Islet allografts are currently associated with a high rate of early insulin independence, but after 1 year insulin-independence rates rapidly decline for unclear reasons. In contrast, as shown here, islet autotransplants (IATs) show durable function and extended insulin-independence rates, despite a lower beta-cell mass. METHODS: IAT function was determined in 173 patients after total pancreatectomy at our center. Islet function was considered full in insulin-independent patients, partial when euglycemic on once-daily long-acting insulin (all tested were C-peptide positive), and failed if on a standard diabetic regimen. Outcomes for autoislet recipients by Kaplan-Meier survival analysis were compared with those of alloislet recipients in the Collaborative Islet Transplant Registry. RESULTS: IAT function (full/partial combined) and insulin independence correlated with islet yield. Overall only 65% functioned within the first year, and only 32% were insulin independent, but of IATs that functioned initially (n=112), 85% remained so 2-years later, in contrast to 66% of allografts (n=262). Of IAT recipients who became insulin independent (n=55), 74% remained so 2-years later versus 45% of initially insulin-independent allograft recipients (n=154). Of IATs that functioned or induced insulin independence, the rates at 5 years were 69% and 47%, respectively. CONCLUSION: Islet function is more resilient in autografts than allografts. Indeed, the 5-year insulin-independence persistence rate for IATs is similar to the 2-year rate for allografts. Several factors unique to allocases are likely responsible for the differences, including donor brain death, longer cold ischemia time, diabetogenic immunosuppression, and auto- and alloimmunity. IAT outcomes provide a minimum theoretical standard to work toward in allotransplantation.