Intraoperative Anastomotic Evaluation Methods: Rigid Proctoscopy Versus Flexible Endoscopy.

INTRODUCTION: Rigid proctosigmoidoscopy (RP) and flexible sigmoidoscopy (FS) are two modalities commonly used for intraoperative evaluation of colorectal anastomoses. This study seeks to determine whether there is an association between the endoscopic modality used to evaluate colorectal anastomoses and the rate of anastomotic leak (AL), organ space infection, and overall infectious complication. METHODS: The 2012-2018 American College of Surgeons National Surgical Quality Improvement Program database was queried for patients undergoing colorectal anastomoses. Anastomotic evaluation method (RP versus FS) was identified by Current Procedural Terminologycoding and used for group classification. Outcomes measured included AL, organ space infections, and overall infection. Multivariable logistic regression analysis for predicting AL was performed. RESULTS: We identified 7100 patients who underwent a colorectal anastomosis with intraoperative endoscopic evaluation. RP was utilized in 3397 (47.8%) and FS in 3703 (52.2%) patients. RP was used more commonly in diverticulitis (44.5% versus 36.2%, P < 0.01), while FS was used more frequently in malignancy (47.5% versus 36.7%, P < 0.01). Anastomotic evaluation with FS was associated with lower rates of organ space infection (3.8% versus 4.8%, P = 0.025) and AL (2.9% versus 3.8%, P = 0.028) compared to RP. On multivariate logistic regression modeling, anastomotic evaluation with RP was associated with a higher risk of AL (odds ratio 1.403, 95% CI 1.028-1.916, P = 0.033) compared to FS. CONCLUSIONS: Compared to FS, rigid proctosigmoidoscopic evaluation of a colorectal anastomosis was associated with an increased rate of AL and organ space infection.

Comparison of surgical fixation and non-operative management in patients with traumatic sternum fracture.

PURPOSE: The incidence of sternal fractures in blunt trauma patients lies between 3 and 7%. The role, timing and indications for surgical management are not well delineated and remain controversial for patients undergoing surgical stabilization of sternum fracture (SSSF). We sought to identify the national rate of SSSF in patients with a sternum fracture hypothesizing patients undergoing SSSF will have a decreased rate of mortality and complications. METHODS: The Trauma Quality Improvement Program (2015-2016) was queried for patients with sternum fracture. Propensity scores were calculated to match patients undergoing SSSF to patients managed non-operatively in a 1:2 ratio using demographic data. RESULTS: From 9460 patients with a sternum fracture, 114 (1.2%) underwent SSSF. After propensity-matching, 112 SSSF patients were compared to 224 patients undergoing non-operative management (NOM). There were no differences in matched characteristics (all p > 0.05). Compared to patients undergoing NOM, patients undergoing SSSF had an increased median length of stay (LOS) (16 vs. 7 days, p < 0.001), ICU LOS (9.5 vs. 5.5 days, p = 0.016) and ventilator days (8 vs. 5, p = 0.035). The SSSF group had a similar rate of ARDS (2.7% vs. 2.2%, p = 0.80), pneumonia (1.8% vs. 0.9%, p = 0.48) and unplanned intubation (8.9% vs. 5.8%, p = 0.29) but a lower mortality rate (2.7% vs. 11.2%, p = 0.008). CONCLUSION: Just over 1% of patients with sternum fracture underwent SSSF in a national analysis. Patients undergoing SSSF had an increased LOS and similar rate of all measured pulmonary complications, however a lower mortality rate compared to patients managed non-operatively.

Intentional Bilateral Renal Artery Coverage During Ruptured Endovascular Paraanastomotic Pseudoaneurysm Repair.

The development of a paraanastomotic pseudoaneurysm is a serious complication after open prosthetic reconstruction of the aorta for occlusive or aneurysmal disease. Open repair of these lesions has previously been associated with high rates of morbidity and mortality. Endovascular repair may provide suitable treatment for proximal paraanastomotic aortic bypass graft pseudoaneurysms in patients who are poor candidates for open surgery. Bilateral renal artery coverage may be necessary to achieve adequate fixation and seal during life-threatening emergency cases of pseudoaneurysm rupture. Due to the infrequency of reported cases, the consequences of bilateral renal artery occlusion during these complex procedures are poorly understood. We present a case of a proximal paraanastomotic aortobifemoral bypass pseudoaneurysm rupture that was managed using endovascular repair with intentional coverage of both renal arteries. We also review the contemporary literature on endovascular management of paraanastomotic aneurysms and discuss the role of bilateral renal artery coverage in treating select patients with complex ruptured aortic pathology.

Analysis of Unintentional Falls in Pediatric Population and Predictors of Morbidity.

INTRODUCTION: Unintentional falls are a leading cause of pediatric traumatic injury. This study evaluates clinical outcomes of fall-related injuries in children under the age of 10. METHODS: The National Trauma Database was queried for children who experienced an unintentional fall. Patients were stratified by age in two groups: 1-5 and 6-10 years old. The primary outcome was post discharge extension of care, defined as transfer to skilled nursing facility or rehabilitation center after discharge from the hospital. Descriptive statistics and a multivariable logistic regression analysis were used to compare the two groups. RESULTS: From 2009 to 2016, a total of 8,277 pediatric patients experienced an unintentional fall, with 93.6% of patients being discharged home. Falls were more common in younger children, with greater odds of post discharge extension of care. Predictors of increased associated risk of extended medical care included intracranial hemorrhage (OR 1.05, 95% CI 1.03-1.06) and thoracic injuries (OR 1.03, 95% CI 1.00-1.1.05) (P< 0.05). Mortality in pediatric patients suffering unintentional falls was a rare event occurring in 0.7% of cases in children 1-5 years old and 0.4% of children 6-10 years old. CONCLUSION: The majority of children experiencing an unintentional fall are discharged home, with mortality being very rare. However, younger age is prone to more severe and serious injury patterns. Intracranial hemorrhage and thoracic injury were a predictor of need for extended medical care.

Iatrogenic Arteriovenous Fistula Formation after Endovenous Laser Treatment Resulting in High-output Cardiac Failure: A Case Report and Review of the Literature.

Formation of a clinically significant iatrogenic arteriovenous fistula after endovenous laser treatment of the great saphenous vein is an extremely rare complication. Because of the infrequency of reported cases, there is no clear consensus on how to best manage this complication. We present a unique case of an iatrogenic high-output superficial femoral artery-common femoral vein fistula resulting in right heart failure and a distal deep vein thrombosis. Deployment of a covered arterial stent graft resulted in resolution of the arteriovenous fistula and high-output cardiac state. Clinically significant arteriovenous fistulas resulting from inadvertent vessel injury during endovenous laser treatment appear to be amenable to percutaneous endovascular interventions. During these challenging endovascular cases, intravascular ultrasonography can be used to help delineate the morphology of the fistula tract and obtain vessel measurements to ensure accurate endoprosthesis sizing and placement.

Evolving Utility of Endovascular Treatment of Juxtarenal, Pararenal, and Suprarenal Abdominal Aortic Aneurysms Associated With Increased Risk of Mortality Over Time.

BACKGROUND: Continued advances in endovascular technologies are resulting in fewer open abdominal aortic aneurysm (AAA) repairs. In addition, more complex juxtarenal, pararenal, and suprarenal (JPS) AAAs are being managed with various endovascular techniques. This study sought to evaluate the evolving trends in endovascular aneurysm repair (EVAR) of AAAs, hypothesizing increased rate of JPS AAA repair by EVAR. We also sought to evaluate the risk for morbidity and mortality for EVAR and open aneurysm repair (OAR) of JPS AAAs over time. METHODS: The 2011-2017 American College of Surgeons National Surgical Quality Improvement Program Procedure-Targeted Vascular database was queried for patients undergoing OAR or EVAR for AAAs. A multivariable logistic regression analysis was performed for both infrarenal and JPS AAA repairs. RESULTS: Of 18,661 patients who underwent AAA repair, 3,941 (21.1%) were OAR and 14,720 (78.9%) were EVAR. The rate of OAR decreased from 29.5% in 2011 to 21.3% in 2017 (P < 0.001) with a geometric-mean-annual decrease of 27.8%. The rate of EVAR increased from 70.5% to 78.7% during the same time period (P < 0.001) with a geometric-mean-annual increase of 11.6%. These trends remained true for both infrarenal and JPS AAAs. After adjusting for covariates, there was no difference in associated risk of 30-day mortality, renal complications, or ischemic colitis for either OAR or EVAR over each incremental year for infrarenal AAAs (P > 0.05). However, in patients undergoing EVAR for JPS AAAs, the associated risk of mortality increased with each incremental year (odds ratio [OR]: 1.30, confidence interval [CI]: 1.01-1.69, P = 0.039), whereas there was no difference in the risk of mortality for OAR of JPS AAAs with each incremental year (OR: 1.11, CI: 0.99-1.23, P = 0.067). CONCLUSIONS: The rate of OAR for AAA has decreased over the past seven years with an increase in EVAR, particularly for more complex JPS AAAs. The associated risk for morbidity and mortality for treatment of infrarenal AAAs was not significantly affected by this increased utility of EVAR. The associated risk of mortality for JPS AAAs treated by EVAR increased over time, whereas this trend for associated risk of mortality was not seen for OAR of JPS AAAs. These findings, especially the increased associated risk of mortality over time with EVAR for JPS AAAs, warrant careful prospective analysis.

Racial and Sex Disparities in Trauma Outcomes Based on Geographical Region.

OBJECTIVES: Disparities in outcomes among trauma patients have been shown to be associated with race and sex. The purpose of this study was to analyze racial and sex mortality disparities in different regions of the United States, hypothesizing that the risk of mortality among black and Asian trauma patients, compared to white trauma patients, will be similar within all regions in the United States. METHODS: The Trauma Quality Improvement Program (2010-2016) was queried for adult trauma patients, separating by U.S. Census regions. Multivariable logistic regression analyses were performed for each region, controlling for known predictors of morbidity and mortality in trauma. RESULTS: Most trauma patients were treated in the South (n = 522 388, 40.7%). After risk adjustment, black trauma patients had a higher associated risk of death in all regions, except the Northeast, compared to white trauma patients. The highest associated risk of death for blacks (vs. whites) was in the Midwest (odds ratio [OR] 1.30, P < .001). Asian trauma patients only had a higher associated risk of death in the West (OR 1.39, P < .001). Male trauma patients, compared to women, had an increased associated risk of mortality in all four regions. DISCUSSION: This study found major differences in outcomes among different races within different regions of the United States. There was also both an increased rate and associated risk of mortality for male patients in all regions. Future prospective studies are needed to identify what regional differences in trauma systems including population density, transport times, hospital access, and other trauma resources explain these findings.

Evaluation of Pelvic Anastomosis by Endoscopic and Contrast Studies Prior to Ileostomy Closure: Are Both Necessary? A Single Institution Review.

Contrast enema is the gold standard technique for evaluating a pelvic anastomosis (PA) prior to ileostomy closure. With the increasing use of flexible endoscopic modalities, the need for contrast studies may be unnecessary. The objective of this study is to compare flexible endoscopy and contrast studies for anastomotic inspection prior to defunctioning stoma reversal. Patients with a protected PA undergoing ileostomy closure between July 2014 and June 2019 at our institution were retrospectively identified. Demographics and clinical outcomes in patients undergoing preoperative evaluation with endoscopic and/or contrast studies were analyzed. We identified 207 patients undergoing ileostomy closure. According to surgeon's preference, 91 patients underwent only flexible endoscopy (FE) and 100 patients underwent both endoscopic and contrast evaluation (FE + CE) prior to reversal. There was no significant difference in pelvic anastomotic leak (2.2% vs. 1%), anastomotic stricture (1.1% vs. 6%), pelvic abscess (2.2% vs. 3.0%), or postoperative anastomotic complications (4.4% vs. 9%) between groups FE and FE + CE (P > .05). Flexible endoscopy alone appears to be an acceptable technique for anastomotic evaluation prior to ileostomy closure. Further studies are needed to determine the effectiveness of different diagnostic modalities for pelvic anastomotic inspection.