In vitro Analysis of the Hemostatic Properties of Whole Blood Products Prepared with a Platelet-Sparing Leukoreduction Filter.

Background: Warm fresh whole blood (WFWB) is an ideal resuscitation fluid for exsanguinating patients but there are myriad logistic and infectious issues associated with its use. Cold whole blood (CWB) may be an acceptable alternative to the reconstituted whole blood (RWB), the current standard of care. A leukoreduction filter has been developed which maintains platelet count while eliminating white blood cells but its effect on platelet function is unknown. We hypothesize that CWB will retain an acceptable functional coagulation profile after filtration and over time. Study Design and Methods: WFWB and CWB samples were obtained from eight donors and four units of RWB were created. The quantitative and qualitative in vitro coagulation profiles of WFWB, RWB, and CWB over time were compared. Results: Filtration was successful at removing white blood cells (5.5 ± 1.2 vs. 0.3 ± 0.3 × 106/L) while retaining an adequate platelet count (172.0 ± 47.0 to 166.0 ± 42.3 × 109/L) and hemoglobin concentration (13.7 ± 0.5 vs. 13.0 ± 0.7 g/dL). Rotational Thromboelastography (ROTEM) results revealed a similar clotting time (CT) before and after filtration (64.9 ± 5.1 vs. 64.1 ± 6.8 s) but a decreased maximum clot firmness (MCF) (58.6 ± 4.2 vs. 54.9 ± 4.6 mm). Platelet aggregation decreased substantially (28.8 ± 6.7 vs. 9.3 ± 2.1 ohm) immediately after filtration. CWB function continued to diminish over time. Conclusion: CWB holds great promise as a surrogate for WFWB, but use of a platelet-sparing LR filter diminishes platelet function almost immediately after filtration.

Is Chemotherapy or Radiation Therapy in Addition to Surgery Beneficial for Locally Advanced Rectal Cancer in the Elderly? A National Cancer Data Base (NCDB) Study.

INTRODUCTION: Current National Comprehensive Cancer Network guidelines for Stages II and III rectal cancer recommend neoadjuvant chemoradiation followed by curative intent surgery and adjuvant chemotherapy. It is unclear whether therapies in addition to surgery are truly beneficial in elderly patients. Our aim was to compare the survival of patients over 80 with Stages II and III rectal cancer undergoing curative intent surgery with or without additional therapy. MATERIALS AND METHODS: The National Cancer Data Base (NCDB 2006-2011) was queried for patients over 80 with Stages II and III rectal cancer. The primary outcome was overall survival. Patients were stratified based upon therapy group. Univariate group comparisons were made. Unadjusted Kaplan-Meier and multivariable Cox proportional hazards modeling survival analyses were performed. RESULTS: The query yielded 3098 patients over 80 with Stage II (N = 1566) or Stage III (N = 1532) disease. Approximately, half of the patients received surgery only. Kaplan-Meier analysis showed improved survival for patients receiving neoadjuvant and/or adjuvant therapy in addition to surgery, but there was no significant difference between those that received guideline concordant care (GCC), neoadjuvant chemoradiation only, or post-operative chemotherapy only. Cox proportional hazard modeling identified age >90 and margin positivity as independent risk factors for decreased overall survival. CONCLUSION: Analysis of NCDB data for Stages II and III rectal cancer in patients over 80 shows a survival benefit of adjuvant and/or neoadjuvant therapy over surgery alone. There does not appear to be a difference in survival between patients who received neoadjuvant chemoradiation, post-resection adjuvant chemotherapy, or GCC.

Surgical stabilization of flail chest: the impact on postoperative pulmonary function.

OBJECTIVES: Flail chest results in significant morbidity. Controversies continue regarding the optimal management of flail chest. No clear guidelines exist for surgical stabilization. Our aim was to examine the association of bedside spirometry values with operative stabilization of flail chest. METHODS: IRB approval was obtained to identify patients with flail chest who underwent surgical stabilization between August 2009 and May 2011. At our institution, all rib fracture patients underwent routine measurement of their forced vital capacity (FVC) using bedside spirometry. Formal pulmonary function tests were also obtained postoperatively and at three months in patients undergoing stabilization. Both the Synthes and Acute Innovations plating systems were utilized. Data is presented as median (range) or (percentage). RESULTS: Twenty patients (13 male: 65 %) with median age of 60 years (30-83) had a median of four ribs (2-9) in the flail segment. The median Injury Severity Score was 17 (9-41) and the median Trauma and Injury Severity Score was 0.96 (0.04-0.99). Preoperative pneumonia was identified in four patients (20 %) and intubation was required in seven (35 %). Median time from injury to stabilization was four days (1-33). The median number of plates inserted was five (3-11). Postoperative median FVC (1.8 L, range 1.3-4 L) improved significantly as compared to preoperative median value (1 L, range 0.5-2.1 L) (p = 0.003). This improvement continued during the follow-up period at three months (0.9 L, range 0.1-3.0) (p = 0.006). There were three deaths (15 %), none of which were related to the procedure. Subsequent tracheostomy was required in three patients (15 %). The mean hospital stay and ventilator days after stabilization were nine days and three days, respectively. Mean follow-up was 5.6 ± 4.6 months. CONCLUSION: Operative stabilization of flail chest improved pulmonary function compared with preoperative results. This improvement was sustained at three months follow-up.

Chemical components separation with botulinum toxin A: a novel technique to improve primary fascial closure rates of the open abdomen.

INTRODUCTION: Failure to definitively close the open abdomen (OA) after damage control laparotomy leads to considerable morbidity and mortality. We have developed a novel technique, the "chemical components separation," which incorporates injection of botulinum toxin A (BTX), a long-term flaccid paralytic, into the lateral abdominal wall musculature. METHODS: This is a retrospective review of all OA patients (age ≥18) from December 2009-June 2010 who underwent BTX injection. Under ultrasound guidance, a total of 300 units of BTX were injected into the external oblique, internal oblique and transversus abdominus. RESULTS: A total of 18 patients were injected with a median age of 66 years (56 % male). Indications for OA treatment included questionable bowel viability (39 %), shock (33 %), loss of abdominal domain (6 %) and feculent contamination (17 %). Median ASA score was 3 with an APACHE 3 score of 85. Patients underwent a median of 4 serial abdominal explorations. The primary fascial closure rate was 83 % with a partial fascial closure rate of 6 % and planned ventral hernia rate of 11 %. Of the 9 patients injected within 24 h of their initial OA procedure, 89 % achieved primary fascial closure. Mortality was 11 %; death was unrelated to BTX injection. The overall complication rate was 67 %; specific complications rates included fascial dehiscence (11 %), enterocutaneous fistula development (0 %), intra-abdominal abscess (44 %) and deep surgical site infection (33 %). CONCLUSION: The "chemical components separation" technique described is safe and avoids the extensive dissection necessary for mechanical components separation in critically ill patients with infected/contaminated abdominal domains. While further evaluation is required, the described technique provides potential to improve delayed primary fascial closure rates in the OA setting.

Clinical outcomes after endovascular treatment of superficial femoral disease in patients with disabling claudication and critical limb ischemia: midterm analysis.

We present the midterm clinical outcomes and predictors of balloon angioplasty and stent placement in atherosclerotic femoropopliteal (FP) arterial disease. Between January 2002 and August 2006, 155 patients (men = 56%; 71.4 ± 10.5 years) underwent 171 FP angioplasty or stent for claudication (n = 82, 54%) or critical limb ischemia ([CLI] n = 70, 46%). Follow-up was obtained through September 30, 2009. The average follow-up was 3.25 ± 1.73 years. In claudicants versus CLI, the 12-month patency for TransAtlantic InterSociety Consensus II (TASC II) classification (TASC A/B) was 93% versus 80%, respectively, and TASC C/D 83% versus 80%. At 3 years, TASC A/B was 82% versus 80%, respectively, and TASC C/D was 56% versus 80%, respectively. The predictor of clinical failure in claudicants was chronic renal insufficiency (CRI) and in CLI, the predictor of amputation was hyperlipidemia.