Transition of Resuscitative Endovascular Balloon Occlusion of the Aorta from Zone 3 to Zone 1 to Treat Hemodynamic Collapse during Continued Hemorrhage.

INTRODUCTION: Noncompressible torso hemorrhage (NCTH) accounts for most potentially survivable deaths on the battlefield. Treatment of NCTH is challenging, especially in far-forward environments with limited capabilities. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has shown promise in the care of patients with NCTH. REBOA involves introducing a balloon catheter into the descending aorta in a specific occlusion region (zones 1, 2, or 3) and acts as a hemorrhage control adjunct with resuscitative support. The balloon is placed in zone 3 in the infrarenal aorta for high junctional or pelvic injuries and in zone 1 proximal to the diaphragm for torso hemorrhage. Zone 1 REBOA provides more resuscitative support than zone 3; however, the potential for ischemia and reperfusion injuries is greater with zone 1 than with zone 3 REBOA placement. This study aims to determine the possible benefit of transitioning the REBOA balloon from zone 3 to zone 1 to rescue a patient with ongoing venous bleeding and impending cardiovascular collapse. MATERIALS AND METHODS: Yorkshire male swine (70-90 kg, n = 6 per group) underwent injury to the femoral artery, which was allowed to bleed freely for 60 s, along with a simultaneous controlled venous hemorrhage. After 60 s, the arterial bleed was controlled with hemostatic gauze and zone 3 REBOA was inflated. Five hundred milliliters of Hextend was used for initial fluid resuscitation. The controlled venous bleed continued until a mean arterial pressure (MAP) of 30 mmHg was reached to create an impending cardiovascular collapse. The animals were then randomized into either continued zone 3 REBOA or transition from zone 3 to zone 1 REBOA. Following 30 min, a "hospital phase" was initiated, consisting of cessation of the venous hemorrhage, deflation of the REBOA balloon, and transfusion of one unit of whole blood administered along with saline and norepinephrine to maintain a MAP of 60 mmHg or higher. The animals then underwent a 2-h observation period. Survival, hemodynamics, and blood chemistries were compared between groups. RESULTS: No significant differences between groups were observed in hemodynamic or laboratory values at baseline, postinitial injury, or when MAP reached 30 mmHg. Survival was significantly longer in animals that transitioned into zone 1 REBOA (log-rank analysis, P = .012). The average time of survival was 14 ± 10 min for zone 3 animals vs. 65 ± 59 min for zone 1 animals (P = .064). No animals in the zone 3 group survived to the hospital phase. Zone 1-treated animals showed immediate hemodynamic improvement after transition, with maximum blood pressure reaching near baseline values compared to those in the zone 3 group. CONCLUSIONS: In this swine model of NCTH, hemodynamics and survival were improved when the REBOA balloon was transitioned from zone 3 to zone 1 during an impending cardiovascular collapse. Furthermore, these improved outcome data support the pursuit of additional research into mitigating ischemia-reperfusion insult to the abdominal viscera while still providing excellent resuscitative support, such as intermittent or partial REBOA.

Vascular Reconstruction and Limb Loss in Military Tibial Artery Injuries.

BACKGROUND: Selective operative management of injuries to the tibial arteries is controversial, with the necessity of revascularization in the face of multiple tibial arteries debated. Tibial artery injuries are frequently encountered in military trauma, but revascularization practices and outcomes are poorly defined. We aimed to investigate associations between the number of injured vessels and reconstruction and limb loss rates in military casualties with tibial arterial trauma. METHODS: A US military database of lower extremity vascular injuries from Iraq and Afghanistan (2004-2012) was queried for limbs sustaining at least 1 tibial artery injury. Injury, intervention characteristics, and limb outcomes were analyzed by the number of tibial arteries injured (1, T1; 2, T2; 3, T3). RESULTS: Two hundred twenty one limbs were included (194 T1, 22 T2, 5 T3). The proportions with concomitant venous, orthopedic, nerve, or proximal arterial injuries were similar between groups. Arterial reconstruction (versus ligation) was performed in 29% of T1, 63% of T2, and universally in T3 limbs (P < 0.001). Arterial reconstruction was via vein graft (versus localized repair) in 62% of T1, 54% of T2, and 80% of T3 (P = 0.59). T3 received greater blood transfusion volume (P = 0.02), and fasciotomy was used universally (versus 34% T1 and 14% T2, P = 0.05). Amputation rates were 23% for T1, 26% for T2, and 60% for T3 (P = 0.16), and amputation was not significantly predicted by arterial ligation in T1 (P = 0.08) or T2 (P = 0.34) limbs. Limb infection was more common in T3 (80%) than in T1 (25%) or T2 (32%, P = 0.02), but other limb complication rates were similar. CONCLUSIONS: In this series of military lower extremity injuries, an increasing number of tibial arteries injured was associated with the increasing use of arterial reconstruction. Limbs with all 3 tibial arteries injured had high rates of complex vascular reconstruction and eventual amputation. Limb loss was not predicted by arterial ligation in 1-vessel and 2-vessel injuries, suggesting that selective reconstruction in these cases is advisable.

Revascularization of acute inferior vena cava thrombosis and atresia in an adolescent.

Inferior vena cava (IVC) anomalies will remain silent until collateralized venous drainage has been lost. The initial signs can be subtle, including back pain, and are often missed initially until progressive changes toward motor weakness, phlegmasia cerulea dolens, and/or renal impairment have occurred. We have presented a case of acute occlusion of an atretic IVC and infrarenal collateral drainage in an adolescent patient, who had been treated with successful thrombolysis, thrombectomy, and endovascular revascularization for IVC stenting and reconstruction.

Determinants of midterm functional outcomes, wound healing, and resources used in a hospital-based limb preservation program.

OBJECTIVE: The objective of this study was to assess midterm functional status, wound healing, and in-hospital resource use among a prospective cohort of patients treated in a tertiary hospital, multidisciplinary Center for Limb Preservation. METHODS: Data were prospectively gathered on all consecutive admissions to the Center for Limb Preservation from July 2013 to October 2014 with follow-up data collection through January 2016. Limbs were staged using the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) threatened limb classification scheme at the time of hospital admission. Patients with nonatherosclerotic vascular disorders, acute limb ischemia, and trauma were excluded. RESULTS: The cohort included 128 patients with 157 threatened limbs; 8 limbs with unstageable disease were excluded. Mean age (±standard deviation [SD]) was 66 (±13) years, and median follow-up duration (interquartile range) was 395 (80-635) days. Fifty percent (n = 64/128) of patients were readmitted at least once, with a readmission rate of 20% within 30 days of the index admission. Mean total number of admissions per patient (±SD) was 1.9 ± 1.2, with mean (±SD) cumulative length of stay (cLOS) of 17.1 (±17.9) days. During follow-up, 25% of limbs required a vascular reintervention, and 45% developed recurrent wounds. There was no difference in the rate of readmission, vascular reintervention, or wound recurrence by initial WIfI stage (P > .05). At the end of the study period, 23 (26%) were alive and nonambulatory; in 20%, functional status was missing. On both univariate and multivariate analysis, end-stage renal disease and prior functional status predicted ability to ambulate independently (P < .05). WIfI stage was associated with major amputation (P = .01) and cLOS (P = .002) but not with time to wound healing. Direct hospital (inpatient) cost per limb saved was significantly higher in stage 4 patients (P < .05 for all time periods). WIfI stage was associated with cumulative in-hospital costs at 1 year and for the overall follow-up period. CONCLUSIONS: Among a population of patients admitted to a tertiary hospital limb preservation service, WIfI stage was predictive of midterm freedom from amputation, cLOS, and hospital costs but not of ambulatory functional status, time to wound healing, or wound recurrence. Patients presenting with limb-threatening conditions require significant inpatient care, have a high frequency of repeated hospitalizations, and are at significant risk for recurrent wounds and leg symptoms at later times. Stage 4 patients require the most intensive care and have the highest initial and aggregate hospital costs per limb saved. However, limb salvage can be achieved in these patients with a dedicated multidisciplinary team approach.

Society for Vascular Surgery limb stage and patient risk correlate with outcomes in an amputation prevention program.

OBJECTIVE: Clinical decision making and accurate outcomes comparisons in advanced limb ischemia require improved staging systems. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System (Wound extent, Ischemia, and foot Infection [WIfI]) was designed to stratify limb outcomes based on three major factors-wound extent, ischemia, and foot infection. The Project or Ex-Vivo vein graft Engineering via Transfection III (PREVENT) III (PIII) risk score was developed to stratify patients by expected amputation-free survival (AFS) after surgical revascularization. This study was designed to prospectively assess limb and patient-based staging for predicting outcomes of hospitalized patients in an amputation prevention program. METHODS: This study undertook a retrospective analysis of prospectively gathered registry data of consecutive patients with limb-threatening conditions admitted to a fully integrated vascular/podiatry service over a 16-month period. Upon admission, limb risk was stratified using the WIfI system and patient risk was categorized using PIII classification. Patients were assessed for perioperative and postdischarge outcomes, and their relationship to staging at admission was analyzed. RESULTS: There were 174 threatened limbs (143 hospitalized patients) stratified by WIfI stage (1%-12%, 2%-28%, 3%-24%, 4%-28%, 5%-3%, unstaged-5%) and PIII risk (34% low, 49% moderate, and 17% high risk). Diabetes and end-stage renal disease were associated with WIfI stage (P = .006 and P = .018) and PIII risk (P = .003 and P < .001). Perioperative (30-day) events included 3% mortality, 8% major adverse cardiovascular events and 2.4% major amputation. There were 119 limbs (71%) that underwent revascularization, including 108 infrainguinal reconstructions (endovascular or open revascularization). Rate of revascularization increased with WIfI stage (P < .001), concomitant with the number of podiatric procedures, minor amputations, and initial hospital duration of stay (all P < .001). Increased WIfI stage was associated with major adverse limb events (P = .018), reduced limb salvage (P = .037), and decreased AFS (P = .048). In contrast, PIII risk category was associated with mortality (P < .001) and AFS (P < .001). Among infrainguinal reconstruction procedures, there was a similar distribution of endovascular (46%) and surgical (54%) interventions. Freedom from major adverse limb events was best for autogenous vein bypass (P = .025), and surgical revascularization was associated with improved limb salvage among the most severely threatened limbs (WIfI stage 4: 95% limb salvage for open bypass vs 68% limb salvage for endovascular; P = .026). CONCLUSIONS: Among patients hospitalized with limb-threatening conditions and treated by a multidisciplinary amputation prevention team, PIII risk correlates with mortality whereas WIfI stage strongly predicts initial hospital duration of stay, and key mid-term limb outcomes. Surgical revascularization performed best in the limbs at greatest risk (WIfI stage 4), and autogenous vein bypass was the preferred conduit for open bypass. These data support the use of WIfI and PIII as complementary staging tools in the management of chronic limb-threatening ischemia.

Reliability of Continuous Non-Invasive Assessment of Hemoglobin and Fluid Responsiveness: Impact of Obesity and Abdominal Insufflation Pressures.

BACKGROUND: During surgery, proper fluid resuscitation and hemostatic control is critical. Pleth variability index (PVI) is advocated as a reliable way of optimizing intraoperative fluid resuscitation. PVI is a measure of dynamic change in perfusion index during a complete respiratory cycle. Non-invasive monitoring of total hemoglobin could provide a reliable means to determine need for transfusion. We analyzed the impact of insufflation and obesity on non-invasive measurements of hemoglobin and PVI in laparoscopic procedures to validate reliability of fluid responsiveness and hemoglobin levels. METHODS: A non-invasive hemoglobin and PVI monitoring device was prospectively analyzed in patients undergoing abdominal operations. Patients were stratified by open and laparoscopic approach and obesity (body mass index (BMI) ≥35). PVI and hemoglobin values were assessed before, during, and after insufflation and compared to control patients undergoing open surgery. RESULTS: Sixty-three patients were enrolled (mean age 42 years; 71 % male; mean BMI 36) with 24 patients laparoscopic non-obese (LNO), 20 laparoscopic obese (LO), and 19 undergoing open operations. There was no significant blood loss. Hemoglobin did not change significantly before or after insufflation. There was false elevation of PVI with insufflation and more pronounced in obese patients. CONCLUSIONS: Insufflation or obesity was not associated with significant variations in hemoglobin. Non-invasive monitoring of hemoglobin is useful in laparoscopic procedures in obese and non-obese patients. PVI values should be used cautiously during laparoscopic procedures, particularly in obese patients.

The weekend effect: does time of admission impact management and outcomes of small bowel obstruction?

AIMS: To determine whether day and time of admission influences the practice patterns of the admitting general surgeon and subsequent outcomes for patients diagnosed with small bowel obstruction. METHODS: A retrospective database review was carried out, covering patients admitted with the presumed diagnosis of partial small bowel obstruction from 2004-2011. RESULTS: A total of 404 patients met the inclusion criteria. One hundred and thirty-nine were admitted during the day, 93 at night and 172 on the weekend. Overall 30.2% of the patients were managed operatively with no significant difference between the groups (P = 0.89); however, of patients taken to the operating room, patients admitted during the day received operative intervention over 24 hours earlier than those admitted at a weekend, 0.79 days vs 1.90 days, respectively (P = 0.05). Overall mortality was low at 1.7%, with no difference noted between the groups (P = 0.35). Likewise there was no difference in morbidity rates between the three groups (P = 0.90). CONCLUSIONS: Despite a faster time to operative intervention in those patients admitted during the day, our study revealed that time of admission does not appear to correlate to patient outcome or mortality.

Mesenteric irritation as a means to prevent internal hernia formation after laparoscopic gastric bypass surgery.

INTRODUCTION: Internal hernias (IHs) occur more frequently in laparoscopic gastric bypass (LGB) surgery than in the classic open procedure. The incidence of small bowel obstruction after LGB ranges from 1.8% and 9.7%. Some have theorized that this occurs because of decreased adhesion formation. METHODS: The mesenteric irritation technique is performed after closure of the jejunojejunal mesenteric defect with a running 2-0 silk suture. A sponge is then rubbed against the closed visceral peritoneal mesentery until petechiae are visualized on the surface of the mesentery. RESULTS: In all, 338 LGBs were performed using the standard closure technique with an IH incidence of 5.3% (range 1.7% to 7.8%). When using the mesenteric irritation technique, 72 LGBs were performed with an IH rate of 1.4% (P = .13). CONCLUSIONS: Mesenteric irritation is a novel technique performed with minimal additional time and no additional equipment. This technique may prove beneficial in reducing the incidence of IHs.

The impact of age on colorectal cancer incidence, treatment, and outcomes in an equal-access health care system.

BACKGROUND: Inferior outcomes in younger patients with colorectal cancer may be associated with multiple factors, including tumor biology, delayed diagnosis, disparities such as access to care, and/or treatment differences. OBJECTIVE: This study aims to examine age-based colorectal cancer outcomes in an equal-access health care system. DESIGN: This study is a retrospective large multi-institutional database analysis. PATIENTS: Patients with colorectal cancer included in the Department of Defense Automated Central Tumor Registry (January 1993 to December 2008) were stratified by age <40, 40 to 49, 50 to 79, and ≥80 years to determine the effect of age on incidence, treatment, and outcomes. MAIN OUTCOME MEASURES: The primary outcomes measured were the stage at presentation, adjuvant therapy use, 3- and 5-year disease-free survival, and overall survival. RESULTS: Some 7948 patients were identified; most (77%) patients were in the 50- to 79-year age group. Overall, 25% presented with stage III disease. Compared with patients aged 50 to 79 and ≥80 years, patients aged <40 and 40 to 49 years presented more frequently with advanced disease (stage III (35% and 35% vs 28% and 26%) and stage IV (24% and 21% vs 18% and 15%); all p < 0.001). Adjuvant chemotherapy use in stage III patients was 62%; those patients ≥80 and 50 to 79 years had decreased use (p < 0.001). Overall recurrence was 8.1% at 3 years and 9.7% at 5 years, with the highest rates in patients <40 years (11.8%; p = 0.007). Overall survival was worse in patients ≥80 years, whereas the remaining cohorts were similar. For stage III disease, patients 40 to 49 years had the highest survival among all cohorts (p < 0.001). LIMITATIONS: This study was limited by the lack of specific comorbid information and the limitations inherent to large database reviews. CONCLUSIONS: In an equal-access system, young age at presentation (<50 years) was associated with advanced stage and higher recurrence of colorectal cancer, but similar survival in comparison with older patients. Although increased adjuvant therapy use in younger patients may partially account for stage-specific increases in survival, the relative decreased chemotherapy use overall requires further evaluation.

Outcome comparison following colorectal cancer surgery in an equal access system.

BACKGROUND: Previous reports suggest outcome differences following surgery for colorectal cancer (CRC) based on specialist and volume-related metrics. We sought to compare community and tertiary centers in an equal access system. MATERIALS AND METHODS: Patients treated for CRC at Department of Defense medical facilities were stratified by care at tertiary (MEDCEN) versus community (MEDDAC) medical centers. Disease-free and overall survival outcomes were calculated, including Cox multivariate analysis. RESULTS: A total of 6438 patients met inclusion criteria. Overall, 3347 operations were performed at MEDCENs and 3091 operations at MEDDACs. By stage, 25.6% were stage 1, 27.1% stage 2, 29.1% stage 3, and 18.2% stage 4. Mean number of lymph nodes harvested were 11.3 ± 10.2, with no difference between facilities. Disease-free survival at 5 y was similar between the two cohorts (mean 88.1%). Overall 5-y survival was 52.7% (MEDDAC) versus 46.8% (MEDCEN), P < 0.001, due to significant differences in stage 2 patients. Cox regression and logistic regression analysis identified stage 2 patients as independently associated with significantly increased 5-y mortality risk at MEDCEN. CONCLUSION: Outcomes following surgery for CRC in an equal access system are improved in stage 2 patients treated at MEDDACs compared to high-volume, specialist-centered MEDCENs. Further evaluation into factors impacting improved overall survival at MEDDACs, including adjuvant therapy utilization, is warranted to optimize outcomes.

Examining the accuracy and clinical usefulness of intraoperative frozen section analysis in the management of pancreatic lesions.

BACKGROUND: Intraoperative frozen section analysis is often performed in the surgical management of pancreatic lesions. This test is used to obtain histologic diagnosis, to assess resectability because of unanticipated locoregional spread, and to ensure negative margins after resection. We sought to define the accuracy and clinical usefulness of intraoperative frozen section analysis in patients with pancreatic lesions and to determine the impact on long-term outcomes. METHODS: A retrospective database review was performed for all patients who underwent pancreatic resection at our institution from 2002 to 2011. Patient demographics, indications for frozen section analysis, final pathology, and long-term outcomes were analyzed. Five-year survival was compared using the Kaplan-Meier method. RESULTS: Sixty-eight patients were identified (mean age 65 ± 14 years, 52% female). Malignancy was identified on final pathology in 38 (56%) patients. Intraoperative frozen section analysis was performed in 59 (87%) patients. Frozen section analysis was performed for histologic diagnosis in 6 (10%) cases, to determine resectability in 15 (25%) cases, and to evaluate margin status in 58 (98%) cases. Frozen section analysis for histologic diagnosis was associated with a sensitivity of 80%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 50% with an overall accuracy of 83%. Frozen section analysis for the determination of resectability was associated with a sensitivity of 38%, specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 58% with an overall accuracy of 66%. Intraoperative frozen section analysis for the determination of the final margin status was associated with a sensitivity of 33%, specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 97% with an overall accuracy of 97%. There were no false-positive results on frozen section analysis. Errors on frozen section analysis interpretation did not negatively impact survival outcomes (mean survival = 2.2 years in those with concordant frozen section analysis vs 1.7 years in those with discordant frozen section analysis, P = .69). CONCLUSIONS: Although intraoperative frozen section analysis is helpful for ensuring negative final margins, its usefulness for obtaining histologic diagnosis and determining resectability is limited by low negative predictive potential. These results highlight the importance of preoperative staging and intraoperative surgical judgment for questionable resectable disease.

An evaluation of colonoscopy surveillance guidelines: are we actually adhering to the guidelines?

BACKGROUND: National guidelines put forth by the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Gastroenterology provide recommendations regarding colorectal cancer screening and follow-up surveillance. Practice patterns may differ from these guidelines. This study analyzes the concordance between a tertiary equal access system and national guidelines for colorectal cancer and polyp surveillance. METHODS: We performed a retrospective database review of all patients at a single institution undergoing screening colonoscopy from 2010 to 2011. Patient demographics, indication for colonoscopy, pathologic findings, and follow-up recommendations documented by the provider were analyzed. Multivariate analysis was performed in an attempt to identify predictors of discordant recommendations. RESULTS: One thousand four hundred twenty patients were identified (mean age, 54.3 ± 7.7 years, 48.6% women). The gastroenterology service performed the majority of colonoscopies (87.2%) compared with the surgery service (11.6%). The major indications were routine screening (84.4%) and a strong family history of colorectal cancer (12.2%). The adenoma detection rate for the entire cohort was 27.4%. Other pathologic conditions identified included hyperplastic polyps (16%), lymphoid aggregates (3.5%), and invasive adenocarcinoma (0.1%). Overall, follow-up recommendations correlated with established guidelines in 97% of cases. By multivariate analysis, only the final pathologic finding of lymphoid aggregates was associated with discordant recommendations (odds ratio [OR], 4.62; 95% confidence interval [CI], 1.64 to 12.99; P = .004). When comparing discordant recommendations between specialties, there was a statistically significant difference between gastroenterology (1.6%) and surgery (7.6%) (P < .0001) providers; surgeons trended toward recommending earlier follow-up examinations (P = .37). CONCLUSIONS: Overall, surveillance recommendations correlated well with current national guidelines. Concordance rates were higher with gastroenterologists in this cohort. Alterations based on final pathologic examination and individual cases remain clinically important.

Examining the relevance of the physician's clinical assessment and the reliance on computed tomography in diagnosing acute appendicitis.

BACKGROUND: The aim of this study was to examine the relevance of clinical assessment in diagnosing appendicitis in the current medical environment, in which routine use of computed tomography (CT) has become the norm. METHODS: A retrospective review was conducted, analyzing patient demographics, Alvarado clinical assessment scoring, and radiologic and pathologic results. RESULTS: A total of 664 patients were identified. Higher Alvarado scores were significantly associated with pathologically confirmed appendicitis (low, 87%; moderate, 92%; high, 96%; P = .05). As clinical assessment scores increased, use of CT decreased significantly (low, 97%; moderate, 85%; high, 79%; P = .01). The negative appendectomy rate for patients with clinical assessments consistent with appendicitis was 4%, compared with 3% associated with CT. Regardless of assessment scores, 82% of the cohort underwent CT. From a random sample of 100 charts, 87% of initial emergency department plans stratified disposition on the basis of the results of CT. CONCLUSIONS: Although physical examination remains crucial, CT has become the primary modality dictating care of patients with presumed appendicitis.

Operating room efficiency improvement after implementation of a postoperative team assessment.

INTRODUCTION: Operating room time is highly resource intensive, and delays can be a source of lost revenue and surgeon frustration. Methods to decrease these delays are important not only for patient care, but to maximize operating room resource utilization. The purpose of this study was to determine the root cause of operating room delays in a standardized manner to help improve overall operating room efficiency. METHODS: We performed a single-center prospective observational study analyzing operating room utilization and efficiency after implementing an executive-driven standardized postoperative team debriefing system from January 2010 to December 2010. RESULTS: A total of 11,342 procedures were performed over the 1-y study period (elective 86%, urgent 11%, and emergent 3%), with 1.3 million min of operating room time, 865,864 min of surgeon operative time (62.5%), and 162,958 min of anesthesia time (11.8%). Overall, the average operating room delay was 18 min and varied greatly based on the surgical specialty. The longest delays were due to need for radiology (40 min); other significant delays were due to supply issues (22.7 min), surgeon issues (18 min), nursing issues (14 min), and room turnover (14 min). Over the 1-y period, there was a decrease in mean delay duration, averaging a decrease in delay of 0.147 min/mo with an overall 9% decrease in the mean delay times. With regard to overall operating room utilization, there was a 39% decrease in overall un-utilized available OR time that was due to delays, improving efficiency by 2334 min (212 min/mo). During this study interval no sentinel events occurred in the operating room. CONCLUSIONS: A standardized postoperative debrief tracking system is highly beneficial in identifying and reducing overall operative delays and improving operating room utilization.

Laparoscopy impacts outcomes favorably following colectomy for ulcerative colitis: a critical analysis of the ACS-NSQIP database.

INTRODUCTION: The surgical management of ulcerative colitis (UC) often involves complex operations. We investigated the outcome of patients who underwent surgery for UC by analyzing a nationwide database. METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program database (ACS-NSQIP, 2005-2008) for all UC patients who underwent colectomy. To analyze by operation, groupings included: partial colectomy (PC; n = 265), total abdominal colectomy (TAC; n = 232), total proctocolectomy with ileostomy (TPC-I; n = 134), and total proctocolectomy with ileal pouch-anal anastomosis (IPAA; n = 446) to analyze 30-day outcomes. RESULTS: From 1,077 patients (mean age, 44 years; 45 % female; 7 % emergent), a laparoscopic approach was used in 29.2 %, with rates increasing 8.5 % each year (18.5 % in 2005 to 41.3 % in 2008, P < 0.001). Complications occurred in 29 %, and laparoscopy was associated with a lower complication rate (21 vs. 32 % open, P < 0.001). On multivariate regression, postoperative complications increased when patients were not functionally independent [odds ratio (OR) = 3.2], had preoperative sepsis (OR = 2.0), or prior percutaneous coronary intervention (OR = 2.8). A laparoscopic approach was associated with a lower complication rate (OR = 0.63). When stratified by specific complications, laparoscopy was associated with lower complications, including superficial surgical site infections (11.4 vs. 6.7 %, P = 0.0011), pneumonia (2.9 vs. 0.6 %, P = 0.023), prolonged mechanical ventilation (3.9 vs. 1.3 %, P = 0.023), need for transfusions postoperatively (1.6 vs. 0 %, P = 0.016), and severe sepsis (2.9 vs. 1.0 %, P = 0.039). Laparoscopy was also was associated with a lower complication rate in TACs (41.7 vs. 18.8 %, P < 0.0001) and IPAA (29.9 vs. 18.2 %, P = 0.005) and had an overall lower mortality rate (0.2 vs. 1.7 %, P = 0.046). CONCLUSIONS: Results from a large nationwide database demonstrate that a laparoscopic approach was utilized in an increasing number of UC patients undergoing colectomy and was associated with lower morbidity and mortality, even in more complex procedures, such as TAC and IPAA.

Surgical therapy for epidermoid carcinoma of the anal canal: an NSQIP assessment of short-term outcomes.

BACKGROUND: Although modern therapy for anal canal cancer typically consists of combined chemoradiation therapy (CRT), surgery remains an option for patients with small lesions, for palliative purposes, and for failure of nonoperative management. This study assesses the short-term outcomes of surgical management for epidermoid carcinoma of the anal canal using a large nationwide database. METHODS: We performed a retrospective review of 30-d outcomes using American College of Surgeons National Surgical Quality Improvement Program database (2005-2009) for all patients with the primary diagnosis of anal canal cancer undergoing oncologic or palliative surgery. We defined preoperative CRT using standard National Surgical Quality Improvement Program time frames of 30 and 90 d, respectively, before surgery. RESULTS: We identified 295 patients (mean age, 58.6 y; 54% female; 77% white). A total of 34 patients received prior CRT and had age, body mass index, American Society of Anesthesiologists class, and preoperative laboratory values similar to those without CRT; the only significant differences was a lower hematocrit and platelet count in the CRT group. For the entire cohort, 30% (N = 89) underwent local excision (LE), 24% (N = 71) diversion, and 46% (N = 135) abdominoperineal resection (APR). Complications occurred in 23.7% of the entire cohort, and overall complication rates significantly differed based on the type of procedure [3.4% for LE and 18.3% for diversion, versus 40% for APR (P < 0.001)]. Only operative approach significantly affected morbidity, as patients receiving APR had a 1.67-fold (range, 1.14-2.45; P = 0.008) increased risk of complications. The 30-d mortality for the entire cohort was 2.7%, and was highest in the diversion group (7%) compared with the APR (1.5%) and local excision groups (1.1%; P = 0.036). However, by multivariate analysis, the only factors associated with death were preoperative sepsis (hazard ratio [HR] = 27.5; P = 0.005), lack of functional independence (HR = 26.3; P = 0.001), hypertension (HR = 14.4; P = 0.028), and prior alcohol use (HR = 21.4; P = 0.026). Chemoradiation therapy use did not have a significant effect on complication (36.0% versus 40.9%; P = 0.651) or mortality rates (0% versus 1.8%; P = 0.497). CONCLUSIONS: Surgical intervention for anal canal cancer remains a necessary option for select patients. Morbidity rates vary significantly based on the type of treatment; operative approach is the primary factor associated with postoperative short-term complications. When surgery is required, recent CRT is not associated with a higher complication rate. With proper perioperative care and surgical technique, mortality rates remain low, and the increased death rate with diversion, even in the short term, likely represents advanced disease.

Cefazolin-induced neutropenia and thrombocytopenia following trauma: a case report.

Cefazolin, a first generation cephalosporin, is a rare cause of cyclical fevers, neutropenia, and thrombocytopenia following surgical prophylaxis. We present the case of an otherwise healthy 21-year-old male who sustained a 50-cm laceration to his chest and abdomen. He received emergency department prophylaxis with cefazolin and surgical repair. Subsequently, he developed cyclical fevers, neutropenia, and thrombocytopenia, all of which resolved after antibiotic discontinuation. This is the first case report in which the perioperative administration of cefazolin following trauma resulted in significant neutropenia and thrombocytopenia. Also discussed in this report are the etiology, workup, and treatment of cefazolin-induced neutropenia.

The impact of obesity on outcomes following major surgery for Crohn's disease: an American College of Surgeons National Surgical Quality Improvement Program assessment.

BACKGROUND: Whereas Crohn's disease is traditionally thought to represent a wasting disease, little is currently known about the incidence and impact of obesity in this patient cohort. OBJECTIVE: This study aimed to evaluate the perioperative outcomes in patients with Crohn's disease who were obese vs those who were not obese undergoing major abdominal surgery. DESIGN: This study is a retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database (2005-2008). Risk-adjusted 30-day outcomes were assessed by the use of regression modeling accounting for patient characteristics, comorbidities, and surgical procedures. PATIENTS: Included were all patients with Crohn's disease who were undergoing abdominal operations. MAIN OUTCOME MEASURE: The primary outcomes measured were short-term perioperative outcomes. Obesity was defined as a BMI of 30 or greater. RESULTS: We identified 2319 patients (mean age, 41.6 y; 55% female). Of these patients, 379 (16%) met obesity criteria, 2% were morbidly obese, and 0.3% were super obese. Rates of obesity significantly increased each year over the study period. Twenty-five percent of the surgeries were performed laparoscopically (obese 21% vs nonobese 26%). Six percent were emergent, with no difference in patients with obesity. Operative times were significantly longer among patients with obesity (177 min) compared with patients who were not obese (164 min). After adjusting for differences in comorbidities and steroid use, overall perioperative morbidity was significantly higher in the obese cohort (32% vs 22% nonobese; OR 1.9). In addition, the rates of postoperative complications increased directly with rising BMI. Irrespective of procedure type, the patients who were obese were significantly more likely to experience wound infections (OR 1.7), which increased even further in patients who were morbidly obese (BMI >40; OR 7.1). By specific operation, postoperative morbidity was increased in patients with obesity following colectomies with primary anastomosis for both open and laparoscopic approaches (OR 2.9 and OR 3.8). Cardiac, pulmonary, and renal complications as well as overall mortality did not differ significantly based on BMI. LIMITATIONS: This study was limited by being a retrospective review, and by using data limited to the American College of Surgeons National Surgical Quality Improvement Program database. CONCLUSION: Increasing BMI adversely affects perioperative morbidity in patients with Crohn's disease.