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1.
Am J Surg ; 2020 Jan 10.
Artigo em Inglês | MEDLINE | ID: mdl-31964524

RESUMO

BACKGROUND: There is significant variation in rectal cancer outcomes in the USA, and reported outcomes have been inferior to those in other countries. In recognition of this fact, the American College of Surgeons (ACS) recently launched the Commission on Cancer (CoC) National Accreditation Program for Rectal Cancer (NAPRC) in an effort to further optimize rectal cancer care. Large surgical databases will play an important role in tracking surgical and oncologic outcomes. Our study sought to explore the trends in surgical outcomes over the decade prior to the NAPRC using a large national database. METHODS: The ACS National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2017 was used to select colorectal cancer cases which were divided into abdominal-colonic (AC) and pelvic-rectal (PR) cohorts based upon the operation performed. Outcomes of interest were occurrence of any major surgical complication, mortality within 30 days of procedure, and postoperative length of stay (LOS). Chi-square and two sample t-tests were used to evaluate association between various risk factors and outcomes. Modified Poisson regression was used to compare and estimate the unadjusted and adjusted effect of procedure type on the outcomes. STATA 15.1 was used for analysis and statistical significance was set at 0.05. RESULTS: A total of 34,159 patients were analyzed. AC cases constituted 50.7% of the overall cohort. The two groups were relatively similar in demographic distribution, but the PR patients had higher rates of hypoalbuminemia and were sicker (ASA class 3 or greater). Rates of non-sphincter preserving operations ranged from 30 to 34%. Higher complication rates in the PR cohort were mainly infectious and surgical site complications, while rates of deep vein thrombosis and pulmonary embolism were similar between the two cohorts. On bivariate analysis, rates of mortality were similar between the two groups (AC: 1.02% vs PR: 0.91%, p = 0.395), while PR patients were found to be 1.36 times (95% CI: 1.32-1.41) more likely to have major complications and 1.40 times (95% CI: 1.35-1.44) more likely to have an extended LOS as compared to the AC patients. After multivariable analysis, PR patients continued to have a higher likelihood of major complications (IRR: 1.31, 95% CI 1.25-1.36) and extended LOS (IRR: 1.38, 95% CI: 1.33-1.43). 10-year trends showed a significant reduction in the percentage of patients with prolonged lengths of hospitalization as well as a reduction of nearly 20% in the mean LOS, but without improvement in morbidity or mortality. CONCLUSIONS: Patients undergoing PR operations were more likely to have had major complications than were patients who underwent AC procedures; unfortunately no improvement in the rate of these complications or in mortality occurred. Perhaps the significant reduction in LOS is due in part to an increased prevalence of minimally invasive surgery and/or enhanced recovery protocols. Data were found to be lacking within NSQIP for several important variables including key oncologic data, stratification by surgical volume, and patient geographic location. We anticipate that the NAPRC should help improve PR surgical and oncologic outcomes including decreasing morbidity and mortality rates during the next decade.

2.
Am J Physiol Gastrointest Liver Physiol ; 318(3): G479-G489, 2020 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-31790273

RESUMO

During intestinal inflammation, immature cells within the intestinal crypt are called upon to replenish lost epithelial cell populations, promote tissue regeneration, and restore barrier integrity. Inflammatory mediators including TH1/TH17-associated cytokines influence tissue health and regenerative processes, yet how these cytokines directly influence the colon crypt epithelium and whether the crypt remains responsive to these cytokines during active damage and repair, remain unclear. Here, using laser-capture microdissection and primary colon organoid culture, we show that the cytokine milieu regulates the ability of the colonic crypt epithelium to participate in proinflammatory signaling. IFN-γ induces the TH1-recruiting, proinflammatory chemokine CXCL10/IP10 in primary murine intestinal crypt epithelium. CXCL10 was also induced in colonic organoids derived from mice with active, experimentally induced colitis, suggesting that the crypt can actively secrete CXCL10 in select cytokine environments during colitis. Colon expression of cxcl10 further increased during infectious and noninfectious colitis in Il17a-/- mice, demonstrating that IL-17A exerts a negative effect on CXCL10 in vivo. Furthermore, IL-17A directly antagonized CXCL10 production in ex vivo organoid cultures derived from healthy murine colons. Interestingly, direct antagonism of CXCL10 was not observed in organoids derived from colitic mouse colons bearing active lesions. These data, highlighting the complex interplay between the cytokine milieu and crypt epithelia, demonstrate proinflammatory chemokines can be induced within the colonic crypt and suggest the crypt remains responsive to cytokine modulation during inflammation.NEW & NOTEWORTHY Upon damage, the intestinal epithelium regenerates to restore barrier function. Here we observe that the local colonic cytokine milieu controls the production of procolitic chemokines within the crypt base and colon crypts remain responsive to cytokines during inflammation. IFN-γ promotes, while IL-17 antagonizes, CXCL10 production in healthy colonic crypts, while responses to cytokines differ in inflamed colon epithelium. These data reveal novel insight into colon crypt responses and inflammation-relevant alterations in signaling.

3.
J Gastrointest Surg ; 24(1): 209-211, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31734775
4.
J Gastrointest Surg ; 2019 Nov 25.
Artigo em Inglês | MEDLINE | ID: mdl-31768824

RESUMO

The Society for Surgery of the Alimentary Tract is a robust clinical society with over 2500 members. As a society that is focused on the entire alimentary tract, we overlap with other more organ-centric societies. This has led to a constant struggle of knowing how the Society for Surgery of the Alimentary Tract can best serve the surgical community. The board of directors held its second strategic retreat in 10 years to develop aspirational goals in hopes to define the direction of the society for the next 5 years. The output of this meeting is presented in this document.

6.
Am J Surg ; 218(1): 51-55, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30791991

RESUMO

BACKGROUND: We investigated the impact of blunt pulmonary contusion (BPC) in patients with rib fractures. METHODS: Adult patients with rib fractures caused by blunt mechanisms were enrolled over 3 years at a Level 1 trauma center. BPC was defined according to percentage of lung affected as: moderate (1-19% contusion) or severe (≥20% contusion). RESULTS: In total, 1448 of the 7238 admitted patients had rib fractures. Of these, 321 (22.2%) had BPC: 236 moderate and 85 severe. Patients with BPC were more likely to be admitted to the ICU (moderate: OR 1.55, 95% CI 1.10-2.19; severe: OR 2.74, 95% CI 1.41-5.32). Significantly increased rates of pneumonia (OR 2.52, 95% CI 1.43-4.90) and empyema (OR 4.80, 95% CI 1.07-21.54) were found for moderate and severe BPC, respectively. CONCLUSIONS: ICU admission and infectious pulmonary complications were more likely with BPC. The presence of BPC on admission CT is also prognostic of increased resource utilization.


Assuntos
Contusões/epidemiologia , Lesão Pulmonar/epidemiologia , Traumatismo Múltiplo/epidemiologia , Fraturas das Costelas/epidemiologia , Ferimentos não Penetrantes/epidemiologia , Adulto , Contusões/mortalidade , Feminino , Humanos , Escala de Gravidade do Ferimento , Lesão Pulmonar/mortalidade , Masculino , Pessoa de Meia-Idade , Traumatismo Múltiplo/mortalidade , New York/epidemiologia , Fraturas das Costelas/mortalidade , Medição de Risco , Centros de Traumatologia , Ferimentos não Penetrantes/mortalidade
7.
Am J Surg ; 218(1): 32-36, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30709551

RESUMO

BACKGROUND: Although associated with significant morbidity, there is no universally accepted management of rib fractures. We hypothesized that variations in risk stratification may influence this. METHODS: A questionnaire was developed to assess providers' perceived risk factors and injury stratification of rib fracture patients at a Level 1 trauma center. RESULTS: There were 143 responses (36% physician response rate). Hypoxia, age, number of ribs fractured, pre-existing pulmonary disease, and flail chest were identified as the most important risk factors determining morbidity and mortality in blunt chest trauma. While clinicians agreed on predicted mortality for <2 fractured ribs, significant variation for 5-6 and >8 rib fractures was seen. EM and surgery providers significantly differed in assessment of injury severity. CONCLUSION: Providers identified common risk factors for increased morbidity and mortality. However, the difference in perceived severity between providers indicates a need for clinical tools to assist in better standardizing rib fracture management.


Assuntos
Padrões de Prática Médica/estatística & dados numéricos , Fraturas das Costelas/mortalidade , Fraturas das Costelas/terapia , Medição de Risco , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Inquéritos e Questionários
8.
Am J Surg ; 217(1): 29-33, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-29929907

RESUMO

BACKGROUND: Anticoagulant and antiplatelet agents (ACAP) have been shown to negatively affect trauma patients. METHODS: Outcomes in adults with rib fractures were reviewed. Pearson chi-square test was used for analysis. Multivariate logistic regression was used to adjust for potential confounders. RESULTS: Of the 1448 included patients, 149 (10.3%) took preinjury ACAP; these patients were significantly older than non-anticoagulated patients (72 vs. 54 years, P ≤ 0.05). There was no difference in pulmonary complications, ICU admissions or ICU LOS. The preinjury ACAP group had a significantly longer LOS (12.03 vs. 9.33 days, P = 0.004), fewer pulmonary contusions (15.43% vs. 22.94%, P = 0.037), and fewer thoracic drainage procedures (10.74% vs. 18.17%, P = 0.023). Multivariate adjustment for possible confounders revealed that patients taking warfarin had a significantly longer LOS (+7.38 days). After adjustment there was no difference in mortality. CONCLUSION: Preinjury ACAP use does not increase mortality or morbidity in patients with rib fractures. SUMMARY: We demonstrated that preinjury anticoagulation and antiplatelet agents do not increase mortality or morbidity in patients with rib fractures. However, they lead to a longer hospital length of stay, particularly in patients on warfarin.


Assuntos
Anticoagulantes/uso terapêutico , Tempo de Internação , Inibidores da Agregação de Plaquetas/uso terapêutico , Fraturas das Costelas/complicações , Fraturas das Costelas/mortalidade , Idoso , Feminino , Humanos , Escala de Gravidade do Ferimento , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Varfarina/uso terapêutico
10.
Horm Cancer ; 9(6): 420-432, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30187356

RESUMO

Drug resistance complicates the clinical use of gefitinib. Tetraiodothyroacetic acid (tetrac) and nano-diamino-tetrac (NDAT) have been shown in vitro and in xenografts to have antiproliferative/angiogenic properties and to potentiate antiproliferative activity of other anticancer agents. In the current study, we investigated the effects of NDAT on the anticancer activities of gefitinib in human colorectal cancer cells. ß-Galactoside α-2,6-sialyltransferase 1 (ST6Gal1) catalyzes EGFR sialylation that is associated with gefitinib resistance in colorectal cancers, and this was also investigated. Gefitinib inhibited cell proliferation of HT-29 cells (K-ras wild-type), and NDAT significantly enhanced the antiproliferative action of gefitinib. Gefitinib inhibited cell proliferation of HCT116 cells (K-ras mutant) only in high concentration, and this was further enhanced by NDAT. NDAT enhancedd gefitinib-induced antiproliferation in gefitinib-resistant colorectal cancer cells by inhibiting ST6Gal1 activity and PI3K activation. Furthermore, NDAT enhanced gefitinib-induced anticancer activity additively in colorectal cancer HCT116 cell xenograft-bearing nude mice. Results suggest that NDAT may have an application with gefitinib as combination colorectal cancer therapy.


Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/farmacologia , Neoplasias Colorretais/patologia , Gefitinibe/farmacologia , Poliglactina 910/farmacologia , Tiroxina/análogos & derivados , Animais , Apoptose/efeitos dos fármacos , Proliferação de Células/efeitos dos fármacos , Ativação Enzimática/efeitos dos fármacos , Receptores ErbB/efeitos dos fármacos , Receptores ErbB/metabolismo , Células HCT116 , Células HT29 , Humanos , Camundongos , Camundongos Nus , Fosfatidilinositol 3-Quinases/efeitos dos fármacos , Fosfatidilinositol 3-Quinases/metabolismo , Tiroxina/farmacologia , Ensaios Antitumorais Modelo de Xenoenxerto
11.
Gene ; 677: 299-307, 2018 Nov 30.
Artigo em Inglês | MEDLINE | ID: mdl-30121380

RESUMO

Chronic intestinal inflammation predisposes patients with Inflammatory Bowel Disease (IBD) to Colitis-Associated Cancer (CAC). In the setting of chronic inflammation, microsatellite instability (MSI) results from early loss of DNA damage response (DDR) genes, ultimately leading to tumor formation. Despite continued efforts to improve early detection of high risk, pre-dysplastic regions in IBD patients, current macroscopic and genetic surveillance modalities remain limited. Therefore, understanding the regulation of key DDR genes in the progression from colitis to cancer may improve molecular surveillance of CAC. To evaluate DDR gene regulation in the transition from colitis to tumorigenesis, we utilized the well-established Azoxymethane/Dextran Sodium Sulfate (AOM/DSS) pre-clinical murine model of CAC in C57BL/6 mice. In order to assess colonic tumor burden in the setting of mutagen and intestinal irritation, tumors were visualized and graded in real time through high-resolution murine colonoscopy. Upon sacrifice, colons were opened and assessed for macroscopic tumor via high magnification surgical lenses (HMSL). Tissues were then sectioned and separated into groups based on the presence or absence of macroscopically visible tumor. Critical DDR genes were evaluated by semi-quantitative RT-PCR. Interestingly, colon tissue with macroscopically visible tumor (MVT) and colon tissue prior to observable tumor (the non-macroscopically visible tumor-developing group, NMVT) were identical in reduced mRNA expression of mlh1, anapc1, and ercc4 relative to colitic mice without mutagen, or those receiving mutagen alone. Colitis alone was sufficient to reduce colonic ercc4 expression when compared to NMVT mice. Therefore, reduced ercc4 expression may mark the early transition to CAC in a pre-clinical model, with expression reduced prior to the onset of observable tumor. Moreover, the expression of select DDR genes inversely correlated with chronicity of inflammatory disease. These data suggest ercc4 expression may define early stages in the progression to CAC.


Assuntos
Carcinogênese/genética , Colite/genética , Colite/patologia , Neoplasias do Colo/genética , Neoplasias do Colo/patologia , Dano ao DNA/genética , Animais , Azoximetano/farmacologia , Carcinogênese/patologia , Colo/efeitos dos fármacos , Colo/patologia , Dano ao DNA/efeitos dos fármacos , Sulfato de Dextrana/farmacologia , Modelos Animais de Doenças , Progressão da Doença , Regulação da Expressão Gênica/efeitos dos fármacos , Regulação da Expressão Gênica/genética , Inflamação/genética , Inflamação/patologia , Doenças Inflamatórias Intestinais/genética , Doenças Inflamatórias Intestinais/patologia , Intestinos/efeitos dos fármacos , Intestinos/patologia , Masculino , Camundongos , Camundongos Endogâmicos C57BL , Instabilidade de Microssatélites/efeitos dos fármacos , Transdução de Sinais/efeitos dos fármacos , Transdução de Sinais/genética
13.
Ann Surg ; 268(3): 403-407, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30004923

RESUMO

OBJECTIVE: The leadership of the American Surgical Association (ASA) appointed a Task Force to objectively address issues related to equity, diversity, and inclusion with the discipline of academic surgery. SUMMARY OF BACKGROUND DATA: Surgeons and the discipline of surgery, particularly academic surgery, have a tradition of leadership both in medicine and society. Currently, we are being challenged to harness our innate curiosity, hard work, and perseverance to address the historically significant deficiencies within our field in the areas of diversity, equity, and inclusion. METHODS: The ASA leadership requested members to volunteer to serve on a Task Force to comprehensively address equity, diversity, and inclusion in academic surgery. Nine work groups reviewed the current literature, performed primary qualitative interviews, and distilled available guidelines and published primary source materials. A work product was created and published on the ASA Website and made available to the public. The full work product was summarized into this White Paper. RESULTS: The ASA has produced a handbook entitled: Ensuring Equity, Diversity, and Inclusion in Academic Surgery, which identifies issues and challenges, and develops a set of solutions and benchmarks to aid the academic surgical community in achieving these goals. CONCLUSION: Surgery must identify areas for improvement and work iteratively to address and correct past deficiencies. This requires honest and ongoing identification and correction of implicit and explicit biases. Increasing diversity in our departments, residencies, and universities will improve patient care, enhance productivity, augment community connections, and achieve our most fundamental ambition-doing good for our patients.


Assuntos
Centros Médicos Acadêmicos , Diversidade Cultural , Docentes de Medicina , Liderança , Seleção de Pessoal , Especialidades Cirúrgicas , Comitês Consultivos , Humanos , Cultura Organizacional , Justiça Social , Sociedades Médicas , Estados Unidos
14.
Am Surg ; 84(6): 983-986, 2018 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-29981635

RESUMO

Current anesthesia guidelines require tube feed (TF) interruption for at least four hours before tracheostomy. We hypothesized that preprocedural TF interruption is not required before tracheostomy. We developed a protocol allowing continued feeding. Fifty-six patients undergoing tracheostomy with or without percutaneous endoscopic gastrostomy placement were included. Eleven patients underwent tracheostomy without TF interruption (TF group); the remaining 45 patients had TFs held per the existing anesthesia protocol (nil per os group). Data were collected by retrospective chart review. The groups were similar with regard to age, sex, race, risk of mortality, and preoperative albumin levels (3.2 vs 2.9 g/dL). There was no difference in pulmonary complications. No intraoperative aspiration occurred in either group, and there was no increase in mortality in the TF group (9.1 vs 22.2%, P = 0.43). The TF group had feeds held for 9.5 ± 6.3 vs 25.4 ± 19.0 hours (P = 0.0018). The TF group had a decreased missed caloric intake [761.5 ± 566.6 vs 1983.5 ± 1590.8 kcal (P = 0.0039)]. The TF group had a shorter time from consultation [40.4 vs 50.6 hours (P = 0.54)] and case booking [7.9 vs 12.8 hours (P = 0.40)] to the OR. The average length of stay for the TF group was 26.3 versus 31.1 days (P = 0.45). There was no increase in pulmonary complications or mortality in the fed patients, who experienced less procedural delays. Meanwhile, patients kept nil per os sustained a substantial caloric deficit. Tracheostomy without TF interruption is feasible and reduces malnutrition.


Assuntos
Cuidados Críticos , Nutrição Enteral , Traqueostomia , Protocolos Clínicos , Ingestão de Energia , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
15.
Am Surg ; 84(2): e40-43, 2018 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-29580325

RESUMO

Becoming compliant with the Accreditation Council for Graduate Medical Education (ACGME) requirements for scholarly activity and remaining compliant over time requires time and attention to the development of an environment of inquiry, which is reflected in detailed documentation submitted in program applications and annual updates. Since the beginning of the next accreditation system, all ACGME programs have been required to submit evidence of scholarly activity of both residents and faculty on an annual basis. Since 2014, American Osteopathic Association-accredited programs have been able to apply for ACGME accreditation under the Single Graduate Medical Education Accreditation initiative. The Residency Program Director, Chair, Designated Institutional Official, Faculty, and coordinator need to work cohesively to ensure compliance with all program requirements, including scholarly activity in order for American Osteopathic Association-accredited programs to receive Initial ACGME Accreditation and for current ACGME-accredited programs to maintain accreditation. Fortunately, there are many ways to show the type of scholarly activity that is required for the training of surgeons. In this article, we will review the ACGME General Surgery Program Requirements and definitions of scholarly activity. We will also offer suggestions for how programs may show evidence of scholarly activity.


Assuntos
Acreditação/normas , Pesquisa Biomédica/educação , Educação de Pós-Graduação em Medicina/normas , Cirurgia Geral/educação , Internato e Residência/normas , Pesquisa Biomédica/normas , Educação de Pós-Graduação em Medicina/métodos , Docentes de Medicina/normas , Cirurgia Geral/normas , Humanos , Medicina Osteopática/economia , Medicina Osteopática/normas , Editoração/normas , Apoio à Pesquisa como Assunto/normas , Estados Unidos
16.
Am J Surg ; 215(4): 643-646, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29061282

RESUMO

BACKGROUND: Postoperative pain management is a major contributor to recovery and discharge in bariatric surgery. Local anesthetic agents are of particular interest: they're non-sedating and may reduce postoperative pain and hospital length of stay (LOS). DESIGN: Researchers queried the Bariatric Surgery Service Database for patients undergoing laparoscopic weight loss surgery from January 2012-December 2014. Patients were divided between those who did and did not receive liposomal bupivacaine intra-operatively. Measures included demographics, narcotic use, LOS, antiemetic use, and pain scales. RESULTS: The liposomal group consisted of 233 patients and the PCA group consisted of 243 patients. The liposomal group had significantly less narcotic use than the PCA group in terms of IV morphine equivalents. This did not translate into a reduction in LOS in the liposomal group. CONCLUSIONS: TAP block using liposomal bupivacaine provides effective analgesia comparable to PCA.


Assuntos
Músculos Abdominais/cirurgia , Anestésicos Locais/administração & dosagem , Cirurgia Bariátrica , Bupivacaína/administração & dosagem , Laparoscopia/métodos , Bloqueio Nervoso/métodos , Dor Pós-Operatória/prevenção & controle , Analgésicos Opioides/administração & dosagem , Antieméticos/administração & dosagem , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Lipossomos , Masculino , Pessoa de Meia-Idade , Manejo da Dor , Medição da Dor , Resultado do Tratamento
19.
J Surg Res ; 208: 180-186, 2017 02.
Artigo em Inglês | MEDLINE | ID: mdl-27993206

RESUMO

BACKGROUND: Little is known about how the immunologic microenvironment changes during tumor progression and metastatic spread. Recently, murine models have shown the T-helper 17 (Th17) pathway to play an important role in promoting colorectal cancer (CRC). The purpose of this study was to compare cytokine profiles in the tumor microenvironment of CRC between local disease (stages I/II) and advanced disease (stages III/IV), and to determine whether these changes were manifest in the systemic circulation of patients with advanced disease. MATERIALS AND METHODS: Serum and tissue cytokine profiles were assayed among patients with documented adenocarcinoma before surgical resection at a single institution from September 2014 to February 2015. Using the Bio-Plex Pro Human Th17 Cytokine Assay Kit (Bio-Rad Laboratories), the concentrations of multiple cytokines were determined. Multiple logistic regression analyses were used to evaluate the association between TNM staging and cytokine levels. RESULTS: A total of 33 patients with documented adenocarcinoma were included. None of the patients received neoadjuvant chemotherapy. American Joint Commission on Cancer TNM classification was used. Advanced disease was associated with elevated tumor levels of tumor necrosis factor-alpha, interleukin (IL)-4, IL-10, IL-17A, and IL-17F, and only stage IV showed elevated systemic levels of Th17-associated cytokines IL-17F, IL-23, and IL-25. CONCLUSIONS: The Th17 pathway likely has important mechanistic implications in human CRC. Metastatic disease was associated with elevated Th17-associated cytokines both in colonic tissue and systemically. These changes in systemic expression of Th17-associated cytokines could establish novel pathways for CRC and warrant further investigation.


Assuntos
Adenocarcinoma/imunologia , Neoplasias do Colo/imunologia , Células Th17/fisiologia , Adenocarcinoma/sangue , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias do Colo/sangue , Citocinas/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
20.
Ann Surg ; 264(3): 538-43, 2016 09.
Artigo em Inglês | MEDLINE | ID: mdl-27433898

RESUMO

OBJECTIVE: Safe and efficient endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (r-AAA) requires advanced infrastructure and surgical expertise not available at all US hospitals. The objective was to assess the impact of regionalizing r-AAA care to centers equipped for both open surgical repair (r-OSR) and EVAR (r-EVAR) by vascular surgeons. METHODS: A retrospective review of all patients with r-AAA undergoing open or endovascular repair in a 12-hospital region. Patient demographics, transfer status, type of repair, and intraoperative variables were recorded. Outcomes included perioperative morbidity and mortality. RESULTS: Four hundred fifty-one patients with r-AAA were treated from 2002 to 2015. Three hundred twenty-one patients (71%) presented initially to community hospitals (CHs) and 130 (29%) presented to the tertiary medical center (MC). Of the 321 patients presenting to CH, 133 (41%) were treated locally (131 OSR; 2 EVAR) and 188 (59%) were transferred to the MC. In total, 318 patients were treated at the MC (122 OSR; 196 EVAR). At the MC, r-EVAR was associated with a lower mortality rate than r-OSR (20% vs 37%, P = 0.001). Transfer did not influence r-EVAR mortality (20% in r-EVAR presenting to MC vs 20% in r-EVAR transferred, P > 0.2). Overall, r-AAA mortality at the MC was 20% lower than CH (27% vs 46%, P < 0.001). CONCLUSIONS: Regionalization of r-AAA repair to centers equipped for both r-EVAR and r-OSR decreased mortality by approximately 20%. Transfer did not impact the mortality of r-EVAR at the tertiary center. Care of r-AAA in the US should be centralized to centers equipped with available technology and vascular surgeons.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/cirurgia , Regionalização/métodos , Procedimentos Cirúrgicos Vasculares/organização & administração , Aneurisma da Aorta Abdominal/mortalidade , Ruptura Aórtica/mortalidade , Hospitais Comunitários/estatística & dados numéricos , Humanos , Estudos Retrospectivos , Centros de Atenção Terciária/estatística & dados numéricos , Resultado do Tratamento
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