48.07 Pediatric Vascular Injury: Experience of a High Volume Level 1 Trauma Center

Posted on December 22, 2014

C. J. Allen3, R. J. Straker3, J. Tashiro1, J. P. Meizoso3, J. J. Ray3, M. Hanna3, C. I. Schulman3, N. Namias3, K. G. Proctor3, J. Rey2, J. E. Sola1  1University Of Miami,Pediatric Surgery,Miami, FL, USA 2University Of Miami,Vascular Surgery,Miami, FL, USA 3University Of Miami,Trauma And Critical Care,Miami, FL, USA

Introduction:  Trauma is the leading cause of death and morbidity in children. Youth firearm related injuries are rising and traumatic injury is the most common indication for pediatric vascular surgery.  Our purpose is to analyze modern vascular injury patterns in pediatric trauma, interventions performed, and outcomes at a high volume level 1 trauma center.

Methods:  From January 2000 to December 2012, all pediatric admissions (≤17y) at a level 1 trauma center were reviewed for demographics, mechanisms of injury (MOI), injury severity score (ISS), vascular injury, surgeries performed, length of stay (LOS), and survival.  Parametric data is expressed as mean±standard deviation and non-parametric data as median(interquartile range).  Univariate analysis determined significant factors of mortality.  Multivariate analysis with logistic regression determined the injury locations with independent mortality risk.

Results: Of 1,928 pediatric admissions, 103 (5.3%) sustained a major vascular injury (MVI). This cohort was 85% male, age 15±3y, 55% black, 58% penetrating, ISS of 23±15, with a LOS of 8(5)d. The most common MOI were GSW (47%) and MVC (17%). Injury by location includes the extremities (50.5%), abdomen/pelvis (29.1%), and chest/neck (20.4%). Surgeries performed included repairs/bypasses (75.3%), ligation (12.7%), limb amputation (10.8%), or with temporary shunt (2.9%). The most common vessels requiring operative intervention were the superficial femoral artery (11.7%), common femoral artery (9.8%), and brachial artery (6.9%). The vessel most commonly repaired by a vascular specialist was the popliteal artery (55.6%). 3 injuries (2.4%) were treated endovascularly, 2 injuries required embolization of a branch of the internal iliac artery, and 1 injury to the thoracic aorta required endovascular stent grafting. MVI patients had a mortality rate of 19.4%, significantly increased when compared to the total pediatric trauma population mortality rate of 3.5% (p<0.001).  Mortality rate also varied according to injury location (chest: 67%, abdomen/pelvis: 40%, neck: 21%, extremity: 4% (p<0.001)). Following multivariate analysis with logistic regression, significant independent risk factors of mortality were vascular injury to the neck (odds ratio (OR): 6.5; confidence interval (CI): 1.1-39.3), abdomen/pelvis (OR: 16.3; CI: 3.13-80.2), and chest (OR: 49.0; CI: 3.0-794.5).

Conclusion:  MVI in children more commonly results from firearm related injury. The mortality rate associated with MVI is profoundly higher than that of the overall pediatric trauma population. These findings underscore the major public health concern of firearm related injury in children and to the importance of improving management and prevention of these lethal injuries. 

48.08 Vascular Access Modifies the Protective Effect of Obesity on Hemodialysis Survival

Posted on December 22, 2014

M. B. Malas1, I. J. Arhuidese1, T. Obeid1, U. Qazi1, C. Abularrage1, I. Botchey1, J. H. Black1, T. Reifsnyder1  1Johns Hopkins Medical Institutions,Department Of Surgery, Division Of Vascular Surgery,Baltimore, MD, USA

Introduction: The protective effect of obesity on survival of patients undergoing hemodialysis for end stage renal disease; described as the obesity paradox has previously been established. Increased survival benefits have also been ascribed to permanent modes of hemodialysis access (fistula/graft) compared to catheter at first hemodialysis. The purpose of this study is to evaluate the impact of incident hemodialysis access type on the obesity paradox.

Methods: We conducted a retrospective study of all patients with end stage renal disease in the United States Renal Database System, who initiated hemodialysis between 2006 and 2010 without prior renal replacement therapy. Relative mortality within categories of body mass index (BMI) as well as modes of hemodialysis access (fistula/graft Vs catheter) was quantified using multivariable Cox proportional hazard models. Multivariable logistic regression was employed to compare vascular access utilization between the BMI categories. Interaction terms were employed to assess the modifier effect of hemodialysis access type on the association between BMI and survival.

Results: There were 510,000 dialysis initiates in the study cohort; 83% via catheter, 14% via fistula and 3% via grafts. Mortality was significantly lower for patients initiating hemodialysis with permanent forms of access compared to catheter (aHR 0.68, 95%CI 0.67-0.69, P value<0.001). Higher BMI categories were associated with lower mortality as shown in Table 1. Patients in the higher BMI categories were also more likely to initiate hemodialysis via permanent modes of access. Table 1. The interaction term for the modifier effect of vascular access method on the association between BMI and mortality was significant (P<0.001).

Conclusion: We have shown that the highly popularized protective effect of increased BMI on survival in hemodialysis patients is significantly influenced by the method of hemodialysis access. Thus, the obesity paradox is in part accounted for by hemodialysis access type. There is greater use of catheters with their attendant complications and higher mortality amongst patients in the lower BMI categories compared to patients in higher BMI categories. There remains a critical need to increase permanent access utilization at incident hemodialysis so as to improve survival outcomes irrespective of BMI status. 

 

48.09 Factors Associated with Ischemic Colitis in Contemporary Aortic Surgery

Posted on December 22, 2014

J. C. Iannuzzi1, F. J. Fleming1, K. N. Kelly1, K. Noyes1, J. R. Monson1, M. J. Stoner2  1University Of Rochester,Surgical Health Outcomes & Research Enterprise, Department Of Surgery,Rochester, NY, USA 2University Of Rochester,Vascular Surgery,Rochester, NY, USA

Introduction:

While large clinical databases in surgery have been useful for defining mortality and overall morbidity, vascular specific morbidity has been absent representing a major gap in quality reporting for vascular surgery.  Ischemic colitis (IC) following abdominal aortic aneurysm repair is a potentially devastating complication yet little data exists in part due to the relative infrequency, leaving surgeons and patients subject to historical dogmatic practices. 

 

Methods:

NSQIP vascular procedure specific data was abstracted from the 2011-2012 NSQIP participant user file.  Open abdominal aortic aneurysm repair (OPEN) and endovascular abdominal aortic aneurysm repair (EVAR) were evaluated for factors associated with IC.  Bivariate analysis identified candidate variables, and subsequent manual stepwise binary logistic regression was performed assessing factors with p<0.1 for association with the primary end point of IC.   Factors meeting p<0.05 were retained in the model.

 

Results:

Overall, 3734 cases were analyzed comprising 949 OPEN and 2,785 EVAR cases.  The IC rate was 2.4% (n=88), [OPEN: 5.6% (n=53), EVAR: 1.6% (n=35,) p<0.001].  On multivariable analysis OPEN was associated with 2.25 times the odds of IC compared to EVAR (table). Other risk factors included male sex, renal insufficiency, operative time, and preoperative blood transfusion.  On multivariable analysis of OPEN alone, only supraceliac clamping was additionally associated with increased IC risk (OR 2.62, CI: 1.26-5.04, p=0.004).  Inferior mesenteric artery IMA management was not associated with IC risk. Procedural factors associated with IC after EVAR on multivariable analysis included ruptured aneurysm for hypotension (OR: 21.39, CI:9.44-48.49p<0.001), ruptured aneurysm without hypotension (OR:10.74, CI: 3.86-29.83, p<0.001), iliac-branched device (OR: 2.71, CI:1.22-5.99, p<0.001), prior abdominal surgery (OR, 2.39, CI: 1.14-5.04, p=0.022), and renal stenting (OR: 3.25, CI: 1.29-8.22, p=0.013).  IC itself was associated with longer ICU stay, increased hospital stay, and overall major complications.

 

Conclusion:

 Procedural data on abdominal aortic aneurysm repair demonstrates that the OPEN approach has over twice the adjusted risk for IC compared to EVAR.   This study for the first time describes the association of renal insufficiency with IC.  Procedural specific data also demonstrated significantly increased risk particularly when patients present with rupture increasing IC risk from ten to twenty fold depending on presence of hypotension.  These findings help in risk stratifying patients for post-operative IC.

48.10 Transfusion During Amputation has Increased Risk of Pneumonia, Thromboembolism and Length of Stay

Posted on December 22, 2014

T. Tan1, W. W. Zhang1, M. Eslami2, A. Coulter1, D. V. Rybin2, G. Doros2, A. Farber2  1Louisiana State University Health Shreveport,Vascular And Endovascular Surgery,Shreveport, LA, USA 2Boston Medical Center,Vascular And Endovascular Surgery,Boston, MA, USA

Introduction

We evaluated the outcomes of patients undergoing major lower extremity amputation who received packed red blood cell transfusion.
Methods
Using the NSQIP(2005-2011), we examined 5739 above knee(AKA) and 6725 below knee amputations(BKA). Patients were stratified by perioperative (preoperative, intraoperative and postoperative) transfusion. Outcomes included perioperative mortality, surgical site infection(SSI), myocardial infarction(MI), thromboembolism and hospital length of stay(LOS). Patients who received transfusion were cohort matched for risk-adjusted comparisons using age, smoking, diabetes, cardiac disease, renal failure, ASA Classification, functional status, indication and procedure(AKA vs. BKA) with those who were not transfused. Multivariable logistic and gamma regression was used to examine associations between transfusion and outcomes.
Results
There were 12,464amputations in the study cohort and 2,133patients required transfusion(17%). 8205 amputations(66%) were performed for critical limb ischemia and overall 30-days mortality was 9%. In both crude and matched cohorts transfusion was associated with a higher risk of pneumonia(crude:6.1%vs.3%,p<.001;matched:5.9%vs.3.7%,p<.001), thromboembolism(2.5%vs.1.6%,p=.003;2.5% vs.1.4%,p=.002) and longer LOS (18±19 vs.13.6±14.3day,p<.001; 17.8±18.4vs.14.2±14.5day,p<.001). In multivariable analysis of the crude cohort, transfusion was associated with a higher risk of perioperative pneumonia(OR 1.6, 95%CI1.3-2, p<.001), thromboembolism(OR 1.6, 95%CI1.1-2.4, p=.03) and longer LOS (OR1.3, 95%CI 1.1-1.2, p<.0001). 
Conclusions
Patients who receive perioperative transfusion during major limb amputation have a higher risk of perioperative pneumonia, thromboembolism and longer hospital length of stay.  Further study is required to clarify the role of transfusion during lower extremity amputation.   

 

49.01 Low Anterior Resection after Neoadjuvant Chemoradiation for Rectal Cancer: To Divert or Not Divert?

Posted on December 22, 2014

A. N. Kulaylat1, T. M. Connelly1, J. Miller2, N. J. Gusani2, G. Ortenzi1, J. Wong2, N. H. Bhayani2, E. Messaris1  1Penn State Hershey Medical Center,Division Of Colon And Rectal Surgery,Hershey, PA, USA 2Penn State Hershey Medical Center,Division Of General Surgical Specialties & Surgical Oncology,Hershey, PA, USA

Introduction:  A diverting stoma is often performed at the time of low anterior resection (LAR) for rectal cancer in patients that have undergone neoadjuvant chemoradiation (nRT) thus protecting the newly created anastomosis by diverting the fecal stream. The aim of this study was to examine large cohort of rectal cancer patients undergoing elective LAR after nRT.  

Methods:  The National Surgical Quality Improvement Program database records from 2005 – 2012 were utilized to identify patients undergoing LAR for rectal cancer following nRT (ICD-9 diagnosis code 154.*). Patients who underwent emergency resection, had Stage IV disease and/or had a permanent end colostomy were excluded. Patients were grouped for comparison based on Current Procedural Terminology (CPT) codes:  diverting stoma (CPT code 44146, 44208) or no diverting stoma (CPT code 44145, 44207). The primary outcomes were postoperative infectious complications, reoperation and mortality.

Results: 1,406 patients were included in the analysis: 607 (43.2%) received a protective stoma and 799 (56.8%) were not diverted. There were no significant differences between the stoma and no stoma groups in demographic variables, comorbidities (except hypertension) or weight loss (p>0.05). The mean body mass index was greater in the stoma group (28.3±7.2 m/kg2 versus no stoma, 27.4±6.6 m/kg2, p=0.02). Although operative time was increased in patients that received a stoma (230±94 minutes versus no ostomy, 218±99 minutes, p=0.02), there were no differences in overall anesthesia time or hospital length of stay (p>0.05). Overall morbidity was 27.3% in the LAR cohort vs 29.7% in the stoma cohort (p>.05). There were no significant differences in   deep organ space infection, sepsis and septic shock, unplanned reoperation and overall mortality between the groups (p>0.05).  

Conclusion: 1) Diverting stoma does not decrease mortality or infectious complications in rectal cancer patients undergoing a low anterior resection after neoadjuvant radiation. 2) No factors were identified that could assist surgeons in deciding whether to perform a protective ostomy in patients undergoing neoadjuvant radiation and subsequent LAR for rectal cancer. Patients with higher body mass index have higher chances of receiving a protective stoma.

 

49.02 Suture, Synthetic, or Biologic Mesh? A Multi-Center Comparison of Contaminated Ventral Hernia Repair

Posted on December 22, 2014

I. L. Bondre1, J. L. Holihan1, E. P. Askenasy2, J. A. Greenberg3, J. Keith6, R. G. Martindale5, J. S. Roth4, C. J. Wray1, L. S. Kao1, M. K. Liang1  1University Of Texas Health Science Center At Houston,Houston, TX, USA 2Baylor College Of Medicine,Houston, TX, USA 3University Of Wisconsin,Madison, WI, USA 4University Of Kentucky,Lexington, KY, USA 5Oregon Health And Science University,Portland, OR, USA 6University Of Iowa,Iowa City, IA, USA

Introduction:

While there is little controversy regarding the improved outcomes associated with mesh use in uncomplicated ventral hernia repair(VHR), data is lacking to support the choice between suture, light-weight synthetic mesh, or biologic mesh in contaminated VHR. We hypothesize that in contaminated VHR, suture repair is associated with a lower rate of surgical site infection (SSI) and a higher rate of hernia recurrence compared to light-weight synthetic and biologic mesh.

Methods:  

We reviewed a multi-center, retrospective database of all open VHR performed at seven institutions between 2010-2011. All patients with a Centers for Disease Control and Prevention (CDC) wound classification of II-III were included.  The primary outcome was SSI as defined by the CDC.  The secondary outcome was hernia recurrence (assessed clinically and radiographically). Multivariable analysis using stepwise regression was performed including variables selected a priori (ASA, BMI, current smoking, acute, primary versus incisional hernia, prior hernia repair, wound class II or III, fascial release, fascial closure, repair technique-suture or light-weight mesh or biologic mesh, and follow-up duration).  Inverse probability weighting (which corrects for selection bias and missing data) was also performed adjusting for the listed variables as well as defect size and institution.

Results: 

204 contaminated VHRs were reviewed for a median follow-up of 12.8 months (range 1-49); there were 72(35%) suture, 66(32%) light-weight synthetic mesh, and 66(32%) biologic mesh repairs.  On univariate analysis, there were differences in the three groups including institution, ASA score, prior hernia repair, wound class, size, and fascial release. The unadjusted outcomes of SSI (9.7%,18.2%,12.1%;p=0.32) and recurrence (26.4%,13.6%,19.7%;p=0.17) were not statistically different between the groups. On multivariable analysis, repair technique was not associated with SSI but did impact recurrence (Table). Using inverse probability weighting, there was no difference in SSI between the study groups.  The rate of recurrence for suture repair was 38.6%; synthetic mesh reduced the recurrence rate to 8.8% (CI2.5-15.2%) while biologic mesh had no impact (31.8%,CI9.9%-53.7%).

Conclusion:
In contaminated ventral hernias, mesh repair (lightweight synthetic or biologic) compared to suture repair, does not increase the surgical site infection rate but may decrease the recurrence rate.  While we attempted to risk-adjust our outcomes, this study is limited by selection bias and its retrospective nature.  In the absence of higher level data, the results of this multi-center study suggest that light-weight synthetic mesh may be a safe choice in contaminated ventral hernia repair.   

49.03 Comparative Effectiveness Of Bariatric Surgery Upon Liver Function

Posted on December 22, 2014

T. Mokharti1, A. Nair1, D. Azagury1, H. Rivas1, J. Morton1  1Stanford University,Bariatric And Minimally Invasive Surgery,Palo Alto, CA, USA

Introduction: Nonalcoholic fatty liver disease (NAFLD) is a common cause of chronically elevated liver function tests (LFTs) and predisposes patients to the development of fibrosis. Obesity is a known risk factor for the development of NAFLD. This study aims to evaluate the effect of bariatric surgery on liver function in the morbidly obese by comparing changes in LFTs in patients undergoing laparoscopic Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and adjustable gastric banding (LB).

Methods: At a single academic institution, prospective data from 1063 patients undergoing bariatric surgery was analyzed.  LFTs including total bilirubin, aspartate transaminase (AST), alanine transaminase (ALT), and alkaline phosphatase (AlkPhos) as well as platelet counts were determined preoperatively and 12-months postoperatively. Comparison of LFTs between pre-op and 12-months post-op was performed using paired Student’s t-tests. LFT values, AST-to-ALT ratios (AST/ALT) across surgery types were analyzed with one-way ANOVA for continuous variables and chi-squared analysis for dichotomous variables. All analysis was performed using GraphPad Prism 6.

Results:In this cohort, 839 patients underwent RYGB, 149 SG, and 75 AGB. The mean preoperative serum total bilirubin, AST, ALT, AlkPhos, and platelet levels were 0.705 mg/dL, 27.27 U/L, 39.78 U/L, 88.37 U/L, and 276.1, respectively. At 12 months post-op, total bilirubin, AST, ALT, AlkPhos, and platelet levels were 0.749 mg/dL, 22.70 U/L, 27.82 U/L, 86.40 U/L, and 247.1. Preoperatively, there was a difference in mean platelet count (p=0.0004) but no difference in mean LFT values across the 3 surgeries. 12 months post-op, there was a significant difference in mean ALT (p<0.0001) and AlkPhos (p=0.0303) values. Using paired t-tests, all patients saw a decrease in AST (p<0.0001), ALT (p<0.0001), and AlkPhos (p=0.0217) 12-monts post-op. At 12 months post-op, RYGB patients had a significant decrease in their AST (p<0.0001) and ALT (p<0.0001) levels. SG patients saw a decrease in 12-month AST (p=0.0002), ALT (p<0.0001), and AlkPhos (p=0.001). LB patients also had improvements in 12-month AST (p=0.0012), ALT (p<0.0001), AlkPhos (p=0.0004). Looking at the relationship between 12-month percent excess weight loss (%EWL) and the change in LFTs from pre- to 12-months post-op, %EWL in SG patients was positively correlated to the change in AST (r=0.4360, p<0.0001) and in LB patients, was positively correlated to the changes in both total bilirubin (r=0.6137, p<0.0001) and AST (r=0.6963, p<0.0001). RYGB patients saw no correlation between 12-month %EWL and change in LFTs despite large improvements in weight and LFTs.

Conclusion:

In this study, all bariatric surgeries (RYGB, SG, and LB) improved LFTs. RYGB was unique in that LFT improvement associated with this procedure was independent of weight loss. Improvements in LFTs are promising given the high incidence of nonalcoholic fatty liver disease in the bariatric population.

 

49.04 A US Population Based Study Comparing Bile Duct Injury After Open and Laparoscopic Cholecystectomy

Posted on December 22, 2014

S. Patil1, S. H. Fletcher1, F. C. Nance1, R. S. Chamberlain1,2,3  1Saint Barnabas Medical Center,General Surgery,Livingston, NJ, USA 2University Of Medicine And Dentistry Of New Jersey,Newark, NJ, USA 3Saint George’s University,Grenada, Grenada, Grenada

Introduction: Bile duct injury (BDI) during cholecystectomy is a serious complication associated with high morbidity and mortality. This study aimed to determine and analyze the trends and clinical outcomes in BDI and factors influencing BDI in the US over 22 years.

Methods: Data on patients undergoing Open Cholecystectomy (OC) and Laparoscopic Cholecystectomy (LC), as a primary procedure were abstracted from Nationwide Inpatient Sample (NIS) database (1988-2010). Demographic, clinical and hospital characteristics were analyzed as shown in Table 1. BDI rates were compared across two study periods, First (1988-1997) and Second (1998-2010), for both OC and LC. Categorical variables were compared using the Chi-square test and the Student’s t-test was used to compare continuous variables. Multivariate analysis was performed to identify factors influencing BDI.

Results: 1,756,962 (34.0% OCs and 66.0% LCs) cholecystectomy were performed with 9,464 (0.5%) BDIs (1.35% OC and 0.13% LC). OCs decreased by 88.3% with corresponding BDIs decreased by 22.9%. LCs increased by 22.4% with corresponding BDIs decreased by 45%. BDI patients were significantly older in both OC and LC. Overall males had higher BDI for both OC and LC. In OC the overall BDI rates increased in the second study period for all the variables analyzed, except for African Americans, CBD obstruction and in private (for profit) hospitals. Among OC with BDI there was decreased LOS from admission to OC, and discharge to short term hospital, nursing home, and home health care. Among the LC group, the overall BDI rates remained unchanged or decreased in the second study period for all the variables analyzed, except for elective admission and non-inflammatory diagnosis. Among LC with BDI there was increased LOS from admission to LC and discharges with home health care. For both OC and LC with BDI there was increase in the primary repair rates and total charges with decrease in biliary-enteric anastomosis, overall LOS and mortality. On multivariate analysis, age > 50 years, males, OC, large bedsize, urban, teaching hospitals, Northeast US, non-inflammatory diagnosis and patients with CBD stones had increased risk of BDI.   

Conclusion: Several independent risk factors for BDI have been identified as outlined above.  Notably, obesity is not a risk factor for BDI. LC during acute attack is associated with fewer BDI then a delayed approach. Increased BDI in the absence of inflammation at diagnosis may indicate chronic disease state with dense adhesions. BDI in LC appears to be less complex considering high number of primary repairs. Primary repair appears to be the preferred treatment for both OC and LC BDIs, however long term success remains unknown. Increased morbidity and mortality in OC needs critical attention. Increasing mortality in LC with no BDI needs further evaluation.          

 

49.05 Clinical comparison of laparoscopic and open liver resection after propensity matching selection

Posted on December 22, 2014

M. Meguro1, T. Mizuguchi1, M. Kawamoto1, S. Ota1, M. Ishii1, T. Nishidate1, K. Okita1, Y. Kimura1, K. Hirata1  1Sapporo Medical University School Of Medicine,Department Of Surgery, Surgical Oncology And Science,Sapporo, HOKKAIDO, Japan

Introduction:  Number of laparoscopic liver resection (LR) tends to be increasing in recent years.  Although the short term safety in the LR was comparable to the classical open liver resection (OR), the long-term prognosis between LR and OR has not been elucidated yet. So, we retrospectively analyzed the patients who received liver resection consecutively and selected matching paired group among LR and OR after propensity score analysis.  Aim of this study was to show any prognostic difference between LR and OR in the hepatocellular carcinoma (HCC) patients who received initial liver resection.  

Methods: From January 2003 and June 2011, consecutive 260 HCC patients (LR: n=60 and OR: n=200) were enrolled in this study.  Propensity scores were calculated for each patient in the two groups, using the following 10 covariate factors, such as age, gender, tumor size, number of tumors, vascular invasion, poor differentiation/non-poor differentiation, serum total bilirubin, serum albumin, PT, and ICGR15.  One-to-one matching was carried out by propensity score analysis with Greedy method.  The survival curves were compared by log-rank test using the Kaplan-Meier method.

Results: In the full analysis set (n = 260), patients of advanced age and female patients were significantly different between the groups.  Tumor factors such as size, the number of tumors, vascular invasion, and the frequency of poor differentiation were significantly more favorable, the amount of bleeding during surgery was significantly lower, and operation time was significantly shorter in the Lap group.  A recurrence-free survival rates (RFS) and postoperative overall survival rates (OS) in the LR (Fig. 1a and 1b) were significantly longer than in the OR (P = 0.048 and 0.004, respectively).  After propensity score matching analysis, 35 each patient was selected and analyzed as matching set.  The intraoperative bleeding in the LR was significantly lower than in the OR (p=0.002), although other clinical variables were generally consistent in the two groups.  In addition, there was no significant difference (Fig. 1c and 1d) in the RFS and OS (P = 0.954 and 0.672, respectively).

Conclusions: When the prognoses of HCC patients after initial liver resection were compared between the LR and the OR after matching patient background factors, including tumor factors and liver function factors, no significant differences in RFS or OS were observed, demonstrating non-superiority of LR.  Therefore, LR seems to offer comparable oncological curability to the classical OR in the long-term prognosis.

49.06 A United States Population-Based Study Analyzing Trends In Acute Diverticulitis Readmission Rates

Posted on December 22, 2014

S. Patil1, S. H. Fletcher1, F. C. Nance1, R. S. Chamberlain1,2,3  1Saint Barnabas Medical Center,General Surgery,Livingston, NJ, USA 2University Of Medicine And Dentistry Of New Jersey,Newark, NJ, USA 3Saint George’s University,Grenada, Grenada, Grenada

Introduction: Acute diverticulitis (AD) and relapse are common indications for colectomy. This study examines the impact of AD on the type of operation performed and the clinical outcome.      

Methods: Data on 168,816 AD patients was abstracted from the State Inpatient Database (SID) database (2006-2011). Readmission rates (New York and California) for Young (Y; 20-40 years and Older (O; >41 years) patients were compared.

Results: 54,302 (32.2%) readmissions for AD were identified. Readmissions were higher in the young cohort (NY; 37.5%, CA; 38.6%. vs O NY; 32.9%, CA; 30.1%, p<0.001). Young males (NY; 40.3%, CA; 32.6%) and O females (NY; 34.1%, CA; 30.4%) had higher readmissions, p<0.001. NY caucasians ( Y 39.6% and O 33.4%) and CA African Americans (Y 42.6% and O32.3%) had higher readmission rates, p<0.001. Younger patients had at least one co-morbidity, with 51.5% having >3 co-morbidities, p< 0.001. Disease free interval decreased and LOS increased with each readmission, p<0.001. 7% had surgery during the initial admission, which increased to ≥40% by the 2nd or 3rd admission. Young patients underwent more primary resection and anastomosis (Y: NY; 57.9% and CA 45.8% vs. O: CA; 38.7% and NY us 38.7%, p <0.001). No differences were noted in regards to diverting ileostomy, diagnostic laparoscopy or percutaneous drainage.

Conclusion: Readmission for recurrent diverticulitis is common in all age groups. Disease-free interval decreases and LOS and surgical intervention increase with each readmission resulting in a higher % of patients undergoing surgery at each subsequent admission. One stage procedure is among the most common procedures performed for AD.   

 

49.07 Sublay Versus Underlay in Open Ventral Hernia Repair: A Multi-Institutional Risk-Adjusted Comparison

Posted on December 22, 2014

J. Holihan1, I. L. Bondre1, E. P. Askenasy2, J. A. Greenberg3, J. Keith6, R. G. Martindale5, J. S. Roth4, C. J. Wray1, L. S. Kao1, M. K. Liang1  1University Of Texas Health Science Center At Houston,Houston, TX, USA 2Baylor College Of Medicine,Houston, TX, USA 3University Of Wisconsin,Madison, WI, USA 4University Of Kentucky,Lexington, KY, USA 5Oregon Health And Science University,Portland, OR, USA 6University Of Iowa,Iowa City, IA, USA

Introduction:
The ideal location for mesh placement in open ventral hernia repair(OVHR) remains under debate. Current trends lean toward underlay (intra-peritoneal) or sublay (retro-muscular or pre-peritoneal) with onlay and inlay repairs being largely abandoned. We hypothesize that in patients undergoing OVHR, sublay versus underlay placement of mesh results in fewer recurrences and surgical site infections(SSI).

Methods:
A multi-institution retrospective study was performed of all patients who underwent OVHR from 2010-2011. All patients with mesh placed in a sublay or underlay position and with at least 1 month of clinical follow-up were included. Primary outcome was SSI as defined by the Centers for Disease Control and Prevention (CDC). Secondary outcome was hernia recurrence (assessed by clinical examination or radiographic diagnosis). Multivariable analysis was performed using backwards stepwise logistic regression adjusting for variables selected a priori (ASA, smoking, BMI, acute, primary versus incisional, prior VHR, wound class, fascial release, fascial closure, and mesh type-biologic versus synthetic). Data was also analyzed using inverse probability weighting, which corrects for selection bias and missing data.

Results:
Of 328 patients followed for a median (range) of 17.2 (1.0-50.2) months, 97(29.6%) had a sublay repair.  The unadjusted rates of SSI and recurrence were lower for the sublay group compared to the underlay group (Table). Underlay repair had more superficial, mesh/deep, and organ/space SSIs.  On multivariable analysis, underlay was associated with an increased risk of SSI compared to sublay (OR 2.5, 95% CI 1.1-5.2).  There was no statistically significant difference in hernia recurrence between the two techniques (OR 1.0, 95% CI 0.5-2.1). Using inverse probability weighting, sublay placement of mesh had a 9.3% (4.2-14.4%) rate of SSI, and underlay placement had a 22.3% (15.2-29.4%) rate of SSI.  There was no difference in recurrence between the two techniques (underlay 18.5% CI 8.9-28.3%%; sublay 15.3% CI 7.0-23.7%).

Conclusion:
In this multi-center, risk-adjusted study, sublay repair was associated with fewer SSIs than underlay repair; however, there was no difference in rates of hernia recurrence.  In the absence of a randomized trial or more rigorous data, sublay mesh placement should be considered whenever possible for open ventral hernia repairs. 
 

49.08 Voice Messaging System Associated With Improved Survival In Patients With Hepatocellular Carcinoma

Posted on December 22, 2014

A. Mokdad1, A. Singal1, J. Mansour1, G. Balch1, M. Choti1, A. Yopp1  1University Of Texas Southwestern Medical Center,Surgery Oncology,Dallas, TX, USA

Introduction:  Hepatocellular carcinoma (HCC) treatment involves multiple specialties risking delayed treatment and worse outcomes. The aim was evaluating outcomes following implementation of a voice messaging system (VMS) designed to reduce delays in treatment following HCC diagnosis.

Methods:  A retrospective study of HCC patients was conducted in an outpatient safety net hospital between February 2008 and January 2012. In February 2010, VMS notification of HCC to the ordering physician and downstream treating physicians was implemented. Patients were divided into: 1) pre-intervention: diagnosis two years prior to implementation or failure of notification following implementation, 2) post-intervention: diagnosis two years following implementation. Demographics, tumor characteristics, treatment, and survival were compared.

Results: Ninety-seven patients diagnosed with HCC, 51 in the pre-intervention group and 46 in the post-intervention group. The main etiology of chronic liver disease was HCV infection and no differences in symptoms, liver dysfunction, tumor characteristics, or treatment were observed between groups. The time from diagnosis to clinic contact (0.5 months vs. 2.9 months, p=0.003) and time from detection to treatment (2.2 months vs. 5.5 months, p=0.005) was significantly shorter following VMS. BCLC A status (HR 3.4, 95%CI 2,6), treatment (HR 2.0, 95%CI 1,4), and VMS (HR 1.7, 95%CI 1,3) were independently associated with improved overall survival. Patients diagnosed following VMS had a median survival of 31.7 months compared to 15.7 months, p=0.008.

Conclusion: Implementation of VMS reduces time to treatment and reduction in time to initial clinic visit. Reduction in time to treatment is associated with improved outcome independent of tumor stage, underlying liver function, and treatment.

 

49.09 Outcomes Of Major Colorectal Surgery Of The Mid And Hindgut In Australia: A Population-Based Study

Posted on December 22, 2014

K. S. Ng1, Y. Y. Lee1, M. K. Suen1, N. Nassar2, M. A. Gladman1  1Sydney Medical School – Concord, University Of Sydney,Academic Colorectal Unit,Sydney, NSW, Australia 2The Kolling Institute, University Of Sydney,Clinical And Population Perinatal Health Research,Sydney, NSW, Australia

Introduction:
Previous population-based outcomes studies of colorectal surgery have been limited to patients with cancer and / or procedures performed only on the colon and / or rectum. Given that colorectal practice encompasses other diseases that affect the hindgut (e.g. diverticular disease) or the midgut (e.g. Crohn’s disease), an accurate appreciation of overall outcomes of major colorectal procedures is currently unknown. Therefore, we aimed to determine the statewide outcomes of patients undergoing major colorectal surgery on the mid and hindgut in the last decade in Australia.

Methods:
A population-based study was conducted using longitudinally linked statutory Admitted Patient Data Collection (hospital data) and Registered Deaths in New South Wales, Australia. The study population was defined as all patients undergoing major colorectal procedures on the mid and hindgut for colorectal disease in 2000-2010. These were identified via relevant procedural and diagnostic codes based on the Australian Classification of Healthcare Interventions and International Classification of Diseases version 10- Australian Modification (ICD10-AM), respectively. Descriptive statistics, 28-day readmission rate and 30-day and 1-year mortality rates, both overall and stratified by age and sex were calculated.

Results:
A total of 109,149 major colorectal procedures were performed in 89,053 patients during the study period. Over one-quarter (n=30,287; 27.7%) of patients were >75years, 47.2% were male and 11.1% (n=12,076) had a Charlson co-morbidity score ≥3. Almost two-thirds (63.5%) of all procedures were performed on the colon and / or rectum. Obstruction / adhesions and cancer accounted for more than half of all indications for surgery. The 28-day readmission rate was 22.7% (n=24,818) and overall 30-day and 1-year mortality was 6.1% (n= 5,451) and 13.5% (n=12,041), respectively. Compared with females, males had consistently higher 30-day (6.5 versus 5.8 deaths per 100 patients) and 1-year (42.5 versus 38.0 per 100 patients) mortality rates. Overall, 30-day mortality rates increased with age being 2.8, 8.0, 13.8 and 21.8 per 100 patients aged <70, 70-79, 80-89 and 90+ years, respectively. Similarly, 1-year mortality rates increased with age being 7.8, 17.4, 26.3 and 39.3 years per 100 patients for <70, 70-79, 80-89 and 90+ years, respectively.

Conclusion:
This, the first population-based study of outcomes following major colorectal surgery, including procedures on the mid and hindgut, demonstrates that overall Australian mortality rates are similar to those of other countries. However, findings reveal colorectal surgeons are facing an increasingly co-morbid and aged population, where the mortality is substantially higher. This suggests that new models of perioperative care need to be considered for colorectal surgery, especially for “high risk” patients.

49.10 The Relationship Between Length of Stay and Readmissions in Bariatric Surgery Patients

Posted on December 22, 2014

A. W. Lois1, M. J. Frelich1, N. Sahr2, S. F. Hohmann3, T. Wang2, J. C. Gould1  1Medical College Of Wisconsin,General Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,Biostatistics,Milwaukee, WI, USA 3University HealthSystem Consortium,Comparative Data & Informatics Research,Chicago, IL, USA

Introduction:  Readmissions are a potential quality metric in bariatric surgery. A readmission substantially increases the cost of a bariatric operation. In the current era of laparoscopic surgery, bariatric surgery patients are being discharged early, sometimes within 1 day of surgery. Early discharge has been implicated as a possible cause of early readmission. We hypothesized that early discharge following bariatric surgery is not associated with an increased rate of readmission.

Methods:  The University Health System Consortium (UHC) is an alliance of academic medical centers and 244 affiliated hospitals.  The database contains information on inpatient stay up to 30 days post-discharge.  A multicenter analysis of patient outcomes was performed using the 5-year discharge data from December 2008 to December 2013 for patients 18 years and older.  Patient data was collected using procedure codes for gastric bypass, laparoscopic adjustable gastric band, and laparoscopic sleeve gastrectomy. All procedures were restricted by diagnosis codes for morbid obesity.

Results: A total of 95,294 patients met inclusion criteria. The mean age of the study population was 45.4 (±0.11) years and 73,941 (77.6%) subjects were female. The most common procedure was gastric bypass (58,036; 60.9%), followed by sleeve gastrectomy (26,669; 28.0%), and gastric banding (10,589; 11.1%). There were a total of 5,423 (5.7%) readmissions. Readmission rates were 6.3% for gastric bypass, 5.6% for sleeve gastrectomy, and 2.7% for gastric banding (p<0.01). Complications were experienced in 1.1% of gastric bypass, 1.3% of sleeve gastrectomy, and 0.3% of gastric banding procedures (p<0.01). An increasing number of comorbid conditions and increasing number of complications were both independently associated with higher rate of readmission on logistic regression (p<0.01, p<0.01).

Conclusion: Early discharge from the hospital following bariatric surgery does not appear to be associated with an increased rate of readmissions.  In fact, we observed the opposite effect with patients staying longer at the index admission more likely to be readmitted within 30 days.  Hospitals capable of efficiently discharging patients sooner may have other factors favoring a lower likelihood of readmission (surgeon experience, standardized pathways) not discernable from the current data. Complications, gastric bypass, and comorbidities are also associated with an increased risk of readmission.  Targeted interventions for patients with specific risk factors for readmission (early clinic visit for patients experiencing complications on the index admission for example) may be an effective strategy for reducing readmissions after bariatric surgery. 

 

47.01 Age-related Mortality in Blunt Traumatic Hemorrhagic Shock: the Killers and the Life Savers

Posted on December 22, 2014

J. O. Hwabejire1, C. Nembhard1, S. Siram1, E. Cornwell1, W. Greene1  1Howard University College Of Medicine,Surgery,Washington, DC, USA

Introduction:
Hemorrhagic shock (HS) is the leading treatable cause of trauma deaths but there are sparse data on the association between age and mortality in this condition. We examined the relationship between age and mortality as well as identified the predictors of mortality in HS.

Methods:
The Glue Grant database  was analyzed. Patients aged≥16 years who sustained blunt traumatic HS were initially stratified into 8 age groups (16-24, 25-34, 35-44, 45-54, 55-64, 65-74, 75-84, 85 and above) in order to identify the mortality inflection point. For subsequent analyses, patients were stratified into: Young (16-44), Middle Age (45-64) and Elderly (65 and above). Multivariable  analysis was then used to determine predictors of mortality by group.

Results:
1976 patients were included, 66% males and 89% white, with mortality of 16%. Mortality by  initial age group are as follows: 16-24 (13.0%), 25-34 (11.9%), 35-44 (11.9%), 45-54 (15.6%), 55-64 (15.7%), 65-74 (20.3%), 75-84 (38.2%), 85 and above (51.6%), delineating 65 years as the mortality inflection point. Overall, 55% were Young, 30% Middle Age, and 15% Elderly. In the Young, survivors had lower emergency room (ER) lactate (4.4±2.5 vs. 8.0±4.3, p<0.001), Marshall’s multiple organ dysfunction score, MODS (4.8±2.4 vs. 6.8±4.1, p<0.001), and Injury Severity Score (ISS,32±13 vs. 39±14, p<0.001) than non-survivors. Predictors of mortality include MODS (OR:1.93,CI:1.62-2.30, p<0.001), ER lactate (OR:1.14,CI:1.02-1.27, p<0.022), ISS (OR:1.06,CI:1.03-1.09, p<0.001) and cardiac arrest (OR:10.60,CI:3.05-36.86, p<0.001. In Middle, survivors had lower MODS (5.0±2.3 vs. 7.3±4.2, p<0.001) and higher ER mean arterial pressure (74±41 mmHg vs. 63±43 mmHg, p=0.023) and were less likely than non-survivors to get a craniotomy (4% vs. 10%, p=0.025) or a thoracotomy (8% vs. 26%, p<0.001). Predictors of mortality in this group include MODS (OR:1.38,CI:1.24-1.53, p<0.001), cardiac arrest (OR:12.24,CI:5.38-27.81, p<0.001), craniotomy (OR:5.62,CI:1.93-16.37, p=0.002), and thoracotomy (OR:2.76,CI:1.28-5.98, p=0.010. In Elderly, survivors were slightly younger (74±7 vs. 78±7, p<0.001), had  lower MODS (5.3±2.1 vs. 6.6±3.0, p<0.001), received higher volume of prehospital hypertonic saline (1.97±0.16 L vs. 1.83 ±0.38 L, p=0.002) and were less likely to get a laparotomy (26% vs. 63%, p<0.001).  Predictors of mortality in this group include age (OR:1.07,CI:1.02-1.13, p=0.005), MODS (OR:1.47,CI:1.26-1.72, p<0.001), laparotomy (OR:2.04,CI:1.02-4.08, p=0.045) and cardiac arrest (OR:11.61,CI:4.35-30.98, p<0.001) .

Conclusion:
In blunt HS, mortality parallels increasing age, with the inflection point at 65 years. MODS and cardiac arrest uniformly predict mortality across all age groups. Open fixation of non-femur bone is uniformly protective against mortality across all age groups. Craniotomy and thoracotomy are associated with mortality in Middle Age whereas laparotomy is associated with mortality in Elderly.
 

47.02 Serum Transthyretin is a Predictor of Clinical Outcomes in Critically Ill Trauma Patients

Posted on December 22, 2014

V. Cheng1, K. Inaba1, T. Haltmeier1, A. Gutierrez1, S. Siboni1, E. Benjamin1, L. Lam1, D. Demetriades1  1University Of Southern California,Division Of Trauma And Surgical Critical Care, Department Of Surgery, LAC+USC Medical Center,Los Angeles, CA, USA

Introduction:
In surgical patients, low preoperative serum Transthyretin (TTR) level is associated with significantly longer hospital and intensive care unit (ICU) stays, higher infectious complication rates, and mortality rates.  However, the predictive value of TTR levels on outcomes after major trauma has not yet been studied.

Methods:
After IRB approval, a retrospective analysis was conducted on critically ill trauma patients admitted to the Surgical ICU at the LAC+USC Medical Center between January 2008 and May 2014.  The study included all patients who underwent a surgical procedure for trauma and had their TTR measured ≤24 hours after ICU admission.  Outcome metrics included hospital length of stay (LOS), ICU LOS, ventilator days (VD), infectious complication rate, and mortality rate.  Significance of TTR on outcome metrics was determined using univariable (Mann-Whitney U test and Fisher’s exact test) and multivariable (linear and binary logistic regressions) analyses.  In univariable analysis, patients were stratified into two TTR groups: Normal (≥19 mg/dL) and Low (<19 mg/dL).  In multivariable analysis, TTR level was maintained as a continuous variable.

Results:
348 patients met inclusion criteria (median age 36 years, 79.6% male, median Injury Severity Score 17, 71.0% blunt trauma).  The Normal and Low TTR groups consisted of 189 (54.3%) and 159 (45.7%) patients, respectively.  Compared to the Normal TTR group, the Low TTR group was associated with longer hospital LOS (median: 17 vs. 9 days, p < 0.001), longer ICU LOS (6 vs. 4 days, p < 0.001), increased VD (1 vs. 0 days, p < 0.001), higher infectious complication rates (45.3% vs. 20.1%, p < 0.001), and higher mortality rates (17.0% vs. 7.4%, p = 0.007).  Even after adjusting for age, sex, and Injury Severity Score in multivariable regression analyses, TTR level was a significant independent predictor of clinical outcomes.  Lower TTR levels were associated with longer hospital LOS (p < 0.001), longer ICU LOS (p = 0.005), increased VD (p = 0.018), higher infectious complication rates (p < 0.001), and higher mortality rates (p = 0.017).

Conclusion:
In critically ill trauma patients, low serum TTR level is associated with longer hospital LOS, longer ICU LOS, increased VD, higher infectious complication rates, and higher mortality rates.  These results warrant prospective validation of the utility of TTR levels as an outcome predictor for critically ill trauma patients.
 

47.03 Will I miss an aneurysm? The role of CTA in traumatic subarachnoid hemorrhage

Posted on December 22, 2014

K. J. Balinger1, A. Elmously1, B. A. Hoey1, C. D. Stehly1,2, S. P. Stawicki1,2, M. E. Portner1  1St Luke’s University Health Network,Level I Regional Trauma Center,Bethlehem, PA, USA 2St. Luke’s University Health Network,Department Of Research & Innovation,Bethlehem, PA, USA

Introduction: Computed tomographic angiography (CTA) tends to be over utilized in patients with traumatic subarachnoid hemorrhage (tSAH) to rule out occult aneurysmal rupture and arteriovenous malformations (AVM).  We hypothesized that there are two specific categories of patients with tSAH that are at increased risk for aneurysm/AVM and warrant targeted CTA use: (a) patients "found down" with an unknown mechanism of injury and (b) those with central subarachnoid hemorrhage (CSH) or blood in the subarachnoid cisterns and Sylvian fissures.

Methods: A retrospective analysis was performed on trauma patients with blunt head injury and tSAH who underwent CTA of the brain between January 2008 and December 2012 at a Level I Regional Trauma Center. Variables utilized in the current analysis included patient demographics, injury mechanism and severity (ISS), Glasgow Coma Scale (GCS), CTA and related radiographic studies, as well as operative interventions.  The principal outcome measure was "confirmed diagnosis" of a ruptured aneurysm/AVM.  Independent sample t-test and chi square test were used for univariate analyses. Logistic regression was utilized in multivariate analyses. Statistical significance was set at alpha = 0.05.

Results: Out of 617 patients with tSAH, 186 underwent CTA.  Mean age of the study group was 57 years, with 64% of patients being male. The mean GCS on presentation was 11±5.0, with mean ISS of 20±11.5. CTA scans were positive in 23/186 cases (12.3%) with an aneurysm found in 21 patients and an AVM in 2 patients. Findings were felt to be incidental in 15/23 patients with "positive" CTA.  Among 14/186 patients (7.5%) who were "found down" none had an aneurysm or an AVM. A total of 8 patients had a ruptured aneurysm, with 5/8 (62.5%) presenting after a fall and 3 (37.5%) presenting after an MVC.  All 8 patients with aneurysmal rupture (100%) had CSH.  None of the 81 patients with only peripheral SAH had a ruptured aneurysm/AVM. Multivariate regression analysis demonstrated that suprasellar cistern hemorrhage on CT is independently associated with aneurysm rupture (OR, 6.39; CI 1.32-30.8). Patients with a ruptured aneurysm had a significantly higher mean arterial pressure (MAP) on presentation (mean, 116±7 mmHg) than those without an aneurysm/AVM (mean, 104±18 mmHg, p<0.005). Of the 8 patients with a ruptured aneurysm, 6 patients underwent neurosurgical clipping or coiling, 1 underwent a ventriculostomy, and 1 underwent a craniotomy for evacuation of hemorrhage.

Conclusion: These preliminary data support a more selective approach to screening CTAs in patients with tSAH. CTA should be utilized in those patients with CSH regardless of mechanism of injury.  A more selective approach should be considered in those patients with only peripheral SAH. Overall cost savings would be significant.
 

47.04 CANNABIS USE HAS NEGLIGIBLE EFFECTS AFTER SEVERE INJURY

Posted on December 22, 2014

K. R. AbdelFattah1, C. R. Edwards1, M. W. Cripps1, C. T. Minshall1, H. A. Phelan1, J. P. Minei1, A. L. Eastman1  1University Of Texas Southwestern Medical Center,Burns, Trauma, And Critical Care Surgery,Dallas, TX, USA

Introduction:  Since 1996, 22 states have legalized medical marijuana (MJ) use and two have legalized recreational use.  With more states considering legislation to legalize the use of the drug, emergency responders and facilities recieving these patients need to understand the impact on acute injuries. The effects of MJ use on injured patients has not been thoroughly evaluated. Our group sought to evaluate the effects of cannabis use at the time of severe injury on hospital course and patient outcomes.

Methods:  A retrospective chart review was undertaken at an urban Level 1 Trauma Center covering a two-year period. Patients presenting with an ISS>16 were divided into four groups based on urine drug screen results. Negative urine drug screen patients represented our control group.  Positive subjects were subdivided into marijuana-only (MO), other-drugs only (OD), and mixed-use (MU) groups.  These groups were compared for differences in presenting characteristics, hospital length of stay, ICU stays, ventilator days, and death.

Results: 8441 subjects presented during the study period, of which 2134 had drug testing performed. 843(40%) had an ISS>16, with 347(41%) having negative tests (NEG). 70(14%) tested positive for marijuana only (MO), 325 (65%) for drugs other than marijuana (OD), and 103 (21%) subjects showed mixed-use (MU). Alcohol levels were higher in the MO group than any other group (p<0.05) No differences were seen in presenting GCS, ICU/hospital length of stay, ventilator days, and blood administration when comparing the MO group to the NEG group. Significant differences were found between the OD group and the NEG/MO/MU groups for presenting GCS (OD 9.7 vs NEG 11.9, MO 12.4, MU 10.7, p<0.05), ICU days (OD 6.0 vs NEG 4.7, MO 4.6, MU 3.7, p<0.05) and hospital days (OD 14.2 vs. NEG 12.0, MO 12.0, MU 10.5 p<0.05), and hospital charges (OD 182k vs. NEG 147k, MO 157k, MU 132k p<0.05).

Conclusion: Cannabis users suffering severe injury demonstrated no acute detrimental outcomes in this study compared with non-drug users. With regards to presenting GCS, ICU/hospital length of stay, and hospital charges, marijuana, alone or in combination with other drugs appeared more similar to the NEG group rather than the OD group.

 

47.05 Pre-Hospital Care And Transportation Times Of Pediatric Trauma Patients

Posted on December 22, 2014

C. J. Allen2, J. P. Meizoso2, J. Tashiro1, J. J. Ray2, C. I. Schulman2, H. L. Neville1, J. E. Sola1, K. G. Proctor2  1University Of Miami,Pediatric Surgery,Miami, FL, USA 2University Of Miami,Trauma And Critical Care,Miami, FL, USA

Introduction:  Trauma is the leading cause of death and morbidity in children in the US.  Aggressive efforts have been made to improve emergency medical transportation of injured children to major trauma centers. Still, controversy exists whether pre-hospital care improves outcomes or simply delays the necessary immediate transportation. We hypothesize that at large level 1 trauma center, with a mature pre-hospital network, pre-hospital care of severely injured children does not influence transportation time.

Methods:  From January 2000 to December 2012, consecutive pediatric admissions (≤17y) at a Level I trauma center were retrospectively reviewed for demographics, mechanisms of injury (MOI), mode of transportation, transportation times, pre-hospital interventions, injury severity score (ISS), length of stay (LOS), and survival. We analyzed pre-hospital interventions and compared transport times in survivors and non-survivors, as this cohort represents the most severely injured. Parametric data presented as mean±standard deviation and nonparametric data presented as median(interquartile range).

Results:  1,878 admitted patients were transported via emergency medical services (EMS).  Age was 11±6y with 70% male, 50% black; 76% sustained blunt injuries with an ISS of 13±12. Of these, 31% required operative intervention, LOS of 7±12, and mortality of 3.6%.  Pre-hospital care, transport times, and ISS were compared between survivors and those who died in-hospital, see Table. There were no significant differences in EMS scene to hospital arrival times between those with and without on-scene shock (27(15)min vs 27(15)min, p=NS), or between those who required on-scene intubation (32(14)min vs 27(15)min, p=NS). 

Conclusion: In the most severely injured children, those with ultimately fatal injuries, there are significantly increased rates of pre-hospital interventions, but on-scene and transportation times are not prolonged. There is no difference in pre-hospital transportation times between those with and without on-scene shock, or those requiring on-scene intubation. These results support the concept that pre-hospital interventions by skilled EMS are not associated with prolonged transportation times of critically injured pediatric trauma patients.

47.06 Trends in 1029 Trauma Deaths at a Level 1 Trauma Center

Posted on December 22, 2014

B. T. Oyeniyi1, E. E. Fox1, M. Scerbo1, J. S. Tomasek1, C. E. Wade1, J. B. Holcomb1  1University Of Texas Health Science Center At Houston,Acute Care Surgery/Surgery,Houston, TX, USA

Introduction:  Over the last decade the age of trauma patients and injury mortality has increased. At the same time, we have implemented many interventions focused on improved hemorrhage control. The objective of our study was to analyze the temporal distribution of trauma-related deaths, the factors that characterize that distribution and how those factors have changed over time at our level 1 trauma center. 

Methods:  The trauma registry, weekly Morbidity & Mortality reports and electronic medical records at Memorial Hermann Hospital in Houston, TX were reviewed.  Patients with primary burn injuries and pediatric age (<16) patients were excluded.  Two time periods (2005-2006 and 2012-2013) were included in the analysis. Baseline characteristics, time and cause of death were recorded. Mortality rates were directly adjusted for age, gender and mechanism of injury.  Results are expressed comparing 2005-2006 with 2012-2013. The Mann-Whitney and chi square tests were used to compare variables between periods, with significance set at the 0.05 level.

Results: 7080 patients including 498 deaths were examined in the early time period, while 8767 patients including 531 deaths were reviewed in the recent period.  The median age increased 6 years between the two groups, with a similar increase in those who died, 46 (28-67) to 53 (32-73) (p<0.01) years. In patients that died, no differences by gender, race or ethnicity were observed. Fall-related deaths increased from 20% to 28% (p<0.01) while deaths due to motor vehicle collisions decreased from 39% to 25% (p<0.01). Deaths associated with hemorrhage decreased from 36% to 25% (p<0.01).   26% of all deaths (including dead on arrival, DOAs) occurred within one hour of hospital arrival, while 59% occurred within 24 hours, and were similar across time periods. Unadjusted overall mortality dropped from 7.0% to 6.1% (p=0.01) and in-hospital mortality (excluding DOA) dropped from 6.0% to 5.0% (p<0.01). Adjusted overall mortality dropped 24% from 7.6% (95% CI: 6.9-8.2) to 5.8% (95% CI: 5.3-6.3) and in-hospital mortality decreased 30% from 6.6% (95% CI: 6.0-7.2) to 4.7% (95% CI: 4.2-5.1). 

Conclusion: Although US data show a 20% increase in death rate due to trauma over a similar time period, this single-site study demonstrated a significant reduction in adjusted overall and in-hospital mortality. It is possible that concentrated efforts on improving resuscitation and multiple other hemorrhage control interventions resulted in the observed reduction in hemorrhage related mortality. Most trauma deaths continue to be concentrated very soon after injury. We observed an aging trauma population and an increase in deaths due to falls. These changing factors provide guidance on potential future prevention and intervention efforts. 

 

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