6.03 Enterocutaneous Fistula Treatment (ECF) with Fibrin Glue Injection – Does it work?

Posted on December 22, 2014

J. S. Merkow1, A. Paniccia1, M. Gipson1, J. Durham1, L. Wilson1, J. Vogel1  1University Of Colorado Denver,Aurora, CO, USA

Introduction:  ECF is a challenging problem that often requires complex surgery for resolution.  A reliable nonsurgical cure for ECF would be welcome.  Fibrin glue treatment of anal fistula tract is an accepted and commonly used therapy with several studies demonstrating its efficacy.  The value of fibrin glue treatment for ECF has been relatively poorly evaluated.  The PURPOSE of this study was to describe our experience with fibrin glue therapy of ECF and determine characteristics associated with therapeutic success or failure. 

Methods:  Clinical data was extracted from a chart review of patients with ECF who underwent fibrin glue injection at the University of Colorado Hospital from 2003 to 2014.  Eligible patients had clinical and radiologic evidence of a fistula originating from the small or large intestine, between the ligament of Trietz and the upper rectum. Low output vs. high output fistula were <200 cc/day vs. >200cc/day.  Complete success was defined as 100% closure of the ECF.  Partial success was defined as decreased output reported by patient or physician after the gluing and during follow up.  Demographic and clinical data were recorded. 

Results: There were 38 patients with a median age of 55 years (IQR 45-62) with 22 (58%) male and 16 (42%) female patients. The median BMI was 24 (IQR 22-29), albumin 2.5 g/dL (IQR 1.9-2.9), and hemoglobin 9.9 g/dL (IQR 8.6-11).  Average ECF duration was 5 months (IQR 2-19).  20 (52%) patients had low output fistulas compared to 1 (3%) with a high output fistula. ECF origin was 17 (45%) small bowel, 16 (42%) colon, and 1(13%) rectum.  Etiology of fistula formation was iatrogenic in 21 (55%) patients, of which 18 (47%) occurred after a surgical procedure.  Other causes of fistula formation were infection/abscess (9, 24%) and pancreatitis (8, 21%).  The median number of gluing procedures was 1 (IQR 1-2).  Median follow-up after glue therapy was 17 months (IQR 5-52). Complete success occurred in 12 (34%) patients and partial success in 6 (17%).  Complete and partial therapeutic success was 23% and 18% for small bowel and 50% and 12% for colorectal fistula.  Of patients with complete success, 83% closed within 1 week of therapy and 75% required only a single fibrin treatment.  There were no complications associated with the use of fibrin therapy.  Analysis of factors including immunosuppression, albumin, obesity, IBD, cancer, output volume, repeated gluing procedures and fistula duration did not predict successful fibrin glue therapy.  

Conclusion: Fibrin glue therapy was a complete success in one-third of patients with an ECF that originated from the small or large bowel.  There were no complications associated with this therapy.  Further studies on a larger sample will be required to identify factors associated with successful fibrin glue therapy of ECF.  In the meantime, with little to lose and much to gain, we advocate a trial of fibrin glue therapy for ECF prior to surgical intervention. 
 

6.04 Laparoscopic Appendectomy: Who Falls Through the Cracks?

Posted on December 22, 2014

K. N. Marley1, A. M. Fecher1, B. L. Zarzaur1, G. A. Gomez1  1Indiana University School Of Medicine,Department Of Surgery,Indianapolis, IN, USA

Introduction:  Laparoscopic appendectomy (LA) is well accepted as a standard treatment for patients with acute appendicitis.  However, the types of complications and the patients likely to suffer them are not well characterized.  The purpose of this study was to characterize the types of complications that occur after LA and to determine factors for complication occurrence.  

Methods:  A retrospective review was performed to include patients 15 years and older undergoing a LA (CPT code 44970) between January 1, 2009 and April 1, 2014 at a single institution.  Demographic data, imaging, pathology, operative reports, length of stay, complications, and relevant history were obtained. Bivariate and multivariable analyses were used to determine risk factors for complications.  

Results: 625 patients met inclusion criteria.  Complications occurred in 14.6% (n=91) of patients. The 3 most common complications were organ space infections (n=45, 7.2%), superficial surgical site infection (n=23, 3.7%) and ileus (n=15, 2.4%). After bivariate and multivariable analysis, age (45-54yrs vs 15-24yrs – OR 4.14 95%CI 1.83, 9.37), perforated appendix (OR 6.85, 95% CI 3.99, 11.80), and pain prior to surgery (5-7 days vs ≤1 day OR 4.37 95%CI 1.46, 13.14) were associated with complications.  Of all LA only one procedure related complication was noted (0.2%) due to a trocar placement injury, but no further complications occurred.  

Conclusion: Despite being considered minimally invasive and perceived as safe, LA is associated with complications in nearly 15% of patients undergoing the procedure.  Patients who are of middle age, with history of prolonged pain and perforation are at increased risk of suffering complications.  Earlier recognition of the signs and symptoms of acute appendicitis in this atypical age range could result in fewer complications overall for LA.  Future research should focus on possible areas of intervention in this vulnerable patient population.

 

6.05 Surgical Frailty in elderly patients undergoing urgent abdominal surgery

Posted on December 22, 2014

H. H. Garzon1, C. Restrepo1, E. L. Espitia1, L. Torregrosa1, L. C. Dominguez1  1Pontificia Universidad Javeriana – Hospital Universitario San Ignacio,Surgery,Bogota, , Colombia

Introduction: The association between frailty and worse outcomes in urgent abdominal surgery has not been completely evaluated. There is no information in Colombia. The objective of this study is to establish the relation between frailty, mortality, morbidity and readmission rates confined to the first 30th postoperative days, in a prospective cohort of elderly patients undergoing urgent abdominal surgery.   

Methods: The Canadian Study of Health and Aging Frailty Scale (CSHA) was applied at admission to the emergency room to elderly patients (>65 years). We determinate the association between CHSA frailty scale, demographic, clinical and surgical factors with the probability of complications, death and readmission by Chi-square and Fisher’s exact tests. Multivariate analyses were conducted to identify the independent association of previous significant factors with major outcomes. Survival analysis was performed by Kaplan-Meier analysis with a log-rank test.

Results:A total of 300 consecutive patients fulfilled the inclusion criteria and were included. The global mortality rate was 14% (42 patients), the morbidity rate was 27.6% (83 patients) and the readmission rate was 15.67% (47 patients). Fifteen percent presented a frailty degree (CSHA Frailty Scale>5). The main independent factor associated to mortality was the CSHA Frailty Scale>5 (OR:4,49 p<0,001). The main independent factors associated with morbidity were the CSHA Frailty Scale>5 (OR:2,78 p<0,014) and LoS>12 days (OR:6,83 p<0,001). The independent factors associated to readmission were malnutrition (OR:1.97 p<0,04) and previous major surgery (OR:2.27 p<0,04).

Conclusion:Surgical frailty is associated to postoperative morbidity and mortality in urgent abdominal surgery in the elderly population. This association was not demonstrated with the readmission. Additional interventions are needed to control this factor in the perioperative period, which must be evaluated in new studies.  

 

6.06 Costly Complications: Readmissions in Elderly Following Appendectomy

Posted on December 22, 2014

L. A. Bliss1, C. J. Yang1, Z. Chau2, E. Witkowski2, S. Ng1, W. Al-Refaie3, J. F. Tseng1  1Beth Israel Deaconess Medical Center,Surgical Outcomes Analysis & Research,Boston, MA, USA 2University Of Massachusetts Medical School,Department Of Surgery,Worcester, MA, USA 3Georgetown University Medical Center,Department Of Surgery,Washington, DC, USA

Introduction:  Elderly patients (65 years of age or older) may be at risk after routine surgical procedures given underlying co-morbidities, frailty, and decreased physiologic reserve. Research regarding readmissions in the elderly population following appendectomy for acute appendicitis is limited. This study examines rates, risk factors, and costs for readmission among elderly patients undergoing appendectomies for acute appendicitis.

Methods:  The Healthcare Cost and Utilization Project (HCUP) Florida State Inpatient Database and State Emergency Department Database with HCUP supplemental files for revisit analysis were used to identify inpatient admissions between 2007 and 2011 for patients age 65 years or older who underwent appendectomy for acute appendicitis.  Readmission was defined as emergency department (ED) visit or inpatient admission within 30 days of discharge. Demographic data included sex, age, Elixhauser co-morbidity score, and race.  Index admission information included procedure, length of stay (LOS), and complications. Total costs were determined using HCUP Cost-to-Charge Ratio Files. Univariate and multivariate analysis performed by chi-square and logistic regression. For all, p-values <0.05 were considered statistically significant.

Results: Within this large, racially diverse state, 8,669 elderly patients underwent appendectomy for acute appendicitis from 2007 to 2011. Appendectomy median LOS was 3 days (interquartile range (IQR) 2-6 days) and median cost was $9,384 (IQR $7,211-$13,009). 12.94% experienced inpatient complications. 13.39% (1,161) were readmitted within 30 days, of whom 39.19% (455) experienced an ED visit only and 60.81% (706) underwent inpatient readmission. After adjustment, readmission was more likely among males (p=0.0147) discharged to skilled nursing or other facilities (p<0.0001) with 3 or more co-morbidities (p<0.0001) and with select inpatient complications. On the other hand, within-elderly age and prolonged LOS did not predict re-admission. Of those readmitted, 16.37% had more than one readmission and median total cost of care was $16,624 (IQR $11,419-$25,244).

Conclusion: Appendicitis is not uncommon in elderly patients, who are at risk for both ED visits and inpatient admissions after appendectomy. Readmissions are more common among those discharged to facilities or with select complications during index admission. The financial impact of readmission is significant. Identifying elderly at risk of post-operative readmission may offer significant cost and resource savings.

6.07 Pneumatosis Intestinalis: Considerations for this Clinical Conundrum

Posted on December 22, 2014

E. Insley1, B. Braslow1, Z. Maher1, S. Allen1  1Hospital Of The University Of Pennsylvania,Philadelphia, PA, USA

Introduction: The radiographic finding of pneumatosis intestinalis (PI) raises the concern for ischemic bowel and possible need for urgent surgical intervention.   Lactic acidosis, peritonitis, and the systemic inflammatory response have been show to be predictors of surgical pathology in patients with PI, but how immunosuppressant may impact on the reliability of these findings is not well characterized. We hypothesized that the use of immunosuppressants and their effect on physical exam findings in patients with PI would lead one to rely on physiologic and metabolic derangements to base operative decision making.

Methods: The institutional radiology database from our urban academic medical center was queried over a 5 year period for patients with CT scans that had the presence of PI as determined by board-certified radiologists.  Radiology reports containing the words “pneumatosis intestinalis” were obtained and the scans were reviewed to confirm the presence of PI.  Only the index CT scan of each patient was included.  Demographics, comorbidities, laboratory values, physiologic data, and operative findings were abstracted by chart review for these patients.  Patients were stratified by immunosupression (defined as steroids, transplant immunosuppressants or recent chemotherapeutic agents) and univariate logistic regression was used to determine the association of these factors with the outcomes of interest including need for operation, therapeutic laparotomy (Ther lap) and in-hospital survival. 

Results:A total of 124 patients met inclusion criteria. Demographics were similar between the 2 groups. Statistically more patients in the immunosuppression group presented with > 2 SIRS criteria while lactic acid levels were similar. Other laboratory markers of acid/base status were also similar. There was no difference in the percentage of patients that underwent an operation with over 80% in each group receiving a therapeutic intervention (bowel resection). Those in the immunosuppression group without abdominal pain demonstrated the lowest proportion of a ther lap (Table).

Conclusion:The association between abdominal examination and positive operative findings appears to be similar in immunocompromised and immunocompetent hosts.  Additionally, patients taking immune suppressing medications demonstrated the ability to mount an inflammatory response based on defined SIRS criteria. The decision to operate in patients with PI should be based on SIRS criteria, acid base status and abdominal exam in both immunocompetent and immunocompromised patients.
 

6.08 Anxiolytic Medication is an Independent Risk Factor for Short-Term Major Morbidity after Surgery

Posted on December 22, 2014

D. L. Davenport1, J. S. Roth1, N. Ward3, L. Mutiso4, C. C. Lester2, K. M. Lommel2, D. L. Davenport1  1University Of Kentucky,Dept. Of Surgery,Lexington, KY, USA 2University Of Kentucky,Dept. Of Psychiatry,Lexington, KY, USA 3University Of Kentucky,College Of Medicine,Lexington, KY, USA 4University Of Kentucky,College Of Nursing,Lexington, KY, USA

Introduction: The incidence of psychiatric illness is increasing in the United States as is treatment with psychotropic medication. The area of the country in which this study was conducted also has a known high incidence of prescription drug abuse. There have been several reports of the effects of depression and antidepressants on cardiac surgery outcomes, but chronic anxiety and anxiolytics have been understudied.  This study aimed to determine the relationship, if any, between preoperative anxiolytic medication and morbidity after a broad range of non-cardiac surgeries.

Methods: A retrospective review of the American College of Surgeons National Surgery Quality Improvement Program data at a single large academic medical center was performed with the addition of anxiolytic prescription medication (AXM, benzodiazepines or hydroxyzine HCL) identified at admission from the patients’ active medication list. The data reflected a prospective, 100% sample of 20 major general, vascular, urologic and plastic surgical procedures performed at our hospital between October 1, 2011 and September 30, 2012. The data included demographics, >30 comorbid clinical risks, procedural variables and 21 specific complications and death for up to 30 days after major surgery. Major morbidity (MM) was defined as a patient having one or more of the complications or death.

Results: We reviewed a total of 1847 surgical patients of whom 289 (15.6%)  were taking AXM at admission. AXM use varied significantly by type of procedure (p <.001) with breast reconstruction patients having >25% AXM use while appendectomy and prostatectomy <7% AXM use. Operative duration was ½ hour longer on average in AXM patients (p <.001) who were also more likely to be smokers, suffer from COPD, dyspnea and hypertension (all p <.001). They had higher MM (24.3% vs 14.9%, p <.001), particularly infections (16.3% vs. 9.4%, p =.001) and 1 day longer median hospital stay (3 vs 2 days, p <.001).  In multivariable logistic regression, AXM was an independent predictor of MM (odds ratio 1.73, 95% CI 1.09-2.75, p=.021) after adjustment for the procedure performed, clinical and demographic risk factors. Conclusion: We found that 15.6% of our non-cardiac surgery patients were actively taking anxiolytics at admission and that these patients had significantly worse risk-adjusted short-term surgical outcomes, particularly infection.  Future studies are needed to study mechanism; particularly whether the observed outcomes were caused by physiologic changes due to chronic anxiety or to the medications themselves.

 

6.09 Impact of Health Literacy on Post-Operative Outcomes in Patients Undergoing Major Abdominal Surgery

Posted on December 22, 2014

G. C. Edwards1, K. M. Goggins2, J. Ehrenfeld3, H. R. Mir4, A. A. Parikh1, N. B. Merchant1, S. B. Kripalani2, K. Idrees1  2Vanderbilt University Medical Center,Center For Health Services Research,Nashville, TN, USA 3Vanderbilt University Medical Center,Department Of Anesthesiology, Vanderbilt Anesthesiology & Perioperative Informatics Research (VAPIR) Division,Nashville, TN, USA 4Vanderbilt University Medical Center,Department Of Orthopaedics & Rehabilitation,Nashville, TN, USA 1Vanderbilt University Medical Center,Department Of Surgery, Division Of Surgical Oncology,Nashville, TN, USA

Introduction:  

Health literacy (HL) is broadly defined as an individual’s ability to obtain, process, and understand health information in order to make informed health care decisions. Low HL status adversely affects health outcomes in patients living with chronic diseases such as diabetes, hypertension, and congestive heart failure. However, the link between HL and post-operative outcomes has not been evaluated in the surgical population. The aim of this study is to evaluate the influence of HL on post-operative outcomes in patients undergoing major abdominal surgery.

Methods:  

From 2010 to 2013, 1,376 patients undergoing elective gastric, colorectal and hepato-pancreatico-biliary resections at a single academic institution were assessed. Patient demographics, education and insurance status, procedure type, American Society of Anesthesiologists (ASA) status, Charlson comorbidity index (CCI), and post-operative outcomes [complications, length of stay (LOS), 30- and 90-day emergency department (ED) visits, and 30- and 90-day unplanned hospital readmissions] were obtained from the electronic medical records.  HL was assessed using the Brief Health Literacy Screen (BHLS), a validated tool administered by nursing staff upon hospital admission. This tool is scored 3-15 and divided into four HL categories [low (3-8), intermediate (9-11), intermediate-high (12-14), and high (15)].  Multivariable logistic regression modeling was utilized to determine the association of HL and other covariates on post-operative outcomes.

Results: 

In this cohort, there was a median HL score of 15.0 and a median educational attainment of 13.0 years. Hospital readmission and re-presentation to the ED within 30 days were 16% and 13.5%, respectively, and within 90 days were 19% and 16%, respectively. ASA status, pancreatic and gastric resections, and postoperative complications were independently associated with increased LOS [p<0.05], while post-operative complications [OR 3.482, CI 2.4-5.1, p<0.001], increased LOS [OR 0.972, CI 0.953-0.992, p=0.007], and higher CCI [OR 0.949, CI 0.905-0.992, p=0.030] were associated with increased rates of readmission within 90 days. After controlling for all factors, patients with a higher HL score had a shorter LOS [p=0.016]. However, low HL was not significantly associated with increased rates of complications [OR 0.994, CI 0.935-1.056], 30- or 90-day hospital readmission [OR 0.972, CI 0.921-1.026], or 90-day ED visits [OR 0.991, CI 0.935-1.050]. 

Conclusion: 

Higher HL status is independently associated with shorter LOS in patients undergoing major abdominal surgery. In contrast, lower HL status is not associated with increased complication rates or 30- and 90-day hospital readmissions or ED visits. Decreased LOS results in decreased hospital cost and improved overall patient satisfaction. Therefore, the role of health literacy should be considered within surgical practice to improve health care utilization. 

6.10 Laparoscopic Inguinal Herniorrhaphy: Comparing Outcomes Between Self-adhering Versus Tacked Mesh

Posted on December 22, 2014

I. S. Pourladian1, A. W. Lois1, M. J. Frelich1, A. S. Kastenmeier1, J. R. Wallace1, J. C. Gould1, M. I. Goldblatt1  1Medical College Of Wisconsin,General Surgery,Milwaukee, WI, USA

Introduction:  Inguinal herniorrhaphy is one of the most common surgical procedures performed annually. Several synthetic meshes are available to reinforce the inguinal region following laparoscopic hernia reduction. Historically, most surgeons secure mesh with tacks; however, self-adhering mesh now allows the elimination of fixating tacks. We sought to compare postoperative outcomes of patients who underwent laparoscopic inguinal herniorrhaphy using self-adhering polyester mesh to those who had non-adhering, synthetic mesh implanted using absorbable tacks.

Methods:  This study is a retrospective review of patients who underwent primary laparoscopic inguinal herniorrhaphy at the Medical College of Wisconsin between October 2012 and July 2014. Procedures were performed by four surgeons. Clinical information and perioperative outcomes were collected up to one year following surgery when available. The Surgical Pain Scale (SPS) was used to evaluate pain preoperatively, at two weeks, six weeks, six months, and one year after surgery.

Results: One hundred and four patients (94 male) underwent laparoscopic inguinal herniorrhaphy during the study interval. Forty-two patients received the self-adhering mesh and 62 patients received a mesh adhered with tacks. Patient demographics and comorbidities did not differ significantly between the two groups. The mean patient age was 51.5 (±14.3) years with a mean BMI of 26.5 (±4.0).  Complications, which included seroma, hematoma, urinary retention, emesis, and constipation, did not differ between groups perioperatively or post-discharge (p=0.7 and p=0.06, respectively).  No hernias recurred in either group during the study interval.

Conclusion: Postoperative complications did not occur more frequently in patients undergoing laparoscopic inguinal herniorrhaphy receiving non-adhering mesh implanted using absorbable tacks versus self-adhering mesh.  SPS responses differed significantly at six weeks suggesting that patients receiving self-adhering mesh may experience less postoperative pain in the short term compared to tacked, non-adhering mesh, but this advantage goes away as the tacks dissolve.  We will continue to follow patients to evaluate for risk of recurrence and other postoperative complications.

 

6.11 Elective versus Non-elective Ventral Hernia Repairs utilizing the Nationwide Inpatient Sample

Posted on December 22, 2014

K. Simon1, M. Frelich1, J. Gould1, H. Zhao1, T. Chelius1, M. Goldblatt1  1Medical College Of Wisconsin,Milwaukee, WI, USA

Introduction: Ventral hernia (VH) repair remains one of the most common general surgery procedures.  The majority of hernia repairs are performed electively.  Patients who present emergently with hernia related concerns may experience increased morbidity with repair when compared those repaired electively.  Patients who undergo elective surgery may also be different than those who opt to undergo elective surgery.  We sought to characterize the outcomes of patients who undergo elective and non-elective VH repair using a large population-based data set.

Methods: The Nationwide Inpatient Sample (NIS) was queried for primary ICD-9 codes associated with VH repair (years 2008-2011). Outcomes were in-hospital mortality and the occurrence of a pre-identified complication.  Multivariate analysis was performed to determine the risk factors for complications and mortality following both elective and non-elective VH repair.

Results: We identified 74,151 VH repairs performed during the study interval. Of these procedures, 67.3% were elective and 21.6% were performed laparoscopically.  The overall complication rate was 20.0% and overall mortality was 0.95%. Non-elective repair was associated with a significantly higher rate of morbidity (22.5% vs. 18.8%, p<<0.01) and mortality (1.8% vs. 0.52, p<<0.01) than elective repair.  Elective repairs were more likely to occur in younger patients, Caucasians, and were more likely to be performed laparoscopically.  Logistic modeling revealed that female gender, Caucasian race, elective case status, and laparoscopic approach were independently associated with a lower probability of complications and mortality. Minority status and Medicaid payer status ware associated with increased probability of non-elective admission.

Conclusion: Patients undergoing elective ventral hernia repair in the United States tend to be younger, Caucasian and more likely to have a laparoscopic repair. The need for non-elective VH is associated with a substantial increase in morbidity and mortality.  Minority status and Medicaid payer status were associated with increased probability of non-elective admission. Considering the above, we recommend that patients consider elective repair of ventral hernias when possible, to avoid the increased risk of complications associated with non-elective repair.

6.12 Abdominal Wall Reconstruction: A Comparison of Totally Extraperitoneal and Intraperitoneal Approaches

Posted on December 22, 2014

J. S. Roth1, M. T. Miller1, K. Johnson1, M. Plymale1, S. Levy1, D. Davenport1, J. Roth1  1University Of Kentucky,General Surgery/Surgery/College Of Medicine,Lexington, KENTUCKY, USA

Introduction: Abdominal wall reconstruction for complex hernia repairs are challenging with significant complications.  The retro-rectus approach typically involves creation of submuscular flaps from an intraperitoneal approach following adhesiolysis, potentially resulting in visceral injuries.  A totally extraperitoneal approach to abdominal wall reconstruction is feasible in most hernia repairs and may minimize visceral injuries without impacting outcomes.  This study compares outcomes following abdominal wall reconstructions by means of an extraperitoneal and intraperitoneal approach.

Methods: An IRB approved review of a prospective hernia database was performed for all abdominal wall reconstructions between 2009 and 2013. Pre-operative patient characteristics including demographics and comorbidities; operative variables including surgical technique (intraperitoneal vs. extraperitoneal), operative duration, type, size and location of mesh, concomitant procedures, and incidence of inadvertent injury; and patient outcomes in terms of length of stay, wound and non-wound complications, readmissions and return to the operating room were obtained. Cases were evaluated based surgical approach. Groups were compared using t-tests, Mann-Whitney U tests, chi-square and Fisher’s Exact tests as appropriate. Significance was set at p < .05.

Results: Patient groups were compared based upon surgical approach; intraperitoneal (n=121) vs. extraperitoneal (n=54). Pre-operative patient characteristics were similar between the two groups including age, BMI, gender, comorbidities, smoking status, and prior hernia repairs. Hernia defect sizes were similar; mesh size was larger in the extraperitoneal group (675 ±317 vs. 440 ± 185 cm2; p<.001); Operative time was less in the extraperitoneal group (172 ±46 vs. 217 ±52 minutes; p<.001). An extraperitoneal approach resulted in fewer inadvertent bowel injuries ( 0 vs 9.1%, p = .02). Readmissions, reoperations, recurrences and other patient outcomes were similar between the two groups.  Among patients undergoing mesh placement in the retrorectus space (extraperitoneal n=47; transabdominal preperitoneal n=74) operative time was less in the extraperitoneal group while other outcomes were similar.

Conclusion: Abdominal wall reconstruction may be performed in a totally extraperitoneal fashion.  The extraperitoneal approach results in fewer enterotomies, shorter operative duration and similar readmissions, reoperations and recurrences when compared to an intraperitoneal approach.  
 

6.13 Does Preoperative Opioid Use Affect Bariatric Surgery Outcomes?

Posted on December 22, 2014

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

Introduction:
Long-term opioid use has recently increased. However, the interaction of opioid use as it relates to obese populations remains understudied. This study aims to investigate the effect of pre-operative use of opioid analgesics on weight loss outcomes, reoperation rates, readmission rates, and complication rates for patients undergoing laparoscopic Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG) and gastric banding (LB).

Methods:

A prospective cohort of 1139 patients undergoing bariatric surgery at a single academic institution was analyzed preoperatively, three-months, six-months, and twelve-months postoperatively. Patients were stratified into opioid analgesic users and non-opioid users based on narcotic questioning at the consult or preoperative visit. The effect of pre-operative opioid use on bariatric surgical outcomes was analyzed using Student t-test for continuous variables and chi-squared analysis for dichotomous variables. All data was analyzed using Stata/SE, 12.1.

 

Results:

Within the cohort of 1139 patients, 77.81% underwent RYGB (n = 866) 9.34% underwent LB (n=104) and 12.85% underwent SG (n= 143). Of the patient population, 105 patients were reported as having preoperative use of opioid medications. Patients on opioid medications had a 4.7% lower percent excess weight loss (%EWL) 12-months postoperatively compared to those not on opioid medications (70.35 %EWL vs. 65.69 %EWL, p = 0.035). However by surgical type, no statistically significant difference was found among RYGB and SG patients. LB patients on preoperative opioid analgesic medication were found to have a 16.6% decreased excess weight loss as compared to non-opioid users (44.04 %EWL vs. 27.44 %EWL, p = 0.021). No statistically significant differences between opioid analgesic users and non-users were found collectively or for the individual procedures for changes in BMI, reoperation incidence, readmission incidence, or incidence of post-surgical complications.

 

Conclusion:

Preoperative opioid analgesic use is a negative predictor for 12-month excess weight loss, particularly for patients undergoing laparoscopic adjustable gastric banding. These results indicate the need for thoughtful preoperative management of pain and opioid analgesics in bariatric patients to optimize surgical weight loss.

 

 

6.14 Analytic Morphomics Predicts Body Composition Associated with Diabetes

Posted on December 22, 2014

O. C. Juntila1, J. Friedman1, D. Cron1, M. Terjimanian1, M. Lindquist1, A. Hammoud1, M. Alameddine1, J. Claflin1, M. Englesbe1, S. Wang1, C. Sonnenday1  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction:

Risk stratification for surgical procedures is traditionally done using demographic factors, such as: age, BMI, and comorbid disease. Better methods are needed to measure body composition and assess risk in surgical patients with chronic disease. BMI, for example, is limited in describing characteristics associated with diabetes, a chronic disease with profound impact on overall health and surgical outcomes. This study aims to use analytic morphomics to describe differences in fat distribution and trunk muscle size among patients with and without diabetes.

 

Methods:
A retrospective cohort study was established using CT scans and associated clinical profiles of trauma patients at the University of Michigan between 2000 and 2013. The visceral fat area and lean psoas area were measured at the L4 level using established analytic morphomic techniques.  Patients were stratified by gender and BMI weight categories: obese (BMI >30 kg/m²), overweight (25<BMI<30 kg/m²), and normal weight (BMI <25 kg/m²). Statistical analysis was performed to determine differences between morphomic measurements within each weight category. 

Results:

We identified 1178 patients (66.7% male) with an overall presence of Type II diabetes of 9.2%. Across all male weight categories diabetics consistently had significantly greater visceral fat area than non-diabetics (obese: P=<0.001, overweight: P=0.074, normal weight: P=<0.001) and displayed significantly smaller lean psoas area when compared to non-diabetics within the same weight category (obese P=0.001, overweight P=<0.001, normal weight P=0.0056). Similarly, female diabetics showed greater visceral fat area (obese P=0.0035, overweight P=0.043, normal weight P=<0.001), and smaller lean psoas area (obese P=0.031, overweight P=0.003, normal weight P=0.18) when compared to non-diabetic females. Figure 1 compares lean psoas and visceral fat areas of diabetic and non-diabetic males across weight categories.

 

Conclusion:

Diabetics have greater visceral fat and smaller lean trunk muscle mass than non-diabetics. Analytic morphomics appears to offer greater characterization of body composition than that offered by BMI. Future study is needed to identify morphomic phenotypes associated with chronic disease and adverse health outcomes.

 

59.13 Novel Use of Porcine Extracellular Matrix with Basement Membrane for Pilonidal Wound Care in Children

Posted on December 22, 2014

R. M. Dorman1, K. D. Bass1,2  1State University Of New York At Buffalo,Department Of Surgery,Buffalo, NY, USA 2Women And Children’s Hospital Of Buffalo,Department Of Pediatric Surgery,Buffalo, NY, USA

Introduction:   Extracellular matrix is used in various applications. We sought to use a new device that incorporates a porcine extracellular matrix with a basement membrane (ACELL)  for adolescent pilonidal disease.  Pilonidal disease is characterized by deep sinus tracts that result in large soft tissue abscesses.  Current treatment includes debridement with the following options: primary closure, saline dressings, or negative pressure dressings. Primary closure results in a high rate of recurrence therefore wound care is favored in our practice. Saline dressings are the most inexpensive method, but are associated with the most pain and longest recovery time. Negative pressure dressings are more expensive but reduce the number of dressing changes, and accelerate wound healing reducing duration of wound care and pain. The goals for children with pilonidal disease are accelerating wound healing while minimizing painful dressing changes, in order to return to baseline function. Experience with ACELL in other wound applications prompted our investigation with children.

Methods:   A series of 4 patients with pilonidal abscess were debrided.  Three occurred in the gluteal cleft, and the fourth in the umbilicus. In the first patient, the wound deficit was filled with ACELL powder and a sheet of 2-ply ACELL was placed to close the wound. In the second patient, two sinus tracts were debrided, packed with ACELL, and a sheet of 5-ply ACELL was applied.  In the third patient, powder and a 6-ply ACELL was applied as a roll filling the dead space.  In the last patient, an umbilical sinus 3 cm deep was packed with ACELL powder followed by a roll of 2 ply ACELL sheet. Patients were evaluated weekly postoperatively and more powder and sheet ACELL material was added if their wound deficit was still present.  Measurements were taken in three dimensions to characterize wounds.

Results: Resolution of wound deficit was graphed vs. time. Pain was assessed by scoring 0-10.  The graph depicts rapid wound healing by both depth and maximum diameter.  The rate of wound healing increased as the volume or thickness (ply) of ACELL material in the wound deficit increased. Two of the patients had failed wound healing with saline dressing changes prior to ACELL application. These 2 patients specifically were highly satisfied with minimal pain scores in their first week postoperative compared to their time with saline dressings.  All 4 patients had no pain after 1 week when bolster sutures were removed.

Conclusion: The use of ACELL in adolescent pilonidal disease was extremely well tolerated with decreased pain compared to saline dressings.  The rate of wound healing was accelerated by the volume of ACELL material used.  The patient satisfaction with the device was high.  This experience supports a prospective study.

59.14 Receptor-interacting Protein Kinase 3 Deficiency Delays Cutaneous Wound Healing

Posted on December 22, 2014

A. J. Godwin1, W. Yang1,2, A. Sharma2, J. Nicastro1, G. F. Coppa1, P. Wang1,2  1Hofstra North Shore-LIJ School Of Medicine,Surgery,Manhasset, NY, USA 2The Feinstein Institute For Medical Research,Manhasset, NY, USA

Introduction:  Acute cutaneous wounds from trauma can become chronic non-healing wounds, resulting in a significant morbidity and mortality to the patients. Wound healing consists of a complex, dynamic process which involves three overlapping processes, namely; inflammation, proliferation and tissue remodeling. A better understanding of wound healing process at the molecular levels is needed for the development of novel therapeutic strategies. Receptor-interacting protein kinase 3 (RIPK3) has been identified to involve in controlling programmed necrosis in response to TNF-α during inflammation. We then hypothesized that RIPK3 regulated the progress of cutaneous wound healing.

Methods:  Full-thickness 2.0-cm diameter circular wounds were created on the dorsum of male wild-type (WT) and RIPK3-knockout (KO) mice on C57BL/6 background. Wound area was measured daily until day 14 post-wound and the pixel of the traced area was analyzed by NIH ImageJ. Skin tissues were collected from the wound sites at various days for histological evaluation and gene expression analysis by qPCR. Mouse embryonic fibroblasts (MEFs) were isolated from WT and RIPK3-KO mice for a transwell migration assay.

Results: The wound healing rate in RIPK3-KO mice was slower than the WT mice over the 14-day course; especially, at day 7, the wound size in RIPK3-KO mice was 53% larger than WT mice (n=7/group, P < 0.05). H&E and Masson-Trichrome staining indicated that RIPK3-KO wounds had a worse quality of wound closure and less collagen deposition in comparison with WT wounds. The number of Gr-1-positive cells for indicating neutrophils infiltrating in RIPK3-KO wounds was much less than WT wounds at day 1. The expression of growth factors (VEGF and TGF-β) and proinflammatory cytokines (TNF-α and IL-1β) were less and delayed in RIPK3-KO wounds, compared to WT wounds (Table). Furthermore, the numbers of migrated MEFs from RIPK3-KO mice toward PDGF and TGF-β, as chemoattractants, were 62% and 73%, respectively, lower than those of MEFs from WT mice. 

Conclusion: RIPK3-KO mice exhibit impairment of wound healing in association with reduced and delayed production of growth factors and proinflammatory cytokines. The chemotactic activity of RIPK3-deficient fibroblasts to growth factors is suppressed. Thus, RIPK3 is an important molecule required for normal progression of wound closure.

 

59.15 Can exposure to a healthy systemic circulation improve fracture healing in diabetic mice?

Posted on December 22, 2014

R. Tevlin1,2, A. Mc Ardle1,2, E. Seo2, K. Senarath-Yapa1,2, C. Duldulao1, T. Wearda1,2, O. Marecic1,2, E. R. Zielins1, D. Atashroo1, M. S. Hu1, G. G. Walmsley1,2, S. Li1, Z. Maan1, D. C. Wan1, C. K. Chan2, G. C. Gurtner1, M. T. Longaker1  1Stanford University,Division Of Plastic Surgery,Palo Alto, CA, USA 2Stanford University,Institute For Stem Cell Biology And Regenerative Medicine,Palo Alto, CA, USA

Introduction:
Diabetes mellitus results in a decline in the regenerative capacity of bone and is associated with increased incidence of malunion, non-union and delayed union of fractures. Our previous studies have illustrated that this phenotype of impaired fracture healing is preserved in a mouse model of diabetes and that reduced angiogenesis occurs in the diabetic fracture callus. As osteogenesis and angiogenesis are intrinsically linked, we hypothesize that exposure to a healthy, wild-type (Wt) circulation will ameliorate the impairment of fracture healing in diabetic (Db) mice and that this effect may arise from improved systemic response to the ischemic injury of a fracture. 

Methods:
Parabiosis was surgically established between Db and Wt mice, and experimental chimeric controls were created consisting of homogenous Wt/Wt pairs and Db/Db pairs. The creation of a chimeric circulation between Db and Wt mice allowed for evaluation of the role of the skeletal niche in promoting a diabetic phenotype during normal homeostasis and in response to injury. Four weeks post parabiosis, after confirmation of chimeric circulation, a stabilized midshaft femoral fracture was created in one mouse of each chimeric pair. Fracture healing was assessed by weekly radiography and femoral mechanical strength testing was performed at 4 weeks post injury. Protein immunoblot of the circulating serum was performed prior to harvest at 4 weeks post fracture to delineate the effect of parabiosis on the systemic angiogenic response, quantifying angiokines known to be of importance in response to fracture healing

Results:
Diabetes is associated with impaired fracture healing. Heterogenous parabiosis (Db/Wt) accelerates both the development of the diabetic callus as seen radiographically and increases resistance to failure upon mechanical strength testing. Furthermore, exposure of the injured Db mouse to a healthy Wt circulation results in a significant increase in systemic angiokines, such as stromal derived factor-1, matrix metalloproteinases and serpin F1, in response to fracture injury in comparison to Db/Db control chimeric pairs (p<0.05). 

Conclusion:
Skeletal regeneration is intrinsically linked to angiogenesis, a process known to be dysfunctional in the presence of diabetes. Following exposure to a healthy wild-type circulation, we note improvement in indices of fracture healing in a mouse model of diabetes, with concomitant significant systemic upregulation of angiokines, known to play an instrumental role in fracture healing. 
 

59.16 Simplified Prenatal Coverage of Fetal Myelomeningocele with Biosurgical Sealant in Sheep Model

Posted on December 22, 2014

J. L. Peiro1,2, J. Orellana2, S. G. Keswani1, M. Marotta1,2, M. Aguirre2, F. Soldado2, C. G. Fontecha2  1Cincinnati Children’s Hospital Medical Center,The Center For Fetal, Cellular And Molecular Therapy – Pediatric Surgery Division,Cincinnati, OH, USA 2Vall D’Hebron Research Institute (VHIR),Bioengineering, Orthopedics And Pediatric Surgery Group,Barcelona, BARCELONA, Spain

Introduction:  

Myelomeningocele (MMC) is the most frequent non-lethal congenital malformation of the central nervous system, appearing in 1 in every 2000 babies. It is characterized by a deficit of closure of the posterior part of the spine, causing neural tissue exposure to the intrauterine environment, which causes a loss of cerebrospinal fluid and a mechanical-chemical injury on the neural tissue exposed. The closure of the defect by intrauterine open fetal surgery repair has shown better results than the postnatal treatment. Simplified techniques are seeking to enable this repair by fetoscopic approach. Our aim is to assess whether a simple technique of coverage with a biosurgical sealant achieves complete closure and produces the same neural protection as the classic technique of fetal MMC repair.

Methods:

Twenty fetal lambs underwent a surgically like-myelomeningocele lumbar defect on the 75th day of gestation. Four of them were non-repaired (NR). Eight of them underwent immediate coverage with a synthetic biosurgical sealant  (IC). The other 8 underwent delayed coverage with same sealant on the 95th day (DC). Animals were obtained every week, from 1st to 7th postoperative week by c-section for histological analysis.

Results:

All NR animals showed a wide defect of closure, continuous leakage of cerebrospinal fluid, and histological neural damage. All IC and DC animals showed partial coverage of the defect (30 to 100%), with regeneration of dura-mater, muscle and skin only in the covered segment.

Conclusion:

Synthetic bio-surgical sealant applied  over the MMC spinal defect produces partial closure of the neural tube defect without complete healing after its reabsorption in 4 weeks in the fetal lamb model.
 

59.17 Inhibition of Heterotopic Ossification by Cox-2 Inhibitors Is Independent of BMP Receptor Signaling

Posted on December 22, 2014

S. Agarwal1, J. Peterson1, S. Loder1, O. Eboda1, C. Brownley1, K. Ranganathan1, D. Fine1, K. Stettnichs1, A. Mohedas2, P. Yu2, S. Wang1, S. Buchman1, P. Cederna1, B. Levi1  1University Of Michigan,Surgery,Ann Arbor, MI, USA 2Brigham And Women’s Hospital,Boston, MA, USA

Introduction:  Treatment options for heterotopic ossification (HO) including surgical excision and radiation cause tissue damage and result in recurrence. Prophylactic treatment with non-steroidal anti-inflammatory drugs (NSAIDs) including aspirin and celecoxib has been reported to decrease ectopic bone formation in patients after orthopedic procedures although the pathway remains unexplored. Here we demonstrate that administration of celecoxib, a Cox-2 specific inhibitor, decreases HO formation following trauma independent of bone morphogenetic protein receptor (BMPR) function.

Methods:  For our HO model, male C57BL/6 mice underwent Achilles tenotomy of the left hindlimb with 30% total body surface area partial-thickness burn over the dorsum. Mice were administered intraperitoneal celecoxib or carrier daily.  HO was quantified by micro-CT imaging at 2 week intervals up to 9 weeks after trauma (threshold Hounsfield units 1250). Wound-healing was assessed by daily imaging.  To analyze BMP signaling, we used the BRE-luc reporter in C2C12 cells in vitro. C2C12 cells were administered indomethacin (cox-1/cox-2 inhibitor) in the presence of BMP2, BMP4, BMP6, or BMP9 followed by quantification of luciferase activity.  

Results: Administration of celecoxib resulted in an 80 percent decrease in HO formation at 7 weeks (5.06 mm3 v. 1.30 mm3, p<0.05) and 77 percent decrease at 9 weeks (5.61 mm3 v. 1.55 mm3) after trauma. In contrast to the carrier-treated group, HO formation was undetectable for the first 3 weeks in the celecoxib-treated group. All Achilles tenotomy incision and dorsal burn sites showed grossly normal healing. Mesenchymal stem cells from burned mice treated with 1 uM celecoxib in vitro demonstrated 60% less alkaline phosphatase staining and 75% less alizarin red staining than untreated cells. Finally, in vitro administration of indomethacin to C2C12 cells with the BRE-luc reporter resulted in no significant decrease in luciferase activity, suggesting that Cox-2 inhibition does not inhibit BMP receptor function. 

Conclusion: We demonstrate that Cox-2 inhibition decreases HO volume in a burn/trauma model. Decreased mineral deposition also occurs in the in vitro setting with mesenchymal stem cells, suggesting a direct effect on the cells responsible for bone formation. Furthermore, the BRE-luc reporter assay demonstrates that Cox-2 inhibition likely does not impart its effect through the BMP pathway.  Our findings suggest that therapeutic targets for HO need not be limited to the BMP pathway, and that the Cox-2 enzyme deserves further attention.  Patients at risk for HO following trauma may benefit from early celecoxib treatment with minimal impact on wound healing. 

59.18 Hesperidin Accelerates Closure of Splinted Cutaneous Excisional Wounds in Mice

Posted on December 22, 2014

A. A. Wick1, T. Lecy1, T. W. King1  1University Of Wisconsin,Plastic Surgery,Madison, WI, USA

Introduction:
Every year in the United States, more than 6.5 million patients suffer from wound-related complications, and treatment is estimated to cost over $25 billion. After an injury, keratinocytes from the wounded edge must proliferate, migrate across the wound bed, and differentiate in order to restore normal barrier function. We are interested in discovering new methods by which to enhance proliferation, migration, and differentiation in order to improve the wound healing process. Hesperidin, a natural flavonoid found in citrus fruits and honey, has been shown to improve epidermal barrier function. In this study, we investigated the effects of hesperidin on the rate of wound healing in murine splinted cutaneous excisional wounds, a model shown to simulate healing in human tissue. 

Methods:
Six week old, male mice (n=14) were anesthetized, shaved, and two full-thickness 6 mm wounds were created on their backs under aseptic conditions. A 12 mm silicone stent was secured around each wound using cyanoacrylate glue and interrupted 5-0 nylon sutures in order to prevent healing by contraction and to promote healing by formation of granulation tissue. A sterile non-adherent dressing and transparent occlusive dressing were placed over the wound. Twenty-four hours after injury, hesperidin (10 μM) or vehicle  (0.01% DMSO) was applied topically to each wound and was repeated daily. Digital photographs were taken of the wounds every day at each dressing change and treatment application. Wound closure was defined by gross visualization of resurfacing epithelia and calculated as a percent area of the original wound size. Wounds were quantified using ImageJ software (NIH) and expressed as a ratio of wound area to stent area, with scaling normalized to the inner diameter of the splint.

Results:
The wound sizes were similar in both groups at the beginning of treatment.  Addition of hesperidin (10 μM) significantly accelerated the rate of wound closure compared to DMSO control on day 4 (% open, 44±3 vs 53±2 respectively, p<0.05) and on day 5 (% open, 23±3 vs 33±3 respectively, p<0.05).  Wound closure for both groups was complete by day 8.  No negative side effects were noted in the mice.

Conclusion:
Hesperidin accelerates cutaneous wound closure in our in vivo model. Based on this novel finding, further studies should evaluate the mechanisms by which hesperidin accelerates the wound healing process, possibly leading to the development of new and effective therapeutics for wound healing in patients.
 

59.19 Raman Spectroscopy Provides a Rapid, Non-invasive Method for Identifying Calciphylaxis

Posted on December 22, 2014

S. Agarwal1, B. Lloyd1, S. Nigwekar2, S. Loder1, K. Ranganathan1, P. Cederna1, S. Fagan2, J. Goverman2, M. Morris1, B. Levi1  1University Of Michigan,Surgery,Ann Arbor, MI, USA 2Massachusetts General Hospital,Boston, MA, USA

Introduction:  Calciphylaxis is a painful and debilitating condition which creates large open wounds most frequently in patients with renal failure. Calciphylactic lesions are characterized by the precipitation of calcium deposits in the skin and soft tissues, resulting in vessel thrombosis and tissue necrosis. Diagnosis of calciphylaxis traditionally occurs via histologic evaluation of biopsy specimens. However, incisional biopsy of the affected site may result in further local inflammation leading to a cycle of further calcium deposition. We set out to develop a non-invasive diagnostic method which can identify calciphylaxis lesions and avoids creating local inflammatory trauma. 

Methods:  Two histology-confirmed human calciphylaxis biopsy specimens and normal surrounding tissue were examined using either a Raman microscope (interrogating a tissue area < 1 mm) or a hand-held Raman spectroscopy probe (interrogating a tissue volume < 1 mm3). Characteristic spectra for each specimen including the normal surrounding tissue and the known calciphylaxis regions were collected and compared to identify common peaks contributed by apatite.  Spectra were pre-processed for removal of cosmic spikes and correction of spectrograph/detector alignment and grating-induced anamorphic magnification (curvature).  Spectra were corrected for the fluorescence background by fitting background to a low order polynomial (Polynomial order = 5). Band heights and areas are measured. Concurrently nano-CT scans were performed to confirm the regions of calcification.

Results: Using nano-CT imaging, we demonstrate large areas of calcification including within the vasculature. Both calciphylaxis specimens exhibited a strong peak at 960 cm-1, consistent with Raman spectrum attributed to apatite and apatitic-like tissue components. Here, this strong peak is attributed to small calcium phosphate precipitates within the tissue. Normal tissue examined from these patients showed no Raman signature of calcium phosphate.   Our results suggest that Raman spectroscopy can differentiate the calcium phosphate deposition of calciphylaxis from normal tissue. 

Conclusion: Here we differentiate calciphylaxis and normal surrounding tissue based on the physical characteristics of the tissue using Raman spectroscopy. Although we have employed this technique in previously excised biopsy specimens, a hand-help, fiber-optic probe can be developed to analyze surface tissue in humans prior to biopsy. In the future, Raman spectroscopy may provide a rapid and non-invasive method for diagnosing calciphylaxis. By avoiding an incisional biopsy, we will be able to avoid exacerbating the cycle of inflammation which precipitates calcium phosphate deposition in these patients.   

59.20 Negative Pressure Wound Therapy in Severe Open Fractures: Complications Related to Length of Therapy

Posted on December 22, 2014

K. A. Rezzadeh1, L. A. SEGOVIA1, A. HOKUGO1, R. Jarrahy1  1University Of California, Los Angeles,Surgery- Plastic,Los Angeles, CA, USA

Introduction: Negative pressure wound therapy (NPWT) is a widely accepted method of temporary wound coverage prior to soft tissue flap reconstruction of severe lower extremity injuries. However, an examination of the effects of NPWT on complications related to limb salvage surgery has yet to be performed. The precise role of NPWT in the perioperative management of patients with complicated lower extremity injuries remains unclear. In this study we examine the impact of NPWT on the outcomes of traumatic lower extremity wounds treated with flap coverage for the purpose of limb salvage. Specifically, we elucidate the effect of NPWT on flap complications and overall outcomes based upon the timing of soft tissue reconstruction relative to initial injury.

Methods: :  An institutional case series was performed consisting of thirty-two consecutive patients receiving lower extremity reconstruction following Gustilo Class IIIB and IIIC open tibial fractures from 1996 to 2001. Demographic, operative, and clinical data were collected retrospectively.  Outcomes of interest included length of hospitalization, number of surgical procedures, extremity amputation, and non-union. 

Results:Among patients reconstructed within all study time periods (i.e., acute, subacute, and chronic), the incidence of overall complications was lower for the group treated with NPWT than for those patients who underwent conventional wet-to-dry dressing changes. Patients operated on in the chronic period and who received conventional dressing changes had the highest rate (83.3%) of complications while those who were reconstructed in the acute period with perioperative NPWT had the lowest incidence (0%). 

Conclusion:We have shown that the use of NPWT therapy in the perioperative management of patients with open distal lower extremity fractures reduces complication rates associated with limb salvage surgery. Based on our results, we conclude that NPWT can be used as a temporizing measure to optimize patients prior to flap surgery, effectively lengthening the window of opportunity for reconstructive surgeons to manage these challenging patients.

 

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