85.04 A Very Unhappy Birthday

Posted on January 26, 2017

P. P. Patel1, E. Clark1, K. Cerasoli1, C. F. McNicoll1, C. W. Katona1, P. R. McGrew1, P. J. Chestovich1  1University Of Nevada,School Of Medicine,Las Vegas, NV, USA

Introduction:

Experience has shown the incidence of traumatic injuries spikes during the summer, holidays, and weekends.  Many epidemiology studies have demonstrated deviations from expected mortality rates with peaks on birthdays. We hypothesized that there was an increased incidence of traumatic injuries on one's birthday, which may be linked to risky behavior resulting in increased mortality

Methods:

We retrospectively reviewed all patients admitted to our Level 1 trauma center during a 10-year period from January 1, 2006, to December 31, 2015. Demographic and resuscitation data were obtained from our trauma registry.  A cohort of patients that were injured on their birthday were selected and further analyzed.  Data points included gender, mechanism of injury, and injury severity score (ISS).  Additional points linked to behavior assessed if the patient was visiting the city as tourist, if there was suspicion for alcohol or drug use, and if proper safety equipment was utilized. Patients entered as a Doe were excluded.

Results:
A total of 29,657 patients were seen during this 10 year span of which 339 (1.14%) patients were injured on their birthday.  Within this cohort, 248 (73%) patients were male, average ISS was 18, 91 (27%) cases were due to a penetrating mechanism and 103 (30%) died.  Tourists accounted for 10% of cases, while risky behavior as defined by suspicion of substance use or improper safety precautions was present in over two-thirds of cases (68%). Self-inflicted trauma resulted in 16 injuries.

Conclusion:

There is an increased incidence of traumatic injuries on birthdays.  The cause of this added injury burden is unclear, however our data shows that risky behavior is suspected in over half of these cases. Additional research could clarify the strength of that relationship, any potential causality, and the impact of behavioral interventions to prevent injury.

 

85.03 The Utilization of Continuous Renal Replacement Therapy for Malignant Hypervolemia

Posted on January 26, 2017

M. Choi1, N. K. Dhillon1, E. J. Smith1, J. M. Tatum1, G. Barmparas1, H. Rodriguez1, E. J. Ley1  1Cedars-Sinai Medical Center,Los Angeles, CA, USA

Introduction:  Continuous renal replacement therapy (CRRT) is utilized primarily in patients with renal failure and hemodynamic instability. The role of CRRT in patients without renal failure who have malignant hypervolemia has not been studied.

Methods:  A review of all patients receiving CRRT in the surgical intensive care unit from February 2013 to February 2015 was performed. Patients undergoing CRRT for hypervolemia without a prior diagnosis of chronic kidney injury and creatinine of 1.5 or less were identified. The group was analyzed for patient characteristics including diagnosis, ICU length of stay (LOS), hospital LOS, APACHE II scores, CRRT duration, volume removed with CRRT, and mortality.

Results: Fifty-nine patients underwent CRRT during the study period. Of the 59, 21 (35.6%) had undergone CRRT for hypervolemia without presence or history of renal failure. Mean age was 61.2 ± 15.2 years, 15 (71%) were male, and median APACHE II score was 28.5 (4.5-47.2). The median ICU and Hospital LOS were 16 (7.5-22) and 29.9 ± 14.2 days, respectively. Mean creatinine prior to the initiation of CRRT in the study population was 1.1 ± 0.3. Patients underwent CRRT for a median of 6 (4-13) days with a total median volume of 15.9 (9.6-3.8) liters removed. A mean of 2.8 ± 1.1 liters was removed per day. The mortality rate for this group was 33%.

Conclusion: CRRT can be utilized to remove volume from critically ill patients with malignant hypervolemia in the setting of normal renal function. Further investigation is warranted on how to best use this therapy for patients without renal failure.

85.02 Cirrhosis and Splenic Trauma: Case Series and Systematic Review

Posted on January 26, 2017

R. A. Rasheed1, E. A. Rogers-Delmas1, A. H. Tyroch1, B. R. Davis1  1Texas Tech University Health Sciences Center In El Paso,Department Of Surgery,El Paso, TX, USA

Introduction:
The purpose of this paper is to analyze the effect of cirrhosis on morbidity and mortality incurred by patients that have sustained splenic injuries due to non-penetrating abdominal trauma.

Methods:

CPT codes for “cirrhosis” and “injury to spleen” were submitted to the UMC Trauma Data Bank as search criteria for patient selection. The period of evaluation spanned from January 01 2009 to August 31 2014. Over this period of time, 266 patients suffered splenic trauma. Multiple points of demographic data were obtained, the most important of which was grade of splenic injury and procedures undergone during hospitalization.

Of these 266 patients, 11 patients carried a diagnosis of cirrhosis due to any etiology. Once this pool of patients was obtained, we used laboratory parameters to calculate a MELD score for each patient. We then searched for evidence of non-operative management and subsequent conversion to procedural management, which was either indicated by the presence of an operative report for laparotomy and splenectomy, or a procedure report for splenic artery embolization.

We then analyzed the data, and attempted to sort patients into subsets of splenic injury grading and determine the threshold MELD that predicted the need for operative management.

Results:
In patients with Grade I & II splenic injury, MELD did not seem to predict failure of non-operative management. In patients with Grade III splenic injury, a MELD > 18 predicted failure of non-operative management. In patients with Grade IV injury, failure of non-operative management occurred, regardless of MELD.

Conclusion:

This correlative data could be used to predict failure rates of non-operative management, and may allow surgeons to better prepare for operative management in this subset of challenging trauma patients.

Due to the limited data, the power of this analysis is limited. However, this limited series does seem to suggest that greater severity of cirrhosis portends a higher failure rate of non-operative management in the setting of blunt splenic injury. This is consistent with the findings of larger studies that demonstrate cirrhosis is an independent risk factor for failure of non-operative management in this unique subset of trauma patients. The published literature will be reviewed during the course of the presentation. Further plans for this study include pooling data from other trauma centers in the state in an attempt to power the study and reach statistical significance.

85.01 The Impact of Trauma Centers on Statewide Organ Donation Rate

Posted on January 26, 2017

C. Santino1, K. Ibraheem1, N. Kulvatunyou1, A. Azim1, G. Vercruysse1, A. Tang1, R. Friese1, L. Gries1, T. O’Keeffe1, B. Joseph1  1University Of Arizona,Division Of Trauma, Critical Care, Burns & Emergency Surgery,Tucson, AZ, USA

Introduction:

Trauma care has evolved with several studies demonstrating that patients treated at trauma centers have better outcomes. Trauma patients also form the major pool of organ donors in the United States. However, it is unknown if the distribution of trauma centers has affected organ donation. The aim of this study was to assess the association between trauma center distribution across states and organ donation rates.

Methods:

We performed a one year analysis (2013) of the CDC WISQARS database for all injury related deaths in a state. Number of organ donors after trauma-related death were obtained from the UNOS database. Number of trauma centers and their level of verification (Level I, II, III) in each state were obtained from American College of Surgeons’ (ACS) trauma center registry. Only states with data available for organ donation were included. States were divided into two groups based on the trauma center distribution per million population: high density states (HDS) where trauma center density was greater than the national average and low density states (LDS) where trauma center density was less than the national average. Stepwise linear regression analysis was performed for the predictors of organ donors per million population and organ donors per 100,000 trauma deaths.

Results:

A total of 40 states were included in the analysis with mean trauma center distribution of 5.7 trauma centers per one million population and an organ donation rate of 16.8±12.8 organ donors per one million population. 30 states were included in LDS and 10 in HDS. HDS states had a higher number of total adult trauma centers (5 [2-11] vs. 2 [1-7]; p=0.02), a higher number of level 1 and 2 trauma centers (5 [1-10] vs. 2 [1-5]; p=0.02), and a lower area of coverage per trauma center (p=0.001). HDS states had a higher rate of organ donors per one million population (24.8±21.9 vs. 14.2±6.5;p=0.022) and a higher rate of organ donors per 100,000 trauma deaths (32.2±22.1 vs. 17.4±7.8;p=0.025). On stepwise linear regression analysis, trauma center distribution per million population was independently associated with higher rate of organ donors per one million population (β [95% CI]: 0.38 [0.01-0.49]; p=0.04) and organ donors per trauma death (β [95% CI]: 0.40 [0.03 – 0.59]; p=0.03).                 

Conclusion:

Regional variability of ACS verified trauma centers significantly impact statewide trauma-related organ donation rate. The findings of this study highlight a correlation between statewide organ donation rates and ACS verified trauma center density.

 

84.20 Ventral hernia repair and mesh infection survey.

Posted on January 26, 2017

L. Knaapen1, O. Buyne1, S. Feaman4, P. Frisella4, N. Slater2, B. Matthews3, H. Van Goor1  1Radboud University Medical Center,Department Of Surgery,Nijmegen, GELDERLAND, Netherlands 2Radboud University Medical Center,Department Of Plastic And Reconstructive Surgery,Nijmegen, , Netherlands 3Carolinas Hernia Institute,Charlotte, SOUTH CAROLINA, USA 4Washington University,Department Of Surgery, Section Of Minimally Invasive Surgery,St. Louis, MISSOURI, USA

Introduction:
Choice of mesh and surgical technique in ventral hernia repair represent major surgical challenge, especially under contaminated conditions. Aim of this survey was to present international overview of current practice concerning ventral hernia repair in clean or contaminated condition.

Methods:
A survey (2013-2015) was send to surgeons worldwide performing ventral hernia repair. This survey was designed to compare differences in ventral hernia repair concerning life style/pre-operative work-up, antibiotic prophylaxis, hernia repair in clean/contaminated environment, recurrence and mesh infection. 

Results:
Responders (n=417) were male (92%;n=381), aged 36-65 (84%;n=351) and practicing inNorth- America (56%;n=234). Open repair was performed by 99% (20% expert level). Laparoscopic repair by 77% (15% expert level).
The majority agrees on benefit of pre-operative work-up/lifestyle changes like smoking cessation (80%;n=319) and weight-loss (64%;n=254)). Not reaching target(s) does not change decision on whether to operate or not.
Common practice is administer antibiotics at least one hour preoperatively (71%;n=295).
Synthetic (43%;n=180) and biologic (42%;n=175) mesh are used as often in contaminated primary hernia repair.
Concerning recurrent hernia repair, synthetic mesh (87%;n=359) is used in clean environment, biological (53%;n=215) or no mesh (28%;n=112) in contaminated environment. American surgeons prefer biologic mesh over  synthetic mesh in contaminated environment. 
Generally, percutaneous drainage and antibiotics is the first step regarding mesh abscess, independent of type of repair or mesh used. Concerning synthetic mesh infection with sepsis most explant the mesh and repair with biologic mesh (54%;n=217). There is no agreement on mesh infection without sepsis on when to explant  and how to repair.

Conclusion:
The majority agrees on the benefit of pre-operative work-up however not always with consequences. Both synthetic and biologic meshes are used for primary hernia repair in contaminated environment. Concerning recurrent hernia repair, synthetic mesh is used in clean environment and biologic mesh or no mesh in contaminated environment. 

84.19 Trends in CIRP Levels and Wound Healing

Posted on January 26, 2017

A. Baig1, A. Jacob1,3, S. Kaplan1, M. Akerman3, P. Wang1,2,3, A. Oropallo1,2  1Northwell Health,Surgery,Manhasset, NY, USA 2Hofstra Northwell School Of Medicine,Hempstead, NY, USA 3The Feinstein Institute For Medical Research,Manhasset, NY, USA 4Hofstra Northwell School Of Medicine,Hempstead, NY, USA

Introduction:  It has been well established that many factors affect how quickly and effectively different wounds heal. We evaluated cold inducible RNA binding protein (CIRP), an inflammatory mediator that has been shown to be increased in patients with sepsis and suggested to be an outcome predictor in sepsis. We hypothesize that circulating levels of CIRP are associated with wound size and healing rates. There are no published data regarding the relationship of CIRP levels and wound healing

Methods:  This study is a prospective study of individuals with venous stasis ulcers of at least 1 cm at the start of the study, with adequate vascular perfusion as measured by ankle brachial index (ABI).  Exclusion criteria included: diabetes, suspicion of wound infection or osteomyelitis, immunosuppressants, and autoimmune connective tissue disorders. Patients were enrolled in the study for a total of 12 weeks. Patients’ blood was drawn weekly and CIRP level was measured using Western blot with wound measurements taken as well. 

Results: Patients in our case series that met the exclusion and inclusion criteria, the CIRP levels decreased over time (n=4). We noticed a correlation between average primary wound size and average CIRP level. Multiple patients developed new wounds during the course of the 12 week period, and we noticed an increase in CIRP levels of those patients that correlated to the discovery of a new, separate wound. CIRP is a potential systemic inflammatory marker and the rise in CIRP levels in patients who developed a second wound is in accordance with our hypothesis. Using a mixed model repeated measures ANOVA, our sample size of four patients yielded a trend showing a decrease in CIRP across week 0 to week 11, but was not statistically significant (p=0.052). The data was also suggestive of a positive association between CIRP levels and wound size; as the wound size decreased over the weeks, the CIRP levels correspondingly decreased as well. 

Conclusion: Although the results need to be further explored with a well-structured study using a larger sample size, initial results of using CIRP demonstrate a promising correlation between CIRP and wound measurement.
 

84.18 Frailty as a Predictor of Complications in Plastics

Posted on January 26, 2017

O. Trofymenko1, H. Aziz1, B. Joseph1  1University Of Arizona,General Surgery,Tucson, AZ, USA

Introduction:

Frailty has emerged as an important patient-specific characteristic that has been show to positively correlate with various surgical and medical complications encompassing a broad range of surgical practices.

Methods:
National Surgical Quality Improvement Program (NSQIP) was quarried to select all of the cased from 2011-2012 of non-emergency elective outpatient and inpatient plastic surgery procedures. The data was separated into inpatient and outpatient procedures and analyzed separately for each cohort. Modified frailty (mFI), previously described measure of frailty, was used as a proxy for frailty.

Results:
Out of 23,661 cases quarried, 63.48% (n=16,440) were inpatient and 30.52% (n=7,221) – outpatient. For outpatient cohort, 73.29% of patients had mFI of 0 (non-frail), 20.10% were ASA class 3 or above, 3.30% had postoperative complication(s), and 2.11% were readmitted within 30 days. For outpatient sample, 63.99% of patients were non-frail, 34.10% were ASA class 3 or above, 15.51% had postoperative complication(s), and 6.62% were readmitted within 30 days. On univariate analysis, higher mFI positively correlated with outpatient (p=0.017) and inpatient (p<0.001) overall complication rates; as well as outpatient (p<0.001) and inpatient (p<0.001) unplanned readmission rates. Multivariate CC model showed mFI to independently correlated with outpatient unplanned readmission rate (Odds Ratio (OR): 18.657; p=0.020) and inpatient overall complication rate (OR: 26.107; p=0.001). MICE model indicated mFI to be independently predictive of outpatient unplanned readmission rate (OR: 69.059; p<0.001), inpatient overall complications rate (OR: 28.553; p<0.001), and inpatient unplanned readmission rate (OR: 20.358; p=0.013).

Conclusion:
Our findings suggest that frailty, as a patient-specific characteristic, may add value to stratification of operative risks, preoperative planning, and implementation of a more effective post-operative management.
 

84.17 Long Term Results In Abdominal Wall Reconstruction

Posted on January 26, 2017

J. Zakhary1,2, C. A. Sedano1, C. D. Killingsworth1, L. O. Vásconez2, J. I. De La Torre1,2  1University Of Alabama At Birmingham,Plastic Surgery,Birmingham, AL, USA 2Birmingham V.A. Medical Center,Plastic Surgery,Birmingham, AL, USA

Introduction: Incisional hernias are a common problem for which the optimal surgical technique has yet to be established.  Several key advances in the mangement of incisional hernias have contributed to a decrease in recurrence rates, including the use of mesh for tension free colsure, laparoscopic approaches, component separation and acellular dermal matrix.  The published recurrence rates for primary repair of hernias (25-60%) open componenet separation (14-27%) and laparoscopic repair (4-19%) do not usually include long term outcomes.

Methods: A retropsective chart review was perfromed for a abdominal wall reconstructive procedures utilizing component separation by a single surgeon over a six year period.  Data abstraction was perfromed by review of patient electronic health records for preoperative risk factors, hernia characteristics and postoperative course.  Operative notes were reviewed for specific technical details.  In addition, patients completed a phone interview and survey to establish long term outcomes.  All patients had a minimum follow-up time of three years or until recurrence.

Results: A total of 81 consecutive patients were evaluated.  Thirteen patients were excluded for insufficient follow-up   Of the remaining patients, all underwent reconstruction using a component separation and in most cases had acellular demal matric reinfrocement.  The median followup time was 40 months.  The average hernia size was 223 cm2.  Factors associated with recurrence included the inability to establish myofacial continuity (p= 0.018), contaminated field (p= 0.07) and prior failed hernia reconstruction (p= 0.10).  Of the patients in whom successful components separation with myofascial continuty was perfromed, the recurrence rate was 10%. 

Conclusion: The inability to restore myofascial continuity is a critical risk factor for recurrence.  Long term recurrence rate seen in this patient population is well within the range of published outcomes.  Incisional hernia reconstruction in a contaminated field is a risk factor for recurrence even with the use of acellular dermal matrix for reinfrocement.  Postoperative wound complicatins, most commonly seroma or skin ischemia occured at a significant rate, These complications may be avoided by minimally invasive approaches and require further evaluation.

 

84.16 Evolution of Abdominal Wall Reconstruction for Incisional Hernia Repair

Posted on January 26, 2017

J. Zakhary1,2, B. D. Denny1, A. Kilic1, J. I. De La Torre1,2  1University Of Alabama At Birmingham,Plastic Surgery,Birmingham, AL, USA 2Birmingham V.A. Medical Center,Plastic Surgery,Birmingham, AL, USA

Introduction: Abdominal wall reconstruction with mobilization of autologous tissue has continued to evolve as a safe and reliable option for patients with large ventral wall hernias.?

Methods: With the goal of evaluating how the application of components separation has evolved in our practice, morbidity and recurrence rates in patients who underwent reconstruction for incisional ventral hernia, were retrospectively reviewed. The charts of 284 patients treated by a single surgeon between 1999 and 2016 were reviewed and patients with a minimum of two-year follow-up were included.  Two data groups, an early group (1999-2004) and a late group (2009-2014) were evaluated, each over a five-year period. Outcomes from the data collection period were compared and significant changes in technique were noted.

Results: In the early group, the recurrence rate was 13% and primary approximation of the fascial defect was achieved in 77% of the patients. Overall morbidity rate was 38%, with significant complications occurring in 17% of patients, wound healing problems occurring in 13% and seromas occurring in 3%.  In the late group, the recurrence rate was 7% and and primary approximation of the fascial defect was achieved in 92% of the patients. Overall morbidity was 46%, with significant complications occurring in 17% wound healing problems occurring in 14% and seromas occurring in 17%.

Conclusions: In patients with incisional hernias, techniques involving autologous tissue mobilization are safe and associated with low recurrence rates. Refinements in techniques have led to decreased recurrence rate.

84.15 Cleft Care in the Medically Complex Patient

Posted on January 26, 2017

F. Fallahian1, M. Tracy1, A. Kaye1  1Children’s Mercy Hospital- University Of Missouri Kansas City,Department Of Plastic Surgery,Kansas City, MO, USA

Introduction:  Direct causality of congenital cleft conditions is often not known and is currently considered to represent a combination of complex environmental and genetic factors and interactions. There are numerous syndromes which can be associated with cleft lip and/or palate as well as unique patients with multiple medical problems without an over-arching diagnosis. This provides us with a number of patients for whom highly individualized treatment plans must be devised. Safety and appropriateness for surgery or the need to prioritize other necessary surgeries are factors that may preclude following typical cleft treatment protocols. This study aims to determine the prevalence of children in our Cleft Team population who also carry concomitant complex medical diagnoses in order to assess the challenges of this population and the alterations in their ultimate cleft-related care.

Methods:  This study is a retrospective review of patients presenting to the Cleft Team for cleft care with a history of multiple medical issues in addition to a diagnosis of cleft lip and/or palate.

Results: 133 patients were identified with a variety of cleft conditions: incomplete cleft lip (CL) = 7, cleft lip and palate (CL/P) = 51, isolated cleft palate (CP) = 53, and submucous cleft palate (SMCP) = 22. A numerous variety of concomitant diagnoses were seen including 37 named syndromes, 20 unique chromosomal abnormalities, and 17 unidentified constellations of anomalies. Diagnoses were made by a combination of clinical assessment (30.7%), specific gene studies (25.0%), high resolution chromosome (18.3%) or CGH microarray analysis (16.3%). 51.9% of patients have congenital heart disease, 40.6% of which required surgery to treat. 36.8% of patients have brain abnormalities. 23.3% have congenital hearing loss. 63.9% have developmental delays. 81.2% of patients are cared for by 3 or more subspecialty teams aside from the Cleft Team, most commonly: ENT, Cardiology, Ophthalmology and Orthopedic Surgery. 54.1% of these patients have surgical feeding tubes and 15.0% have tracheostomies. 6.7% of these patient have died prematurely related to their condition. Average age at cleft lip repair when performed in this group is 7.29 months (SD 2.65). Average age at primary palate repair in this group is 23.13 months (SD 20.56). One third of patients have delayed or missed cleft-related surgeries. 60.9% of these patients have global developmental delays. More than half have speech-language delays, 59.4% of which are severe or profound.

Conclusion: Patients with congenital cleft conditions and concomitant complex medical presentations present unique situations for coordinated cleft team care. These patient have frequent delays in the timing of their cleft-related surgeries resulting from poor health condition, need for other surgery, or significant speech/developmental delays.  
 

84.14 Disparities in Management of Below Elbow Injuries at a Single, Level 1 Trauma Center

Posted on January 26, 2017

C. Kerby1, K. E. Leibl3, E. K. Awad2, T. A. Swain1, R. L. Griffin1, T. W. King1  1University Of Alabama at Birmingham,Birmingham, Alabama, USA 2University Of South Alabama,Mobile, AL, USA 3University Of Wisconsin,Madison, WI, USA

Introduction:  It has been shown previously that disparities exist in treatment and access to care by race, insurance coverage, and age in the United States. Our objective was to evaluate if treatment and time to treatment disparities exist in patients sustaining injuries below the elbow managed at a single level 1 trauma center in the United States. 

Methods:  The number of upper limb injuries below the elbow seen at a level 1 trauma center from 2010-2014 were determined using the trauma registry. Injuries were defined as any injury in the upper extremity below the elbow and were identified by anatomical region using the abbreviated injury scale (AIS). Only anatomical regions clearly defined by AIS which were below the elbow were used; therefore, whole limb categories were excluded as well as injuries specific to vessels, nerves, and skin since AIS does not specify anatomical regions for these structures below the elbow. ICD-9 procedural codes for amputation on the upper limb were used to identify patients undergoing amputation. Patient demographic, injury, and clinical variables were compared by amputation procedure status using the chi-square and t-test for categorical and continuous variables, respectively. 

Results: There were 2059 patients from 2010 to 2014, which had an upper extremity injury below the elbow. Of these patients, 77 (3.7%) required an amputation. Injury severity score was significantly higher (p<0.0001) for those who did not undergo amputation (14.8) when compared to those who did (6.0). Time to admission from injury was also longer for those not undergoing amputation (0.3 days) compared to those undergoing amputation (0.1 days) (p=0.0005). Those who underwent amputation were more likely to be male (80.5%) (p=0.0244). There was no difference for race (p=0.7326), age (p=0.8724), hospital LOS (p=0.0834), ICU LOS (p=0.1463), or time to admission from injury (p=0.4501). Payment type differed significantly by amputation procedure status (p<0.0001), with 23.4% of those amputated paying through workers’ compensation, compared with only 4.6% among those not amputated.

Conclusion: Amputation is uncommon following upper extremity injury below the elbow. Ironically, the ISS was lower for patients receiving amputations. This likely implies, but can not be absolutely concluded, that the below elbow amputation injury was an isolated injury   Those requiring amputation were more likely male, presented for treatment sooner, and were more often associated with a work-related injury.  This data does not support previous studies’ findings of racial or age disparities. However, this analysis is limited by being at a single center and the limitations associated with the AIS.  Further investigations utilizing a multicenter, nationwide database should be performed to verify and validate these results.

 

84.13 DIEP Flap Breast Reconstruction: Predictive Factors for Perioperative Blood Loss and Transfusion

Posted on January 26, 2017

E. Conci1, M. Khatib2, F. Barakat3, P. Forouhi4, C. M. Malata2,5  1Cambridge University Medical School,Cambridge, , United Kingdom 2Cambridge University Hospitals NHS Trust,Plastic Surgery,Cambridge, , United Kingdom 3Barnet General Hospital,London, , United Kingdom 4Cambridge University Hospitals NHS Trust,Cambridge Breast Unit,Cambridge, , United Kingdom 5Anglia Ruskin University,Faculty Of Health Sciences,Cambridge, , United Kingdom

Introduction: Peri-operative blood loss contributes to the morbidity of patients undergoing immediate and delayed autologous free flap breast reconstruction post-mastectomy. The study aims to develop predictors for blood loss and transfusion requirements in microvascular breast reconstruction.

Methods:

A retrospective cohort study of autologous free flap breast reconstructions by a single plastic surgeon performed from January 2010 – December 2015 was conducted. Data from patient medical records were input into databases of electronic health records (EMR and EPIC).  Data analysis was performed using STATA software. 

Outcomes collected include haemoglobin drop (preoperative Hb – lowest Hb following surgery), estimated blood loss (EBL) and the total units of blood transfused (intra-operative and perioperative). Estimated blood loss (EBL) was the total weight of the swabs used during surgery minus their weigth prior to surgery while the estimated blood volume (EBV) was calculated using a validated formula [InBV= 70/√(BMI/22 )]. lnBV represents the indexed blood volume in ml/kg.

Variables studied pertain to the patient, namely age, BMI and chemotherapy status; the operation, namely timing, duration and extent (laterality, axillary clearance, mastectomy weight); and the flap transferred, namely its weight, number of pedicles and ischaemia time. 

Results:

Of the 163 microvascular procedures, 133 were unilateral and 30 were bilateral.

The median estimated blood loss (EBL) was 640ml (IQR=407-1000) and the mean haemoglobin drop was 29.9g/L (±11.1). 44% of patients required a transfusion.

Multivariable linear regression analysis showed that immediate timing of reconstruction (p=0.016), concomitant lymph node dissection (p=0.01), increased duration of surgery (p<0.001) and higher mastectomy weight (p<0.001) were significantly associated with higher EBL.

Independent predictors of the likelihood of blood transfusion were bilateral reconstruction (p=0.02), lower estimated total blood volume (p=0.04) and higher mastectomy weight (p<0.001).

Haemoglobin drop was predicted by chemotherapy (including tamoxifen) within six months prior to surgery (p=0.006) and the duration of the operation (p=0.04).     

Conclusion:

A significant association between higher EBL and transfusion requirements was found with several variables that denote the extent of the operation. This has provided empirical information to our unit in predicting perioperative blood loss and preoperative patient counselling. It has also enabled us to design measures to restrict blood loss in these “high-risk” patients and hence reduce patient morbidity and length of stay. 

84.12 Superomedial Pedicle Reduction Mammaplasty: Increased Resection Weight Does Not Increase Nipple Necrosis

Posted on January 26, 2017

P. Brownlee1, D. Chesire1, M. Crandall1, J. Murray1  1University Of Florida,Jacksonville, FL, USA

Introduction:  Nipple-areola complex (NAC) necrosis is a dreaded complication of reduction mammaplasty that results from tissue ischemia. Multiple breast reduction techniques have been designed, each with the goal of minimizing complications and optimizing aesthetic outcomes. The superomedial pedicle (SMP) reduction mammaplasty offers several advantages over more traditional operative techniques, such as improved preservation of long-term breast shape. However, many surgeons believe that using the superior and superomedial pedicles cause an increase in NAC necrosis rates up to 7.0-10.0% as the degree of macromastia increases. The aim of this paper is to show that the superomedial pedicle has comparable NAC necrosis rates to other breast reduction techniques and can be used in any size reduction without a significant risk to the NAC.

Methods:  We performed a retrospective study of patients who underwent breast reduction surgery by a single surgeon between May 1, 2013 and May 1, 2015. We reviewed patient demographics, operative details, the weight of the breast tissue removed per pathology report, and post-operative findings up to six months after the date of their operation. Patients were excluded from this study if they were converted to free nipple grafting intra-operatively prior to completion of their initial operation (n=3). Each breast was counted as an individual data point and then divided into subgroups based on the weight of the tissue removed. Using SPSS version 23 and chi-square analysis, the subgroups were compared against each other to look for a significant difference in rates of NAC necrosis. The overall rate of NAC necrosis in this study was also determined and compared to those of previously reported rates for alternative pedicle techniques.

Results: 70 patients (130 breasts) met inclusion criteria for this study. The average age at time of reduction was 38 years old, and the patients had a mean body mass index (BMI) of 36.6 kg/m2. The mean resection weight per breast was 1016.7 grams (± 478.3). The mean pre-operative sternal notch to nipple distance was 36.3 cm (± 5.3). The overall NAC necrosis rate was 0.7%, with 0% in the groups where less than 1200 grams of tissue were removed and 2.3% in the group where 1200 grams or more of tissue were removed. There was no significant difference with respect to the number of patients developing NAC necrosis across these groups.

Conclusion: The superomedial pedicle breast reduction has an overall rate of NAC necrosis which compares favorably to other more popular techniques, and this study shows no significant increase in NAC necrosis with larger volume tissue reductions. Given the benefits of this technique when compared to alternative pedicles, such as preservation of breast shape and nipple sensitivity, it should be considered a safe choice for any size breast reduction.

 

84.11 Usage of Skin Graft Procedures during the Past Two Decades in the United States

Posted on January 26, 2017

J. Buckley1, R. S. Elliott1, A. Seifi1  1University Of Texas Health Science Center At San Antonio,San Antonio, TX, USA

Introduction:  Often utilized in the setting of serious trauma or burns, skin grafting procedures (SGP) are applied by physicians in order to transplant skin to a different area of the body where skin is absent. Using a robust database, we sought to determine the incidence of SGP for patients in the United States and the impact of an institution’s teaching status on these trends.

Methods:  Utilizing the Nationwide Inpatient Sample database, we identified 1,567,966 discharges involving procedures requiring skin grafts (SGP, CCS Procedure Code 172) from 1997 to 2013 in United States. Year-wise distribution of number and rate of patients who underwent SPG at teaching and non-teaching hospitals was described. Z-test statistic was used to compare the two groups.

Results: During seventeen years of the study period, approximately 60.06% of patients who received procedures involving skin grafts (SGP) were males and 34.19% of patients were between 45 and 64 years old. The total annual number of patients who underwent SGP at all institutions increased insignificantly overall and ranged from 83,903 to 101,285 (Fig. 1, P=0.3185). The rate of patients who underwent skin grafts at all institutions varied insignificantly as well and ranged from 28.5 to 34.7 per 100,000 patients (P=0.2329). Throughout the duration of the study period, the mean number of SGP performed in teaching and non-teaching institutions was 64,505 and 26,832 respectively; with an average of 92,233 SGP occurring in all institutions annually. Annually, the number of patients who underwent SGP at teaching institutions ranged from 53,278 to 76,265, whereas the number of patients at non-teaching institutions ranged from 21,110 to 40,604. Notably, from 1997 to 2004 and from 2006 to 2013, the number of patients who received SGP was consistently and significantly higher for patients treated at teaching hospitals as opposed to those treated at non-teaching hospitals (Fig. 1, P<0.0001). However, from in 2005, there was no significant difference between the numbers of SGP performed by these two types of institutions.

Conclusion: The usage of procedures involving skin grafts (SGP) has been consistent in the United States during the past two decades. Teaching status of institutions has an impact on the utilization of SGP in patients. Future research should attempt to explore whether teaching status affects clinical outcomes for patients after SGP and make a recommendation to our patients regarding where to seek optimal care.

 

84.10 The Impact of the Timing of Radiation in Implant Based Breast Reconstruction: A Systematic Review

Posted on January 26, 2017

J. A. Ricci1, B. T. Lee1  1Beth Israel Deaconess Medical Center,Plastic And Reconstructive Surgery,Boston, MA, USA

Introduction: Postmastectomy radiation (PMRT) in the setting of implant based immediate breast reconstruction has been associated with higher rates of complications and poorer aesthetic outcomes. Many centers have attempted to avoid deleterious complications such as implant loss or capsular contracture associated with PMRT by implementing an algorithmic approach to breast reconstruction. As such, PMRT may be delivered directly to a tissue expander (TE) before an exchange for a permanent implant (PI) or afterwards. However, the literature regarding the optimal timing of radiotherapy and breast reconstruction remains controversial. This study aims to systematically review all recent literature on this subject to identify differences in patient outcomes related to the timing of PMRT.

Methods:  A PubMed literature search was performed to summarize the latest data (2000-2016) regarding the impact of the timing of PMRT on the outcomes of implant based breast reconstruction. The search was conducted using the parameters: breast reconstruction AND radiation AND (implant OR expander). Data was pooled from relevant articles and outcomes compared based on whether PMRT occurred before or after exchange of tissue expander for permanent implant.
 

Results: The search returned 336 articles, of which 20 were acceptable for inclusion. Primary outcomes of interest included capsular contracture and reconstructive failure (implant loss). A total of 2348 patients were identified, with PMRT administered to 1479 before exchange and 869 after exchange. The mean follow-up for all patients was 39.5 months (14.3 to 73.5) and a majority of studies (14, 70%) were retrospective in nature (6 prospective, 30%). Patients receiving PMRT to TE before exchange to PI were at higher risk for reconstructive failure (20.0% vs 13.4%; p= 0.001) while patients receiving PMRT after exchange had higher rates of Grade III/IV capsular contracture (49.4% vs 24.5%; p= 0.0001). The average level of evidence of all studies was III. 

Conclusion: While PMRT remains an undesired event when pursuing an implant-based breast reconstruction, it does not represent an absolute contraindication. However, high rates of significant complications, often necessitating operative intervention, occur regardless of whether PMRT is delivered before or after exchange of TE for PI. Accordingly, a case should be made for the use of autologous breast reconstruction when faced with the prospect of PMRT, regardless of the timing, to improve patient outcomes by avoiding unnecessary complications and prevent unplanned returns to the operating room.

 

84.09 Prealbumin and C-reactive Protein Levels Predict Clinical Outcomes in Burn Patients

Posted on January 26, 2017

S. J. Day1, D. E. Bell1  1University Of Rochester,School Of Medicine And Dentistry,Rochester, NY, USA

Introduction:  Low prealbumin levels in burn patients at admission is an indicator of poor baseline nutrition status, which can negatively influence wound healing. This study aimed to identify the role of prealbumin and C-reactive protein (CRP) levels in predicting clinical outcomes of burn injuries.

Methods:  Retrospective case review was conducted of burn patients admitted to an American Burn Association-verified regional burn center from July 2015 to December 2015. Demographic, injury-related and hospitalization-related variables were assessed for correlation with prealbumin and C-reactive protein (CRP) levels collected within 48 hours of admission. Patients were stratified by normal (≥ 20 mg/dL) or low-normal (< 20 mg/dL) prealbumin levels at admission, and normal (≤ 10 mg/dL) or high (> 10 mg/dL) CRP levels at admission.

Results: 

From July 2015 to December 2015, 131 burn patients were admitted to a regional burn center (69.5% male; mean age, 32 years). Average TBSA burned was 5.17% (range 0.03 – 25.37%), with average 2nd degree burn size of 4.42% TBSA and 3rd degree burn size of 0.77% TBSA.

 

Patients in the two groups of normal (58 patients, 44.3%) vs low-normal (50 patients, 38.2%) prealbumin at admission were matched in age, sex, and TBSA. Compared to patients with normal prealbumin levels, patients with prealbumin < 20mg/dL had longer length of hospital stay (13 days vs 8 days, p < 0.05). Patients admitted with prealbumin < 20mg/dL also had significantly improved prealbumin at discharge (15.52 vs 18.91, p = 0.005). Low-normal prealbumin at admission was associated with higher CRP levels (p < 0.0001).

 

The two groups of normal (56 patients, 42.7%) vs high (36 patients, 27.4%) CRP at admission were matched in sex and TBSA but significantly different in age (30 vs 44 years, p = 0.002). Therefore, we controlled for age by stratifying patients into those ≤ 40 years old, and those older than 40 years. After stratification, we found that in patients ≤ 40 years old, high CRP at admission was associated with longer duration of mechanical ventilation (1.85 days vs 0 days, p < 0.05) and increased hospital cost ($82,079 vs $27,701, p < 0.05). In patients older than 40 years, CRP level at admission was not statistically related to length of stay, hospital cost, or days of mechanical ventilation.

Conclusion: Low prealbumin at admission is predictive of longer length of hospital stay in burn patients of all ages, as age was matched between the normal and low-normal prealbumin groups in our study. In patients 40 years or older, elevated CRP is associated with longer duration of mechanical ventilation and increased hospital cost. Thus, prealbumin and CRP levels at admission should be incorporated into prognostic calculations of burn injury outcomes. 
 

84.08 Readability, Complexity, and Suitability Analysis of Online Lymphedema Resources.

Posted on January 26, 2017

B. N. Tran1, M. Singh1, B. T. Lee1  1Beth Israel Deaconess Medical Center,Plastic And Reconstructive Surgery/Surgery,Boston, MA, USA

Introduction:  As many as 72% of Americans use online health information to aid them in healthcare decision-making. It is, therefore, very important to have resources written at the recommended literacy level. Previous studies primarily focused on readability analysis of online lymphedema literature, consistently showing that they are too advanced for the average American to comprehend.  This study expands such analysis to include complexity and suitability of these materials. 

Methods:  Top ten websites on lymphedema were identified using the most popular search engine, Google. Content of these websites was analyzed for readability, complexity, and suitability using Simple Measure of Gobbledygook (SMOG), PMOSE/iKIRSCH, and Suitability Assessment of Materials (SAM) respectively. PMOSE/iKIRSCH and SAM were performed by two independent raters. Fleiss’ kappa score was calculated to ensure inter-rater reliability. 

Results: Lymphedema literature average SMOG reading grade level was 14.0, above the recommended sixth grade level per the American Medical Association and National Institute of Health. Overall PMOSE/iKIRSCH score was 6.7 corresponding to “low” complexity and requiring a 8th-12th grade education. Fleiss’ kappa score was 80% (p=0.04), interpreted as “substantial” agreement. Overall SAM score was 45% correlating to “adequate” suitability, however this is borderline low for “adequate” category (0-39% Not Suitable, 40-69% Adequate). Fleiss’ kappa score was 76% (p=0.06), interpreted as “substantial” agreement.   

Conclusion: Online lymphedema literature is written above recommended level for readability and complexity. It is adequately suitable for intended audience. Overall, online lymphedema literature is too sophisticated for the average American reader. Further efforts to revise these materials are needed to improve patient’s comprehension and understanding. 

 

84.07 Disparities in Management of Lower Extremity Injuries at a Single, Level 1 Trauma Center

Posted on January 26, 2017

E. K. Awad3, K. Leibl1, C. Kerby2, T. A. Swain2, R. L. Griffin2, T. W. King2  1University Of Wisconsin,Madison, WI, USA 2University Of Alabama at Birmingham,Birmingham, Alabama, USA 3University Of South Alabama,Mobile, AL, USA

Introduction:  The goal of this study was to determine if disparities exist in the care of patients with lower extremity trauma. We aimed to compare rate of limb salvage v. amputation for race, sex, age, and insurance status. We hypothesized that there would be disparities in salvage v. amputation. Uncovering these differences could help target those within disadvantaged populations and help find interventions to improve their quality of care.

Methods:  The institution trauma registry was used to identify patients admitted with lower extremity injuries from 2010-2014. Lower extremity injuries were defined as any injury in the lower extremity below the pelvis and were identified by anatomical region using the abbreviated injury scale (AIS). Whole limb categories were excluded as well as injuries specific to vessels, nerves, and skin as the AIS does not specify anatomical regions for these structures below the knee. ICD-9 procedural codes for amputation were used to identify patients undergoing any amputation below the knee. Patient demographic, injury, and clinical variables were compared by amputation procedure status using the chi-square and t-test for categorical and continuous variables, respectively. Stratified analysis was completed to compare patient characteristics among those with and without amputation.

Results: Between 2010 and 2014, 6902 patients were admitted to a level 1 trauma center with a lower extremity injury, of which 131 patients underwent amputation. 105 of those patients were amputations below the knee (p<0.0001). Among those with leg injuries, those who underwent amputation had significantly longer length of stay (19.7±21.6 versus 8.8±13.3, p<0.0001) and were more likely to be male (79.39%, p=0.0021). No difference was observed for mean age (p=0.9936), race (0.0666), or injury severity score (ISS) (p=0.1495) when comparing those who underwent amputation to those who did not. The time to seek care was significantly longer (p=0.0028) when comparing those who underwent amputation (0.70 days) to those who did not (0.30 days). There was a significant difference (p<0.0001) in payment with a larger portion of those undergoing amputation having payment of other (7.63%) or workers’ compensation (9.92%) when compared to the same payment type among those without amputation.  

Conclusion: There was no significant difference in amputation v. salvage by race, sex or ISS for patients with lower extremity trauma. Patients who underwent amputations were noted to have a longer length of stay and more likely to be male. The results demonstrate a significant difference in the patients who underwent amputation with those undergoing amputation having a payment type of other or workers’ compensation, demonstrating that patients who had private insurance were more likely to receive limb salvage.  Further investigations utilizing a multicenter, nationwide database should be performed to verify and validate these results.

 

84.06 Disparities in the Treatment of Facial Fractures: A Single Center Study

Posted on January 26, 2017

K. E. Leibl1, E. K. Awad3, C. Kerby2, T. A. Swain2, R. L. Griffin2, T. W. King2  1University Of Wisconsin,Madison, WI, USA 2University Of Alabama at Birmingham,Birmingham, Alabama, USA 3University Of South Alabama,Mobile, AL, USA

Introduction:  Previous studies have shown that disparities in treatment and access to care by race, age, and insurance coverage exist in the US. Our goal was to determine if disparities in treatment, specifically surgical versus nonsurgical treatment and time delay from admission to treatment, exist by race, sex, age, and insurance coverage for patients treated for facial fractures at a level 1 trauma center in the southern US.

Methods:  Patients with facial fractures who were admitted for treatment at a level 1 trauma center from 2010-2014 were identified using the trauma registry. ICD-9 diagnosis codes 802-802.9 were used to identify patients with facial fractures. ICD-9 procedural codes were used to determine which patients underwent surgical repair procedures. Patient demographic information, injury characteristics, and clinical data were compared by surgical repair status using a chi-square and t-test for categorical and continuous variables, respectively. Analysis of variance was used for comparison of time to surgery for demographic variables. 

Results: There were 2267 patients with facial fractures from 2010-2014, 473 of which underwent reparative operatory procedures. There was a significant difference in age between those undergoing reparative surgery (40.5±17.4) compared to those who did not undergo surgical procedures (42.8±18.8) (p=0.0088). Those undergoing operative procedures had significantly longer length of stay (13.0±12.8 versus 8.1±13.5, p<0.0001), number of days in the intensive care unit (6.8±9.0 versus 4.3±9.5, p<0.0001), and higher facial abbreviated injury score (2.0±0.6 versus 1.8±0.5, p<0.0001) compared to those who did not. There were no observed differences in surgical status of facial fractures by sex (p=0.6264), race (p=0.8602), payment type (p=0.5044), or injury severity score (p=0.0528). When comparing the time from injury to admission, those undergoing surgical procedures waited longer to seek care when compared to those who did not undergo surgery (0.42 days versus 0.21 days, p=0.0069). Time to facial surgical procedure from admission was slightly longer for females (4.6±6.3 days) compared to males (3.7±4.0 days) (p=0.0643) and for whites (4.2±5.0 days) compared to blacks (3.07±3.8 days) and others (3.3±3.16 days) (p=0.0556).  

Conclusion: Patients receiving nonsurgical care were slightly older than those receiving surgical repair. Female patients undergoing surgical treatment had a slightly longer wait time than males. This data does not support previous studies’ findings of disparities in treatment based on race and insurance status. This may be attributable to the diversity of this trauma center’s patient population and staff and possibly a higher level of cultural competency in treatment. Further investigations utilizing a multicenter, nationwide database should be performed to verify and validate these results.

 

84.05 Early Results in Preventing Lymphedema: A Potential Paradigm Shift in Lymphatic Surgery.

Posted on January 26, 2017

D. Singhal1, M. Hahamoff2, N. Gupta2, D. Munoz2, C. Shaw2, L. Spiguel2, D. Singhal1  1BIDMC,Plastic & Reconstructive Surgery/ Surgery,Boston, MA, USA 2University Of Florida School Of Medicine,Plastic & Reconsruction/ Surgery,Gainesville, FL, USA

Introduction: Lymphedema is a progressive disease with no known cure.  Lymphatic procedures for chronic lymphedema have not been able to deliver consistent results.  More efforts have been put into early prevention. The Lymphedema Microsurgical Preventative Healing Approach (LYMPHA) was introduced in 2009 as a method to prevent lymphedema at the time of axillary lymph node dissection (ALND).  We present our early results with a modified LYMPHA technique at the University of Florida.

Methods: We reviewed our prospectively collected database of all patients with a newly diagnosed breast cancer participating in a lymphedema surveillance protocol at our institution from February 2014 to February 2016. 

Results: Eighty-seven patients participated in our lymphedema surveillance program during the study period with an average age of 60 years, BMI 30, and follow-up of 11.5 months.  Six patients developed lymphedema with the strongest correlation to ALND (p<0.0012).  Of eighteen patients who underwent ALND, 10 did not undergo the modified LYMPHA procedure and 8 completed the procedure.  Fifty percent of patients who did not undergo the modified LYMPHA procedure developed lymphedema (5 patients).  No incidence of lymphedema was detected in patients who underwent the modified LYMPHA procedure. One patient developed lymphedema after sentinel node biopsy and did not undergo modified LYMPHA. (Figure 1)

Conclusion: Our early results demonstrate promising support of the modified LYMPHA procedure in preventing lymphedema in patients undergoing ALND.  If these results are maintained in longer follow-up, this will represent a paradigm shift for the lymphatic surgeon to focus on preventative procedures.

 

« Previous Page
Next Page »