61.05 Safety, Efficacy and Cost Analysis of Robotic Sleeve Gastrectomy Compared to Standard Laparoscopy

Posted on January 31, 2019

J. P. Kuckelman1, T. Holtestaul1, D. Lammers1, J. Bingham1  1Madigan Army Medical Center,General Surgery,Tacoma, WA, USA

Introduction: The increasing comfort with robotic methods in concert with technological advances has led to a surge in robotic approaches for bariatric operations, the most common of which being sleeve gastrectomy (SG).  The progression of robotic use for bariatric procedures has forged forward despite a lack of evidence-based support. Current database studies have demonstrated conflicting data regarding the safety of the robotic approach for sleeve gastrectomy. We evaluate the safety and effectiveness of robotic methods when compared to a standard laparoscopic approach.

Methods: Retrospective review of all SG performed between 2010 and 2017 at a single bariatric center of excellence. Patients were followed for a minimum of 3 months with ongoing follow up to one year. Cases were grouped as laparoscopic (LSG) or robotic (RSG) and propensity matched for age, sex, BMI, and co-morbidities. Patient characteristics, intra-operative indices as well as follow up data including weight loss was collected. Patients were categorized based on operative approach and propensity matched for comparison.

Results: 479 patients were included with the majority being categorized as laparoscopic sleeve gastrectomy (LSG, N=403) with 76 patients included in the robotic group (RSG).  There was 99% follow up for 30 day outcomes. LSG had significantly more patients with pre-operative diabetes at 15.8% compared to 1.3% in the RSG group (p=0.003). There were no differences in terms of pre-operative age, weight, BMI, smoking status, ASA, or rates of any other comorbidity. Operative time was significantly longer with RSG at 138 minutes compared to 104 minutes with LSG (p=<0.001). There were no differences in rates of intra and post-operative blood transfusions, hospital length of stay, unplanned return to the operating room or readmission (Figure). Propensity matching resulted in reduction to 75 patients in each group and did not alter the primary results. Estimated percent weight loss (EWL%) was similar at 3 and 6 months between the two groups. Only 41 patients met had 12-month follow-up in the RSG group but EWL% was significantly lower with RSG at 101% compared to 60% in the LSG group (p=<0.001, see figure).

Conclusion:Robotic sleeve gastrectomy was found to be safe and effective with similar results in terms of weight loss when compared to laparoscopic sleeve gastrectomy. Operative times were longer with a robotic approach which did not result in any adverse postoperative events.
 

61.04 Feeding Outcomes in Neonates with Trisomy 21 and Duodenal Atresia

Posted on January 31, 2019

M. D. Smith2, M. P. Landman1  1Indiana University,Division Of Pediatric Surgery, Department Of Surgery,Indianapolis, IN, USA 2Indiana University-Purdue University, Indianapolis,Department Of Biology,Indianapolis, IN, USA

Introduction:

Duodenal Atresia (DA), a common cause of congenital duodenal obstruction, is commonly repaired early in life via intestinal bypass. Many of these patients can have feeding difficulties in the early, postoperative period.  DA has a known association with Trisomy 21.  The postoperative feeding issues are not well described in this population.  We hypothesize that the combination of DA and Trisomy 21 is associated with worse postoperative feeding outcomes and increased need for gastrostomy button placement when compared to non-trisomy DA patients.

Methods:

A retrospective review of patients at Riley Hospital for Children between 2010-2017 with the diagnosis of duodenal atresia or stenosis was performed.  Prenatal and postnatal clinical data was abstracted.  Additionally, intra-operative and postoperative data was collected.  Univariate analyses were performed.  

Results:

We identified 43 patients with duodenal atresia; 22 (51.2%) were male.  Patients were born at a median gestation age of 37 (IQR 34-38) weeks. Thirty-one (72.1%) of all DA patients were diagnosed prenatally.  Nineteen patients (44%) were diagnosed with Trisomy 21. Repair occurred at a median age of 2 (IQR 1-5) days.  Postoperative feedings were started on average by day 7 (+/- 3.2 days) and there was no difference between patients with Trisomy 21 (6.47 +/- 3.89 days) and those without Trisomy 21 (7.42 +/- 2.47 days; p = 0.34).  There was no difference in days to full enteral nutrition between these groups (13.47 +/- 4.55 vs. 16.46 +/- 9.43 days; p = 0.21). Sixteen patients (84.2%) with Trisomy 21 required gastrostomy at any point versus only 6 (25%) patients without Trisomy 21.  On univariate analysis, there was significant association between Trisomy 21 and the lifetime need for gastrostomy button placement (p < 0.001); however, this association did not hold when evaluating the association of gastrostomy during the index admission (p = 0.11).

Conclusion:

Our data suggests that a correlation exists between Trisomy 21, duodenal atresia, and the eventual need for gastrostomy, that may not be evident when only looking at the index admission alone.  Surgeons should consider placement of gastrostomy button at the time of DA repair in this population to facilitate postoperative feeding and prevent the need for additional operations to obtain durable feeding access. 
 

61.03 Endoscopic Gastro-Jejunostomy Outlet Reduction (EGOR) after Roux-en-Y gastric bypass: Is it worth it?

Posted on January 31, 2019

A. Valencia1, D. E. Azagury1, L. Voller1, T. E. Mokhtari1, P. Pradhan1, N. Strauch1, S. Koontz1, J. Morton1  1Stanford University,Surgery,Palo Alto, CA, USA

Introduction:
Roux-en-Y Gastric Bypass (RYGB) remains the gold standard in bariatric surgery and can lead to significant, sustainable weight loss. However, weight regain remains a long-term risk and very few options are available in the setting of significant weight regain. Previous studies have demonstrated a relationship between increased gastrojejunal stoma diameter and impaired weight loss/weight regain. In this setting, endoscopic suturing may be a useful tool in order to help patients struggling with weight regain and recurrence of their comorbidities. We present a review of full thickness endoscopic gastro-jejunal outlet reductions (EGOR) performed at our institution and resulting weight loss, comorbidity resolution, and perioperative outcomes.

Methods:
Thirty-eight patients underwent EGOR after RYGB and were included in this retrospective analysis of a prospective bariatric database. Pre-EGOR data collected included patients’ demographic information, body mass index (BMI), and percent excess weight loss (%EWL). Perioperative data were recorded. Postoperative complications, BMI, %EWL, and comorbidities were collected at 3, 6 and 12 months. Dichotomous and continuous variables were examined by Chi-Square analysis and Student’s t-test, respectively. Fisher’s exact test was used for categorical variables if cell counts were less than five.

Results:
Average time between RYGB and EGOR was 120.6 ± 67.2 months [range: 37 – 436]. Average BMI at the time of EGOR was 42.0 ± 9.9 kg/m2 [range: 32.7 – 55.2]. Mean operative time was 70.4 minutes [range: 25 – 177]. All cases were performed as outpatient procedures. Average BMI decreased from 42.0 ± 9.9 kg/m2 preoperatively (n=38) to a nadir of 34.4 ± 5.4 kg/m2 (p=0.0038) 6 months after EGOR. At both 3- and 6-months postop, all patients had lost weight from their preop baseline. At 12 month post-operative visit, the weight of five patients either returned or surpassed baseline weight. Of the seven patients with recurrent diabetes, three experienced remission at the 12-month visit. Recurrent hypertension was resolved in four of nine patients, hyperlipidemia was resolved in six of eight patients, and six of eight patients reported significant improvements in sleep apnea at the 12-month post-operative visit.

Conclusion:
This study is one of very few reports regarding outcomes for EGOR after RYGB. Our results show that EGOR can be performed as an outpatient procedure with an excellent safety profile. This procedure may lead to very significant weight loss in select patients, but results vary between individuals and more so beyond 6 months. Importantly, impact on recurrence of comorbidities, including diabetes, is significant even in the setting of modest weight loss. Further studies are needed to assess the long-term sustainability of weight loss following EGOR and to evaluate methods to identify which patients might benefit most from this intervention.
 

61.02 The Impact of Self-Efficacy on Pursuit of Bariatric Surgery

Posted on January 31, 2019

S. M. Jafri1, C. A. Vitous1, D. A. Telem1,2  1University Of Michigan,Center For Healthcare Outcomes And Policy, Institute For Healthcare Policy And Innovation,Ann Arbor, MI, USA 2University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction:
Underutilization of bariatric surgery, even for persons who initiate interest in these operations, is well accepted, but poorly understood. Current estimates demonstrate up to 60% of persons who initiate the process leading to bariatric surgery will ultimately not pursue an operation. It is imperative to understand the rationale behind why individuals discontinue their pursuit of weight-loss surgery (WLS) in order to design effective intervention strategies aimed at obesity treatment. While the reasons for the elevated dropout rate are multifactorial, we hypothesized that self-efficacy, one’s belief in the one’s ability to succeed in specific situations or accomplish a task, would impact pursuit of surgery.

Methods:
To determine the self-efficacy of potential WLS patients, a validated 8-question self-efficacy questionnaire that utilized a five-point Likert scoring scale was administered to 276 participants who participated in bariatric surgery information sessions held at a single institution from 2017-2018. The information session is standard at most bariatric programs and held prior to scheduling the initial consult that initiates the path towards surgery. Patients were then longitudinally followed to determine how far along the process they progressed. Initial consultations were used as the primary outcome metric. Data relating to the patient’s demographics, insurance, medical history, and bariatric progress records were collected and analyzed using varied analysis to determine the significance and independence of self-efficacy as a preoperative predictor. 

Results:
Of the 276 patients who presented to an initial information session, the survey completion rate was 100%. In total, 50% (n=138) proceeded to initial consultation. Patients who proceeded to consultation were significantly younger as compared to older (43.0 ± 12.6 vs. 47.5± 13.6, p-value=0.007) and commercially insured versus insured by Medicare (44.9% vs. 27.5%, p-value=0.02). No significant difference was demonstrated in perception of self-efficacy between populations that went on to consultations versus those that did not (Table 1). Furthermore, no difference in self-efficacy was demonstrated when comparing older and younger counterparts and Medicare to commercially insured persons. 

Conclusion:
Older adults and those with Medicare insurance are less likely to proceed with initial consultation. Self-efficacy, conversely, was not influential in patient decision to proceed with initial consultation. We will continue to explore whether self-efficacy impacts actual completion of operation or weight loss outcomes in this patient population.
 

61.01 Short- and Long-term Respiratory Functions After Esophagectomy for Esophageal Cancer

Posted on January 31, 2019

H. Ichikawa1, T. Otani1, T. Hanyu1, T. Ishikawa1, K. Usui1, M. Nemoto1, T. Sakai1, Y. Kano1, Y. Muneoka1, Y. Shimada1, M. Nagahashi1, J. Sakata1, T. Kobayashi1, H. Kameyama1, T. Wakai1  1Niigata University Graduate School of Medical and Dental Sciences,Division Of Digestive And General Surgery,Niigata, NIIGATA, Japan

Introduction: The impact of surgical procedures on respiratory functions after esophagectomy for esophageal cancer is not fully investigated. The aim of this study is to clarify the difference in short- and long-term respiratory functions after esophagectomy between the surgical procedures.

Methods: A total of 48 patients who underwent curative esophagectomy for thoracic esophageal cancer from 2003 to 2012 were enrolled in this single-institutional prospective study. We evaluated volume capacity (VC) and forced expiratory volume 1.0 (FEV1.0) at six points as follows: before esophagectomy (baseline), 3, 6, 12, 24 and 60 months after esophagectomy. We compared the change ratio to baseline values between the three surgical procedures: open esophagectomy (OE, N = 19), minimally invasive esophagectomy (MIE, N = 16), and transhiatal esophagectomy (THE, N = 13). The baseline respiratory functions before esophagectomy were not significantly different between the three groups.

Results: The decline of VC in THE group (median change ratio: 0.91) were significantly less than that in OE (0.75) and MIE group (0.80) 3 months after esophagectomy (P < 0.01). VC in MIE and THE group recovered at 0.94 and 0.98 of the median change ratios; however, VC in OE group remained at 0.85 and lower than that in MIE and THE group 12 months after esophagectomy (P = 0.016). The median change ratios of VC in OE (0.83), MIE (0.84) and THE groups (0.88) were not significantly different 60 months after esophagectomy (P = 0.176). FEV1.0 in OE (0.78) and MIE (0.81) group significantly more declined than that of THE group (0.97) after 3 months (P < 0.01). FEV1.0 in OE and MIE group recovered at 0.89 and 0.89; however, they were significantly lower than that in THE group (0.99) 12 months after esophagectomy (P = 0.015). Although FEV1.0 in THE group kept the baseline value after esophagectomy, the median change ratios of FEV1.0 in OE (0.84), MIE (0.86) and THE groups (0.94) were not significantly different 60 months after esophagectomy (P = 0.46).

Conclusion: THE contributes to maintaining short-term respiratory function after esophagectomy for esophageal cancer. MIE is advantageous in the early recovery of VC as compared with TTE. The differences in respiratory functions after esophagectomy between the surgical procedures are not observed after a long-term follow-up.
 

60.20 Injury Severy and Alcohol Intoxication in the "Found Down" Trauma Patient

Posted on January 31, 2019

L. T. Knowlin1, S. Siram1, E. E. Cornwell1, M. Williams1  1Howard University College Of Medicine,General Surgery,Washington, DC, USA

Introduction: The “Found Down” descriptor for trauma patients in our urban setting is common.  It often is unclear whether these patients have experienced significant traumatic injury necessitating an extensive trauma workup versus medical conditions that require acute management. Furthermore, many “Found Down” patients are not severely injured, but rather are suffering from acute substance abuse. We evaluated the association between overall blood alcohol levels (BAL) and injury severity.

Methods: A retrospective cohort study using trauma registry data for non-motorized patients presenting to a Level I Trauma Center between 2015-2018.  Patients who had elevated BAL measurements were included.  Patients were divided in 4 distinct subgroups based on BAL: 1. < 200 mg/dl  2. 200-300 mg/dl  3. 300-400 mg/dl  4. > 400 mg/dl.  Descriptive analysis of the cohort was performed.  Bivariate analysis was conducted comparing injuring level of patients in the 4 groups.

Results:The “Found Down” descriptor was utilized in 554 trauma patients in the study time frame.  There were a total of 325 patients were included in this study with 312 (96%) having a BAL > 50 mg/dl.  Concomitant substance abuse with an additional drug was seen in 39 patients (12%).  Of the 325 patients labelled “Found Down” 314 (97%) had injuries on evaluation and 6 (2%) required surgical intervention. Of the 2% with surgical intervention, 3 (50%) had an Injury Severity Score (ISS) greater than 16. Moderate to severe injuries (ISS ≥ 8) was seen highest in patients with BAL < 200mg/dL. Found down patients with a BAL > 400 mg/dl were more likely to present with minor injuries (extremity and trunk contusions and lacerations) and have a lower Injury Severity Score.

Conclusion:The “Found Down” descriptor for urban trauma patients is associated with alcohol intoxication.  Most of the cohort of “Found Down” trauma patients in this study were mildly injured.  Alcohol intoxication of > 400 mg/dl (Group 4) was not associated with increased injury severity when compared to similar patients with BAL of < 200 mg/dl.  Most “Found Down” trauma patients who were moderately to severely injured were found in Group 1 (BAL < 200 mg/dl).  “Found Down” patients are likely to have a low injury severity and there is no association with injury severity and increasing BAL.

 

60.19 Predictors of Mortality Following Hemorrhagic Shock from Blunt Thoracic Trauma

Posted on January 31, 2019

J. O. Hwabejire1,2, B. A. Adesibikan2, T. A. Oyetunji3, M. Williams2, S. M. Siram2, E. Cornwell III2, W. R. Greene4  1Massachusetts General Hospital,Division Of Trauma, Emergency Surgery, And Surgical Critical Care/Department Of Surgery,Boston, MA, USA 2Howard University College Of Medicine,Surgery,Washington, DC, USA 3Children’s Mercy Hospital- University Of Missouri Kansas City,Surgery,Kansas City, MO, USA 4Emory University School Of Medicine,Surgery,Atlanta, GA, USA

Introduction:  Major thoracic injury is one of the causes of hemorrhagic shock in patients who suffer severe blunt trauma. The goal of this study is to determine the factors that contribute to increased mortality in blunt traumatic hemorrhagic shock necessitating a thoracic surgical procedure.

Methods:  The Glue Grant database was retrospectively examined. Patients aged ≥ 16 years and had either a thoracotomy, sternotomy or video-assisted thoracoscopic surgery (VATS) were included in the analysis. Univariate analysis was used to compare survivors and non-survivors, while multivariable analysis was used to ascertain predictors of mortality.

Results: A total of 205 patients were included in the analysis. Their average age was 43 years (SD=18), 72% were males, and 87% were White.  This subset had an in-hospital mortality of 37 %.  When compared to non-survivors, survivors had a higher BMI (28.0 ±6.7 vs. 22.3 ±12.4 kg/m2, p<0.001), higher emergency room (ER) systolic BP (104±36 mmHg vs. 90 ±36 p=0.010), lower ER lactate (5.1 ±3.0 vs. 8.0 ±3.8 mg/dL, p<0.001), were less coagulopathic (ER INR: 1.4 ±0.5 vs. 2.0±1.9, p=0.002 ), and received a lower volume of blood products within 12 hours of presentation (3599±3249 vs. 8470±6978 mL, p<0.001). There were no differences in age, gender, race, Injury Severity Score (ISS), multiple organ dysfunction score, volume of crystalloids received within 12 hours of presentation, and pre-injury comorbidities between the two groups. About half of survivors (53.4%) underwent a laparotomy compared to 73.7% of non-survivors (p=0.004). In the multivariable analysis, ER lactate (OR: 1.21, CI 1.07-1.37, p=0.002) was the only independent predictor of mortality. Higher BMI appeared to be protective against mortality (OR: 0.951, CI 0.905-0.998, p=0.043).

Conclusion: In blunt traumatic hemorrhagic shock requiring a thoracic surgical procedure, the degree of tissue hypoperfusion as represented by the serum lactate on presentation in the ER is an independent predictor of mortality.  

 

60.18 Validating the ATLS Shock Classification for Predicting Death, Transfusion, or Urgent Intervention

Posted on January 31, 2019

J. Parks1, G. Vasileiou1, J. Parreco1, R. Rattan1, T. Zakrison1, D. G. Pust1, N. Namias1, D. D. Yeh1  1University Of Miami,Department Of Surgery,Miami, FL, USA

Introduction:
The Advanced Trauma Life Support (ATLS) Program of the American College of Surgeons shock classification has been accepted as the de facto conceptual framework for most clinicians caring for trauma patients.  We sought to validate its usefulness and ability to predict mortality, blood transfusion, and urgent intervention.

Methods:
We performed a retrospective review of trauma patients using the 2014 National Trauma Data Bank. Adults (age ≥18) were included in the analysis if they were not missing data for vital signs, GCS, sex, or disposition. Using emergency department vital signs data, patients were categorized into shock class based on the 10th edition of ATLS, rates for blood product transfusion within 24 h, urgent operative intervention (laparotomy, thoracotomy, or IR embolization within 24 h), and in-hospital mortality were calculated.

Results:
After exclusions, 630,635 subjects were included for analysis. Classes 1, 2, 3, and 4 included 312,404, 17,133, 31, and 43 patients, respectively. 300,754 (48%) patients did not meet the criteria for any ATLS shock class and were not categorized. Clinical outcomes are presented in the Table. Uncategorized patients had a higher mortality (7.1%) than the patients in shock classes 1 and 2 combined. Additionally, Shock Classes 3 and 4 each only accounted for 0.009% and 0.013%, respectively, of the categorizable patients.

Conclusion:
Almost half of all trauma patients do not meet the criteria for any category of shock according to the ATLS classification definitions and Class 3 and 4 Shock accounted for <0.1% of all injured patients. The current classification system requires better calibration in order to include more patients and to be clinically useful in predicting meaningful outcomes.
 

60.17 Management of Isolated Blunt Splenic Injuries: OIS Grade III versus Grade IV

Posted on January 31, 2019

J. Wycech1,2, J. Owens2,3, M. Gomez1, A. Tymchak1,2,3, M. Crawford2, A. A. Fokin2, I. Puente1,2,3,4  1Broward Health Medical Center,Trauma Services,Fort Lauderdale, FL, USA 2Delray Medical Center,Trauma Services,Delray Beach, FL, USA 3Florida Atlantic University,College Of Medicine,Boca Raton, FL, USA 4Florida International University,College Of Medicine,Miami, FL, USA

Introduction:
Non-operative management (NOM) is the standard of care for blunt splenic injuries (BSI) in hemodynamically stable patients. Traditionally, use of NOM is debatable when solid organ injury scale (OIS) Grade is III or higher with a tendency to expand the use of NOM to Grade IV injuries of liver, pancreas and kidneys. The goal of this study was to investigate whether NOM should be extended to higher grade spleen injuries, and to examine failure of NOM in isolated blunt splenic injuries (IBSI) in relation to the severity of spleen injury.

Methods:
This IRB approved retrospective cohort study included 133 adult patients with IBSI who were delivered to a level I trauma center between 2012 and 2017 and had attempted NOM of abdominal trauma. Patients were grouped by their OIS Grades and their management approach and outcomes, such as failure of NOM (FNOM), were compared. Furthermore, age, Injury Severity Score (ISS), comorbidities, packed red blood cells transfused within 24 hours (PRBC24), rate of hemoperitoneum, angiography, embolization, repeat abdominal computed tomography (CT), hospital length of stay (HLOS) and mortality were compared in OIS Grade III and IV groups. FNOM was defined as laparotomy after initially attempting NOM.

Results:

The average Spleen OIS was 2.4 (range I-V) with overall FNOM of 11.5% (n=12) and 1.9% (n=2) mortality. There were 33 patients with OIS I, 24 with OIS II, 32 with OIS III, 35 with OIS IV, 7 with OIS V. 2 patients did not have an assigned OIS Grade, because of the lack of precise radiological description of their spleen injury. Rate of attempted NOM in each OIS Grade group was as follows: OIS I 100.0%, OIS II 95.8%, OIS III 71.9%, OIS IV 65.7%, OIS V 28.6%. FNOM was 0% for OIS Grades I and II with no mortalities. In OIS Grades III and IV, FNOM rates were the same (21.7% vs 21.7%; p=1.0) with 1 mortality in patients with OIS Grade III. All patients with OIS Grade V, who had attempted NOM (n=2) failed NOM and underwent laparotomy.

Between OIS Grade III and IV, mean ISS (13.6 vs 19.4; p=0.001) and hemoperitoneum rate (69.6% vs 95.7%; p=0.02) were significantly higher in OIS Grade IV patients. Age (40.2 vs 41.1), comorbidities (65.2% vs 65.2%), PRBC24 (34.8% vs 34.8%), rates of angiography (52.2% vs 65.2%), embolization (30.4% vs 26.1%), repeat CT (30.4% vs 39.1%), HLOS (6.8 vs 9.4 days) and mortality (4.3% vs 0.0%) were not statistically different between patients with OIS Grades III and IV (all p>0.1).

Conclusion:
The rate of FNOM in patients with OIS Grade III and IV was the same, despite a significantly higher ISS and hemoperitoneum rate in Grade IV patients. Expansion of NOM to higher grade splenic injuries is cautiously recommended.

60.16 Non-operative Management vs. Laparotomy for Abdominal Gunshot Wounds: A Matched Analysis

Posted on January 31, 2019

S. W. De Geus1, C. D. Barrett2, M. Neufeld1, C. D. Graham1, S. E. Byerly3, S. Ng1, M. B. Yaffe2, J. F. Tseng1, S. E. Sanchez1  1Boston Medical Center,General Surgery,Boston, MA, USA 2Beth Israel Deaconess Medical Center,General Surgery,Boston, MA, USA 3Ryder Trauma Center,Miami, FL, USA

Introduction: Non-operative management of penetrating trauma has been increasing in the last decade. The purpose of this study was to compare the outcomes of selective non-operative management (NOM) versus laparotomy (LAP) in patients with gunshot wounds to the abdomen.

Methods: Patients with gunshot wounds to the abdomen were extracted from the Healthcare Cost and Utilization Project Florida State Inpatient Database. Patients with brain and/or spinal cord injuries, or who were hemodynamically unstable were excluded. Propensity-score models were created predicting the odds of undergoing NOM. Patients were matched based on propensity-score. Inhospital mortality, complicationd, and length of stay were compared.

Results: In total, 743 patients were identified. 74% (n=548) of patients underwent LAP. Unadjusted, NOM was associated with age  ≤28 year (59% vs. 51%; p=0.035), black/Hispanic race (73% vs. 63%; p=0.011), absence of insurance (51% vs. 39%; p=0.004), low-volume (< 10 abdominal gunshot wounds/year) treatment center (69% vs. 58%; p=0.005), a lower complication rate (14% vs. 27%; p<0.001), and shorter length of stay (median length of stay: 4 vs. 9 days; p<0.001). Unadjusted, in-hospital mortality (6% after NOM vs. 5% after LAP; p=0.853) was similar for both groups. After matching, baseline characteristics were equally distributed, with 170 patients in each group.  Adjusted, NOM remained associated with shorter length of stay (median length of stay: 4 vs. 8 days; p<0.001). However, the prevalence of complications (14% after NOM vs. 19% after LAP: 25% vs. 22%; p=0.191) were comparable.

Conclusions: The results of this study suggest that NOM may be safe in well selected patients with abdominal gunshot wounds. NOM was associated with shorter length of stay, possibly reducing overall cost.
 

60.15 A Statewide Assessment of Rib Fixation Patterns Reveals Missed Opportunities

Posted on January 31, 2019

C. L. Mullens1,2, M. J. Seamon1, A. Shiroff1, J. Cannon1, L. Kaplan1, J. Pascual1, D. Holena1, N. D. Martin1  1Hospital Of The University Of Pennsylvania,Department Of Surgery; Division Of Traumatology, Surgical Critical Care, And Emergency Surgery,Philadelphia, PA, USA 2West Virginia University School of Medicine,Morgantown, WV, USA

Introduction:

Rib fractures are a common consequence of traumatic injury and can result in significant debilitation.  Rib fixation offers fracture stabilization, resulting in improved outcomes and decreased pulmonary complications, especially in high-risk groups such as those with flail segments.  However, commercial rib fixation has only recently become clinically prevalent and we hypothesize that significant opportunity exists in the broader population to offer this clinical advantage.

Methods:
The Pennsylvania Trauma System Foundation database was queried for all rib fracture patients occurring statewide during calendar years 2016 & 2017.  Demographics including Abbreviated Injury Scores (AIS) for all body areas, the presence of flail, and the occurrence of rib fixation was abstracted.  Outcomes were compared between the fixation group and all rib fracture patients using t-test and chi-square where appropriate.  Each repaired patient was used to identify matched peers in the unrepaired, multiply-fractured cohort using age, sex, ISS, and AIS.  De-identified treating trauma center was used to elicit center-level disparities. 

Results:
During the study period, there were 16,302 patients with rib fractures of which 12,910 had multiple rib fractures and 135 had flail segments.  57 patients underwent rib fixation, 10 of which had a flail.  As compared to the non-operative, multi-rib fractured cohort, those who underwent rib fixation were younger (52.5 vs 61.5, p=0.0009) but similar in gender (68% vs 62% male, p=0.373) and race (80% vs 86% white, p=0.239).  The rib fixation group had higher Injury Severity Scores (19.4 vs 15.4 p=0.0011).  Cumulative non-thorax AIS score means were similar between groups as well (0.58 vs 0.64, p=0.76).  4,430 matched peers were identified in the multiply-fractured, unrepaired group as compared to the rib fixation group.  18 of 42 accredited trauma centers performed rib fixation during the study period.  4,796 (37.1%) of multiple rib fracture patients were cared for at centers not performing rib fixation. 

Conclusion:
Rib fixation is underutilized as compared to the contemporary population of those who underwent repair.  Center-level disparities exist as well, suggesting that further penetrance of this treatment into clinical practice is warranted. Additionally, patient-level disparities suggest further research is needed to illicit better defined indications for operative fixation.

60.14 The Challenge of Enteroatmospheric Fistulas

Posted on January 31, 2019

D. J. Gross1, B. Zangbar1, K. Chang1, E. H. Chang1, P. Rosen1, L. Boudourakis2, M. Muthusamy2, V. Roudnitsky2, T. Schwartz2  2Kings County Hospital Center,Department Of Surgery,Brooklyn, NY, USA 1SUNY Downstate Medical Center,Department Of Surgery,Brooklyn, NEW YORK, USA

Introduction:
With the popularization of damage control surgery and the use of the open abdomen, a new permuation of fistula arose, the entero-atmospheric fistula(EAF); an opening of exposed intestine splling ucontrollably into the peritoneal cavity.  EAF is the most devastating complication of  the open abdomen.  We describe and analyze a single institution's experience in controlling high-output deep exposed (entero-atmospheric) fistulas (DEFs) in patients with peritonitis in an open abdomen.

Methods:
We analyzed 189 consecutive procedures to achieve and maintain definitive control of 24 DEFs in 13 patients between 2006 – 2017. DEFs followed surgery for either trauma (7 patients, 53%) or non-traumatic abdominal conditions (6 patients, 46%). All procedures were mapped onto an operative timeline and analyzed for: success in achieving definitive control, number of reoperations, and feasibility of bedside procedures in the SICU. The end point was controlled enteric drainage through a healed abdominal wound  (superficial exposed fistula) that was no longer life threatening.

Results:

There was a mean delay of 8.5 days (range 2 – 46 days) from the index operation until the DEF was identified. Most DEFs required several attempts (mean: 2.7 per patient, range 1 – 7) until definitive control was achieved. Reoperations were then required to maintain control (Table). While the most effective techniques were endoscopic (clipping and stenting) and proximal diversion, these were applicable only in select circumstances. A "floating stoma" where the fistula edges are sutured to an opening in a temporary closure device, while technically effective, required multiple reoperations in the OR. Tube drainage through a negative pressure dressing (Tube Vac) required the most maintenance usually through bedside procedures. Primary closure almost always failed [18/20]. Twelve of the 13 patients survived

Conclusion:
A DEF is a unique and highly complex surgical challenge. Successful source control of the potentially lethal ongoing peritonitis requires tenacity and tactical flexibility.  The appropriate control technique is often found by trial and error, and must be creatively tailored to the individual circumstances of the patient.

60.13 Relationship Between Sleep-Disordered Breathing And Outcomes After Trauma: A Nationwide Analysis

Posted on January 31, 2019

F. S. Jehan1, J. Con1, M. Khan1, A. Azim1, R. Latifi1  1Westchester Medical Center,Surgery,Valhalla, NEW YORK, USA

Introduction: Sleep-disordered breathing (SDA) also known as obstructive sleep apnea is feared to be associated with respiratory complications especially in surgical patients. Trauma patients with SDA may have increased risk of these complications usually due to complex nature of injuries, increase use of opioids/ sedative medications and decreased consciousness levels. However, the association between SDA and outcomes in trauma patients has not been evaluated.

Methods: We performed a 2-year (2011-2012) analysis of the Nationwide Inpatient Sample (NIS) and included all adult (>18 year) trauma patients. Patients were stratified into those with history of SDA and those without history of SDA. Primary outcomes were complications; respiratory and cardiac; the need for non-invasive ventilation and tracheostomy. Secondary outcomes were hospital length of stay, and mortality. Multivariate regression analysis was performed.

Results: A total of 63,284 trauma patients were included in the study. Mean age was 43±17 years and 60% were males. 7.5%(4746) of patients had a SDB. Overall 16.7% patients developed a complication and overall mortality rate was 5.1%.The unadjusted rate of complications between SDA and non-SDA group was (26% vs. 16%, p=0.01) while the unadjusted mortality was (7.6% vs. 4.9%, p=0.02). After performing regression analysis and controlling for all the possible confounders, trauma patients with SDA had higher adjusted rates of developing any complication (OR: 1.5[1.2-2.5], p=0.03), cardiac complications (OR: 1.7[1.3-2.4], p=0.02), respiratory complication [OR: 3.1[2.1-3.9], p<0.01], the need for non-invasive ventilation (OR: 2.5[1.9-.3.2], p<0.01) and tracheostomy (OR: 1.8[1.3-.2.2], p=0.02). The adjusted hospital length of stay was higher (3 days vs. 2 days, p=0.02) in the SDA group compared to the non-SDA group. However, there was no difference in the adjusted mortality between the two groups.

Conclusion: Trauma patients with sleep-disordered breathing are associated with higher risk of cardiac and respiratory complications, the need for non-invasive ventilation, and tracheostomy rates. Patients with SDA spend longer time in the hospital; however, there was no difference between the mortality compared to patients without SDA. These effects of SDA might be attributed to Use of screening criteria including the STOP BANG, will lead to early identification of these patients, and allocation of resources to prevent these complications.

 

60.12 A Body Of Evidence: Barriers To Family Viewing After Death By Gun Violence

Posted on January 31, 2019

D. Reny1, S. Root1, K. Chreiman1, R. Browning1, C. Sims1  1University Of Pennsylvania,Trauma, Surgical Critical Care And Emergency Surgery,Philadelphia, PA, USA

Introduction: Gun violence remains a staggering public healthcare crisis in the United States with over 11,000 deaths annually. Although viewing of the body after violent crime is an essential component of the grieving process, this practice is not universally practiced in the trauma bay and may not be supported by nursing. This study investigates how trauma nurses perceive bereavement and the potential barriers to family viewing following death by gun violence.

Methods: A survey designed to assess demographics, current practices, knowledge of policies, and personal beliefs regarding family viewing after violent crime was sent electronically to the 3,000 members of the Society of Trauma Nurses. In addition to demographic questions, participants were asked to rank the importance of 14 barriers to viewing on a scale of 1 (least important) to 6 (most important). Descriptive analysis and perception of barriers between those who did and did not permit viewing were compared using Mann Whitney tests. *p<00.5=significant.

Results: Of the 232 participants, the majority were white, female nurses (86%) between the ages of 30 and 60 years who worked at a Level 1 or 2 trauma center (83%) in an urban or suburban setting (58% and 30%). Only 14% had a written hospital policy surrounding viewing; and the majority did not know if the police (64%) or medical examiner (69%) had written policies. Despite lack of clear guidelines, 68% reported that viewing did routinely occur, but only 36.7% permitted touching. Race of the victim did not correlate with viewing. Primary barriers included legal concerns, safety, and a perception that the trauma bay was not designed for viewing. These were ranked significantly higher by nurses who did not permit viewing.

Conclusion:  Although family viewing after gun violence frequently occurs in the trauma bay, there are significant legal concerns despite the lack of formal policies. Collaboration with police and medical examiners could mitigate these fears while promoting a safe and more family-centered experience. 

 

 

60.11 Thromboembolic Prophylaxis in Nonoperatively Managed Patients with Blunt Spleen Injuries

Posted on January 31, 2019

J. Owens1,2, A. A. Fokin2, J. Wycech2,3, M. Crawford2, A. Tymchak1,2,3, M. Gomez3, I. Puente1,2,3,4  1Florida Atlantic University,College Of Medicine,Boca Raton, FL, USA 2Delray Medical Center,Trauma Services,Delray Beach, FL, USA 3Broward Health Medical Center,Trauma Services,Fort Lauderdale, FL, USA 4Florida International University,College Of Medicine,Miami, FL, USA

Introduction:
Nonoperative management (NOM) is the standard of care for blunt splenic injuries (BSI) in hemodynamically stable patients. Low-Molecular-Weight Heparin (LMWH) has been shown to be effective in prevention of thromboembolic complications in trauma patients. Reports are scarce regarding safety of early administration of LMWH in patients with BSI. The goal of this study was to investigate safety of early LMWH use in NOM patients with BSI.

Methods:
This IRB approved retrospective cohort study included 135 adult patients with BSI who were delivered to a level 1 trauma center over a 6 year period (2012 to 2017) with attempted NOM. Patients were divided into three groups: Early LMWH (n=12) who received LMWH within 72 hours of admission; Late LMWH (n=21) who received LMWH after 72 hours; and No LMWH (n=102) who did not receive LMWH or received it only after failed NOM and laparotomy. Injury Severity Score (ISS), Spleen organ injury scale (OIS) grade, rate of hemoperitoneum, units of blood transfused, occurrence of Deep Venous Thrombosis/Pulmonary Embolism (DVT/PE) and mortality were compared between the groups. Failure of NOM (FNOM) was defined as undergoing laparotomy after initially attempting NOM. To compare variability between the three groups one way ANOVA was used, followed by Tukey’s post-hoc comparison within the groups. Categorical variables were analyzed using the Kurskall Wallis test.

Results:

Mean ISS was significantly higher in the Late LMWH group compared to the No LMWH group, (19.4 vs 13.5; p=0.02). Mean spleen OIS grade was not different between the three groups (1.7 vs 2.5 vs 2.4; p=0.1). The percent of high grade spleen injuries (OIS 3+) was not statistically different between three groups (16.7% vs 47.6% vs 46.1%; p=0.1). In the Early LMWH group 7 patients (58.3%) had BSI injuries with other abdominal trauma, in the Late LMWH it was 15 patients (71.4%), and in No LMWH group it was 11 patients (10.8%).

Percent of patients with hemoperitoneum diagnosed on computed tomography CT scan was similar in the three groups (49.2% vs 48.3% vs 48.3%; p=0.9). In 135 patients, 17 (12.6%) had FNOM, and all but two failures occurred either before LMWH administration or in patients who never received LMWH. Mean units of blood transfused during hospital stay were statistically different between the three groups (1.2 vs 3.0 vs 1.6 units; p<0.001), with more units transfused in Late LMWH than in Early LMWH (p=0.005), and than in No LMWH (p<0.001). DVT/PE occurred in 4 patients (1 in Early and No LMWH and in 2 patients in Late LMWH) and was not statistically different between the groups (p=0.06). There were no mortalities in any of the groups that received LMWH.

Conclusion:
In patients undergoing NOM for blunt splenic injuries, early administration of LMWH did not increase the failure rate of NOM, units of blood transfused, or mortality and therefore, is safe and recommended. 

60.10 The Effects of Combined Solid Organ Injuries on Management of Blunt Kidney Injuries

Posted on January 31, 2019

J. Wycech1,2, J. Saluck1,3, A. Tymchak1,3, M. Crawford1,2, M. Gomez2, I. Puente1,2,3,4, A. A. Fokin1  1Delray Medical Center,Trauma Services,Delray Beach, FL, USA 2Broward Health Medical Center,Trauma Services,Fort Lauderdale, FL, USA 3Florida Atlantic University,College Of Medicine,Boca Raton, FL, USA 4Florida International University,College Of Medicine,Miami, FL, USA

Introduction:
In hemodynamically stable patients, nonoperative management (NOM) of blunt kidney injuries (BKI) has become the standard of care. However, the efficacy of NOM in patients with BKI combined with other solid organ injuries (SOI) remains unclear. The aim of this study was to assess the efficacy of NOM in isolated BKI as compared to combined BKI.

Methods:
This IRB approved retrospective cohort study included 74 adult patients, admitted to a level 1 trauma center between 2012 and 2017 with a kidney injury confirmed by computed tomography scan. 49 patients had an isolated BKI (Group I) and 25 patients had BKI combined with additional SOI (Group II). The most common additional SOI in Group II were equally distributed between the spleen and liver (56.0% each), followed by pancreas and adrenal glands (8.0% each). Injury Severity Score (ISS), mechanism of injury (MOI), kidney Organ Injury Scale (KOIS) grade, packed red blood cells transfused within 24 hours of admission (PRBC24), rates of hemoperitoneum, angiography, embolization, Intensive Care Unit length of stay (ICULOS), hospital LOS (HLOS) and mortality were compared.

Results:

Group I compared to Group II had statistically lower mean ISS (17.5 vs 24.0; p=0.02), also having less high impact MOI (61.2% vs 92.0%; p=0.02). Mean KOIS for both groups was similar, grade 2.2 for Group I and 2.3 for Group II (p=0.5). NOM was attempted in 98.0% of patients in Group I and in 80.0% of Group II (p=0.007). Attempted NOM was successful in 100% of Group I and in 85.0% of Group II (p=0.01). Of the 3 patients that failed NOM in Group II, 2 patients failed due to a liver injury and 1 due to a spleen injury. In Group I, 1 patient underwent an early exploratory laparotomy and surgical intervention on the kidney. Early exploratory laparotomy was performed less often in Group I compared to Group II (2.0% vs 20.0%; p<0.001), with 40.0% undergoing surgery of the kidney and 60.0% surgery of other organs only.

Rate of PRBC24 was statistically lower in Group I than in Group II (16.0% vs 24.0%; p=0.004). Hemoperitoneum was detected statistically less often in Group I than in Group II (45.0% vs 72.0%; p=0.003). Angiography was performed statistically less often in Group I than in Group II (8.2% vs 36.0%; p=0.003), as was embolization (0.0% vs 12.0%; p=0.01). ICULOS was similar for the two groups (6.5 vs 6.7 days, p=0.3), however HLOS was statistically shorter in Group I than in Group II (8.2 vs 10.9 days; p=0.04). Mortality rate was not statistically different between two groups (12.2% vs 8.0%; p=0.6) and none of it was attributed to the kidney injury.

Conclusion:
In Group I, attempted NOM was always successful, regardless of severity of kidney injury. However, in Group II, attempted NOM was statistically less successful, due to the other organ injuries. In patients with combined BKI, the consideration of NOM should not be based on the severity of the kidney injury but instead should be based on the severity of other SOI.

60.09 Sternotomy for Hemorrhage Control in Trauma

Posted on January 31, 2019

L. Al-Khouja1, A. Grigorian1, S. Schubl1, K. Galvin1, A. Kong1, M. Lekawa1, T. Chin1, J. Nahmias1  1University Of California – Irvine,Department Of Trauma And Critical Care Surgery,Orange, CA, USA

Introduction: Thoracic trauma accounts for 20-25% of trauma deaths. Little is known about the injuries, mechanisms, and outcomes in trauma patients undergoing sternotomy for hemorrhage control. The purpose of this study is to perform a descriptive analysis of trauma patients undergoing sternotomy for hemorrhage control and identify which thoracic injuries and other factors are predictors of mortality. We hypothesize blunt trauma is associated with higher risk of death compared to penetrating trauma within this population.

Methods: The Trauma Quality Improvement Program (2010-2016) database was queried for patients undergoing sternotomy for hemorrhage control within 24-hours of admission. Patients with blunt and penetrating trauma were compared using chi-square and Mann-Whitney U test. A multivariable logistic regression model was used to determine risk of mortality.

Results: Of the 584 patients undergoing sternotomy for hemorrhage control, 322 (55.1%) were involved in penetrating trauma, 69 (11.8%) in blunt trauma and 193 (33.3%) involved in “other/unknown” mechanism. The median injury severity score (ISS) was 25.0 and the most common known mechanism was a stab wound (49.9%) followed by gunshot wound (19.2%). The overall time to hemorrhage control was 52.8 minutes and was longer in those with blunt compared to penetrating trauma (84.6 vs. 49.8 minutes, p <0.001). Open-cardiac injury (26.4%) and hemothorax (23.5%) were the most common thoracic injuries. The most common procedures involved cardiac repair (44.7%) followed by lung repair (15.8%). The overall mortality rate was 18.2% and was higher in patients with blunt compared to penetrating trauma (29.0% vs. 12.7%, p<0.001). However, after adjusting for covariates there was no difference in risk of mortality between blunt and penetrating trauma (p=0.49). We did not find any independent predictors of mortality in patients with blunt trauma. The strongest independent predictor of mortality in patients with penetrating trauma was ISS≥25 (OR=6.24, CI=2.04-19.11, p=0.001).

Conclusion: Trauma patients who undergo sternotomy for bleeding often achieve hemorrhage control in less than one hour. Nearly half the patients present after a stab wound and require cardiac repair. Trauma patients requiring sternotomy for hemorrhage control after blunt trauma had a higher mortality rate, compared to those involved in penetrating trauma. However, after adjusting for known predictors of mortality in trauma, there was no difference in risk of mortality despite nearly double the time to hemorrhage control in patients presenting after blunt trauma.

60.08 Use of Indirect Calorimetry in a Cohort of Patients with Enterocutaneous Fistula

Posted on January 31, 2019

S. Bou Zein Eddine1, A. Kamien1, Z. Yin1, C. Trevino1, R. Fritzshall1, A. Stachowiak1, A. Szabo1, J. S. Juern1, J. R. Peschman1, M. A. De Moya1, P. A. Codner1  1Medical College Of Wisconsin,Surgery/ Trauma And Acute Care Surgery,Milwaukee, WI, USA

Introduction:
Nutrition is key in Enterocutaneous Fistula (ECF) management.  Predictive Equations (PE) and Indirect Calorimetry (IC) are used to calculate nutritional needs but do not correlate well to each other. We hypothesize that even though IC is the gold standard, it is difficult to implement logistically and has a weak concordance with PE.

Methods:
The study included a retrospective cohort of all patients aged ≥18 with ECF admitted between January 2011 and April 2016 and a prospective cohort admitted between April 2016 and February 2017. Demographics, comorbidities, surgeries, and fistula output were determined.  A dietitian determined nutritional therapy and caloric requirements at initial consult, hospital discharge, and outpatient using the Mifflin St Jeor (MSJ) equation. The baseline Resting Energy Expenditure from PE (REEPE) and REE from IC (REEIC) was evaluated for both cohorts, the difference was calculated, and the concordance were plotted in a Bland-Altman plot.

Results:
A total of 33 patients were included. In the prospective arm (n=12) mean age was 54.3 (±18.9) and 66.7% were male. In the retrospective arm (n=21), mean age was 53.7 (±18.3) and 66.7% were male. The median equation difference of REEPE from REEIC, was 71.0 kcal/24 h (IQR, -203.0 – 173.5) in the prospective arm and 123.0 kcal/24 h (IQR, -97.0 – 177.0) in the retrospective arm. The concordance correlation coefficient between REEPE and REEIC was 0.541 (95%CI, 0.213, 0.785). The Bland-Altman plot for the concordance between the REEIC and REEPE (Figure 1) had wide limits of agreement.

Conclusion:
Assessing accurate nutritional requirements remains an increasingly challenging clinical problem. There’s a weak to moderate agreement between REEPE and REEIC and the standardization for IC measurements is logistically difficult to perform.
 

60.07 Is Hospital-Associated Venous Thromboembolism Preventable in Trauma Patients?

Posted on January 31, 2019

K. L. Florecki1, B. Lau1, O. Owodunni1, J. Sakran1, M. Streiff1, E. Haut1  1The Johns Hopkins University School Of Medicine,Baltimore, MD, USA

Introduction: Venous thromboembolism is a common complication associated with significant morbidity and mortality in the trauma population. We strived  to characterize the true preventability of venous thromboembolism (VTE) in the trauma patient population and the patients who receive “defect-free care” prophylaxis for VTE. 

Methods:  Retrospective review of trauma patients with hospital-acquired VTE (including deep vein thrombosis [DVT] and/or pulmonary embolism [PE]) identified at The Johns Hopkins Hospital from January 2008 – June 2016.  Data on patient risk assessment for VTE, prescription of risk-appropriate VTE prophylaxis and pharmacologic VTE prophylaxis medication administration were extracted from the electronic health record system. Patients were dichotomized into prophylaxis failure vs. defect-free care, defined as receiving all doses of risk-appropriate VTE prophylaxis recommended by our validated, mandatory computerized clinical decision support tool. Prophylaxis failure was divided into prescription failures or dose-administration failures (missed doses).

Results: 92 trauma patients had hospital-acquired VTE. All 92 (100%) were assessed using the VTE risk assessment mandatory computerized clinical decision support tool, however only 75 (81.5%) were prescribed risk-appropriate prophylaxis. Of the 92 patients, 33 (35.9%) received defect free-care. Of the 59 (64.1%) who received suboptimal care, 17 (28.8%) were not prescribed risk-appropriate prophylaxis and 42 (71.2%) missed at least one dose of pharmacologic VTE prophylaxis. 

Conclusion: Our study identifies the need to reevaluate outcome and process measures for VTE prevention after trauma. 33 VTE events occurred in patients who received best-practice defect-free care, showing not all VTE are truly preventable, and should not be included in outcome measures as “potentially preventable events.”  Our findings also identify specific targets and emphasize the importance of ongoing efforts to improve prescription and administration of risk appropriate VTE prophylaxis in trauma centers. 

 

60.06 Trauma Patients with Mangled Lower Extremities Experience a Higher Incidence of VTE

Posted on January 31, 2019

D. Freitas1, E. Warnack1, M. Kim1, C. DiMaggio1, S. Frangos1, M. Klein1, C. Berry1, M. Bukur1  1New York University School Of Medicine,New York, NY, USA

Introduction:
The mangled lower extremity (MLE) is a limb sustaining complex structural injuries (i.e. soft tissue, bone, nerves, and vessels) resulting from a high- energy mechanism. We hypothesized that trauma patients who present with MLE experience a higher rate of deep venous thrombosis (DVT) and pulmonary embolism (PE) when matched with trauma patients of similar injury burden without MLE.

Methods:
Data were abstracted from the Trauma Quality Improvement Program (TQIP) database from 2013- 2016. Characteristics of blunt trauma patients who presented with MLE versus all other patients were compared using Chi-squared, Student’s t-test, or Mann-U Whitney test where appropriate. Propensity score matching, using a 2:1 match of controls versus patients with MLE, was used to compare the occurrence of DVT and PE.

Results:
A total of 1,060 patients presented with MLE from 2013 through 2016. Patients with MLE were younger (median age 42 IQR [28,54] vs. 54 [32,72], p < .001) and were more likely to need immediate operative intervention when compared to other trauma patients (60.5% vs. 11%, p < .001). In controlled models, while patients with MLE had a higher odds of receiving VTE prophylaxis (86% vs. 58.8%, AOR = 3.23, p < .001) and filter placement (6% vs. 1.5%, AOR = 2.81; p < .001), they were over two times more likely to experience DVT (5.4% vs. 1.4%, AOR 2.5, p < .001) or PE (2.3% vs. 0.6%, AOR 2.07, p = .155), although the latter was not statistically significant. In a propensity score model, MLE conferred a significant absolute risk increase of 3.6% for DVT or PE with an odds ratio of 2.43 (7% MLE vs. 3.3% no MLE). Mortality was not significantly lower in MLE patients versus other trauma patients (4.5% vs. 5.5%, p = .157).

Conclusion:
Trauma patients with MLE have a 2.4 times higher odds of having a DVT or PE with an absolute risk increase of 3.6%. Early aggressive prophylactic measures are warranted in this high-risk population.
 

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