67.09 Thyroglossal duct cyst: does surgical specialty impact complication rates?

Posted on December 22, 2014

M. S. Arda1, G. Ortega2, V. F. Pinard2, E. Jelin1, F. Qureshi1  1Children’s National Medical Center,General Pediatric Surgery,Washington, DC, USA 2Howard University College Of Medicine,Department Of Surgery,Washington, DC, USA

Introduction:  Thyroglossal Duct Cyst (TGDC) is the most common congenital neck in children.  Surgical management by sistrunk procedure is the mainstay of treatment.  Pediatric general surgeons (GS) and otolaryngologists (ENT) perform this procedure. Recurrence occurs in 6-10% of children. Studies have suggested preoperative infection, age, abscess and multicystic histology as possible underlying reasons for recurrence.  The impact of surgical subspecialty has not been studied as ENT surgeons often core out the foramen cecum at the base of the tongue.  The aim of our study is to evaluate surgical outcomes of children undergoing sistrunk procedures for TGDC based on surgeon type at an academic pediatric institution. 

Methods:  A retrospective chart review of children diagnosed with TGDC from 2004-2014 was conducted. Inclusion criteria were children who underwent the sistrunk procedure and surgeon type was either GS or ENT. Basic demographic, preoperative clinical signs, age at surgery, surgeon type, operative characteristics, postoperative complication and recurrence rates were extracted. The primary outcome was recurrence rate of TGDC. Statistical analysis was conducted via descriptive statistics, t-test, and Pearson chi-square with p < 0.05 deemed statistically significant.

Results: A total of 165 patients met our inclusion criteria. 53.3% were male with swelling being the most frequent preoperative sign (92.7%), followed by infection (17.4%) and fistula (15.7%). The mean age at surgery was 5.4 years. The mean volume of TGDC excised was 4.7cm3 and most were single cyst (90.5%) The most common complications were swelling (82.0%), followed by seroma (9.0%) and wound infection (7.3%). ENT surgeons performed 106 procedures (64.2%), the mean age at surgery for GS and ENT were 5.6 and 5.3 years, respectively (p=0.67). The mean volume of TGDC for GPS and ENT were 2.5 and 5.9 cm3,  (p<0.01). The overall recurrence rate was 8.4%. The complications by surgeon type were swelling (GPS 18.6%, ENT 17.9%, p=0.90), seroma (GPS 8.5%, ENT 9.4%, p=0.83), and wound infection (GPS 6.8%, ENT 8.5%, p=0.69). The recurrence rates were 11.7% and 6.6% for GPS and ENT, respectively (p=0.25).  

Conclusion: Our study demonstrates that there is no difference in recurrence rates for TGDC excision between GS and ENT specialties. There was no added benefit of foramen cecum resection. Furthermore, no preoperative predictive factors for recurrence were identified.  This study is limited by its retrospective nature and a larger prospective study may be able to identify differences between GS and ENT procedures. 

 

67.10 Injury Patterns Associated with Pediatric Bicycle Accidents: Experience Of A Level 1 Trauma Center

Posted on December 22, 2014

C. J. Allen2, J. Tashiro1, J. P. Meizoso2, J. J. Ray2, C. I. Schulman2, E. A. Perez1, D. Lasko1, H. L. Neville1, K. G. Proctor2, J. E. Sola1  1University Of Miami,Pediatric Surgery,Miami, FL, USA 2University Of Miami,Trauma And Critical Care,Miami, FL, USA

Introduction:  Traffic accidents represent a leading cause of severe injury in children in the USA.  Bicycles are connected to more pediatric injuries than any other consumer product, other than automobiles. Whereas patterns of injury in motor vehicle accidents have been well characterized and have led to major safety initiatives and treatment guidelines, information related to pediatric bicyclist injuries is lacking.   With this recognition, our purpose is to identify major injury patterns associated with bicycle accidents in children admitted over a decade at a large pediatric level 1 trauma center. 

Methods:  From January 2000 to December 2012, consecutive pediatric admissions (≤17y) at a Level I trauma center were retrospectively reviewed for mechanism of injury, demographics, initial laboratory values and vital signs, injury patterns, Injury Severity Score (ISS), operative intervention, length of stay (LOS), and survival.  Analysis was performed to recognize injury patterns and outcomes significantly associated with bicycle related accidents. Parametric data presented as mean±standard deviation and nonparametric data presented as median(interquartile range).

Results: A total of 80 pediatric patients were admitted following bicycle related trauma (4% of all pediatric trauma admissions). The cohort had an age of 11±4y, ISS of 11±10, was 48% black, and 81% male. Injury patterns included 21% isolated head, 21% isolated abdominal, 13% isolated extremity, and 35% multiple injuries.  15% required immediate operative intervention (6.3% abdominal, 8.8% orthopedic, no neurological). LOS was 5±7d with an overall mortality of 2.5%. The most common incident day of the week for bicyclist trauma was Friday at 24%, compared to 15% of all other traumas (p=0.03). Of these patients, 13% were age 0-6y, 49% were age 7-11y, and 39% were 12-17y (p<0.001). Younger children were significantly more likely to require an abdominal operation (20% in 0-6y vs 6.8% in 7-11y vs 3.2% in 12-17y, p=0.05). Mortality rates were similar at 0%, 2.3%, and 3.2% for the three age groups, respectively (p=NS).

Conclusion: The mortality rate associated with bicyclist injury in children is comparable to that of the  overall pediatric trauma population. Orthopedic injury is the most frequent overall indication for surgery, yet the youngest children more often required an abdominal operation. This description of pediatric bicyclist injury patterns may help with the development of more specific preventive measures and anticipate injuries and outcomes according to age group.

67.11 Emergency Department Visits and Readmissions Among Children After Gastrostomy Tube Placement

Posted on December 22, 2014

A. Goldin2, K. Heiss3, M. Hall4, D. Rothstein5, P. Minneci6, M. Blakely7, S. Shah9, S. Rangel10, L. Berman12, C. Snyder11, C. Vinocur12, M. Browne8, M. Raval3, M. Arca13  2Seattle Children’s Hospital,Seattle, WA, USA 3Emory University School Of Medicine,Atlanta, GA, USA 4Children’s Hospital Association,Overland Park, KANSAS, USA 5Women And Children’s Hospital Of Buffalo,Buffalo, NEW YORK, USA 6Nationwide Children’s Hospital,Columbus, OH, USA 7Vanderbilt University Medical Center,Nashville, TN, USA 8Lurie Children’s Hospital,Chicago, ILLINOIS, USA 9Cincinnati Children’s Hospital Medical Center,Cincinnati, OH, USA 10Children’s Hospital Boston,Boston, MA, USA 11Children’s Mercy Hospital- University Of Missouri Kansas City,Kansas City, MO, USA 12Nemours Alfred DuPont Hospital For Chldren,Wilmington, DE, USA 13Children’s Hospital Of Wisconsin,Milwaukee, WI, USA

Introduction:

Gastrostomy tubes (GT) are devices placed to supplement hydration, nutrition, and medication administration in infants and children. Anecdotally, children with these GT’s utilize health resources frequently.  We wanted to quantify the post-operative needs of this population by identifying the incidence of 30-day post-discharge emergency department (ED) visits and hospital readmissions following GT placement.  We wanted to identify the GT-related reasons for visits and readmissions.

Methods:
This multicenter retrospective cohort study used data from the Pediatric Health Information System. Patients <18 years of age who were discharged between January 1, 2010 and December 31, 2012, with an ICD-9-CM procedure code for GT placement during the index hospitalization were included. Subjects were classified as having the GT placed on the date of admission (scheduled gastrostomy cohort) or later in the hospital course (unscheduled gastrostomy cohort). Factors significantly associated with ED revisits and hospital readmissions within 30-days of hospital discharge were identified using multivariable logistic regression.  IRB-approved validation studies were conducted in five institutions on a randomly generated subset of patients to confirm the accuracy of exposures and outcomes.

Results:
During the study period, 15,642 patients had a GT placed; 67% were ≤ one year old, 25% had the GT placed on the day of admission, and 72% had ≥1 chronic comorbid condition (CCC).  Overall, 8.6% of all patients had an ED visit within 30 days of hospital discharge, and 3.9% of all patients were readmitted through the ED with GT-related issues. GT-related events associated with these visits included infection (27%), mechanical complication (22%), and replacement (19%).  In multivariable analysis, timing of GT placement (scheduled vs. unscheduled) was not associated with either ED revisits or hospital readmission. Hispanic ethnicity, non-Hispanic black race, and the presence of three or more CCCs were independently associated with ED revisits, while gastroesophageal reflux and not having a concomitant fundoplication at time of GT placement were independently associated with hospital readmission.

Conclusion:
GT placement is associated with high rates of ED revisits and hospital readmissions in the first 30 days after hospital discharge.  The association of non-modifiable risk factors such as race/ethnicity and medical complexity is an initial step towards understanding this population so that interventions can be developed to decrease these potentially preventable occurrences. 
 

67.12 A Review of Interval Appendectomy

Posted on December 22, 2014

R. C. Brady2, L. S. Burkhalter1, R. I. Renkes1, R. Huang1, A. C. Alder1,2  1Children’s Medical Center,Division Of Pediatric Surgery/Department Of Surgery/UT Southwestern,Dallas, Tx, USA 2University Of Texas Southwestern Medical Center,Dallas, TX, USA

Introduction:
Although acute appendicitis has traditionally been treated with urgent appendectomy, initial nonoperative treatment with antibiotics and abscess drainage has gained wide acceptance when patients present with a complicated appendicitis associated with periappendiceal abscess or phlegmon. Data suggest that adjuncts, such as percutaneous drains, allow for more rapid resolution of symptoms. Following successful nonoperative treatment, an interval appendectomy (IA) is traditionally routinely recommended to eliminate the risk of recurrent appendicitis. Surgeons have questioned the benefit of appendectomy after successful nonoperative management of complicated appendicitis.

Methods:
A retrospective review of children managed nonoperatively for complicated appendicitis between June 2009 and December 2012 at Children’s Medical Center in Dallas was performed. Patients were assessed for the development of recurrent symptoms of appendicitis. Demographic data, presenting symptoms, imaging, treatment, clinical course and outcome were analyzed to identify potential associations with recurrent symptoms. 

Results:

A consecutive series of 100 children treated nonoperatively out of 3491 patients (2.8%) diagnosed with appendicitis during the study period were included. Eighteen patients (18%) experienced recurrent symptoms requiring admission or emergency department visit prior to scheduled IA within a median of 16.1 days from diagnosis (range 6.9 – 73.7d). Seven patients did not undergo an appendectomy.

There were no significant associations between gender, age, obesity status, race, or ethnicity and recurrent appendicitis symptoms.  The presence of a fecalith or well-defined abscess on imaging was not predictive of recurrence. Similarly, analysis revealed no significant difference in recurrence rates or rehospitalization following treatment with aspiration, drain, or neither (i.e. antibiotics alone).

While the length of stay during the initial diagnostic admission was comparable, the cumulative length of stay, including readmissions and appendectomy, was significantly increased in the recurrence group when compared to the no-recurrence group (R median 242h, range 103-400h; NR median 166h, range 23-760h p=0.009).

 

Conclusion:
Significantly increased total hospitalization is associated with recurrent appendicitis. As no significant associations can be made between the clinical and demographic factors analyzed and risk of recurrence, we could not identify any predictors of recurrent symptoms. Similarly, recurrence risk did not appear to be significantly influenced by the use of a drain during nonoperative management in contrast to previous reports. We did not have sufficient numbers of patients who did not undergo IA to make any relevant conclusions.  Additional study investigating the risk factors of recurrent symptoms in children managed nonoperatively for complicated appendicitis may help predict which patients will benefit from interval appendectomy. 

66.11 Benefits of Prophylactic Inferior Vena Cava Filters in High-Risk Bariatric Surgery Patients

Posted on December 22, 2014

M. A. Hornick1, E. K. Lai1, N. N. Williams1, P. J. Foley1, G. J. Wang1, K. R. Dumon1, S. E. Raper1, E. Y. Woo2, R. M. Fairman1, B. M. Jackson1  1Hospital Of The University Of Pennsylvania,Department Of Surgery,Philadelphia, PA, USA 2MedStar Health,Department Of Surgery,Washington, DISTRICT OF COLUMBIA, USA

Introduction: The benefit of prophylactic retrievable inferior vena cava filter (prIVCF) placement prior to bariatric surgery is uncertain. While indications for prIVCF in bariatric surgery patients remain somewhat ambiguous, filters are not infrequently placed in patients deemed relatively high risk for perioperative venous thromboembolism (pVTE) on the basis of body mass index (BMI), functional status, prior history of VTE, or other factors. In this single-institution retrospective review of bariatric surgery patient outcomes, we hypothesized that patients receiving prophylactic IVC filters, despite presumably higher risk for pVTE, ultimately have comparable outcomes to lower-risk patients who do not receive prIVCF.

Methods: We reviewed a single academic bariatric center experience from September 2002 to December 2011. Prophylactic IVC filters were placed in patients perceived to be high risk for pVTE according to an institutional protocol and surgeon judgment. Electronic medical records were reviewed retrospectively, and examined outcomes included perioperative (30-day) deep venous thromboembolism (DVT), pulmonary embolism (PE), and mortality. All statistical comparisons were made by χ2 test, Fisher exact test, or Student’s t-test as appropriate.

Results: 520 patients underwent prIVCF, and 1984 patients did not undergo prIVCF. The majority of patients in both the prIVCF and no prIVCF groups underwent laparoscopic gastric bypass (64.6% and 72.3%, respectively). Patients in the prIVCF group underwent laparoscopic sleeve gastrectomy at a proportionally higher rate (12.1% vs. 3.2%, P<0.0001). Patients in the prIVCF group had higher BMI (57.6+9.8 vs. 48.0±7.1, P<0.0001) and higher rate of prior DVT (8.8% vs. 0.6%, P<0.0001). Rate of perioperative DVT was significantly higher in the prIVCF group (2.3% vs. 0.9%, P=0.02). Rates of perioperative PE (0.8% vs. 0.7%, P=0.80) and perioperative mortality (0.2% vs. 0.1%, P=0.11) were not statistically different between prIVCF and no prIVCF groups.

Conclusion: Although indications for prIVCF in bariatric surgery patients are not well-defined, it is likely that patients referred for prIVCF are at higher risk for pVTE. In this large single-institution experience, bariatric patients receiving prIVCF had significantly higher BMI, higher rate of prior DVT, and ultimately higher rate of perioperative DVT than patients not receiving prIVCF. Despite these risk factors for pVTE, bariatric patients receiving prIVCF had comparable outcomes to patients not receiving prIVCF with respect to perioperative PE and mortality. These results suggest that prIVCF placement may confer substantial benefit in high-risk bariatric surgery patients.

 

66.12 Ultrasound Vascular Mapping Prior to Arteriovenous Fistula Creation Undersizes Vein Diameter

Posted on December 22, 2014

J. J. Kim1, E. Gifford1, V. T. Nguyen1, P. Chisum1, A. Zeng1, C. DeVirgilio1  1Harbor-UCLA Medical Center,Surgery,Torrance, CA, USA

Introduction: Mounting evidence suggests routine ultrasound vascular mapping prior to hemodialysis access surgery leads to higher rates of arteriovenous fistula (AVF) creation. Further, the diameter of vein by pre-operative ultrasound has been shown to correlate with subsequent fistula maturation. Studies define 2.5mm as a minimum vein diameter for autogenous fistula creation. However, whether ultrasonographic vein diameter accurately predicts intra-operative vein diameter is not clear.

Methods: Retrospective review of a prospectively collected database including all hemodialysis access procedures performed by a single surgeon between 2011 and 2014 was performed. Patients without pre-operative vascular mapping and those undergoing revision of AVF were excluded. Pre-operative ultrasound vascular mapping results as well as intra-operative measurements of artery and vein used for anastamosis were recorded. Comparison of ultrasound measurement to intra-operative measurement was performed of the same vein at the same site where the anastamosis was created. All vascular mappings were performed with rubber tourniquet in place and all intra-operative measurements were taken by a single surgeon after complete dissection of the vessel and dilatation of vein with heparinized saline. Two-tailed paired student's t-test was used to analyze vein diameters obtained by pre-operative ultrasound and intra-operative ruler. Chi-squared test was used to compare the number of veins meeting the 2.5mm minimum diameter between the two measurement modalities.

Results: One-hundred and sixty-one patients had pre-operative vascular mapping with subsequent intra-operative vessel measurements. The median age was 52 and most were male (60%, n=97,). One-hundred and three patients (64%) were already hemodialysis dependent at the time of surgery and 132 (82%) underwent their first access surgery. There were 79 brachiocephalic AVF, 37 brachiobasilic AVF, 31 radiocephalic AVF, 2 brachiobrachial AVF, and 11 arteriovenous graft placements. Mean vein diameter by vascular mapping was 3.2mm (SD 1.4) and mean vein diameter by intra-operative measurement was 4.4mm (SD 1.3). This difference was statistically significant (p<0.0001). Of the 161 veins, vascular mapping showed 103 (64%) to be adequate for AVF creation (diameter ≥ 2.5 mm) while intra-operative measurements showed 151 (94%) to be adequate for use (p<0.0001). In contrast, the mean diameter of artery was larger by pre-operative ultrasound (4.0mm vs. 3.4mm, p<0.0001).

Conclusion: Preoperative ultrasound vascular mapping with tourniquet may underestimate the size of vein found during surgery. Inadequate vein diameter measured by ultrasound should not preclude exploration for autogenous AVF creation.

66.13 Metabolic Syndrome Predicts High Risk Status for Vascular Surgery

Posted on December 22, 2014

T. R. Foster1,2, G. Kuwahara2, K. Yamamoto2, R. Assi1,2, C. D. Protack1,2, M. R. Hall1,2, W. Williams1,2, P. Vasilas1, A. Dardik1,2  1VA Connecticut Healthcare System,West Haven, CT, USA 2Yale University School Of Medicine,New Haven, CT, USA

Introduction:
Metabolic syndrome increases the risk of cardiovascular events in patients with peripheral vascular disease. However, the role of metabolic syndrome in predisposing towards postoperative complications after vascular surgery is poorly described. This study explores the effect of metabolic syndrome on adverse events after four commonly performed vascular surgical operations. 

Methods:
The records of patients who underwent carotid endarterectomy (CEA), arteriovenous fistula creation (AVF), major lower extremity amputation, or endovascular abdominal aortic aneurysm repair (EVAR) from 2004-2008 at a single institution were reviewed.  An adverse event was defined according to operation and includes: re-stenosis > 50% after CEA, AVF primary failure < 6 mo, non-healing of the amputation site requiring operative revision, or development of endoleak any time after EVAR. These events were combined to study the effect of metabolic syndrome on the rate of overall post surgical adverse events. Metabolic syndrome (MetS) was defined as three or more of the following: blood pressure ≥ 130/85 or on antihypertensive medication, serum triglycerides ≥ 150 mg/dl, HDL ≤ 40 mg/dl for men or ≤ 50 mg/dl for women, fasting blood glucose ≥ 110 mg/dl or on anti-hyperglycemic medication, or BMI ≥ 27 kg/m2.

Results:

A total of 274 patients were included in the study. 99% of the patients were male. The average age was 69 years, 76% were Caucasian. Mean follow up was 3.6 years. 69% of the patients had MetS and were more likely to be Caucasian. The baseline demographics were otherwise similar except that patients with MetS had statistically significant differences, compared to patients without MetS, in mean triglyceride level of 180 vs 119 (p<0.0001), mean HDL level of 35 vs 50 (p<0.0001), hypertension was present in 98% vs 86% of patients (p<0.0001), diabetes present in 68% vs 18% (p<0.0001), and BMI > 27 in 76% vs 21% of patients (p<0.0001). Patients with MetS had an increased rate of adverse events, 44% versus 33% (p=0.07, Chi-Square). Of all factors examined, logistic regression showed MetS to be the most predictive independent factor for adverse events (OR 2.89, p = 0.0020) There was no statistical significance in overall survival between patients with and without MetS (p = 0.66 Log-rank).  

Conclusion:

Metabolic syndrome is prevalent among patients undergoing vascular surgical operations. MetS is an independent risk factor for adverse events following these operations, suggesting that MetS is a factor identifying high risk patients after vascular surgery. Patients with MetS may require increased post operative surveillance or targeted treatment to reduce the rate of these events.

 

66.14 Peeling the Onion: Procedure Specifics in Abdominal Aortic Aneurysm Repair Related Mortality

Posted on December 22, 2014

J. C. Iannuzzi1, F. J. Fleming1, A. Chandra2, K. Rasheed2, A. Doyle2, K. Noyes1, J. R. Monson1, M. J. Stoner2  1University Of Rochester,Surgical Health Outcomes & Research Enterprise, Department Of Surgery,Rochester, NY, USA 2University Of Rochester,Vascular Surgery,Rochester, NY, USA

Introduction:
While much data on open abdominal aortic aneurysm (OAR) and endovascular abdominal aortic aneurysm repair (EVAR) has been reported, it has either succeeded in depth but with small sample size, or excelled in sample size but without depth.  For the first time, the National Surgical Quality Improvement Program has released procedure-targeted data that allows enhanced analysis of aortic surgery.  A greater understanding of repair technique and its associated mortality will lead to better clinical decision making, and informed patient care.

Methods:
The NSQIP database from 2011-2012 was analyzed for included cases of OAR and EVAR using Common Procedural Terminology Codes.  Bivariate analysis was performed to identify procedure and patient characteristics associated with mortality within 30-days of the procedure.  Factors meeting criteria of p<0.1 were assessed for inclusion into a manual stepwise multivariable binary logistic regression with mortality as the end point.  Factors meeting p<0.05 in the final model were retained.  Model performance was assessed using a c-statistic. OAR and EVAR were assessed separately as procedure specific data was unique to each operative approach. 

Results:
A total 949 OAR cases and 2,785 EVAR cases were included in the NSQIP procedure targeted vascular dataset for 2011-2012.  Mortality following OAR was 12.0% (n=114) and after EVAR was 3.8% (n=105).  After controlling for OAR patient demographics (Age, ASA class, pulmonary comorbidity, elective case, & preoperative transfusion) the following procedure characteristics were independently associated with mortality on multivariable analysis: supraceliac proximal clamp (OR=2.02, 95% CI: 1.18-3.45, p=0.010], and juxtraenal proximal extent (OR=0.54, CI:0.32-0.91, p=0.021). In EVAR cases (after adjustment for age, ASA, pulmonary comorbidity, elective case, and obesity) the following were associated with mortality on multivariable analysis: Diameter as surgical indication (OR=0.41, CI:0.23-0.75, p=0.004), Rupture as surgical indication (OR=5.29, CI:2.83- 9.88, p<0.001), attempted percutaneous access converted to cutdown (OR=4.42, CI:1.16, 16.77, p=0.029), acute conversion to open (OR=7.18, CI:2.078-24.79, p=0.002), juxtarenal proximal extent (OR=3.06, CI: 1.46-6.42, p=0.003), Type IV thoracoabdominal aneurysm (OR=8.16, CI:1.98-33.64, p=0.004), and lower extremity ischemia (OR=2.29, CI:1.09-4.82, p=0.030).  The C-statistic in the OAR model improved with inclusion of procedure specific data from 0.818 to 0.829, and in the EVAR model from 0.852 to 0.881 suggesting significantly improved model performance with the inclusion of procedure specific data.

Conclusion:
Procedure specific data improved mortality modeling using with anatomic considerations being most prominent in OAR.  In EVAR cases, not only were anatomic data important, but also percutaneous access with over 4 times the adjusted odds of death when percutaneous was attempted but failed. 

66.15 Late Mortality in Females After Endovascular Aneurysm Repair: Effect of Preoperative Aneurysm Size

Posted on December 22, 2014

J. E. Preiss1, R. K. Veeraswamy1, Y. Duwayri1, T. F. Dodson1, A. Salam1,2, S. Arya1, S. M. Shafii1, R. Rajani1, L. P. Brewster1,2  1Emory University School Of Medicine,Department Of Surgery,Atlanta, GA, USA 2VA Medical Center,Surgical And Research Services,Atlanta, GA, USA

Introduction:  Abdominal aortic aneurysm (AAA) rupture carries high mortality risk and is the 10th leading cause of death in the United States. Elective aneurysm repair improves survival for patients with AAAs. Since female patients have a greater risk of rupture with smaller AAAs (<5.5 cm), many recommend elective repair prior to 5.5 cm. Endovascular aneurysm repair (EVAR) has significantly lower 30-day morbidity and mortality compared to traditional open repair, but these benefits disappear over time. In order to better assess the benefit of EVAR in female patients at our institution, the objective of this study is to identify if there are differences in late mortality between female patients undergoing elective EVAR for smaller AAAs compared to those who meet standard criteria.

Methods:  Under IRB approval, we performed retrospective analysis of all patients that underwent EVAR for infrarenal AAA at our institution from June 2009 to June 2013. We excluded patients that were male, treated emergently or for iliac artery aneurysm, received renal or mesenteric artery stenting, and that died prior to 1-month follow-up. AAA measurements were obtained from 3D imaging reports. Females were considered to not meet anatomic criteria if preoperative AAA diameter was <5.5 cm or did not enlarge ≥0.5 cm in 6 months. Late mortality was assessed from the Social Security Death Index.

Results: 36 (22.2%) out of 162 elective EVAR patients were female. All 36 were eligible for 1-month follow-up with our institution (mean follow-up 37.2 months). 16 patients had AAA <5.5 cm without rapid growth while 20 patients had AAA ≥5.5 cm or with rapid growth. There were no differences in demographics or comorbidities between groups, although patients that did not meet criteria had smaller mean AAA diameter (5.02 cm vs. 5.83 cm, p=0.001).  Despite no statistical difference in perioperative adverse events (Table 1), patients that did not meet traditional criteria had significantly higher late mortality (37.5% vs. 5%, p=0.02). After controlling for demographics and perioperative events, patients not meeting standard criteria still demonstrated increased risk of late mortality (OR 11.4, p=0.03). However when segregating patients only by AAA size (<5.5 cm vs. ≥5.5 cm), there was no statistical difference in late mortality (24% vs. 9.1%, p=0.30), and size did not influence odds of late mortality (OR 0.51, p=0.38).

Conclusion: There appears to be increased late mortality in female patients treated with EVAR at our institution for smaller and slower-growing AAAs. This late mortality may limit the benefit of EVAR for this population. Future work seeks to identify perioperative risk factors for late mortality that may be modified in postoperative care.

66.16 Endovascular Repair of Penetrating Arterial Injury at the Puerto Rico Trauma Center

Posted on December 22, 2014

J. L. Velazquez1, P. Rodriguez1, F. Joglar1  1University Of Puerto Rico School Of Medicine,Department Of Surgery,San Juan, Puerto Rico, Puerto Rico

Introduction:  The use of endovascular stentgrafts in blunt thoracic aortic injuries (TAI) has become widespread, and it has changed the treatment paradigm for blunt TAI patients due to its lower morbidity and mortality.   Penetrating arterial injury to the aorta, the subclavian artery, and other vessels such as the renal arteries can be difficult to manage with open repair in the acute setting requiring extensive exposure procedures.  For contained penetrating arterial injuries were traditional exposure is associated with higher morbidity and mortality, endovascular management is an option to be considered if the necessary equipment and expertise is available.

Methods:  We studied all adult patients admitted with penetrating arterial injury at the Pueto Rico Trauma Center (PRTC), a state-designated level 1 trauma center.  All patients with thoracic or abdominal large vessel arterial injury due to penetrating trauma consulted to the Vascular Surgery service were included in the study.   Patient that had active bleeding or were hemodynamically unstable underwent emergent open repair.  Patients considered for endovascular repair were those that had contained arterial injuries in the aorta, axillosubclavian, or visceral arteries. Analyses of demographics, injury severity scores, type of injury, procedure-related complications, and outcomes were performed.

Results:  From January 1, 2011 to September 30, 2013 a total of 4,095 patients were admitted to the PRTC.    A total of 218 (5.3%) penetrating arterial injuries were identified.     A total of 8 patients underwent endovascular repair for penetrating arterial injury.  The mean age was 22±  years (range, 16-26) and the mean Injury Severity Score was 23.6 ±  (range, 11-41).  A total of 4 (50%) subclavian vessel injuries, 3 (38%) aortic injuries and 1 (12%) renal artery injury.  All injuries were repaired by endovascular approach with covered stent grafts.  Of the aortic injuries 2 were abdominal posterior aortic pseudoaneurysms (PSAs) and 1 descending thoracic aortic PSA.   All 4 cases of subclavian injury were repaired stentgrafts due to PSAs.  One patient with a right renal artery PSA underwent successful repair with a stentgraft.  There were no access site, renal, or procedure-related complications.  Three patients required video assisted thoracoscopic surgery due to retained hemothorax.  All patients were discharged home without major postoperative complications.  Three patients were lost to follow up.  There is a mean follow up of 9.6±  months (range,1-13).

Conclusion:  Hemodynamically stable trauma patients with penetrating arterial injury in locations where open exposure may be associated with high morbidity and mortality can be successfully treated with an endovascular approach.  Whether these techniques can be applied in unstable patients depends on the availability of the necessary equipment and the expertise of the operating surgeon. 

 

66.17 Aneurysm Development Post Open AAA Repair: Is Current Surveillance Appropriate?

Posted on December 22, 2014

K. Perera1, E. Wong1  1Eastern Health,Melbourne, VICTORIA, Australia

Introduction:
Up to 65% of open abdominal aortic aneurysm (AAA) repairs develop peri-anastomotic pseudoaneurysms; 14% of these requiring surgery. A further 30% may develop metachronous common iliac artery (CIA) aneurysms with up to 15% being surgically significant.[1] Conventional management is to perform a surveillance scan 5 years post-operatively, yet many of these patients are lost to follow-up. This study evaluates the incidence of such aneurysms in our community and will determine appropriate follow-up practice. 

Methods:
Patients having undergone open AAA repair at Eastern Health at least 5-years prior to the study date were identified. Deceased patients and those requiring high level nursing care were excluded. Eligible cases were reviewed in clinic and offered CT evaluation where there was no recent scan available.

Results:
171 operations were identified between 2003- 2008. 90 (53%) patients were confirmed as deceased; with a further 45 (26%) unable to be contacted. Of the 36 eligible patients, 18 (50%) agreed to participate in clinical assessment with only 8 subsequently attending a review clinic; one of whom passed away prior to scanning. 5(63%) were found to have developed a peri-anastomotic aneurysm and 3 (38%) had CIA aneurysms.

Conclusion:
Despite the limited response rate, the incidence of both peri-anastomotic pseudoaneurysms and CIA aneurysms in our experience is significant to warrant closer surveillance.  Routine follow-up with imaging should be considered for the detection of delayed aneurysm development.

66.18 Contemporary Management of Secondary Aortoduodenal Fistula

Posted on December 22, 2014

R. Howard1, S. Kurz1, M. Sherman1, J. Underhill1, J. L. Eliason1, D. Coleman1  1University Of Michigan,Department Of Surgery/Division Of Vascular Surgery,Ann Arbor, MI, USA

Introduction: Secondary aortoduodenal fistula (SADF) is a rare but life-threatening complication of abdominal aortic reconstruction, with mortality rates of 60%. Clinical presentation varies but often includes gastrointestinal (GI) bleed. Treatment typically requires complex surgical repair that has historically been associated with considerable morbidity and mortality. This retrospective study examines the contemporary management of SADF at a tertiary vascular surgical practice.

Methods: Thirteen patients were managed for SADF between 2004-2014. Vascular reconstructions included graft explantation with extra-anatomic bypass (N=10) and endovascular repair followed by definitive reconstruction (N=3). Duodenal reconstruction included primary repair (N=7), resection (N=3), exclusion (N=2), and no repair (N=1). Primary endpoints included bile leak, major complication, and mortality. Student’s t-test was used for data comparisons.

Results: Of the 13 patients with SADF, six presented with GI bleed and seven without. During a mean follow-up of 631 dy the rate of major complication was high (77%). Five patients (38%) developed duodenal leak. All leaks occurred following graft explantation with extra-anatomic bypass, and the majority of these patients (80%) had no prior history of GI bleed. Factors that trended toward increased risk of bile leak included female gender (67% v. 30%, p=0.252) and method of duodenal repair (67% resection v. 43% primary repair, p=0.401). There were no leaks identified following duodenal exclusion with gastrojejunostomy. Patients that developed duodenal leak had longer mean ICU stay (7.0 v. 2.3 dy, p=0.004), longer mean overall hospital stay (36.6 v. 18.5 dy, p=0.012), and greater late mortality (40% v. 13%) (Figure 1). There were two SADF-related deaths. One patient expired POD 1 secondary to hemorrhage, and another patient expired seven weeks post-operatively from persistent sepsis. Overall mortality trended higher in females (67% v. 20%, p=0.125) and those presenting without GI bleed (43% v. 17%, p=0.308).

Conclusion: While the overall mortality of patients treated at our institution for SADF represents an improvement from historical rates, surgical reconstruction results in major morbidity. Interestingly, those patients presenting with acute GI bleed tended to have better outcomes than those without. Duodenal leak remains a serious complication of SADF repair. In cases where duodenal resection is being entertained over primary repair, duodenal exclusion may represent a more appropriate conservative approach. Finally, the greater incidence of morbidity and mortality in females with SADF is consistent with overall disparities in gendered outcomes in vascular surgery and warrants further investigation.

66.19 Early Complications of Biologic Extracellular Matrix Patch After Use for Femoral Artery Repair

Posted on December 22, 2014

N. Dobrilovic1,3, P. Soukas2, I. Sadiq4, J. Raman3  1Brown University School Of Medicine,Cardiovascular And Thoracic Surgery,Providence, RI, USA 2Brown University School Of Medicine,Cardiology,Providence, RI, USA 3Rush University Medical Center,Cardiovascular And Thoracic Surgery,Chicago, IL, USA 4Hartford Hospital,Cardiology,Hartford, CT, USA

Introduction:   The CorMatrix biologic extracellular patch derived from porcine small intestinal mucosa provides a biologic scaffold for cellular ingrowth and eventual tissue regeneration.  It has been used in a variety of applications including cardiac and vascular repair procedures.  In the femoral artery position it potentially offers peripheral vascular patients the benefit of reducing foreign body burden in anticipation of multiple future procedures requiring femoral access.

Methods:   CorMatrix was used as a patch arterioplasty for femoral artery repair in conjunction with endarterectomy for seven (n=7) separate procedures in six patients (one patient underwent staged, bilateral femoral procedures).  The study was initially designed to prospectively follow operative results of ten consecutive procedures but was terminated early due to recognition of significant complications.

Results:  Mean patient age was 68.  Six of seven (86%) procedures were performed on male patients.  There were no operative mortalities.  Three of seven (43%) procedures resulted in significant early complications.  One procedure (14%) resulted in groin pseudoaneurysm formation.  Two procedures (29%) resulted in catastrophic biologic extracellular matrix patch disruption (11 and 19 days after initial procedure), requiring emergent exploration, patch removal and definitive repair with vein patch arterioplasty.

Conclusion:  Use of CorMatrix patch in the femoral artery position demonstrates a high incidence of early postoperative complications including catastrophic patch disruption and pseudoaneurysm formation.

66.20 Incidence and Outcomes of Abdominal Aortic Aneurysm in Patients Presenting with Aortic Dissection

Posted on December 22, 2014

R. Moridzadeh1, M. Sadek1, C. B. Rockman1, T. Maldonado1, M. A. Adelman1, F. F. Mussa1  1New York University School Of Medicine,Division Of Vascular And Endovascular Surgery,New York, NY, USA

Introduction:  Abdominal aortic aneurysms may occur independently or as a consequence of repair of abdominal aortic aneurysms (AAA). We were interested in investigating the risk factors, presentations, and outcomes of patients admitted with a diagnosis of aortic dissection and a history of AAA.

Methods:  A retrospective medical record search was made of patients admitted with a diagnosis of aortic dissection between January 1, 2006 and June 30, 2013. Patients were categorized as to the type of dissection (Stanford A or B) and the presence or history of AAA. Outcome variables included death, post-operative stroke, renal failure, length of stay, and discharge to a rehabilitation facility. 

Results: 124 patients were identified (n=51 type A) of which there were 8 with a history of AAA (6%). Patients presenting with a history of AAA were more likely to have a chronic dissection than patients without AAA (5 [63%] vs. 35 [30%], p = 0.025). Risk factors, presentation characteristics, type and extent of dissection repair, and outcomes did not reveal any significant differences. Subgroup analysis for Type A and Type B dissections also did not reveal differences in outcomes.

Conclusion: Patients with AAA comprise a significant proportion of patients presenting with aortic dissections. Patients with chronic aortic dissections may be more susceptible to developing AAA. However, a history of AAA does not impact presentation or outcome in either Stanford type A or B dissection.

 

67.01 Long Term Outcomes of the Antegrade Colonic Enema for Stooling Dysfunction in Children

Posted on December 22, 2014

M. Zeidan1, D. W. Kays1, J. A. Taylor1, S. Larson1, S. Islam1  1University Of Florida,Gainesville, FL, USA

Introduction:  Severe constipation and encopresis or soiling are significant problems for a number of children and may lead to physical, social, and psychological issues if they persist. Medical management including laxatives and dietary modification usually succedds, but there is a cohort of patients whose problems remain refractory and surgical options are considered such as the Antegrade Colonic Enema (ACE). The purpose of this study is to assess the long-term outcomes in children following the ACE procedure.

Methods:  We reviewed all patients that underwent the open and laparoscopic ACE procedure between 1999 and 2013 at a single institution. Data collected included diagnosis and indication for surgery, change in bowel movements and soiling patterns before and after surgery, admissions for clean-outs before and after surgery, flush therapy and changes to regimen, and long term complications. Comparative data was analyzed using the Fischer’s exact test. 

Results: A total of 42 patients were found who had complete charts.  The mean age at surgery was 10 years, with 54.8% male. Encopresis or soiling was the indication in 56% of cases. Patients suffered for a mean duration of almost 7.5 years prior to surgery, with over half having symptoms since birth (including congenital anomalies).  The appendix was used as conduit in 90% of cases, and a majority were placed in the umbilicus, with over 50% performed laparoscopically. Over an average follow up of 4.5 years, 33 (79%) of the children had improvement in their bowel regimens. Number of children experiencing soiling more than three times per month decreased from 79% to 12% (p<0.0001) and admissions for cleanouts decreased from 52% to 19% (p=0.003). All cases of Hirschsprungs, functional constipation and spina bifida were successful while success rates varied for other diseases such as slow transit constipation (60%), imperforate anus (50%), and cerebral palsy (33%). The most common long-term complications were relatively minor, including leakage from the stoma site (68%) and dislodged tubes (63%), with a mean of 3.2 OR visits per patient during the study period.  85% of successful cases required a change in the enema composition for improvement. Of 10 patients that had the tube removed, 8 patients were weaned off of the ACE and remained clean, while two patients had to have it replaced.

Conclusion: We found the ACE procedure to have a high rate of success in reducing soiling, constipation, and need for disimpaction in children over a long term. Further refinement of the selection criteria would increase the success. Complications were minor and well tolerated, and a majority could not be weaned off the ACE. Enema fluid changes were very frequent and these data will be used to improve family discussion and satisfaction. This procedure should be part of a comprehensive treatment plan for encopresis and constipation in children. 

 

67.02 Outcomes of Pediatric Appendectomy Performed by "Adult" Acute Care Surgeons

Posted on December 22, 2014

B. Pham1, B. Range3, D. S. Plurad1, S. Lee3, A. Kaji2, S. Bricker1, B. Putnam1, D. Y. Kim1  1Harbor-UCLA Medical Center,Division Of Trauma/Acute Care Surgery/Surgical Critical Care,Torrance, CA, USA 2Harbor-UCLA Medical Center,Department Of Emergency Medicine,Torrance, CA, USA 3Harbor-UCLA Medical Center,Department Of Surgery,Torrance, CA, USA

Introduction: Acute care surgery (ACS) is an evolving specialty and studies examining the role of the acute care surgeon in managing pediatric surgical emergencies are limited. The purpose of this study was to compare outcomes following pediatric appendectomy between an ACS service and pediatric surgery (PS) service. We hypothesized that there is no difference in the rate of complications when pediatric appendectomy is performed by an acute care surgeon versus a pediatric surgeon.

Methods: A 5-year retrospective analysis of all appendectomies performed in patients ≤12 years old at a university-affiliated County hospital was performed. The primary outcome was 30-day postoperative complications including superficial and deep surgical site infections, sepsis, readmission, and reoperation. Secondary outcomes included time to the operating room (OR), duration of surgery, and length of stay (LOS). Multivariate logistic regression analysis was performed to identify independent predictors of complications.

Results: Of 503 patients, 320 (64%) were treated by the ACS service and 183 (36%) by the PS service. Patients managed by the ACS service were older (9 vs. 7 years old, p<0.0001), underwent preoperative ultrasonography more commonly (47% vs. 13%, p<0.0001), and were more likely to undergo a laparoscopic appendectomy (40% vs. 15%, p<0.0001). Time to the OR and duration of surgery were shorter among patients managed by the PS service (p<0.01), whereas LOS was increased (OR=3.0; 95%CI=2.0-5.0, p<0.0001). There was no significant difference in the incidence of complications between the ACS and PS services (12% vs. 18%, p=0.06). On multivariate analysis, after adjusting for surgical service and approach, age, gender, body mass index, and appendicitis severity, the intraoperative finding of perforated appendicitis was the only variable associated with postoperative complications (OR=3.6; 95%CI=1.9-6.8, p=0.0001).

Conclusion: Acute care surgeons are capable of managing pediatric appendicitis with outcomes similar to their pediatric surgery colleagues. Patient age alone should not exclude involvement of an ACS service in the management of patients with acute appendicitis.
 

67.03 Ovarian Sparing Surgery For Benign Pediatric Ovarian Tumors

Posted on December 22, 2014

P. I. Abbas1, J. E. Dietrich2, J. C. Francis2, M. L. Brandt1, D. L. Cass1, M. E. Lopez1  1Baylor College Of Medicine,Michael E. DeBakey Department Of Surgery,Houston, TX, USA 2Baylor College Of Medicine,Department Of Obstetrics And Gynecology,Houston, TX, USA

Introduction: Ovarian sparing surgery (OSS) is the recommended treatment for benign pediatric ovarian masses in order to optimize future fertility.  We evaluated the outcomes of pediatric patients after OSS for non-neoplastic and benign neoplastic ovarian lesions.

Methods:   A retrospective review was performed on children under 18 years of age who underwent ovarian sparing surgery for benign ovarian lesions from 2003-2012.  Data collected included demographics, operative details, post operative course, and subsequent surgical intervention. Post-operative menstruation was documented as a potential indicator of intact ovarian function. 

Results: One hundred and nine patients underwent OSS with a median age of 13.4 years (IQR 11.4 -15.1 years). Eighty-two patients were treated laparoscopically with 4 conversions to open. Twenty-seven had open procedures.  Postoperative complication of surgical site infection occurred in 7 patients (6%).  Pathology most commonly revealed functional ovarian cysts (n=57) and mature teratomas (n=37).  Ninety-two patients (84%) were followed for a median of 10.6 months (IQR 0.72 -30.8 months).  Fifty-five patients (60%) had subsequent imaging surveillance a median of 7.3 months postoperatively (IQR 3.9 -13 months).  Twenty-one patients (38%) developed a second lesion within a median time of 11 months (IQR 7.7 -24 months).  This rate was not significantly different for the benign neoplastic compared to the non-neoplastic lesions (28% vs. 47%, p = 0.15).  Nine patients (10%) underwent reoperation for mass enlargement or persistent abdominal pain within a median time of 12.2 months (IQR 8.2 -44.5 months).   Fifty-eight (63%) patients had begun or resumed menses at their most recent follow up.  Three patients were able to conceive after OSS with a median lapse time of 5 years (range 2.4-6.7 years).

Conclusion: Benign ovarian lesions in children can be treated successfully with ovarian sparing surgery with low recurrence and reoperation rates while preserving ovarian function in the majority of patients.  Longer follow-up is needed to determine the utility of menstruation as a predictor of fertility.

 

65.15 Comparing Open Gastrostomy Tube to PEG Tube in Lung Transplant Patients

Posted on December 22, 2014

S. Taghavi1, V. Ambur1, S. Jayarajan1, J. Gaughan1, Y. Toyoda1, E. Dauer1, L. Sjoholm1, A. Pathak1, T. Santora1, J. Rappold1, A. Goldberg1  1Temple University School Of Medicine,Department Of Surgery,Philadelpha, PA, USA

Introduction:   Lung transplant patients require a high degree of immunosuppression, which impairs wound healing when surgical procedures are required.  Open gastrostomy tube (OGT) allows for suturing of the stomach to the anterior abdominal wall, which may decrease the risk of intraperitoneal leak as compared to percutaneous gastrostomy tube (PEG). We hypothesized that because of impaired healing, lung transplant patients requiring gastrostomy tubes would have better outcomes with OGT as compared to PEG.

Methods:   The National Inpatient Sample (NIS) Database (2005-2010) was queried for all lung transplant patients requiring open gastrostomy or PEG tube.   Weighted frequencies and weighted multivariate logistic regression analysis using clinically relevant variables was used to examine mortality.

Results:  There were 215 lung transplant patients requiring gastrostomy tube, with 44 OGT and 171 PEG.  The two groups were not different with respect to age (52.0 vs. 56.9 years, p=0.40), Charlson Comorbidity Index (3.3 vs. 3.5, p=0.75) and private payer status (38.6 vs. 32.7%, p=0.05).  The PEG cohort was more likely to be male (65.9 vs. 45.0%, p=0.01) or white (93.2 vs. 88.3%, p<0.001) and less likely to be Hispanic (0.0 vs. 5.3%, p<0.001).  Incidence of acute renal failure was higher in the PEG group (34.1 vs. 11.7%, p=0.003).   Post-operative pneumonia, myocardial infarction, surgical site infection, DVT/PE, and urinary tract infection was not different when comparing the two groups.  Length of stay (33.0 vs. 27.1 days, p=0.63) and total hospital charges ($203,023 vs. 294.679, p=0.45) were similar.  Post-operative mortality was higher in the PEG group (11.4 vs. 0.0%, p=0.02).  On multivariate analysis, PEG tube was independently associated with mortality (HR: 1.94, 95%CI: 1.45-2.58, p<0.001).  Increasing Charlson Comorbidity Index was associated with mortality.  Variables associated with survival included female gender, age, hospital bed size, and white race (see table).

Conclusion:  In lung transplant patients, OGT results in better outcomes as compared to PEG.  Open gastrostomy should be the preferred method of gastric access in lung transplant patients.

 

65.16 A Novel Approach to Renal Protection in Open Thoracoabdominal Aortic Aneurysm Repair

Posted on December 22, 2014

S. M. Mitchell1, C. Mavroudis1, P. Amin1, J. Frazier1, M. Bakhos1, K. Sawicki1, P. Carmignani1, J. Schwartz1  1Loyola University Chicago Stritch School Of Medicine,Department Of Thoracic And Cardiovascular Surgery,Maywood, IL, USA

Introduction: Acute kidney injury is a significant complication of open thoracoabdominal aortic aneurysm repair and a substantial number of patients go on to need hemodialysis. Various perfusion strategies for renal protection as well as endovascular repair have been used with differing degrees of success. Currently, the ideal method of renal protection is controversial. The purpose of this research was to evaluate the perfusion strategy used at our center with regards to acute kidney injury and post-operative hemodialysis requirement as compared to alternative techniques used at other institutions.

Methods: A retrospective review of 71 patients undergoing open thoracoabdominal aortic aneurysm repair at Loyola University Medical Center between 2002 and 2013 was performed. Effectiveness of intraoperative cold blood perfusion as a renal protection strategy was evaluated by specifically looking at post-operative creatinine trends and need for hemodialysis and comparing our results to those of other institutions. Additional information collected included demographics, cross-clamp time, pump time, visceral perfusion time, and extent of aneurysm.

Results: Acute kidney injury was seen in 18.3% of patients post-operatively, with 5.6% requiring dialysis, and 1.4% being discharged on dialysis. Statistical analysis demonstrated a significant difference between pre-operative and peak creatinine levels, yet not between pre-operative and discharge, 6 month, and 1 year follow-up creatinine levels.

Conclusion: Despite advances in perfusion and surgical technique, acute kidney injury remains a serious complication of thoracoabdominal aortic aneurysm repair. In this study, a statistically significant rise in creatinine was seen post-operatively, however no significant difference was seen between pre-operative and discharge creatinine levels. When compared to benchmark outcomes for open repair, we had a higher incidence of acute kidney injury, however a lower percentage of patients requiring hemodialysis post-operatively. Our low rate of post-operative dialysis requirements compared to other centers and lack of significant difference between pre-operative and discharge creatinine shows that our perfusion technique, continuous cold blood visceral perfusion, is an excellent reno-protective technique compared to others used in open as well as endovascular repair.

 

65.17 The Utility of Esophageal Stents in Management of Postoperative Esophageal Leaks and Perforations

Posted on December 22, 2014

R. Riccardi1,2, C. Nyberg1,2, R. S. Chamberlain1,2,3  1St. George’s University School Of Medicine,St. George’s, St. George’s, Grenada 2Saint Barnabas Medical Center,Livingston, NJ, USA 3New Jersey Medical School,Newark, NJ, USA

Introduction:  Esophageal rupture is a life-threatening event with mortality rates as high as 60%.   Self-expanding removable covered stents are increasingly being used for the treatment of acute benign esophageal injuries such as leaks or perforations.  Data defining the use of esophageal stenting is currently limited or lacking, and the utilization of esophageal stents for perforation or leak is primarily anecdotal.  This report provides a comprehensive systematic review of the indications, efficacy, and safety of endoluminal esophageal stents in the setting of esophageal perforations, anastomotic leaks, and fistulae.  

Methods:  A comprehensive search of PubMed,, Science Direct, Cochrane, and Google Scholar for reports examining the indications, efficacy, and safety of the use of self-expandable stents for the treatment of esophageal perforation and rupture was performed (1989-2014). Keywords included “esophageal stents,” “esophageal rupture,” and “self-expandable stents.” Thirty-five studies involving 907 patients were included in this review after meeting inclusion criteria of N > 5 and reported clinical outcomes. 

Results: Thirty-five studies involving 907 patients reported an average intraoperative esophageal stent placement success rate of 89.8% with a range of 60.9-100%. Clinical success, defined as occlusion of the leak or perforation, was achieved in 79.5% of the patients treated for esophageal leaks, perforations, or fistulae. Length of stay ranged from 5-45 days. Stent migration was the most common complication occurring in 25.9% of patients. Mortality occurred in 69 out of 884 patients, comprising 7.8% of the study population.

Conclusion: Endoluminal esophageal stents are an effective and less invasive treatment for acute perforations.  Successful stent implementation is achieved in a very high percentage of patients (60 – 100%); Specific patient selection criteria are ill defined at present and depend on the ability to provide mediastinal contamination control.  The ideal stent type is poorly analyzed at present, and depends primarily on surgeon experience. Despite these caveats, esophageal stent should be considered as a primary treatment for the majority of patients in whom the stent is successfully deployed. Surgical exploration is warranted if clinical improvement is not achieved rapidly with non-operative management.

 

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