80.10 Prospective, Randomized Study of Short-Term Weight Loss Outcomes Using Gamification-Based Strategy

Posted on January 31, 2019

P. Kaur1, S. V. Mehta5,7, T. Wojda3, P. Bower4, M. Fenty6, M. Kender8, K. Boardman7, M. Miletics7, J. C. Stoltzfus1, S. P. Stawicki1,2  1St. Luke’s University Health Network,Department Of Research & Innovation,Bethlehem, PA, USA 2St. Luke’s University Health Network,Department Of Surgery,Bethlehem, PA, USA 3St. Luke’s University Health Network,Department Of Family Medicinee,Warren, PA, USA 4St. Luke’s University Health Network,Development,Bethlehem, PA, USA 5St. Luke’s University Health Network,Department Of Gastroenterology,Bethlehem, PA, USA 6St. Luke’s University Health Network,Information Technology – Innovation Program,Allentown, PA, USA 7St. Luke’s University Health Network,Weight Management Center,Allentwwn, PA, USA 8St. Lukes University Health Network,St. Luke’s Internal Medicine- Miners,Coaldale, PA, USA

Introduction: In response to the obesity epidemic, various strategies have been proposed. While the surgical approaches remain most effective long-term management option, the effectiveness and sustainability of short-term, non-surgical weight loss remains controversial. Gamification(e.g., point systems and constructive competition) of weight loss activities may help achieve more sustainable results. We hypothesized that the use of smartphone-based gamification platform (SBGP) would facilitate sustained non-surgical weight loss at 3 months. In addition, we sought to examine if intensity of SBGP participation correlates with outcomes, and if it has parallel effects on hemoglobin A1c (HA1c) levels.

Methods:  An IRB-approved, prospective, randomized study (01/2017-02/2018) included 100 bariatric surgery candidates, randomized to either SBGP (n=50) or No SBGP (NSBGP, n=50). Following enrollment, SBGP patients installed a mobile app (Picture It! Ayogo, Vancouver, Canada) and received usage instructions. Patients were followed for 3 months (weight checks, patient engagement questionnaires, health-care encounters). Mobile app frequency was also tracked (number of interactions,  real-time feedback). Primary (weight loss) and secondary (HA1c) outcomes at 3 months were then contrasted between SBGP and NSBGP groups using non-parametric statistical testing. In addition, the intensity of app use was contrasted with weight loss for the SBGP group. Participation was measured on a low-intermediate-high scale (a composite of in-app encouragements, likes, answers and “daily quest” inputs).

Results:After losing 4 patients to follow-up, 49 SBGP and 47 NSBGP patients completed the study. There were no significant demographic differences between the two groups (mean age 38.4±10.4, median weight 273 lbs, 81% female, 28% diabetic, 44% hypertensive). We noted no significant differences in average weight loss at 3 months between SBGP (3.94 lbs) and NSBGP (1.45 lbs) groups. However, actively engaged patients lost more weight (8.33 lbs) compared to less engaged patients (2.51 lbs) in the SBGP group. Of note, absolute measured weight loss was greater among women (Figure 1A). We did not note statistically significant diffrences in HA1c among the groups (Figure 1B).

Conclusion:This study suggests that when using gamification as an adjunct in non-surgical approaches to weight loss, active patient engagement and female gender may be the strongest determinants of success. Our findings will be important in guiding strategies to optimize weight loss through customization and personalization of SBGP approaches to maximize patient engagement and clinical results.

80.09 The Prognostic Value of NLR in Patients that Underwent Neoadjuvant Treatment Before Gastrectomy.

Posted on January 31, 2019

Y. Zager1, A. Dan1, Y. Nevo1, L. Barda1, M. Guttman1, Y. Goldes1, A. Nevler1  1Sheba Medical Center,Surgery B,Ramat-gan, ISRAEL, Israel

Introduction:
Gastric cancer is the fifth most common cancer worldwide. This aggressive gastrointestinal cancer has grim 5 year survival rates of only 30% and is considered the third leading cause of cancer deaths worldwide. Studies in recent years have found hematological markers such as Neutrophil to Lymphocyte ratio (NLR) as potent prognostic immune biomarkers in various malignant conditions including gastric adenocarcinoma (GC). However, chemotherapy has been shown to affect systemic immune responses and local immune signatures and thus, may affect NLR. We therefore aimed to assess the prognostic value of using post-neoadjuvant NLR as a biomarker in gastric cancer patients with resectable disease.

Methods:
We conducted retrospective analysis on a prospectively maintained GC database in our institution. We collected oncologic, perioperative and survival data regarding gastric adenocarcinoma patients that underwent curative intent gastrectomy and D2 lymphadenectomy between the years 2010-2015. Neutrophil-to-Lymphocyte ratio were calculated from preoperative laboratory test. High and low NLR groups were stratified using NLR≥4 as a threshold. Kaplan-Meier analysis and Cox multivariate regression models were used for survival analysis to assess the prognostic value of clinical, histologic and hematological variables.

Results:

We reviewed the data of 174 patients, of which 121 (70%) patients we had the complete necessary data. median follow up duration was 20 months (range 1-88). A total of 54 patients received neoadjuvant chemotherapy (NACT). Postoperatively, High NLR was associated with greater morbidity (ranked with the Clavian-Dindo classification, p=0.011). The rate of major complications (Clavien-Dindo≥3) was higher significantly in the high NLR group (31.25% vs. 5.77%, p=0.015).

Among patients that received NACT, patients in the low NLR groups has a significantly improved disease free survival (Mean DFS, 48.9±5.4 months vs 27.7±10.0 months, p=0.04). Low NLR was not significantly associated with overall survival (OS). Multi-variant analysis demonstrated NLR (p=0.018, HR= 33.7%, CI = 0.12-0.947), and AJCC staging (p=0.01) to be independent prognostic factors associated with DFS.

Conclusion:
Our results suggests that NLR may have prognostic value amongst gastric cancer patients planned for curative intent surgery who underwent NACT.  These effects are evident mainly in terms of disease free survival and perioperative complications. Further studies assessing the value of NLR in predicting chemotherapy response are on their way.

80.08 Superiority of esophageal reconstruction by pedicled jejunal flap with microvascular augmentation

Posted on January 31, 2019

G. Takiguchi1, T. Nakamura1, H. Hasegawa1, M. Yamamoto1, Y. Matsuda1, S. Kanaji1, K. Yamashita1, T. Oshikiri1, T. Matsuda1, S. Suzuki1, Y. Kakeji1  1Kobe University Graduate School of Medicine,Gastrointestinal Surgery,Kobe, HYOGO, Japan

Introduction: The safe and secure esophageal reconstruction method in patients whose stomach is unavailable is still unsettled issue. Recently, the number of cases using pedicled jejunum flap (PJF) as an alternative conduit are increasing when the stomach is unavailable. The objective of this study is to elucidate advantages of reconstruction by PJF.

Methods: Forty-nine patients whose stomach was unavailable for the conduit following esophagectomy were enrolled in this study: 10 patients underwent ileo-colon (IC) reconstruction after esophagectomy from January 2005 to January 2011; after that 39 patients underwent esophageal reconstruction by PJF with microvascular augmentation from February 2011 to January 2018. Surgical outcomes, complications, perioperative serous albumin levels and postoperative body mass index (BMI) changes were retrospectively reviewed and compared between IC and PJF group.

Results:Anastomotic leakage rate was significantly lower in PJF group than those of IC group (10.3 % vs. 50.0 %, P=0.011). There was no severe diarrhea in PJF group while 30.0 % was observed in IC group. The mean serum albumin level was higher all through the postoperative period in PJF group than IC group. Especially, PJF group showed significant better recovery of serum albumin level compared to IC group at two weeks after operation (2.70 g/dl vs 2.20 g/dl, P=0.003). The mean decrease rate of postoperative BMI was lower in the PJF group than in the IC group. In the IC group, one patient died due to the postoperative pneumonia and brain infarction, but there was no mortality in the PJF group.

Conclusion:The reconstruction by PJF with microvascular augmentation following esophagectomy was superior to reconstruction by IC at the point of anastomotic leakage and severe diarrhea. Also, PJF has an advantage in earlier recovery of postoperative serum albumin level and keeping the body weight than IC. PJF might be a better choice for reconstruction after esophagectomy than IC in patients whose stomach is unavailable.
 

 

80.07 Bariatric Surgery in Vulnerable Populations: Early Look at Affordable Care Act’s Medicaid Expansion

Posted on January 31, 2019

K. M. Gould1,2,4, A. Zeymo1,2, K. S. Chan1,2,4, T. DeLeire2,4, N. Shara1,4, T. R. Shope3,4, W. B. Al-Refaie1,2,3,4  1MedStar Health Research Institute,Washington, DC, USA 2MedStar-Georgetown Surgical Outcomes Research Center,Washington, DC, USA 3Integrated Surgical Services of MedStar Washington Region,Washington, DC, USA 4Georgetown University,Washington, DC, USA

Introduction: Obesity disproportionately affects vulnerable populations. Bariatric surgery is a long-term effective treatment for obesity and obesity-related complications; however, utilization rates of bariatric surgery are lower for racial minorities, low-income persons, and publicly-insured patients. The Affordable Care Act’s (ACA) Medicaid expansion increased access to health insurance for millions of low-income adults, but its impact on documented disparities in utilization of bariatric surgery by vulnerable populations has not been evaluated. We sought to determine the impact of the ACA’s Medicaid expansion on disparities in the utilization rates of bariatric surgery by insurance, income, and race.

Methods:  47,974 non-elderly adult patients (aged 18-64) who underwent bariatric surgery were identified in two Medicaid expansion states (Kentucky and Maryland) vs. two non-expansion control states (Florida and North Carolina) from 2012-2015 using the Healthcare Cost and Utilization Project’s State Inpatient Database. Poisson interrupted time series were conducted to determine the adjusted incidence rates of bariatric surgery overall and by insurance (Medicaid vs. privately-insured vs. uninsured), income (high- vs. low-income) and race (African Americans vs. whites). The differences in the counts of bariatric surgery by insurance, income and race were calculated to measure the gap in utilization rates of bariatric surgery.

Results: After the ACA’s Medicaid expansion, the adjusted incidence rate of Medicaid-insured and low-income bariatric surgical patients increased by 16.6% and 4.2% per quarter respectively in expansion states. No significant marginal changes were observed in the adjusted incidence rate of privately-insured and high-income bariatric surgical patients post-ACA in these expansion states. These changed rates of bariatric surgery resulted in a decreased measured gap in the difference of counts of bariatric surgery by insurance status and income in expansion states. In contrast, the overall trend in the utilization rate of bariatric surgery for African Americans vs. whites remained constant pre- and post-ACA’s expansion resulting in an unchanged gap in the difference of counts of bariatric surgery by race in expansion states. (Table)

Conclusion: The Medicaid expansion under ACA reduced the gap in bariatric surgery rates by income and insurance status, but racial disparities persisted. Future research should track these trends and focus on identifying other factors that can reduce disparity in bariatric surgery for minority patients.

80.06 Mesh Reinforcement of Paraesophageal Hernia Repair: Trends and Outcomes from a National Database

Posted on January 31, 2019

K. A. Schlosser1, S. R. Maloney1, T. Prasad1, V. A. Augenstein1, B. T. Heniford1, P. D. Colavita1  1Carolinas Medical Center,Division Of Gastrointestinal And Minimally Invasive Surgery,Charlotte, NC, USA

Introduction:
Mesh placement in paraesophageal hernia repair (PEHR) is controversial. Following encouraging early results, in 2012, Oelschlager et al demonstrated no reduction of recurrence with mesh after five years. This study examines the trends of mesh use before and after this publication, as well as outcomes of PEHR.

Methods:
The American College of Surgeons National Surgical Quality Improvement Program was queried for patients who underwent PEHR with or without mesh (2010-2016). Bariatric procedures were excluded. Demographics, operative approach, and outcomes were compared over time.

Results:

20,798 patients underwent PEHR from 2010-2016. 90.8% were performed laparoscopically (LPEHR). Mean age was 62.1±14.0yr, mean BMI was 30.2±6.2m2/kg, 70.9% were female, 9.0% had diabetes, and 9.1% were active smokers. Most cases were elective (88.9%) and without mesh (61.2%). LPEHR patients had higher BMI (30.3±6.2 vs 29.6±6.7, p<0.0001), and had lower rates of reoperation, readmission, mortality, overall complications, and major complications (2.7 vs 4.8%, 6.3 vs 9.9%, 0.6 vs 3.0%, 7.3 vs 21.5%, 3.9 vs 11.4% respectively; all p<0.0001). Mesh placement was more common in LPEHR (39.8 vs 29.3, p<0.0001).

In primary LPEHR with mesh, patients were older (63.1±13.5yr vs. 61.0±14.3, p<0.0001) and more obese (BMI 31±5.9 vs 30.4±6.4, p=0.0003). Mesh placement was not associated with adverse outcomes.  Trends of LPEHR with mesh were examined over time. From 2010 to 2016, mesh placement decreased from 46.2 to 37.0% of LPEHRs (Figure 1). Mean operative times for LPEHR with mesh also decreased (176.0±71.0 to 152.9±73.3min), while mean operative times for LPEHR without mesh were consistently lower (148.6±71.4 to 134.7±70.4). There were no significant changes in comorbidities or adverse outcomes over time.

Using multivariate analysis to control for potential confounding factors, COPD was most strongly associated with multiple adverse outcomes, including reoperation (OR 1.4, CI 1.02-2.0), readmission (OR 1.17, CI 1.03-1.33), mortality (OR 1.57, CI 1.04-2.36), any complications (OR 1.81, 1.48-2.2), and major complications (OR 1.78, CI 1.36-2.31). Other factors associated with adverse outcomes included older age, higher BMI, male sex, non-elective repair, contaminated operation, diabetes, steroid use, and smoking.

Conclusion:
The placement of mesh during LPEHR is not associated with adverse outcomes despite an older patient population. Use of mesh with LPEHR is decreasing with no apparent adverse impact on available short-term patient outcomes. Further research needs to investigate patient factors not captured by this national database, such as symptoms, hernia recurrence, and hernia type and size.  Additionally, the mesh type and fixation in these cases needs to be separated and short and long term outcomes further defined.

80.05 Association Between Intraoperative Leak Testing and 30-Day Outcomes After Bariatric Surgery

Posted on January 31, 2019

M. C. Cusack2, M. Venkatesh3, A. Pontes3, G. Shea3,4, D. Svoboda3, N. Liu3, J. Greenberg3, A. Lidor3, L. Funk3,4  4William S. Middleton VA,Madison, WI, USA 2Indiana University School Of Medicine,Indianapolis, IN, USA 3University Of Wisconsin-Madison,Madison, WI, USA

Introduction: Bariatric surgery has become much safer over the past two decades; however, postoperative complications remain a concern. Intraoperative leak testing is commonly performed to minimize the risk of postoperative complications, but its impact on outcomes is unclear. The aim of this study was to determine if intraoperative leak testing during sleeve gastrectomy or Roux-en-Y gastric bypass decreases the risk of 30-day postoperative leaks, bleeding, readmissions, and reoperations.

Methods: This was a retrospective cohort study utilizing 2015 and 2016 data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, which includes preoperative, operative, and postoperative data from more than 700 accredited bariatric surgery centers nationally. Postoperative leak was defined as a drain present for >30 days, organ space surgical site infection, or leak-related 30-day readmission, reoperation, or intervention. Postoperative bleed was defined as transfusion within 72 hours or bleed related 30-day readmission, reoperation, or intervention. Patient characteristics and postoperative outcomes were analyzed via Chi-squared tests for categorical variables.

Results: 237,081 patients were included in the study cohort. 29.2% underwent gastric bypass, while 70.8% underwent sleeve gastrectomy. 79.2% were female, and the mean age was 44.7 (SD 11.9). For sleeve gastrectomy patients, intraoperative leak testing was associated with slightly higher rates of 30-day postoperative leak but lower rates of bleeding, reoperation and readmission within 30 days. For gastric bypass patients, intraoperative leak testing was associated with higher rates of 30-day postoperative leaks and bleeds, but lower reoperation and readmission (Table 1). Complications, readmissions and reoperations were 2-3 times more common in bypasses vs. sleeves regardless of whether a leak test was performed. All results were statistically significant (p<0.05).

Conclusion: In this retrospective study of a national sample of bariatric surgery patients, intraoperative leak testing was associated with paradoxically higher rates of 30-day postoperative leaks for both sleeve gastrectomy and bypass patients but lower rates of reoperations and readmissions. However, given the small differences associated with leak testing, its utility is unclear. Gastric bypass was associated with higher complication rates compared to sleeve gastrectomy during the 30-day postoperative period.

80.04 Interim Results from a Prospective Human Study of the Immuno-metabolic Effects of Sleeve Gastrectomy

Posted on January 31, 2019

T. Lo1, G. Williams1, K. Heshmati1, A. Tavakkoli1, D. C. Croteau-Chonka1, E. G. Sheu1  1Brigham And Women’s Hospital,Metabolic Surgery,Boston, MA, USA

Introduction:
Laparoscopic sleeve gastrectomy (LSG) has been proved to be an effective weight loss procedure and has a positive impact on obesity-related comorbidities. We hypothesize that the effects of LSG are reflected in the immune-metabolic changes in a longitudinal human cohort study.

Methods:

Prospective data has been collected from enrolled human subjects from a single institution. Parameters of weight, comorbidities, pulmonary function tests, and trends in blood biomarkers (HbA1C, inflammatory and hormonal biomarkers) were observed from pre-operative baseline to 1 year in a 3-monthly interval follow ups. Subcutaneous and omental adipose tissue biopsies were collected perioperatively in addition to leukocytes every 3 months for RNA sequencing. We have included our interim analysis on immune-metabolic and hormonal profiling in this abstract.

Results:
16 subjects were enrolled (M: F, 3:13; mean age, 45 years old; mean body mass index (BMI) 43.18±5.78 Kg/m2). 13 subjects have competed their 3 month follow up visit with 1 subject dropout. There was a significant reduction in mean total body weight loss at 3 months (17.2±1.2%) and at 6 months (24.99±3.70%). Improvements in obesity-related comorbidities have been observed either by disease remission or reduction in medication. 75% of patients with hypertension, 50% with type 2 diabetes, and 50% dyslipidemia ceased their medication requirements by 3 months after LSG.  Significant improvements in hormonal biomarkers such as insulin (P<0.001), HbA1C (P<0.05), ghrelin (P<0.001) and leptin (P<0.001) were seen by 3 months after LSG. Surprisingly, reductions in ghrelin levels did not predict weight loss. Immunologic markers such as total white cell counts, neutrophils, and C reactive protein (CRP) were found to have significantly decreased as early as 3 months comparing to baseline. Two patterns of CRP responses were seen: one set of subjects had elevated CRP at baseline that resolved to normal by 3 to 6 months post-op. A second subset had normal CRP levels at baseline that remained stable post-op.  Subjects with a baseline, low CRP achieved more weight loss (P<0.001). White cells composition was also altered after LSG, with a significant decrease in neutrophils and increase in lymphocytes. Changes in neutrophil and lymphocyte fraction were reduced in subjects with metabolic diseases (P<0.01), whilst other immunological markers and weight outcomes did not differ between the two groups.

Conclusion:
This interim analysis from our study suggests that LSG induces significant immuno-metabolic changes in obese individuals as early as 3 months post-operatively. The improvement in CRP as well as white cells composition alteration tracks closely with weight loss, suggesting that the immune response plays a role in LSG. Future analyses including a larger sample size and RNA sequencing data will provide additional insights into predicting weight outcomes and metabolic response after LSG.

80.03 Bariatric Surgery Independently Associated with Reduction in Colorectal Lesions

Posted on January 31, 2019

M. Kwak1, J. H. Mehaffey1, R. B. Hawkins1, B. Schirmer1, C. L. Slingluff1, P. T. Hallowell1, C. M. Friel1  1University Of Virginia,Department Of Surgery,Charlottesville, VA, Virgin Islands, U.S.

Introduction:
While bariatric surgery has demonstrated excellent long-term weight loss results, little is known about secondary effects such as cancer risk. Previous studies have shown obesity is a risk factor for colorectal cancer and possibly precancerous colorectal polyp formation, but it is unclear whether bariatric surgery could potentially mitigate this risk. We hypothesized that bariatric surgery would decrease the risk of developing colorectal lesions (defined as new development of colorectal cancer and precancerous colorectal polyps).

Methods:
All patients (n=3,676) who received bariatric surgery (gastric bypass, sleeve gastrectomy, or gastric banding) at a single institution (1985-2015) were included in the study. Additionally, obese patients (n=46,873) from an institutional data repository were included as controls. Cases and controls were propensity score matched 1:1 by demographics, comorbidities, BMI, and socioeconomic factors. The matched cohort was compared by univariate analysis and conditional logistic regression.

Results:
A total of 4,462 patients (2,231 per group) with a median follow-up of 7.8 years were well matched with no significant baseline differences in BMI (49 vs 48 kg/m2, p=0.26), Female gender (51% vs 50%, p=0.16), and Age (43 vs 43 years old, p=0.63) as well as other comorbidities (all p>0.05). The surgical cohort had significantly more weight loss (55.5% vs -1.4% Reduction in Excess Body Mass Index, p<0.0001). The surgical cohort developed significantly fewer colorectal lesions (2.4% vs 4.8%, p<0.0001). There were no significant differences in polyp characteristics or staging for patients who developed cancer (all p>0.05). After risk-adjustment, bariatric surgery was independently associated with reduction in new colorectal lesions (OR 0.62, 0.42-0.91, p=0.016, Table).

Conclusion:
Bariatric surgery was associated with lower risk-adjusted incidence of new colorectal lesions in this large population. These results are encouraging that the benefits of bariatric surgery may extend beyond weight loss and comorbidity mitigation.
 

80.02 Role of Gastroesophageal Reflux Symptoms on Patient Satisfaction in Sleeve Gastrectomy

Posted on January 31, 2019

I. A. Van Wieren1, J. Thumma1, O. Varban1, J. Dimick1  1University Of Michigan,Department Of Surgery, The Center For Healthcare Outcomes & Policy,Ann Arbor, MI, USA

Introduction: Sleeve gastrectomy has emerged as the most common bariatric procedure. However, there is emerging data that this procedure can result in lifestyle limiting gastroesophageal reflux. It is unclear whether these symptoms are severe enough to offset the benefits of the procedure in terms of weight loss and other positive outcomes. Using a validated disease-specific instrument, we evaluated the extent to which reflux symptoms after sleeve gastrectomy affected patients’ satisfaction with the surgery.

Methods: We studied 6,633 patients who underwent laparoscopic sleeve gastrectomy (2013 to 2017) from Michigan bariatric surgical collaborative. We used the GERD-HRQL score which is 10 questions each ranging from 0 for no symptoms to 5 for severe symptoms. To assess the impact of sleeve gastrectomy we calculated change in this score before versus after the procedure. We divided the delta GERD score into quintiles: the bottom quintile represents worsening of GERD symptoms from baseline to 1-year and the top quintile represents improvement in symptoms. We then looked at the relationship between delta GERD score and patient satisfaction at 1-year. We used univariate and multivariate generalized linear mixed models to assess the variation in satisfaction explained by change in GERD score/delta GERD, percent excess body weight loss (%EBWL) at 1-year and other patient outcomes (serious complications, readmission and reoperations). We controlled for patient factors (age, gender, race and comorbidities) and year of surgery.

Results: The average change in GERD score was 1.63 (range: -48 to 48). However, the change in GERD score varied across quintiles with -9.0 point (range: -48 to -3) worsening in the bottom quintile verses a 13.9 point (range: 7 to 48) improvement in the top quintile. Overall, 77.7% of patients were satisfied, but the proportion of patients satisfied was highly dependent on whether there reflux symptoms improved or worsened. For example, in the bottom quintile only 48.9% were satisfied compared to 78.1% in the top quintile. In a multivariate model, changes in GERD score explained 10.5% of the variation in 1-year satisfaction. In fact, change in GERD score predicted the most variation in 1-year patient satisfaction, especially among whose symptoms worsened the most.  For patients in the worst quintile, reflux symptoms explained 30.6% of variation compared to 2.2% with little change or improvement in reflux (quintiles 2-5).  In univariate analyses, %EBWL explained only 2% of variation in satisfaction and <1% was explained by 30-day patient outcomes (serious complications, readmissions or reoperations).

Conclusion: In this state wide study of sleeve gastrectomy in Michigan, we demonstrated that reflux symptoms are the most important determinant of 1-year satisfaction after sleeve gastrectomy particularly among patients whose symptoms worsened the most.

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.

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