26.04 The Prognostic Significance of Tumor-Infiltrating Lymphocytes for Primary Melanoma Varies by Gender

Posted on January 18, 2018

A. J. Sinnamon1, C. E. Sharon1, Y. Song1, M. G. Neuwirth1, D. E. Elder2, X. Xu2, D. L. Fraker1, P. A. Gimotty3, G. C. Karakousis1  1Hospital Of The University Of Pennsylvania,Endocrine And Oncologic Surgery,Philadelphia, PA, USA 2Hospital Of The University Of Pennsylvania,Pathology,Philadelphia, PA, USA 3University Of Pennsylvania,Biostatistics, Epidemiology And Informatics,Philadelphia, PA, USA

Introduction:
The immune response to melanoma, manifested locally by tumor-infiltrating lymphocytes (TILs), has gained increasing attention in the era of effective immunotherapies. Men and women are known to have varying patterns of immunity, yet gender-specific prognostic implications of TILs have not been explored.

Methods:
Patients with clinically localized primary melanoma ≥0.76mm who underwent sentinel lymph node (SLN) biopsy were identified within our institutional melanoma database. Association between TILs (categorized as absent, nonbrisk, and brisk) and SLN positivity was evaluated using logistic regression. The possibility of interaction between gender and TILs on the rate of SLN positivity was assessed using the Wald test. Overall survival estimates were obtained using the Kaplan-Meier method and Cox regression with separate analyses performed by gender.

Results:
Among 1,367 patients identified, 794 (58%) were men. TILs were brisk in 143 (10%) lesions, nonbrisk in 903 (66%), and absent in 321 (23%); this distribution did not vary by gender (p=0.71). Among men, SLN positivity rate was significantly associated with TILs (brisk 3.8%, nonbrisk 16.9%, absent 26.6%, p<0.001). In contrast, there was no significant relationship between TILs and SLN status in women (see figure; p=0.49). Significant interaction between brisk TILs and female gender on SLN status was identified (p=0.029). This interaction remained significant in multivariable analysis adjusting for clinicopathologic factors (p=0.043). Among men, presence of brisk TILs was associated with prolonged overall survival (brisk HR 0.43, p=0.038; nonbrisk HR 0.84, p=0.34). This association was no longer significant after adjustment for SLN status (brisk HR 0.72, p=0.42; nonbrisk HR 1.05, p=0.79). In contrast, no association between TILs status and overall survival was observed among women (brisk HR 0.97, p=0.95; nonbrisk HR 1.06, p=0.85).

Conclusion:
The negative prognostic implications of absent TILs on SLN status and thus on survival appear to be stronger among men than women. This may provide some basis for better melanoma-specific prognosis among women.

21.08 Should Sentinel Lymph Node Biopsy Be Recommended to All Intermediate Thickness Melanoma Patients?

Posted on January 18, 2018

A. Hanna1, A. J. Sinnamon1, R. Roses1, R. Kelz1, D. Elder1, X. Xu1, B. Pockaj2, D. Fraker1, G. Karakousis1  1University Of Pennsylvania,Philadelphia, PA, USA 2Mayo Clinic,Phoenix, AZ, USA

Introduction:

Sentinel lymph node (SLN) biopsy is routinely recommended for patients with intermediate (1.01 – 4.00 mm) thickness melanoma. Prior institutional data from our group,however, suggested significant variation in the risk for SLN metastasis for these patients and we therefore sought to identify subgroups within this cohort with low risk for SLN positivity using a large national data set.

Methods:

Patients with intermediate thickness melanomas who underwent SLN biopsy from 2010 to 2013 were identified using the National Cancer Database. Clinical and pathologic variables associated with SLN positivity were analyzed using logistic regression. Classification and Regression Tree (CART) analysis was used to risk-stratify patients for SLN positivity.

Results:

Of the 23,440 study patients with intermediate thickness melanoma, 14.7% (95% CI, 14.2% – 15.1%) were found to have a positive SLN. Most (59.9%) patients were male and the median age was 62 years (IQR, 51 – 72 years old). In multivariate logistic regression, increased age (OR = 0.89/10 years, 95% CI 0.88 – 0.90), female gender (OR = 0.85, 95% CI 0.79 – 0.93), absence of lymphovascular invasion (LVI) (OR = 0.31, 95% CI 0.27 – 0.36), absent mitoses (OR = 0.61, 95% CI 0.54 – 0.70), a H&N, upper extremity, or shoulder primary site (OR = 0.55, 95% CI 0.49 – 0.63), decreased thickness (OR = 1.55/mm, 95% CI 1.48 – 1.63), and absent ulceration (OR = 0.74, 95% CI 0.68 – 0.81) all were significantly associated with having a negative SLN. In CART analysis, absent LVI, thickness < 1.7 mm, age < 56, and primary site were significant branch points (Figure 1). In patients 56 years of age or older with absent LVI and intermediate thickness lesions < 1.7 mm (29% of all patients analyzed), the rate of SLN positivity was < 5%.

Conclusion:

Despite a SLN positivity rate of 14.7% overall, there exists significant heterogeneity in the risk for SLN metastasis in patients with intermediate thickness melanoma. In a sizable group of patients (nearly 30% undergoing the procedure), the risk for SLN metastasis approximates that seen in lower risk thin melanomas, where the procedure is offered selectively. For these patients (56 years or older with lower depth intermediate lesions and absent LVI) careful consideration should be made weighing the risks and benefits of the SLN procedure.

20.08 Lymph Node Ratio Does Not Predict Survival after Surgery for Stage-2 (N1) Lung Cancer in SEER

Posted on January 18, 2018

D. T. Nguyen2, J. P. Fontaine1,2, L. Robinson1,2, R. Keenan1,2, E. Toloza1,2  1Moffitt Cancer Center,Department Of Thoracic Oncology,Tampa, FL, USA 2University Of South Florida Health Morsani College Of Medicine,Tampa, FL, USA

Introduction:   Stage-2 nonsmall-cell lung cancers (NSCLC) include T1N1M0 and T2N1M0 tumors in the current Tumor-Nodal-Metastases (TNM) classification and are usually treated surgically with lymph node (LN) dissection and adjuvant chemotherapy.  Multiple studies report that a high lymph node ratio (LNR), which is the number of positive LNs divided by total LNs resected, as a negative prognostic factor in NSCLC patients with N1 disease who underwent surgical resection with postoperative radiation therapy (PORT).  We sought to determine if a higher LNR predicts worse survival after lobectomy or pneumonectomy in NSCLC patients (pts) with N1 disease but who never received PORT.

Methods:   Using Surveillance, Epidemiology, and End Results (SEER) data, we identified pts who underwent lobectomy or pneumonectomy with LN excision (LNE) for T1N1 or T2N1 NSCLC from 1988-2013.  We excluded pts who had radiation therapy, multiple primary NSCLC tumors, or zero to unknown number of LNs resected.  We included pts with Adenocarcinoma (AD), Squamous Cell (SQ), Neuroendocrine (NE), or Adenosquamous (AS) histology.  Log-rank test was used to compare Kaplan-Meier survival of pts who had LNR <0.125 vs. 0.125-0.5 vs. >0.5, stratified by surgical type and histology.

Results:  Of 3,452 pts, 2666 (77.2%) had lobectomy and 786 (22.8%) had pneumonectomy.  There were 1935 AD pts (56.1%), 1308 SQ pts (37.9%), 67 NE pts (1.9%), and 141 AS pts (4.1%).  When comparing all 3 LNR groups for the entire cohort, 1082 pts (31.3%) had LNR <0.125, 1758 pts (50.9%) had LNR 0.125-0.5, and 612 pts (17.7%) had LNR >0.5.  There were no significant differences in 5-yr survival among all 3 LNR groups for the entire population (p=0.551).  After lobectomy, 854 pts (32.0%) had LNR <0.125, 1357 (50.9%) pts had LNR 0.125-0.50, and 455 pts (17.1%) had LNR >0.5.  After pneumonectomy, 228 pts (29.0%) had LNR <0.125, 401 pts (51.0%) had LNR 0.125-0.5, and 157 pts (19.9%) had LNR >0.5.  There was no significant difference in 5-yr survival among all 3 LNR groups in either lobectomy pts (p=0.576) or pneumonectomy pts (p=0.212).  When stratified by histology, we did not find any significance in 5-yr survival among all 3 LNR groups in AD pts (p=0.284), SQ pts (p=0.908), NE pts (p=0.065), or AS pts (p=0.662).  There were no differences in 5-yr survival between lobectomy vs. pneumonectomy pts at LNR <0.125 (p=0.945), at LNR 0.125-0.5 (p=0.066), or at LNR >0.5(p=0.39).

Conclusion:  Patients with lower LNR did not have better survival than those with higher LNR in either lobectomy or pneumonectomy pts.  Lower LNR also did not predict better survival in each histology subgroup.  These findings question the prognostic value of LNRs in NSCLC patients with N1 disease after lobectomy or pneumonectomy without PORT and suggest further evaluation of LNRs as a prognostic factor.

20.09 Induction Chemotherapy versus Standard Treatment for Locally Advanced Rectal Cancer

Posted on January 18, 2018

C. Nganzeu1, J. J. Blank1, F. Ali1, W. Hall2, C. Peterson1, K. Ludwig1, T. Ridolfi1  2Medical College Of Wisconsin,Department Of Radiology,Milwaukee, WI, USA 1Medical College Of Wisconsin,Department Of Colorectal Surgery,Milwaukee, WI, USA

Introduction:
The standard treatment of stage II or III rectal adenocarcinoma is chemoradiation therapy (CRT) followed by surgical resection and adjuvant systemic chemotherapy. Recently there has been increased interest in the use of induction chemotherapy (IC), an approach that provides some or all systemic chemotherapy and CRT in the preoperative setting. Potential benefits of this treatment paradigm include tumor downstaging, early treatment of micrometastases, increased rate of sphincter preservation, decreased time with a diverting stoma, and patient compliance. However, little is known about this treatment strategy on a national level. The aims of this study were to define the frequency of IC use and evaluate treatment outcomes compared to standard CRT using the National Cancer Database.

Methods:
The National Cancer Database was queried for patients diagnosed with stage II or III rectal adenocarcinoma having received radiation, chemotherapy and surgical resection between 2004 and 2014. We compared patients with IC to patients having received standard combined CRT. Linear regression was performed to predict percent patients receiving IC by year. Propensity score matching was applied in a 1:10 fashion. A logistic model was fitted to obtain propensity scores. A greedy matching algorithm was then applied for predictor selection. Outcomes including downstaging, readmission, positive margins, and survival were evaluated.

Results:
A total of 33,480 patients met inclusion criteria. 96.4% of patients underwent standard CRT while 3.6% underwent IC. Of all patients diagnosed with stage II and III rectal cancer, only 2.8% received IC in 2004; this number rose to 4.4% in 2014. Propensity score matching yielded 10,531 patients receiving standard CRT and 1,073 patients who received IC for the analysis. The IC group had more tumor downstaging than standard CRT on surgical pathology (54% vs. 48.8%, p=0.006, respectively). This group also had significantly fewer 30-day readmissions after surgery (4.5% vs. 6.4%, p=0.021, respectively). There were no differences observed in 30-day or 90-day mortality (0.5% vs. 0.5%, p= 0.247 and 0.8% vs. 1.1%, P= 0.755, respectively), rate of positive margins (4.8% vs. 5.6%, p=0.398, respectively), or survival (p=0.587) between the two groups.

Conclusion:

The use of induction chemotherapy for patients with stage II and III rectal cancer increased significantly from 2004-2014. Induction chemotherapy was associated with improved downstaging before surgery and improved 30-day readmission rates after surgery without changing overall survival when compared to standard chemoradiation therapy.

 

17.20 Multidisciplinary Approach For Management Of Necrotizing Pancreatitis: A Case Series

Posted on January 18, 2018

P. SENTHIL-KUMAR1, W. Alswealmeen1, Q. Yan1, P. O’Moore1, T. Braun1, D. Ringold1, O. Kirton1, T. Vu1  1Abington Memorial Hospital,Surgery,Abington, PA, USA

Introduction:

 Necrotizing pancreatitis is often a devastating sequelae of acute pancreatitis. Historically several approaches have been described with variable outcome. Open necrosectomy is associated with higher morbidity (95%) and mortality (25%). Endoscopic necrosectomy often is tolerated well but associated with stent migration and multiple procedures. Video-assisted retroperitoneal debridement is tolerated well but associated with severe bleeding if adjacent blood vessels are injured during the procedure leading to severe complications

Methods:
In our series. We perform a step up approach by Involvement of a multidisciplinary group consisting of general surgeons, gastroenterologists, Infectious disease physicians, critical care internalist, interventional radiologist and nutritional services to formulate a management plan. The necrotized pancreas is initially drained with an IR guided drain, fluid cultures sent for microbiology and treatment with appropriate antibiotics if deemed necessary. The drain is gradually upsized to a 24 Fr sized drain to form a well-defined tract for surgical debridement; A pre-operative CT scan of the abdomen with IV contrast to access the location and proximity of the vasculature around the necrotized pancreas. A collaboration with the interventional radiologist to discuss possible IR embolization of splenic artery prior to surgical debridement. The patient would then undergo video assisted retroperitoneal pancreatic necrosectomy and a sump drain left in-situ at the pancreatic fossa. Post-operative management in the surgical ICU would be lead by the critical care internalist.

Results:
Three patients were managed by this multidisciplinary approach with excellent outcomes. One patient underwent preoperative IR embolization followed by surgical debridement; second patient underwent embolization immediately following debridement; one patient did not require any embolization but had IR on standby if needed to intervene. Post-operatively all three patients recovered well. They all were tolerating good oral intake and were discharged to rehabilitation facilities.

Conclusion:

As this series show an early plan and collaboration with various subspecialities will produce an optimal outcome. It will lead us to a pragmatic and successful approach to this potentially catastrophic condition.

 

17.18 Postoperative Outcomes after Esophagectomy for Cancer in Elderly Patients

Posted on January 18, 2018

F. Schlottmann1, P. D. Strassle1, B. A. Cairns1, M. G. Patti1  1University Of North Carolina,Surgery,Chapel Hill, NORTH CAROLINA, USA

Introduction:  The progressing aging of the population in conjunction with the higher incidence of esophageal cancer will dramatically increase the number of elderly patients with esophageal cancer. We aimed to determine the postoperative outcomes after esophagectomy for cancer in elderly patients. 

Methods:  A retrospective, population-based analysis was performed using the National Inpatient Sample for the period 2000-2014. Adult patients (≥18 years old) diagnosed with esophageal cancer and who underwent esophagectomy during their inpatient hospitalization were included. Patients were categorized into <70 years old (yo) and ≥70 yo. Multivariable linear and logistic regression, adjusting for admit year, gender, race, comorbidities, primary insurance, household income, hospital region, hospital teaching status, and hospital size, were used to assess the potential effect of age on length of stay, hospital charges, and patient complications. The predicted probability of inpatient mortality was also estimated using multivariable logistic regression, where age was treated as a restricted cubic spline.

Results: Overall, 5,243 patients were included, with 3,699 (70.6%) <70 yo and 1,544 (29.5%) ≥70 yo. Elderly patients were more likely to be female and have comorbidities. The yearly rate of esophagectomies among patients ≥70 yo did not significantly changed during the study period (28.4% in 2000 and 26.3% in 2014, p=0.76). No significant differences in the incidence of postoperative venous thromboembolism, wound complications, infection, bleeding, renal failure, respiratory failure, shock, or average length of stay were seen. Elderly patients were significantly more likely have postoperative cardiac failure (OR 1.59, 95% CI 1.21, 2.09, p=0.0009) and postoperative mortality (OR 1.84, 95% CI 1.39, 2.45, p< 0.0001). The predicted probability of mortality also exponentially increased with age (1.5% in 40 yo, 2.5% in 50 yo, 3.6% in 60 yo, 5.4% in 70 yo, and 7.0% in 80 yo), Figure 1. Among elderly patients, hospital charges were, on average, $16,320 greater (95% CI $3,110, $29,530) than patients <70 yo, p=0.02. 

Conclusion: Elderly patients undergoing esophagectomy for cancer have a high risk of postoperative mortality and have a higher expense burden on the health care system. Elderly patients with esophageal cancer should be carefully selected for surgery.

 

17.15 The Malnourished Obese Patient: A Unique Paradox in Bariatric Surgery

Posted on January 18, 2018

J. H. Fieber1, P. Dowzicky1, C. Wirtalla1, N. N. Williams1, D. T. Dempsey1, R. R. Kelz1  1University Of Pennsylvania,Department Of Surgery,Philadelphia, PA, USA

Introduction: Hypoalbuminemia is a known risk factor for poor outcomes after elective general surgery. Many obese patients concurrently suffer from modest to severe malnutrition. We seek to evaluate the impact of hypoalbuminemia on surgical outcomes in obese patients undergoing elective bariatric surgical procedures.

Methods: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program for 2015 was queried for adult patients with body mass index [BMI] ≥ 35 undergoing bariatric surgery. Revision procedures and patients missing albumin values were excluded. The analysis was controlled for 12 potentially significant confounders. Low albumin was defined as albumin <3.5, <3.0, and <2.5. Independent logistic models were developed to estimate the adjusted odds of death/serious morbidity (DSM) or readmissions associated with hypoalbuminemia. A test for the interaction between 10% weight loss, measured in kilograms, and hypoalbuminemia was performed. Bonferroni correction was used to correct for multiplicity using 0.006 as the threshold for significance.

 

Results: A total of 106,577 patients were included in the study with a mean age of 44 years-old (IQ: 36-53), 78.9% female, and 74.8% White. By procedure, sleeve gastrectomy was most common (65%), followed by gastric bypass procedure (30.3%), laparoscopic band procedure (3%), and other bariatric procedures (1%). The majority of patients had a BMI of 40-49.9 (52.1%).  Among patients with low albumin, 6.3% (n=6,647) had albumin <3.5, 0.3% (n=350) had albumin <3, and 0.1% (n=94) had albumin <2.5. Patients with albumin <3.5 were 45% (OR: 1.45, CI: 1.25-1.67, p<0.001) more likely to have DSM following bariatric surgery. There was increasing likelihood of DSM with albumin <3 and albumin <2.5 [Table 1]. Patients with albumin <3.5 were 21% (OR: 1.21, CI: 1.09-1.35) more likely to require readmission. There was a significant interaction between 10% weight loss and low albumin for DSM when albumin was <3.0 (OR: 5.10, CI: 1.71-15.22, p=0.003).

Conclusion: Obesity is not uniformly associated with a well-nourished state. More than 5% of patients undergoing bariatric surgery have hypoalbuminemia.  Preoperative albumin is an important and modifiable risk factor for postoperative complications following bariatric surgery. Weight loss of 10% combined with hypoalbuminemia is synergistic for high complication rates and should be investigated before proceeding with elective bariatric surgery.
 

17.16 Comparative Analysis of Black Males vs. Black Females after Bariatric Surgery

Posted on January 18, 2018

E. S. Bauer4, M. S. Pichardo3,5, G. Ortega4, M. F. Nunez4, M. A. Spencer3, M. Wooten3, D. D. Tran2, T. M. Fullum2,4  2Howard University College Of Medicine,Department Of Surgery, Center For Wellness And Weight Loss Surgery,Washington, DC, USA 3Howard University College Of Medicine,Washington, DC, USA 4Howard University College Of Medicine,Clive O. Callender Howard-Harvard Health Sciences Outcomes Research Center,Washington, DC, USA 5Yale University,Department Of Chronic Disease Epidemiology,New Haven, CT, USA

Introduction:
As obesity rates grow, bariatric surgery continues to demonstrate itself as an effective treatment for long-term weight loss, contributing to improvements in obesity related diseases. While females make up 80% of all bariatric surgeries, studies show that males have comparable outcomes. Few studies focus solely on the outcomes of Black males and Black females after bariatric surgery. Our aim is to evaluate and compare the effectiveness of bariatric surgery on weight loss and resolution of co-morbidities among Black males and Black females at an urban institution.

Methods:
Retrospective study of patients who underwent bariatric surgery at a single urban academic institution between 2008 to 2016. Data retrieved from medical records included demographic, pre- and post-operative weight, height and co-morbidities (diabetes mellitus type II [DM], hypertension [HTN], and hypercholesterolemia [HC]), and surgical procedures (laparoscopic roux-en y gastric bypass (LRYGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic adjustable gastric band (LAGB)). All analysis compared males to females and stratified by surgical procedure. Primary outcomes interested were mean, weight loss, and BMI points loss by 12 months. Secondary outcomes were resolution of co-morbidities by 12 months. Adjusted multivariable regression analysis was performed to assess the relation between gender and outcomes of interest.

Results:
In an analytical sample of 422 black patients, 18% were male (n=74). Mean weight was 349 lbs (standard deviation (SD=76.19) for males and 290 lbs (SD=60.91) for females, and mean BMI for males was 50 kg/m2 (SD=9.21) and 48 kg/m2 (SD=8.99) for females. Among these patients, 43% of males and 32% of females had DM, 69% of males and 47% of females had HTN, and 32% of males and 28% of females had HC. At one year postoperatively, the mean BMI was 39 kg/m2 (SD=9.37) for males and 40 kg/m2 (SD= 4.92) for females. Among these patients, 15% of males and 9% of females had DM, 47% of males and females had HTN, 15% of males and 25% females had HC. There was no statistical significance between male and female outcomes in EWL% (OR=1.89, 95% CI=-6.78-4.46), BMI point difference (OR=3.60, CI=-19.03-26.23), resolution of DM (OR=1.55, CI=0.67-3.57), HTN (OR=1.13, CI=0.62-2.05), and HC (OR=1.87, CI=0.69-5.06).

Conclusion:

Our study demonstrates that there were no differences between Black males and Black females after bariatric surgery with respect to weight loss and resolution of co-morbidities.
 

17.06 Pre-Operative Weight-loss on a Liver Shrink Diet Predicts Early Weight-loss after Bariatric Surgery

Posted on January 18, 2018

A. D. Jalilvand1, J. Sojka1, K. Shah1, B. J. Needleman1, S. F. Noria1  1Ohio State University,General And Gastrointestinal Surgery,Columbus, OH, USA

Introduction:  The surgical weight loss program at our institution requires patients to comply with a liver-shrink diet (LSD) 1-3 weeks prior to bariatric surgery (BS) in order to facilitate liver retraction during surgery. However, the effect of LDS-induced weight-loss on weight-loss after BS is unclear. The primary objective of this study was to examine the correlation between LSD-induced weight-loss and post-operative weight loss outcomes. Secondary objectives included identifying other factors that correlated to improved weight-loss after surgery.

Methods:  All patients who underwent primary laparoscopic sleeve gastrectomy (LSG) or Roux-en-Y gastric bypass (LRNYGB) between July 2014 and June 2016 were retrospectively reviewed at a single academic institution. Baseline demographic and operative data was obtained using the electronic medical record. The LSD consisted of a partial-liquid, low carbohydrate, high protein diet that utilized 4 protein shakes and 1 low carbohydrate meal/day. Percent excess body weight-loss (EBWL) was calculated for each patient on LSD (EBWL-LSD), as well as at 2, 8, and 24 weeks after BS. Student’s t-test, Mann-Whitney-U, Chi squared, and Fisher’s Exact were utilized to calculate significance. Multivariate linear regressions were conducted to determine independent predictors of weight-loss. A p-value of <0.05 was considered significant. 

Results: During the study period, 588 patients underwent primary BS, of which 57.14% had LSG and 42.86% underwent LRNYGB. Of these, 78.91% (464) were female, and the mean preoperative BMI was 48.8 ± 8.95 kg/m2. The mean time spent on the LSD was 18.21 ± 7.32 days, and median EBWL-LSD was 4.7% (1.73-7.61). Greater EBWL-LSD was observed in patients who were on the LSD for > 2 weeks (5.35% vs 3.09%, p<0.0005), and in men (median of 6.2% vs 4.23%, p=0.0001). Significant independent predictors of EBWL 2 weeks post-operatively included EBWL-LSD (p<0.0005) and male sex (p<0.0005), when adjusting for surgery type, baseline EBW, and age. Patients who achieved at least the median EBWL at 2 weeks (15.4%) had greater EBWL-LSD than those who did not (5.7% vs 4%, p<0.0005). The only significant predictor of EBWL at 2 months was 2-week EBWL (p <0.0005), when adjusting for EBWL-LSD, surgery type, and gender. At 24 weeks, significant independent predictors for EBWL included EBWL at 2 and 8 weeks (p=0.001, p<0.0005), and LRNYGB (p=0.002).

Conclusion: Greater EBWL-LSD is associated with male gender and longer duration on the LSD. EBWL-LSD was a significant independent predictor of EBWL at 2 weeks, while EBWL at 2 and 8 weeks were independent predictors for weight loss at 24 weeks. Patients who reached at least 5.7% EBWL-LSD were in the 50th percentile of EBWL at 2 weeks. This suggests that EBWL-LSD can predict optimal early weight loss outcomes after BS and be used to guide expectations both in preparation for, and after bariatric surgery. 

 

17.05 Stratification by Age Improves Accuracy of ACS Risk Calculator for Paraesophageal Hernia Repair

Posted on January 18, 2018

A. D. Jalilvand1, M. Al-Mansour1, K. A. Perry1  1Ohio State University,General And Gastrointestinal Surgery,Columbus, OH, USA

Introduction: The ACS-NSQIP Surgical Risk Calculator (ANS-RC) predicts 30-day complication rates for specific surgical procedures. The goal of this study was to assess the accuracy of the ANS-RC for predicting 30-day complication rates in a cohort of patients undergoing laparoscopic paraesophageal hernia repair (LPEHR) in a large academic medical center.

Methods: One hundred seventy-seven patients underwent primary LPEHR between 2011 and 2016 and were included in the study. Using the definitions in the ANS-RC, risk factors and 30-day post-operative complications were obtained for all patients from the electronic medical record. Predicted complication rates were calculated for each patient. Data are presented as incidence (%), mean ± SD, or median (IQ range). Comparisons between predicted and observed complication rates were made using one sample proportion or Wilcoxan paired signed rank tests. A p-value of <0.05 was considered statistically significant.

Results: During the study period, LPEHR was performed for 177 patients with a mean age of 66.2 ± 14.0 years and BMI of 30.2± 6.1 kg/m2. Seventy-three percent (n=156) were female and most patients had an ASA score of 2 (n=47, 26.6%) or 3 (n=122, 68.9%). Compared to the ANS-RC general population, this cohort had higher risks for serious complications (7.0% vs 5.7%), cardiac complication (0.4% vs 0.2%), reoperation (2.3% vs 2.1%), and readmission (6.5% vs 5.2%). Overall, the observed complication rates for any complication (13.6% vs 7.7%, p<0.01), serious complication (11.4% vs 7%, p=0.02), death (1.7% vs 0.3%, p<0.01), reoperation (6.8% vs 2.3%, p<0.01), and readmission (11.3% vs 6.5%, p<0.01) were higher than those predicted by the ANS-RC. The median hospital length of stay (LOS) was significantly shorter than predicted (2 vs 2.5, p<0.01). When stratified for patients with ASA scores of 2 or 3, the calculator more accurately predicted the observed complication rates, although reoperation (p=0.02) for ASA 2, and reoperation (p=0.04), SNF placement (p=0.03) and readmission rates (p=0.04) for ASA 3 were higher than predicted by the ANS-RC. The calculator most accurately predicted complication rates when patients were stratified by age group (<65, 65-79, 80+). Predicted values were lower than observed rates for reoperation in patients <65 (p=0.01) and 65-79 (p<0.01), readmission for patients <65 (p<0.01), and any or serious complications for patients >80 years of age (p=0.01). ANS-RC significantly overestimated LOS for patients <65 (p<0.01) and 65-79 years (p<0.01).

Conclusion: While the ANS-RC provides a useful tool for guiding preoperative discussions, this cohort comprised primarily of elderly patients with significant medical comorbidities had significantly higher than predicted complication rates compared to the general NSQIP population. However, stratifying patients by age and ASA improves the accuracy of the ANS-RC for LPEHR.

17.02 New Onset Alcohol Use Disorder Following Bariatric Surgery

Posted on January 18, 2018

C. Holliday1, M. Sessine1, N. Ibrahim1, M. Alameddine1, J. Brennan1, A. A. Ghaferi1  1University Of Michigan,Ann Arbor, MI, USA

Introduction:

Bariatric surgery is the most effective treatment for morbid obesity; however, there may be significant unanticipated psychosocial effects after surgery. Prior work identified a three-fold increase in the incidence of alcohol use disorder (AUD) after surgery in patients who underwent Roux-en-Y gastric bypass (RYGB). The landscape of bariatric surgery has changed, with sleeve gastrectomy (SG) now comprising over 50% of primary bariatric operations. However, the degree to which patients who undergo SG develop AUD remains unknown. Therefore, we sought to characterize the incidence of AUD in patients who have undergone SG compared to RYGB and potential predisposing patient factors.

Methods:

This study used prospectively collected, patient-reported data from a state-wide quality collaborative. Presence of AUD was determined using the validated Alcohol Use Disorders Identification Test for Consumption (AUDIT-C), with a score ≥4 in men and ≥3 in women suggestive of AUD. We used bivariate chi-square tests for categorical variables and independent samples t-tests for continuous variables. We used multivariable logistic regression to identify patient characteristics that may predispose patients to development of AUD at 1 and 2 years after surgery.

Results:

The prevalence of AUD in all patients who underwent bariatric surgery in our population was 9.6% preoperatively (n=5724), 8.5% at 1 year postoperatively (n=5724), and 14.0% at 2 years postoperatively (n=1381). The preoperative, 1 year, and 2 year prevalence of AUD for SG were 10.1%, 9.0%, and 14.4%, respectively. The preoperative, one year, and two year postoperative prevalence of AUD for RYGB were 7.6%, 6.3%, and 11.9%, respectively. The rate of new onset AUD in the first year following SG and RYGB were 0.75% and 0.54%, respectively. However, in year two, there was a significant increase in the incidence of new onset AUD—8.5% for SG and 7.2% for RYGB (Figure). Predisposing patient factors to AUD development included higher educational level (p<0.01) and higher household income (p<0.01).

Conclusions:

This is the first large, multi-institutional study of AUD in sleeve gastrectomy patients. The prevalence of alcohol use disorder in patients undergoing SG and RYGB was similar pre- and post-operatively. While there was only a slight increase in the incidence of new onset AUD in the first postoperative year, there was a marked increase in new onset AUD in the second year after both SG and RYGB. Understanding the timing and incidence of alcohol use disorder in patients undergoing sleeve gastrectomy—the most commonly performed bariatric operation in the United States—is critical to providing appropriate counseling and treatment. 

16.19 Outcomes and Hospital Resource Utilization in Older Adult Patients After Motor Vehicle Crashes

Posted on January 18, 2018

P. P. Patel1, L. Gryder1, C. McNicoll1, C. Katona1, P. McGrew1, P. Chestovich1, J. Fildes1, D. Kuhls1  1University Of Nevada,Trauma & Critical Care,Las Vegas, NEVADA, USA

Introduction: As the average life expectancy increases, more older adults continue to drive or travel as passengers in motor vehicles. Crashes involving the elderly have worse outcomes compared to younger patients. The purpose of this study is to describe the injury burden, hospital resource utilization (HRU), hospital charges, and disposition incurred by older adult patients after a motor vehicle crash (MVC).

Methods: The Statewide Vehicular Trauma Database was queried for all individuals age ≥65 injured in a MVC from 2005-2014. Patients were stratified by age: 65-74, 75-84, and ≥85. Relevant data include demographics, crash factors, and injury severity score (ISS). Primary outcome was hospital mortality, with secondary outcomes of hospital and ICU length of stay (LOS), hospital charges, and disposition. Analysis was by Chi-squared and Kruskal-Wallis tests, with p<0.05 considered significant.

Results: A total of 2,029 individuals met inclusion criteria. The average age was 75, majority were Caucasian, restrained, and seated in the driver position. Gender distribution was equal. Injury and HRU was significant for a higher average ISS and an increased mean number of hospital and ICU days in the 75-84 age group. Upon nonparametric analysis, the ≥85 group showed significantly increased ISS, hospital and ICU LOS, and hospital charges.  Patients ≥85 were also more likely to die or require disposition to a rehab facility or a nursing home after discharge.

Conclusion: This study demonstrates that although the older adult population is considered a high-risk group, there are significant differences in injury burden, outcomes and HRU within this cohort. Older adults had greater injury severity requiring a higher resource utilization while achieving less desirable outcomes. As the number of older adult trauma patients grows, special attention should be placed on those over age 85 to enhance their recovery after a MVC.

 

16.20 The Influence of Pancreatic Division Technique on Pancreatic Leak Rates Following Traumatic Injury

Posted on January 18, 2018

P. Hu1, R. Uhlich1, J. Kerby1, P. Bosarge1  1University Of Alabama at Birmingham,Acute Care Surgery,Birmingham, Alabama, USA

Introduction:
Pancreatic injury is a rare, potentially devastating consequence of abdominal trauma. While low grade injuries may be successfully managed conservatively, injuries to the pancreatic duct or head typically require operative intervention. Complications following pancreatic resection are historically associated with high rates of morbidity and mortality. We sought to evaluate the influence of intra-operative techniques on postoperative complications.

Methods:
A retrospective case control study was performed at an American College of Surgeons verified level 1 trauma center from 2011-2017. All adult patients admitted to the trauma surgery service were eligible for inclusion, while patients with pregnancy or age <18 years old were excluded. Patients with pancreatic injury were identified from the trauma registry using ICD-10 codes. Pancreatic injuries were graded according to the AAST guidelines (Grades 1-5), with major injury identified as ≥ grade 3 (pancreatic ductal injury). Patients were stratified into cohorts according to the method used for pancreatic division and resection, including stapled, cut and oversewn, stapled and oversewn, or cautery. Pancreatic leak was defined as a drain amylase level three times greater than normal serum amylase (103 U/L), according to institutional standard. Analysis was performed using χ2 and Student's t-test or one-way ANOVA for categorical and continuous variables respectively. The primary outcome of interest was the rate of pancreatic leak following resection. 

Results:

52 patients were identified with pancreatic injury[PLB1] . The majority of patients (90.4%) underwent operative management. Pancreatic resection was required in 40.4% (21/52), with a majority undergoing stapled resection (52.3%). The remaining resections were performed by cut and oversew (14.3%), stapled and oversewn (23.8%), and cautery (9.5%). Pancreatic leak was identified postoperatively in 76.2% (16/21) of patients, with no significant difference between the different types of resection (p=0.27).

 

Conclusion:

Pancreatic injury requiring resection results in significant rates of postoperative leak, regardless of intraoperative technique. Drain placement should be strongly considered at the time of initial operation

16.17 Clinical Outcomes In Patients Requiring Dialysis After Trauma: A National Trauma Database Analysis

Posted on January 18, 2018

A. E. Siletz1, J. Grotts2, C. E. Lewis1, A. Tillou1, H. Cryer1, A. Cheaito1  1University Of California – Los Angeles,Department Of Surgery, David Geffen School Of Medicine At UCLA,Los Angeles, CA, USA 2University Of California – Los Angeles,UCLA Department Of Medicine Statistics Core, David Geffen School Of Medicine At UCLA,Los Angeles, CA, USA

Introduction: AKI requiring renal replacement therapy (RRT) represents the most severe form of post-traumatic AKI, and has been associated with poor outcomes.  Incidence and clinical impact vary by study due to variations in study population and definitions. The objective of this study was to determine the correlation between initiating dialysis and clinical outcomes in trauma patients using a national dataset.  

Methods:  All patients in the National Trauma Database from 2013-2014 with a diagnosis of AKI based on ICD9 code during admission for trauma were reviewed. Patients were excluded if they had no signs of life on arrival, were under age 18, or had pre-existing end-stage renal disease. A propensity score based on ISS, penetrating injury, age, and gender was used to match patients with AKI requiring dialysis with those with AKI who did not need dialysis.  A multivariate logistic regression model using dialysis, ISS, injury type, age, and gender as covariates was also constructed. 

Results: Among adult patients surviving to admission for trauma without pre-existing end-stage renal disease, the incidence of AKI was 1.07%  and the incidence of AKI requiring dialysis was 0.02%.  17668 trauma patients with AKI, of which 282 received dialysis, were compared.  Older age, male gender, black/African American race and Medicare and Medicaid coverage were significantly associated with dialysis (p<0.02). Penetrating injury was more likely to be associated with dialysis than blunt injury (OR 3, 95% CI 2.3-4, p<0.001) and dialysis patients had higher median ISS scores (26.5, IQR 18-35.2 vs. 17, IQR 9-29, p <0.001).  When patients were matched using a propensity score based on ISS, penetrating injury, and age, dialysis patients were found to have higher complication rates including unplanned intubation (OR 3, 95% CI 1.6-5.6, p <0.001), unplanned return to the operating room (OR 7.3, 95% CI 3.8-14, p <0.001), acute lung injury/acute respiratory distress syndrome (OR 4.7, 95% CI 3-7.3, p <0.001), pulmonary embolism (OR 3.1, 95% CI 1.3-7.2, p =0.013), severe sepsis (OR 11.3, 95% CI 6.4-19.9, p <0.001), myocardial infarction (OR 4, 95% CI 1.5-10.7, p =0.009), and death (OR 3.8, 95% CI 2.7-5.2, p <0.001).  Median hospital stay (27 vs. 8 days, p <0.001), ICU stay (19 v. 5 days, p < 0.001), and number of ventilator days (16 vs 5 days (p < 0.001) were significantly higher for dialysis patients.  In a multivariate logistic regression model, initiating dialysis was significantly associated with development of acute respiratory distress syndrome (OR 4.8, 95% CI 3.1-7.6, p < 0.001), severe sepsis (OR 12.2, 95% CI 7.0-22.2, p < 0.001), and mortality (OR 4.0, 95% CI 2.9-5.6, p<0.001).

Conclusion: 

AKI requiring dialysis after trauma is rare. Risk factors include high ISS and penetrating injury.  The need for dialysis after AKI during admission for trauma is associated with increased complications, length of hospital stay, and mortality. 

 

16.18 Current Nutritional Practices and Associated Outcomes in Critically-Ill Trauma Patients

Posted on January 18, 2018

B. E. Haac1, R. Van Besien1, R. Jenkins1, A. Geyer2, J. Diaz1, D. Stein1  1University Of Maryland,R Adams Cowley Shock Trauma Cener,Baltimore, MD, USA 2Air Force Institute Of Technology (AFIT/ENC),Wright-Patterson AFB, OHIO, USA

Introduction: Nutrition is an important component of support for critically-ill trauma patients who often present in a state of catabolic stress but there is limited recent research on this topic specific to trauma patients. We sought to examine nutritional practices in a critically-ill trauma population and to identify baseline factors and outcomes associated with timing, content and route of nutrition.

Methods:  We conducted a retrospective review of adult critically-ill trauma patients admitted to the intensive care unit (ICU) for >72 hours. A multivariable regression model was built for each nutritional variable and outcome variable. Outcomes evaluated include number of operative trips, hospital and ICU length of stay (LOS), ventilator days, mortality, discharge destination and hospital-acquired infections.

Results: 683 patients (mean ISS 24.4) were included. 461 patients received tube feeds within the first 7 days of admission. Two-thirds (n=297, 64%) of these were initiated on early enteral tube feeding within 48 hours. Injury pattern was associated with timing of nutrition initiation, time to goal tube feed rate and percent of goal calories and protein received. Specifically, severe head injury (brain AIS=5) was independently associated with reaching a goal tube feed rate (aOR 3.1, P<0.01) and receiving a greater percent of goal calories (aOR 2.1, p=0.01) in the first 48 hours of admission whereas patients without head injury (brain AIS=0) were less likely to initiate nutrition within 24 hours of admission (aOR 0.3, p<0.01). Higher admission GCS was also associated with decreased odds of reaching goal tube feeds within 24 hours (aOR 0.6, p<0.01). Later initiation of enteral nutrition after 48 hours was associated with increased ICU LOS (aOR 1.4, p<0.01) and more ventilator days (aOR 1.6, p<0.01) in all patients and increased pneumonia rates in patients who required gastrointestional (GI) surgery for their injury (aOR 15.7, p=0.02). Increased percent of goal nutrition received in the first 48 hours was associated with more ventilator days (aOR 2.8, p<0.01) and longer ICU LOS (aOR 1.7, p<0.01). Increased percent of goal nutrition received in the first 7 days was associated with development of urinary tract infection (UTI) (aOR 5.4, p<0.01). Gastric tube feeds were associated with lower bacteremia incidence (aOR=0.4, p=0.01) and longer ICU LOS (aOR 1.2, p<0.01). There was no association of nutrition variables with mortality.

Conclusion: Injury pattern, especially presence of brain injury, may be predictive of ability to initiate early enteral nutrition, time to goal feeds and percent of goal nutrition received. Benefits of early initiation may include decreased LOS and ventilator days and reduced pneumonia rates in patients requiring GI surgery. Trophic feeds may be less likely to result in UTI, and gastric feeds may have a protective role in prevention of bacteremia.

 

16.14 Thyroid Trauma − Incidence, Mortality, and Concomitant Injury

Posted on January 18, 2018

D. Spencer1, A. Grigorian1, S. Schubl1, K. Awad1, D. Elfenbein1, T. Dogar1, J. Nahmias1  1University Of California – Irvine,Division Of Trauma, Burns & Surgical Critical Care,Orange, CA, USA

Introduction:  Traumatic injury to the thyroid is rare with no large studies previously published. Although the thyroid is not considered an immediately vital structure, it is in close proximity to several critical structures such as the carotid arteries, trachea, esophagus, and cervical spine. We sought to describe the national incidence of traumatic thyroid injury as well as mortality rate, rate of operative intervention, and frequencies of concomitant injury to surrounding structures. We hypothesized isolated thyroid injury would have a lower mortality compared to thyroid with concomitant carotid artery, trachea, esophagus or cervical spine injury.

Methods:  National Trauma Data Bank data from 2007-2015 was used to identify patients with thyroid injury. Demographics, associated injuries, operative repair, complications, and outcomes were analyzed. Analysis was performed by odds ratio utilizing a logistic regression model.

Results: 1,395 patients with thyroid injury were identified from over 6.7 million trauma patients. Yearly incidence was 0.02%. The majority of patients were female (79.6%), had a penetrating mechanism of injury (79.7%), and had isolated thyroid injury (59.7%). The most common concomitant injuries were to the trachea (25.9%), carotid artery (9.5%), and cervical spine (7.9%). Operative interventions most frequently performed were direct thyroid repair (13.9%), thyroid blood vessel repair (3.4%), and thyroidectomy (3.2%). No patients experienced postsurgical hypothyroidism. All-cause mortality was 15.6%. After controlling for age  ≥  65, ISS > 25, and gender, non-isolated thyroid injury was shown to be an independent risk factor for mortality when compared to isolated thyroid injury (Odds Ratio 1.67, 95% Confidence Interval 1.17 – 2.34; p<0.05).

Conclusion: Thyroid injury in trauma patients is extremely rare. Interestingly, thyroid trauma is seen more often in females than males. Isolated thyroid trauma presents less of a clinical challenge with a lower risk of mortality than those with concomitant injuries even after controlling for significant covariates. When operative intervention is required, direct thyroid repair is greater than four times more common than thyroidectomy. Regardless of injury type and operation, postsurgical hypothyroidism was not seen.

16.15 Using Injury Severity Score to Determine Venous Thromboembolism Risk in Trauma Patients

Posted on January 18, 2018

T. E. Hereford1, S. Ray1, R. D. Robertson1, M. K. Kimbrough1  1University Of Arkansas For Medical Sciences,Little Rock, AR, USA

Introduction:
Venous thromboembolisms (VTEs) continue to be a leading cause of death among trauma patients. Predicting which patients will develop a VTE can be difficult. This study investigated whether the Injury Severity Score (ISS) could be used in conjunction with the Abbreviated Injury Score (AIS) to assess a trauma patient’s risk for subsequent VTE development. 

Methods:
Participants were found by querying a trauma center registry. There were 2,213 patients included for evaluation. The patients were categorized based on their ISS and the anatomical region with the greatest injury (determined by the AIS). Odds ratios for developing VTEs were calculated for each ISS category. 

Results:
The results showed that in most categories VTE risk increased as ISS increased. Patients with trauma to their head/neck, chest, or extremities with ISS values of 21 or greater were at significantly increased risk for VTE development. Patients in these categories with an ISS less than 21 seemed to have little or only moderately increased odds of developing a VTE, although these values were not statistically significant. Patients with abdominal trauma were at increased risk even with ISS values of 11-21. 

Conclusion:
Trauma to the head/neck region, chest, and extremities (including pelvis) with Injury Severity Scores of 21 or higher had significantly increased odds of developing a VTE. Patients with abdominal trauma of any severity appeared to have increased odds of developing a VTE. Physicians should be aware of patients that fall into these categories and consider whether the risks of developing a VTE outweigh the risk of prophylactic treatment. 
 

16.16 Diminished Physiologic Reserve Predicts Mortality in the Underweight Following Hemorrhagic Shock

Posted on January 18, 2018

J. O. Hwabejire1, B. Adesibikan1, T. A. Oyetunji2, O. Omole1, C. E. Nembhard1, M. Williams1, E. E. Cornwell III1, W. R. Greene3  1Howard University College Of Medicine,Surgery,Washington, DC, USA 2Children’s Mercy Hospital- University Of Missouri Kansas City,Surgery,Kansas City, MO, USA 3Emory University School Of Medicine,Atlanta, GA, USA

Introduction:  We have previously demonstrated that extremes of body mass index (BMI) are associated with poor outcomes following blunt traumatic hemorrhagic shock. In this study, we examined the risk factors for mortality in underweight patients following blunt trauma.

Methods:  The Glue Grant database was retrospectively analyzed. Patients with BMI <18.5 kg/m2 who met criteria for hemorrhagic shock after blunt trauma were included. Survivors were compared to non-survivors using univariate analysis. Multivariable analysis was used to determine predictors of mortality.

Results: There were 102 patients who met criteria for inclusion in the study. Their mean age was 46 years (SD=20), with 62% being males, 89% Whites and 5% black. Mortality in this cohort was 52.9%, compared to 16.0 % in all comers and 14.3 % in patients with a normal BMI. Amongst the underweight, there was no differences in age, multiple organ dysfunction score, or emergency room (ER) shock index or pre-injury comorbidities between survivors and non-survivors. Compared to survivors, non-survivors were hypotensive in the ER (systolic BP: 110 ±27 vs. 87±38 mmHg, p=0.001), had higher ER lactate (7.1 ±4.1 vs. 4.1 ±2.5 mg/dL, p<0.001), were more coagulopathic (ER INR: 1.92 ±1.91 vs. 1.24±0.30, p=0.026 ), had higher APACHE II score (35±6 vs. 28±7, p<0.001), higher injury severity score, ISS (35±13 vs. 27±11, p=0.002), received more crystalloids (12696±6550 vs. 9796±4964 mL, p=0.014), and more blood (6070±4912 vs. 2240±3658 mL, p<0.001) within 12 hours of presentation.  When only patients with ISS >25 were compared, non-survivors were still more likely to be hypotensive (ER SBP: 112 ±28 vs. 87±36 mmHg, p=0.004), acidotic (ER lactate: 7.4 ±4.4 vs. 4.4 ±3.0 mg/dL, p=0.006), received more blood 6174±4926 vs. 3024±4612 mL, p=0.011) and had a higher APACHE II score (35±6 vs. 29±5, p<0.001). In the multivariate analysis, after adjusting for ISS, the only independent predictor of mortality was the APACHE II score (OR: 1.35, CI 1.08-1.1.69, p=0.009). 

Conclusion: The Acute Physiologic and Chronic Health Evaluation (APACHE) II score independently predicts mortality in the underweight after blunt traumatic hemorrhagic shock. Underweight patients appear to lack the physiologic reserve to tolerate severe trauma.

 

16.11 When We Take the Time to Look: Completion Angiography After Major Vascular Injury Repair

Posted on January 18, 2018

S. A. Moore1, J. P. Hazelton3, Z. Maher2, B. L. Frank4, J. W. Cannon1, D. N. Holena1, N. D. Martin1, A. Goldenberg-Sandau3, M. J. Seamon1  4Geisinger Health System,General Surgery,Scranton, PA, USA 1University Of Pennsylvania,Division Of Traumatology, Surgical Critical Care And Emergency Surgery,Philadelphia, PA, USA 2Temple University,Division Of Trauma & Surgical Critical Care,Philadelphia, PA, USA 3Cooper University Hospital,Division Of Trauma Surgery,Camden, NJ, USA

Introduction: Despite the operative vascular trauma advances achieved over the past several decades, these challenging injuries still result in significant morbidity and mortality.  Completion angiography (CA) immediately following repair of major vascular injury (MVI) has been advocated to limit adverse outcomes, but adequate data supporting or refuting this practice is lacking.  We hypothesized that CA after operative MVI repair identifies unsatisfactory repairs requiring intraoperative revision.  

Methods: A multi-center, retrospective cohort study of consecutive patients with operative MVI was conducted at 3 urban, Level-I centers (2005-2013).  Patients (≥15 years) with MVI of the neck, torso, or extremities (proximal to elbows/knees) requiring operative management were included.  Demographics, clinical variables and revision risk factors were analyzed with respect to our primary study endpoint, intraoperative revision following CA.  Secondary endpoints included outcomes after MVI repair.

Results: Of the 435 patients identified in the study, the majority were young (mean = 31 years) male (89%) patients with penetrating (84%) trauma.  Patients who underwent CA after repair (n= 128) were compared to patients who did not (n=303).  Although patients sustaining blunt injuries with associated fractures were both more likely to undergo CA (p<0.01), no differences with respect to age, gender, Injury Severity Score (ISS), initial systolic blood pressure, transfusion requirement and operating surgeon subspecialty were detected between study groups (all p<0.05).  Completion angiography study group patients were then more likely to undergo immediate intraoperative revision than those who did not undergo CA (CA, 21/128 [16.4%] vs. no CA, 4/303 [1.3%]; p<0.01, Figure 1).  Importantly, there were no differences in fasciotomy, delayed revision, arterial patency at discharge, or limb salvage rates between study comparison groups.

Conclusion: CA after operative repair led to intraoperative revision in 16% of MVI patients.  These data suggest that all patients undergoing operative MVI repair should undergo CA, as this additional diagnostic adjunct may prevent later adverse outcomes caused by unsatisfactory repairs.

 

16.13 Could Retained Bullet Fragments Be a Significant Source of Blood Lead Levels in Trauma Patients?

Posted on January 18, 2018

S. A. Eidelson1, C. A. Karcutskie1, A. B. Padiadpu1, M. B. Mulder1, S. K. Madiraju1, G. D. Garcia1, G. D. Pust1, N. Namias1, C. I. Schulman1, K. G. Proctor1  1University Of Miami,Miami, FL, USA

Introduction:
On Feb 17, 2017, the CDC reported that retained bullet fragments (RBF) may be a source of elevated blood lead levels (BLL) in those with no other known exposure.  This conclusion was based on voluntary reports of BLL>10 µg/dl to the CDC’s National Institute for Occupational Safety and Health. Roughly 75,000 non-fatal firearm injuries occur annually in the United States and routine screening for BLL is rarely performed. Thus, the incidence and magnitude of BLLs from RBF are unknown, but the CDC reports that any measurable BLL is unsafe.  We test the hypothesis that BLLs are elevated in trauma patients with RBF.

Methods:
BLL were measured in 23 consecutive adult patients with imaging-proven RBF admitted to an American College of Surgeon’s verified level 1 trauma center from 2/15/17-7/16/17. BLL is considered elevated at >5 μg/dL.  Data are expressed as mean±standard deviation if parametric and median if nonparametric.   Differences are assessed at p<0.05.

Results:
The study population is 95.7% male, 33±15 yrs, 25±4 kg/m2, and 70% African American. Of twenty-three patients with RBF, 35.0% (n=8) were found to have elevated blood lead levels and 74.0% (n=17) were found to have measureable lead levels. 

Conclusion:

These preliminary data provide basic proof of concept that measurable BLL occur in over half of trauma patients with RBF, regardless of days exposed.  Potential deleterious effects include impaired renal function with BLL <5 μg/dL, an increased risk for hypertension and essential tremor with BLL between 5-10 μg/dL, and neurocognitive deficits and adverse reproductive outcomes (including spontaneous abortion and reduced birthweight) with BLL ≥10 μg/dL.  Thus, patients with RBF may benefit from precautionary counseling on lead poisoning and the importance of baseline and periodic monitoring. Moving forward, there may also be a potential benefit of surgical retrieval.   

 

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