81.08 Modified Metabolic Syndrome is Associated with Poor Access Outcomes Following EVR.

Posted on January 31, 2019

M. D. Balceniuk1, P. Zhao1, L. Cybulski1, M. C. Stoner1  1University Of Rochester,Division Of Vascular Surgery,Rochester, NY, USA

Introduction:
Metabolic syndrome (MetS) is a constellation of five clinical and laboratory findings associated with adverse cardiovascular outcomes as well as wound healing outcomes. MetS has also been reported to be associated with type 2 endoleak following endovascular aneurysm repair (EVR). We report impact of modified metabolic syndrome (mMetS) on groin access complications following EVR.

Methods:
The Vascular Quality Initiative (VQI) endovascular aortic repair module 2008-2016 was evaluated. MetS classification was modified based on the variables available within the VQI registry. Patients were considered to have mMetS (study group) if they had all three diagnosis of body mass index (BMI) >30, hypertension and diabetes. Patients missing one or more of these diagnoses were placed in the non-mMetS (control group) group. Access site complications were evaluated between patients with mMetS and those without.

Results:
Over 30,000 patients were included in the analysis, with over 3000 patients met the criteria for mMetS (Table). The non-metabolic group were significantly older and had higher rates of females and white race. The mMetS cohort had higher rates of coronary artery disease, chronic obstructive pulmonary disease and congestive heart failure. Groups were similar regarding access type for percutaneous (65% versus 65%, p=0.987).  Surgical site infections (SSI) were significantly higher in the mMetS group (24 (0.783%) vs 87 (0.317%), p?0.001), whereas no difference was noted for access site hematoma between groups.  Additionally, sub-group regression analysis of the mMetS cohort identified open access type to be a significant predictor of post-operative SSI (p=0.028).

Conclusion:
Our data demonstrates that there is a significantly higher rate of SSI in patients with mMetS following EVR. We have also shown that percutaneous access in patients with modified metabolic syndrome significantly reduced the incidence of post-operative SSI. These data suggest that percutaneous access should be attempted in EVR patients with metabolic syndrome to mitigate the risk of open femoral access SSI.
 

81.07 Transfemoral Carotid Artery Stenting Is Inferior To Carotid Endarterectomy In The Community

Posted on January 31, 2019

J. Nicklas1, J. Albright1, E. Jerzual1, A. Obi1, P. Henke1  1University Of Michigan,Vascular Surgery,Ann Arbor, MI, USA

Introduction: The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) suggested that there was no significant difference between carotid endarterectomy (CEA) and transfemoral carotid artery stenting (CAS) in the endpoint of major adverse cardiovascular events (MACE) including stroke, myocardial infarction, or death but a 2 fold increased risk of stroke with CAS. Limited reports exist in real world hospital outcomes for these procedures.

Methods: 11,290 patients (pts) who underwent CEA and 2,391 pts who underwent CAS in 34 hospitals between 1/3/2012 and 2/28/2018 were assessed for baseline demographics, anatomical variables, medications, and major outcomes, at 30 days. Statistical modeling was done with univariable and multivariable analysis for stroke and MACE.

Results: Demographics in CREST and our population were similar in age (69 vs 70 years), gender (65% vs 60% male), and race (93% vs 93% white). However, in our population, the 30-day incidence of MACE among pts undergoing CEA vs CAS was 2.8% (n=321) vs 5.9%, (n=141), p<0.001 and the incidence of stroke was 2.8% in CEA (n=309) vs 4.4% in CAS (n=105), p<0.001. After multivariable adjustment, CAS was associated with increased stroke risk – (OR = 1.323; 95% confidence interval = 1.018, 1.718, P = .036) and MACE- (1.261; 1.004, 1.584, P = .046) as compared with CEA.
Preoperative risk factors for stroke after CEA included: female gender – (1.33; 1.06-1.67), non-ambulatory status – (1.54; 1.17-2.02), contralateral carotid artery occlusion – (2.19; 1.51-3.17), restenosis of a prior CEA (2.22; 1.21-4.07), prior stroke (2.33; 1.56-3.17), and restenosis of a prior CAS (3.85; 1.31-11.34). Significant perioperative risks of stroke include: non-patch closure – (1.44; 1.03-2.02) and eversion CEA technique – (1.50; 1.02-2.22). 30-day MACE analysis showed that the use of a shunt – (1.28; 1.03-1.59) and renal failure requiring dialysis – (2.44; 1.25-4.74) increased the risk.
Preoperative risk factors for stroke after CAS included: low BMI – (1.06; 1.03-1.10), lack of anemia – (1.56; 1.05-2.57), diabetes – (2.18; 1.43-3.32), and non-white race – (2.25; 1.23-4.10). Significant perioperative risks include: increased operative time – (1.55; 1.23-1.95), embolic protection failure – (1.85; 1.01-3.39), and tracheostomy – (10.35; 1.72-62.33). 30-day MACE factors also included: advanced age – (1.024; 1.01-1.04), lack of Ace/ARB medications – (1.51; 1.05-2.15), >=2 coronary arteries >70% obstructed – (2.60; 1.28-5.27), and left main stenosis >50% – OR 2.84 (1.16-6.91).

Conclusion: Our large multi-hospital real world practice registry suggests that CEA in community practice is associated with better outcomes than transfemoral CAS, and diverges from the CREST results. Differential factors were associated with CEA and CAS risks for stroke and MACE.

 

81.06 Does Kidney Transplant Increase the Risk of Ipsilateral Lower Extremity Deep Venous Thrombosis?

Posted on January 31, 2019

S. Ahmed1, D. Kim2, Z. Al Adas1, M. Weaver1, J. Lin2, T. Nypaver1, A. Shepard1, L. Malinzak2, L. S. Kabbani1  1Henry Ford Health System,Department Of Vascular Surgery,Detroit, MI, USA 2Henry Ford Health System,Department Of Transplant Surgery,Detroit, MI, USA

Introduction:

There is limited information on the development and laterality of symptomatic deep vein thrombosis (DVT) following kidney transplantation. In this study, we want define the incidence of DVT in this population and determine if the side of the DVT corresponds to the side of the transplanted kidney.

Methods:

We performed a retrospective review of all kidney transplant recipients from January, 2004 to August, 2014 at our institution and who subsequently developed symptomatic DVT. Kidney transplant recipients and confirmed DVT patients were obtained as two separate data files and were matched to obtain our cohort. Patients with concomitant pancreatic transplants, repeat, and bilateral kidney transplants were excluded. We used Cohen’s kappa statistic to test the agreement between the surgical incision site of the kidney transplant to the side at which the DVT occurred.

Results:

A total of 1827 kidney transplant recipients were performed between January 2004 to August 2014. A total of 877 kidney transplant recipients met the inclusion criteria as our total cohort. From our total cohort, 217 recipients underwent ultrasounds to rule out DVT. A total of 41 kidney transplant patients received a positive duplex ultrasound. The incidence of DVT in our kidney transplant cohort was 4.7%. The most common period of DVT diagnosis was in the perioperative period within the first 4 weeks. A Cohen kappa statistic of -0.02 occurred between the surgical incision site of the kidney transplant and the side of DVT occurrence. Large positive kappa statistic values indicate agreement, whereas large negative values indicate disagreement. Approximately 64.6% of transplant patients with a positive duplex ultrasound had a 1:1 correlation to the side of DVT, although this did not reach statistical significance. There was no statistically significant difference in patient sex, race, or age between the two groups.

Conclusion:

The incidence of symptomatic DVT in this cohort was 4.7%, which is lower than that reported in the literature. DVT was highest during the first four weeks postoperatively. There was an increased rate of ipsilateral DVTs to the kidney transplant, although this did not reach statistical significance. ?

 

81.05 New 5-Factor Frailty Index Can Predict Outcomes in Patients Undergoing Endovascular Aneurysm Repair

Posted on January 31, 2019

V. Pandit1, M. Zeeshan1, S. Jhajj1, A. Lee1, K. R. Goshima1, C. Weinkauf1, W. Zhou1, T. Tan1  1University Of Arizona,Department Of Surgery,Tucson, AZ, USA

Introduction:
The modified frailty index (mFI-11) is a NSQIP-based 11-factor index that has been proven to adequately reflect frailty and predict mortality and morbidity. In past years, certain NSQIP variables have been removed from the database; as of 2015, only 5 of the original 11 factors remained. The predictive power and usefulness of these 5 factors in an index (mFI-5) have not been proven in patients undergoing endovascular repair (EVAR) of abdominal aortic aneurysm (AAA). The goal of our study was to compare the mFI-5 to the mFI-11 in terms of value and predictive ability for mortality, postoperative infection, and unplanned 30-day readmission.

Methods:
The mFI was calculated by dividing the number of factors present for a patient by the number of available factors for which there were no missing data. Spearman's rho test was used to assess correlation between the mFI-5 and mFI-11. Predictive models, using both unadjusted and adjusted logistic regressions, were created for each outcome for EVAR using 2005-2012 NSQIP data, the last year all mFI-11 variables existed.

Results:
A total of 14,387 patients were included. Mean age was 71.6±6.5. Overall, 22.1% patients were frail. A total of 24.1% had in-hospital complications, while 4.9% patients died. Correlation between the mFI-5 and mFI-11 was above 0.9 across all outcomes for patients undergoing EVAR. Adjusted and unadjusted models showed similar c-statistics for mFI-5 and mFI-11, and strong predictive ability for mortality, postoperative complications and 30-days readmission (Table 1).

Conclusion:
The mFI-5 and the mFI-11 are equally effective predictors of postoperative outcomes in patients undergoing endovascular aneurysm repair of abdominal aortic aneurysm and the mFI-5 is a strong predictor of postoperative complications, mortality and 30-d readmission. It has credibility for future use to study frailty within the NSQIP database. It also has potential in other databases and for clinical use.
 

81.04 Is Non-ruptured AAA Repair Still a Worthwhile Solution for Nonagenarians?

Posted on January 31, 2019

L. A. Huntress3, J. Kalenik2, V. Dombrovskiy3, S. G. Huang3, R. Shafritz3, S. Rahimi3  2University of Georgia,Athens, GA, USA 3Rutgers RWJMS,Division Of Vascular Surgery,New Brunswick, NJ, USA

Introduction:  The practicality of non-ruptured abdominal aortic aneurysm (AAA) repair in patients aged 90 and above (90+) remains in question.  This study assessed the short-term outcomes of elective endovascular aortic repair (EVAR), and compared them between patients aged 90+ and patients aged 80-89.

Methods: The National Inpatient Sample (NIS) was queried from 2012-2015, and patients aged 80 and above who had undergone elective EVAR were identified. Postoperative complications, hospital mortality, hospital length of stay, and total hospital cost in patients aged 90+ were compared to those aged 80-89 using Chi square test; multivariable logistic regression analysis controlled for age, gender, race, comorbidities, and hospital characteristics; and Wilcoxon rank sum test. Total hospital cost was adjusted to 2015 U.S. dollars.

Results: A total of 26,115 patients were estimated: 24,210 (92.7%) aged 80-89 and 1,905 (7.3%) aged 90+. Compared to octogenarians, patients aged 90+ were more likely to develop postoperative cardiac complications (OR [odds ratio]=1.68; 95%CI [confidence interval] 1.29-2.18), stroke (OR=3.19; 95%CI 1.59-6.39), urinary tract infection (OR=1.39; 95%CI 1.06-1.82), and bleeding (OR=1.41; 95%CI 1.23-1.62), the last of which required more blood transfusions (OR=1.31; 95%CI 1.14-1.52). However, hospital mortality did not differ among both age groups, and no differences in mortality among various races or genders were observed. At the same time, mortality overall in urban teaching and non-teaching hospitals was lower than in rural hospitals (OR=0.37; 95%CI 0.22-0.62 and OR=0.43; 95%CI 0.25-0.74, respectively). Hospital length of stay (median= 2 days, IQR [interquartile range] 1-3 days in both groups) and total hospital cost (median= $27,950; IQR $21,193-36,079 in octogenarians vs median= $27,203; IQR $20,436-36,332 in nonagenarians; P=0.47) did not differ between the two age groups

Conclusion: Although patients aged 90+ are at an increased risk of some postoperative complications following elective EVAR, hospital mortality and hospital resource utilization in this group of patients are not greater than in octogenarians. Elective EVAR should be considered in nonagenarians with non-ruptured abdominal aortic aneurysm.

 

81.03 Hepatoportal Venous Trauma: Analysis of Incidence, Morbidity and Mortality

Posted on January 31, 2019

S. Maithel1, A. Grigorian1, N. Kabutey1, B. Sheehan1, S. Gambhir1, J. Nahmias1  1University Of California – Irvine,Surgery,Orange, CA, USA

Introduction:

Traumatic injuries to the superior mesenteric, portal and hepatic veins are rare with an incidence of roughly 0.1%. However, the mortality rates are high ranging from 45-52.7% for superior mesenteric vein (SMV), 50-70% for portal vein (PV), and 50-100% for hepatic vein (HV) injuries in small previous single center reports. We hypothesize that SMV injury is associated with lower risk of mortality compared to HV and PV injury in adult trauma patients.

Methods:

The Trauma Quality Improvement Program database (2010-2016) was queried for patients with injury to either the SMV, PV, or HV. A multivariable logistic regression model was used for analysis.

Results:

From 1,403,466 patients, 509 patients had SMV injury, 357 patients had PV injury and 255 patients had HV injury. Compared to patients with PV and HV injuries, patients with SMV injuries were older (39 years vs 29 years, p<0.01), had lower injury severity score (25 vs 26, p<0.01), and a lower percentage of severe (grade >3) abbreviated injury scale for abdomen (57.6% vs 72.3%, p<0.01). A higher percentage of SMV injuries were from blunt mechanism compared to portal and hepatic vein injury (60.3% vs 48.1%, p<0.01). Patients with a SMV injury had a longer length of stay (9 days vs 6 days, p=0.01), higher rates of concurrent bowel resection (38.1% vs 9.9%, p<0.01), and lower mortality (36% vs 47.9%, p<0.01) compared to patients with PV and HV injuries. However, after controlling for covariates, traumatic SMV injury increased risk of mortality (OR 2.37, CI=1.55-3.62, p<0.001) in adult trauma patients as did PV injury (OR 3.74, CI=2.29-6.12, p<0.001) and HV injury (OR 3.44, CI=1.95-6.07, p<0.001).

Conclusion:

Traumatic SMV injury is associated with a lower rate of mortality compared to injuries of the HV and PV. SMV injury greater than doubles the risk of mortality in adult trauma patients, whereas HV injury more than triples the risk and portal vein injury nearly quadruples the risk of mortality.

 

81.02 Image Based 3D CT Decreases Radiation Exposure During Fenestrated Endovascular Aortic Aneurysm Repair

Posted on January 31, 2019

H. Weissler1, K. Southerland1, S. Nag1, C. Long1, B. Gilmore1, M. Turner1, L. Olivere1, M. Cox1, C. Shortell1  1Duke University Medical Center,Vascular Surgery,Durham, NC, USA

Introduction: Fenestrated endovascular aortic aneurysm repair (FEVAR) has expanded the benefits of endovascular aortic aneurysm repair (EVAR) to a population of patients who would have otherwise been anatomically unfit for endovascular repair.  However, FEVAR is associated with high radiation doses and contrast loads due to its increased complexity.  Three-dimensional (3D) fusion computed tomography (CT) merges the preoperative CT with intraoperative imaging to create a vascular mask and has been shown to decrease radiation and contrast use during FEVAR.  Currently available 3D fusion systems use hardware-based (i.e. operating table) tracking to position the overlay on the fluoroscopic image.  This is labor intensive and often leads to inaccurate overlays.  Our institution recently implemented a novel, cloud-based 3D fusion system which uses the patient’s vertebral anatomy rather than the operating table to register and create the overlay.  This system has been shown in prior studies to be highly accurate and decrease radiation dose required for EVAR. The purpose of this study was to determine if radiation dose reduction during FEVAR would occur with this new 3D fusion strategy.

Methods:
Our institutional database was reviewed to identify patients who underwent elective FEVAR.  Patients treated using our cloud-based 3D fusion software CT were compared to patients treated in the immediate 6 months prior to the implementation of 3D fusion CT.  Primary end points included patient radiation exposure (mGy), contrast use (mL), and fluoroscopy and procedure times (minutes).

Results:
Thirty-three patients underwent FEVAR from October 2016 through June 2018, twenty prior to implementation of 3D fusion CT and thirteen after. There was no difference between these groups regarding demographics, BMI  or comorbidities. Radiation dose was significantly decreased following 3D fusion CT implementation (5735 ± 2651 mGy versus 3503 ± 2422 mGy, p=0.019).  In addition, there was a significant decrease in the number of FEVARs requiring a high radiation dose (> 2Gy) with 3D fusion CT (9 vs 19, p=0.044).  There was no difference in fluoroscopy time (72.7 ± 16.9 minutes versus 62.9 ± 15.1 minutes, p=0.061), procedure time (257.6 ± 100.1 minutes versus 213.3 ± 41.1 minutes, p=0.118) and contrast volume (94.5 ± 34.7 mL versus 72.8  ± 37.8 mL, p=0.168) between the two groups.

Conclusions:
These results demonstrate that the use of an intraoperative image-based 3D fusion CT strategy based on the patient’s vertebral anatomy rather than hardware can significantly decrease radiation exposure during FEVAR.  Endovascular solutions to aortic pathology will undoubtedly continue to expand; therefore radiation safety will be paramount.  Image based 3D fusion CT has the potential to improve clinical and safety outcomes for both patients and providers.

 

81.01 Incidence and Risk Factors Associated with Ulcer Recurrence among Patients with Diabetic Foot Ulcers

Posted on January 31, 2019

C. J. Abularrage1, J. K. Canner2, N. Mathioudakis3, C. Lippincott4, R. L. Sherman1, C. W. Hicks1  1The Johns Hopkins University School Of Medicine,Division Of Vascular Surgery And Endovascular Therapy,Baltimore, MD, USA 2The Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA 3The Johns Hopkins University School Of Medicine,Division Of Endocrinology And Metabolism,Baltimore, MD, USA 4The Johns Hopkins University School Of Medicine,Division Of Infectious Diseases,Baltimore, MD, USA

Introduction:

Recent studies demonstrate favorable diabetic foot ulcer (DFU) healing outcomes with the implementation of a multidisciplinary team. However, the long-term outcomes of this approach to DFU care are unknown. We aimed to describe the incidence of and risk factors associated with ulcer recurrence after initial complete healing among a cohort of DFU patients treated in a multidisciplinary setting.

Methods:
All patients presenting to our multidisciplinary diabetic limb preservation service from 6/2012-04/2018 were enrolled in a prospective database. Wounds were classified according to the SVS-WIfI at initial presentation. The incidence of ulcer recurrence after complete wound healing was assessed per limb using the Kaplan Meier method, and a stepwise multivariable Cox proportional hazards model was created to identify independent predictors of ulcer recurrence.

Results:
A total of 244 patients with 304 affected limbs were included. Mean age was 59.2±3.8 years, 62.7% of patients were male, and 61.9% were black. Nearly all (95.1%) of patients has loss of protective sensation, with abnormal proprioception in 23.9%. Ulcer recurrence occurred in 38.5% of limbs at a mean time of 310±30 days. Only 12.8% of recurrent ulcers occurred at the same site as the initial wound. Ulcer recurrence rates at one- and three-years post-healing were 30.6±3.0% and 64.4±5.2%, respectively (Figure), and did not significantly differ by the WIfI stage of the initial wound (P=.34). Recurrent ulcers were smaller (4.4±1.1cm2 vs. 8.2±1.2cm2; P=0.04) and had a lower WIfI stage (stage 4: 7.7% vs. 22.4%; P<0.001) than initial ulcers. Time from ulcer onset to assessment was lower for recurrent ulcers (0.9±0.3 vs. 2.4±0.2 months; P<0.001), and wound healing time was significantly reduced (95.0±9.8 vs. 131.8±7.0 days; P=0.004).  Independent predictors of ulcer recurrence included abnormal proprioception [HR 1.57 (95%CI 1.02-4.43); P=.04] and younger age [HR 1.02 per year (95%CI 1.01-1.04). Patient race, BMI, socioeconomic status, comorbidities, blood sugar control (hemoglobin A1c), and wound location were not independently associated with ulcer recurrence.

Conclusion:
In this prospective cohort of diabetic foot ulcer patients, ulcer recurrence occurred in nearly two-thirds of limbs within three years. Importantly, time to diagnosis and healing was significantly lower for recurrent ulcers, and downstaging was common. These data suggest that engaging DFU patients in a multidisciplinary care model with frequent follow-up and focused patient education may serve to decrease DFU morbidity.

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.

79.10 The Impact of Medicaid Expansion on Utilization of Vascular Procedures and Rates of Amputation

Posted on January 31, 2019

K. G. Bennett1, M. E. Smith1, N. F. Matusko1, J. F. Waljee1, N. H. Osborne1, P. K. Henke1  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction:
In 2001, the state of New York expanded Medicaid coverage, providing access to care for thousands of previously uninsured patients. Although these policy changes can enhance the opportunity for obtaining care, little is known regarding care utilization, especially amongst patients with vascular disease and critical limb ischemia for whom access to procedures may prevent limb loss. We sought to measure the impact of Medicaid expansion on the rates of total vascular procedures, open procedures, endovascular procedures, and amputations.

Methods:
We examined discharge records from the 1998-2006 State Inpatient Databases of New York (intervention) and Arizona (control). Discharge records of interest were identified using ICD-9 vascular procedure codes. To measure the impact of Medicaid expansion on the rates of total vascular, open vascular, and endovascular procedures, as well as amputations, we used a difference-in-difference analysis to compare the number of procedures performed per admission within each state. We used logistic regression, truncated poisson, and zero-inflated poisson regression to model each outcome while adjusting for relevant patient covariates.

Results:
In this cohort of 112,624 patients undergoing vascular procedures, the difference-in-difference estimator demonstrated that expansion of Medicaid coverage was associated with lower odds of mortality (OR 0.77, p=0.043), but this became insignificant after controlling for patient-level covariates (OR 0.92, p=0.5). The difference-in-difference estimators also demonstrated that Medicaid expansion was associated with lower incidence rate ratios of total vascular procedures (IRR 0.65, p<0.001) and open vascular procedures (IRR 0.92, p=0.002), but a higher incidence rate ratio of endovascular procedures (IRR 1.13, p<0.001). There was no change in the incidence rate ratio of amputations (IRR 1.02, p=0.53). In patients with critical limb ischemia (N =12,668), the difference-in-difference estimators were also significant, demonstrating that expansion was associated with a lower incidence rate ratio of total procedures (IRR 0.59, p<0.001) and endovascular procedures (IRR 0.59, p<0.001) but a higher incidence rate ratio of amputations (IRR 1.43, p=0.001) and higher odds of mortality (OR 2.21, p=0.032).

Conclusion:
After Medicaid expansion, the rates of total vascular procedures decreased, with no impact on amputations rates in New York. Moreover, the utilization of interventions that could prevent amputations in patients with critical limb ischemia did not increase. Thus, while Medicaid expansion may improve access to care, significant barriers and disparities continue to prevent appropriate utilization of limb-saving procedures.
 

79.09 Elderly Patients With Cervical Spine Fractures Following Ground Level Falls are at Risk for BCVI

Posted on January 31, 2019

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

Introduction:
Osteopenia is common in the elderly, increasing their risk of sustaining cervical fractures after ground level falls (GLF). Neck CTA is used to screen for Blunt Cerebrovascular Injuries (BCVI) after high cervical (C) spine fractures. We sought to examine the incidence of BCVI and subsequent stroke in elderly GLF patients as compared to other higher injury mechanisms.

Methods:

The Trauma Quality Improvement Program database (2011-2016) was used to identify blunt trauma patients with isolated (other body region AIS <3) high C spine (C1- C4) fractures. Patients were stratified into three groups: non-elderly patients (<65) with all mechanisms of injury, elderly patients (≥ 65) with GLF, and elderly patients with all other mechanisms of injury. Demographics and outcomes were compared. Multivariable logistic regression was used to determine predictors for BCVI, stroke, and mortality. Secondary outcomes included rates of spinal cord injury (SCI) and acute kidney injury (AKI), given risk for contrast exposure.

Results:

17,558 patients with high C spine injuries were identified. 50.2% involved patients ≥ 65. BCVI was highest in the < 65 group (0.8%) and lowest in elderly patients with GLF (0.3%, p = .001). When controlling for other factors, elderly patients with GLF were less likely to sustain BCVI (AOR 0.46, p = .03) but had comparable rates of stroke attributable to BCVI (15.4% vs. 9.5%, p= .685), compared to elderly patients with other mechanisms of injury. There was no significant difference in mortality (AOR 1.08, p = .34). SCI was less common (AOR 0.78, p = .002) in elderly patients with GLF. AKI was more common in elderly patients (0.9% vs. 0.5%, p = .002).

Conclusion:
In elderly patients with isolated C spine fracture after GLF, BCVI occurs less frequently, but is associated with a comparable rate of stroke as compared to other mechanisms.  Low injury mechanism should not preclude BCVI screening in the presence of high C spine fractures.
 

79.08 Using Myoglobin as Serum Marker in Administering Renal Protective Therapy in Electrical Burn Patients

Posted on January 31, 2019

J. H. Henderson1, P. Attaluri1, E. He1, J. Kesey1, M. Tan1, J. Griswold1  1Texas Tech University School of Medicine,Department Of Surgery,Lubbock, TEXAS, USA

Intro: Electrical high-voltage contact injuries are the second leading cause of occupational death in the U.S. The electrical surge encounters muscle cells, causing sudden and intense myocyte contraction, releasing intracellular contents such as myoglobin and creatine kinase (CK). The released pigments cause obstruction of renal tubules leading to acute renal failure. Currently, the trauma literature supports use of elevated serum CK to indicate muscle and renal damage. While CK can be a reliable screening method for muscle injury, we believe myoglobin is a more sensitive and specific indicator of risk and severity of renal damage. Our study aims to determine whether elevated CK or elevated myoglobin is more sensitive in predicting the risk of renal injury for electrical burn patients and to define parameters of serum myoglobin for implementing renal protective therapies.

Methods: A retrospective, single institution review was conducted on all patients over the age of 18 years who suffered a high voltage electrical injury (>1,000 volts) admitted to the Burn Center from 2006 to 2017. Patients who had preexisting end stage renal disease, were on dialysis, or died within 48 hours of admission were excluded. Chi-Square Testing was used to compare means in serum myoglobin and serum CK levels collected daily and acute kidney injury (AKI) as defined by the RIFLE criteria, which breaks AKI into three categories Risk, Injury, and Failure. Urine output and fluid resuscitation therapies were collected daily to track the progression of AKI. A Pearson product-moment correlation coefficient was computed to assess the relationship between AKI and serum myoglobin and serum CK. An independent sample mean's test was performed on patients who developed AKI to determine a serum myoglobin threshold for initiation of treatment.

Results: A total of 207 patients were analyzed 2006-2017; 27.1% of patients developed AKI as defined by RIFLE criteria. Mean serum myoglobin in patients with AKI was found to be 2,336.9 vs. no AKI 1,140.14 (P=0.0001). Mean serum CK level in patients with AKI was found to be 10,926 vs. no AKI 8,174 (P=0.132). There was a positive correlation between serum myoglobin levels and developing AKI (r = 0.212, n = 120, p = 0.02), whereas there was no statistically significant correlation between serum CK levels and AKI. Patients with myoglobin level 1,449.52 or above are at high risk of developing AKI (P=0.053) and require renal protective measure.

Conclusion: Serum myoglobin is a more sensitive marker for predicting AKI when compared to serum CK in high-voltage electrical burns. A serum myoglobin threshold of >1500 was associated with increased risk of AKI, indicating the need to start renal protective therapies. Although trauma and rhabdomyolysis patients’ CK may be useful for indication of risk of renal damage, in electrical contact injuries myoglobin must be used to determine risk of renal damage and to direct renal protective therapy.

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