Outcomes of balloon-expandable versus self-expandable stent graft for endovascular repair of iliac aneurysms using iliac branch endoprosthesis.

PURPOSE: The purpose of this study was to compare outcomes of internal iliac artery (IIA) stenting using balloon-expandable (BESG) or self-expandable stent grafts (SESG) during endovascular repair of aortoiliac aneurysms with iliac branch endoprosthesis (IBE; W. L. Gore, Flagstaff, Ariz). METHODS: We retrospectively reviewed all consecutive patients treated for aortoiliac aneurysms using IBE between 2014 and 2020. IIA stenting was performed using either the IIA side branch SESG or a Gore VBX BESG (W. L. Gore). Indications for use of BESGs were "up-and-over" IBE technique for type IB endoleak after prior endovascular aortic aneurysm repair (EVAR), short IIA length, and need for IIA extension into divisional branches (outside instructions for use). End points included technical success, freedom from buttock claudication, primary IIA patency, and freedom from IIA branch instability (eg, branch-related death or rupture, occlusion, disconnection, or reintervention for stenosis, kink, or endoleak), freedom from type IC/IIIC endoleak, and freedom from secondary interventions. RESULTS: There were 90 patients (86 males and 4 females) with a mean age of 74 ± 7 years treated by EVAR with 108 IBEs. Choice of stent was BESG in 43 and SESG in 65 targeted IIAs. BESGs were used more frequently in patients with prior EVAR (22% vs 2%; P = .003,), isolated IBEs (31% vs 2%; P < .001), and in patients with IIA aneurysms requiring stenting into divisional branches (36% vs 5%; P < .001). Technical success was similar for BESGs and SESGs (97% vs 100%; P = .40), respectively. The mean follow-up was 25 ± 16 months (range, 11-34 months). At 2 years, freedom from buttock claudication was 100% for BESG and 95 ± 3% for SESG (Log-rank 0.26), with no difference in primary patency (BESG, 100% vs SESG, 94 ± 4%; Log-rank 0.94). There were four (9%) IIA-related endoleaks in the BESG group and one (2%) in the SESG group (P = .08). Freedom from IIA branch instability was 87 ± 6% for BESG and 96 ± 3% for SESG at 2 years (Log-rank 0.043). Freedom from type IC/IIIC endoleak was 87 ± 7% for BESG and 98 ± 2% for SESG at the same interval (Log-rank 0.06). There was no difference in freedom from reinterventions for BESG and SESG (92 ± 6% vs 98 ± 2%; Log-rank 0.34), respectively. CONCLUSIONS: BESGs were used more frequently during IBE procedures indicated for failed EVAR, isolated common iliac aneurysms, and IIA aneurysms requiring extension into divisional branches. Despite these differences and BESG being used outside instructions for use, both stent types had similar primary patency, freedom from buttock claudication, and freedom from reinterventions. However, BESGs were associated with higher rates of IIA-related branch instability.

Staged total arch replacement, followed by fenestrated-branched endovascular aortic repair, for patients with mega aortic syndrome.

OBJECTIVE: The aim of the present study was to review the clinical outcomes of a staged approach using total arch replacement (TAR) with an elephant trunk or a frozen elephant trunk, followed by fenestrated-branched endovascular aortic repair (F-BEVAR) for patients with mega aortic syndrome. METHODS: We reviewed the clinical data and outcomes of 11 consecutive patients (8 men; mean age, 71 ± 7 years) treated by staged TAR and F-BEVAR from January 2014 to December 2018. The F-BEVAR procedures were performed under a prospective, nonrandomized, physician-sponsored investigational device exemption protocol. All patients had had mega aortic syndrome, defined by an ascending aorta, arch, and extent I-II thoracoabdominal aortic aneurysm. The endpoints were 30-day mortality, major adverse events (MAE), patient survival, freedom from reintervention, and freedom from target vessel instability. RESULTS: Of the 11 patients, 6 had developed chronic postdissection aneurysms after previous Stanford A (three A11, two A10, one A9) dissection repair and 5 had had degenerative aneurysms with no suitable landing zone in the aortic arch. The thoracoabdominal aortic aneurysms were classified as extent I in four patients and extent II in seven. One patient had died within 30 days after TAR (9.0%). However, none of the remaining 10 patients who had undergone F-BEVAR had died. First-stage TAR resulted in MAE in three patients (27%), including one spinal cord injury. The mean length of stay was 12 ± 6 days. The mean interval between TAR and F-BEVAR was 245 ± 138 days with no aneurysm rupture during the interval. Second-stage F-BEVAR was associated with MAE in two patients (20%), including spinal cord injury in one patient from spinal hematoma due to placement of a cerebrospinal fluid drain. The mean follow-up period was 14 ± 10 months. At 2 years postoperatively, patient survival, primary patency, secondary patency, and freedom from renal-mesenteric target vessel instability was 80% ± 9%, 94% ± 6%, 100%, and 86% ± 8%, respectively. No aortic-related deaths occurred during the follow-up period. Four patients had required reintervention, all performed using an endovascular approach. CONCLUSIONS: A staged approach to treatment of mega aortic syndrome using TAR and F-BEVAR is a feasible alternative for selected high-risk patients. Larger clinical experience and longer follow-up are needed.

Two-Stage Redo Aortic Arch Repair in a Patient With an Isolated Left Vertebral Artery.

A 47-year-old male presented with an enlarging distal aortic arch false lumen 6 months status post ascending and hemiarch replacement with antegrade endograft insertion for acute type A aortic dissection complicated by lower body malperfusion. Preoperative computed tomographic angiography showed an isolated but dominant left vertebral artery. A 2-stage open surgical repair was performed. First, the left subclavian artery was transposed on the common carotid and vertebral onto the subclavian. At the second stage, a redo total arch reconstruction was done with bypass grafts taken to the innominate and left common carotid arteries. The patient did well postoperatively.

Techniques and outcomes of total aortic arch repair with frozen elephant trunk for DeBakey I dissections.

Total aortic arch replacement (TAR) with frozen elephant trunk (FET) technique (FET) has been increasingly used to treat a variety of aortic pathologies over the past two decades. Because FET can effectively treat the diseased arch and cover the proximal entry tear in the distal arch, it is a valuable option in the treatment of DeBakey I aortic dissections. This report focuses on the techniques and outcomes of TAR with FET for acute/chronic aortic dissection. A review of pooled literature including 27 observational studies showed in-hospital mortality, permanent stroke, and spinal cord injury rates of 8.4%, 5.9% and 2.6% for acute aortic dissections, and 7.5%, 4.0% and 4.6% for chronic aortic dissections, respectively. In most of the studies, complete false lumen thrombosis rate was achieved in 80% of patients at the level of FET for acute and chronic aortic dissections. Mid-term outcomes are equally promising. For chronic aortic dissections, positive remodeling of the non-stented distal aortic segments is less frequent leading to secondary reinterventions within 3 to 5 years. However, most studies have not applied distal abdominal extensions of the repair using fenestrated and branched endografts. In the current endovascular era, TAR + FET should be considered as an alternative to conventional open surgical repair in centers of excellence.

Outcomes after splenectomy in children: a 48-year population-based study.

PURPOSE: In children who have undergone splenectomy, there may be impaired immunologic function and an increased risk of infection. We aimed to define the long-term rate of and risk factors for post-splenectomy infection using a population-based cohort study. METHODS: All children (< 18 years) who underwent splenectomy from 1966 to 2011 in Olmsted County, MN were identified using the Rochester Epidemiology Project (REP). Descriptive statistics, Kaplan-Meier estimates, and Cox Proportional hazard ratios were performed to evaluate for risk factors associated with developing infection. RESULTS: Ninety patients underwent splenectomy and 46% were female. Indications included trauma (42%), benign hematologic disease (33%), malignancy (13%), and other (11%). Most were performed open. Vaccination was completed in (72%) for pneumococcal, H. influenza, and meningococcal vectors. Nineteen patients developed infection, and associated factors included non-traumatic, non-malignant disease [HR 4.83 (1.18-19.85)], and performance of multiple surgical procedures [HR 2.80 (1.09-7.21)]. Estimated survival free of infection rates at 15 and 20 years following surgery was both 97%. CONCLUSIONS: After splenectomy in children, most patients do not develop infection. Nearly three-quarters of patients were vaccinated with the lowest rates in patients that underwent a splenectomy for trauma. In patients who received multiple procedures during a splenectomy, the infection risk was higher.

Prehospital Transfusion for Gastrointestinal Bleeding.

OBJECTIVE: Gastrointestinal (GI) bleeding is a common medical emergency with significant morbidity and mortality. Many patients are coagulopathic, which may perpetuate bleeding. Remote damage control resuscitation, including early correction of coagulopathy and anemia, may benefit exsanguinating patients with GI bleeding. METHODS: We conducted a retrospective review of patients with acute GI bleeding who received packed red blood cells (pRBC) and/or plasma during transportation to our institution between 2010 and 2014. A comparison group of patients who were not transfused en route was selected, and demographics, outcomes, and response to resuscitation were compared. RESULTS: A total of 112 patients with GI bleeding received pRBC (82%, n = 92 pRBC, mean 1.7 ± 0.9 units), plasma (62%, n = 69, mean 1.7 ± 0.8 units) or both (44%, n = 49) en-route. The comparison group comprised 49 patients transported by helicopter who were not transfused en-route. Demographics, crystalloid resuscitation, transfusion prior to transfer, rate of intervention, ICU days, length of stay, and mortality were similar between groups. Patients transfused en route had a significant increase in hemoglobin from 8.3 ± 2.2 to 8.9 ± 2.1 (P = .03) and decrease in INR from 2.0 ± 1.0 to 1.6 ± 1.4 (P = .01), whereas those not transfused en route experienced stable hemoglobin (8.7 ± 2.8 to 9.4 ± 2.5; P = .21) and INR values (1.9 ± 1.0 to 1.6 ± 1.4; P = .32). Both groups had a significant improvement in hemodynamic parameters with resuscitation. CONCLUSION: Prehospital damage control resuscitation with pRBC and/or plasma resulted in the improvement of hemodynamic instability, coagulopathy and anemia in patients with acute GI bleeding. Almost all patients required additional inpatient interventions and/or transfusions, suggesting that pre-hospital transfusion is being utilized for appropriately selected patients.

Obese Patients Undergoing Ileal Pouch-Anal Anastomosis: Short-and Long-term Surgical Outcomes.

BACKGROUND: Ileal pouch-anal anastomosis (IPAA) is the preferred surgical treatment for patients with chronic ulcerative colitis. Little is known about the impact of obesity on operative characteristics, short-term postoperative complications and long-term functional outcomes after IPAA. METHODS: A retrospective review of all patients undergoing IPAA for chronic ulcerative colitis at a single tertiary referral center between January 2002 and August 2013 was performed. Thirty-day postoperative complications and long-term functional outcomes were analyzed according to body mass index. RESULTS: Nine hundred nine IPAAs (154 obese [body mass index ≥ 30] and 755 not obese [body mass index < 30]) were performed during the study period. For 2-stage IPAA, obese patients were less likely to undergo laparoscopic IPAA (P < 0.0001), had greater estimated blood loss (P = 0.005), and longer operative times (P = 0.02). For 3-stage IPAA, obese patients were less likely to undergo a laparoscopic procedure (P = 0.03), had greater estimated blood loss (P < 0.0001), and longer operative times (P = 0.0002). Postoperatively, obese patients had a longer length of stay after a 2-stage procedure (P = 0.009), an increased rate of superficial surgical site infections (P = 0.003), and an increased rate of urinary tract infections (P = 0.03). Of the 61% (n = 546) of patients with IPAA with long-term (median 5.0 years) follow-up, there were no significant differences in functional outcomes including incontinence, frequency of bowel movements, pad usage, and pouchitis between the groups. CONCLUSIONS: Obesity impacts intraoperative complexity and 30-day postoperative outcomes. Long-term functional outcomes are not affected. These findings underscore the need to counsel patients on preoperative weight loss before undergoing elective IPAA.

Surgical Fires and Operative Burns: Lessons Learned From a 33-Year Review of Medical Litigation.

OBJECTIVE: We aimed to understand the setting and litigation outcomes of surgical fires and operative burns. METHODS: Westlaw, an online legal research data-set, was utilized. Data were collected on patient, procedure, and case characteristics. RESULTS: One hundred thirty-nine cases were identified; 114 (82%) operative burns and 25 (18%) surgical fires. Median plaintiff (patient) age was 46 (IQR:28-59). Most common site of operative burn was the face (26% [n = 36]). Most common source of injury was a high energy device (43% [n = 52]). Death was reported in 2 (1.4%) cases. Plaintiff age <18 vs age 18-50 and mention of a non-surgical physician as a defendant both were shown to be independently associated with an award payout (OR = 4.90 [95% CI, 1.23-25.45]; p = .02) and (OR = 4.50 [95% CI, 1.63-13.63]; p = .003) respectively. Plaintiff award payment (settlement or plaintiff verdict) was reported in 83 (60%) cases; median award payout was $215,000 (IQR: $82,000-$518,000). CONCLUSION: High energy devices remain as the most common cause of injury. Understanding and addressing pitfalls in operative care may mitigate errors and potentially lessen future liability. LEVEL OF EVIDENCE: III.

Impact of BMI on Ability to Successfully Create an IPAA.

BACKGROUND: IPAA is the surgical treatment of choice for patients with ulcerative colitis. Limited data exist on how obesity impacts the ability of the surgeon to successfully create an IPAA. OBJECTIVE: We aimed to determine how BMI affects the ability to successfully complete the operation. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted at a single tertiary care center. PATIENTS: We included all of the patients undergoing an IPAA for ulcerative colitis between January 2002 and August 2013 at our institution. A total of 1175 patients underwent proctocolectomy for ulcerative colitis during the study period; 129 were not offered IPAA (reasons included patient preference (n = 53), advanced age/comorbidity (n = 28), obesity (n = 23), incontinence (n = 8), suspicion of Crohn's disease (n = 8), rectal cancer (n = 3), and other (n = 6)). Twenty-six patients had a concurrent cancer diagnosis, and 5 had a polyposis syndrome. MAIN OUTCOME MEASURES: We used logistic regression modeling to estimate the association between BMI and unsuccessful pouch attempts. RESULTS: Of the 1046 patients offered IPAA, 19 (1.82%) could not be technically completed at the time of surgery. Increasing BMI was associated with a higher risk of not being able to technically perform IPAA (OR = 1.26 (95% CI, 1.17-1.34)). The chance of an unsuccessful pouch rose from 2.0% at a BMI of 30 to 5.7% at a BMI of 35 and 15.0% at a BMI of 40 (p < 0.01). The area under the receiver operator characteristics curve was 0.82. BMI explained 21% of the variation in pouch success rate. LIMITATIONS: This study is limited in its generalizability. Also, the verbosity within the operative dictations varied among surgeons, making it impossible to be certain which maneuvers were performed to gain length in each patient. In addition, we were limited to BMI as a surrogate for visceral obesity, and we did not include medical therapy at the time of IPAA attempt. CONCLUSIONS: There is a strong association between increasing BMI and the ability to technically perform IPAA. Obese patients should be counseled to lose weight preoperatively to increase the probability of successful IPAA construction at the time of operation.

Validation of the anatomic severity score developed by the American Association for the Surgery of Trauma in small bowel obstruction.

BACKGROUND: The anatomic severity schema for small bowel obstruction (SBO) has been described by the American Association for the Surgery of Trauma (AAST). Although acknowledging the importance of physiological and comorbid parameters, these factors were not included in the developed system. Thus, we sought to validate the AAST-SBO scoring system and evaluate the effect of adding patient's physiology and comorbidity on the prediction for the proposed system. METHODS: Patients aged ≥18 y who were treated for SBO at our institution between 2009 and 2012 were identified. The physiology and comorbidity as well as the AAST anatomic scores were determined, squared, and added to calculate the score that we termed Acute General Emergency Surgical Severity-Small Bowel Obstruction (AGESS-SBO). The area under the receiver operating characteristic (AUROC) curve analyses were performed for the AAST anatomic score and compared with the AGESS-SBO score as a predictor for inhospital mortality, extended hospital stay, and inhospital complications. RESULTS: A total of 351 patients with mean age of 66 ± 17 years were identified, of whom 145 (41%) underwent operation to treat bowel obstruction. Extended hospital stay (>9 d) occurred in 86 patients (25%), inhospital complications in 73 (21%), and inhospital mortality in eight patients (2%). The median (interquartile range [IQR]) AAST anatomic score was 1 point (IQR: 1-2), physiology score was 0 point (IQR: 0-1), and comorbidity score was 1 point (IQR: 1-3); for overall median AGESS-SBO score of 5 points (IQR: 3-13). The AUROC curve analyses demonstrated that the AGESS-SBO system with measures of presenting physiology, comorbidities in addition to AAST anatomic criteria could be beneficial in predicting key outcomes including inhospital mortality (AUROC curve: 0.80 versus 0.54, P = 0.03). CONCLUSIONS: The AAST anatomic score is a reliable system, which assists care providers to categorize SBO. Adding physiology and comorbidity parameters to the described anatomic criteria can be helpful in predicting the outcomes including mortality. Further studies evaluating its usefulness in research and quality improvement purposes across institutions are still required.

Long-term outcomes of gastrografin in small bowel obstruction.

BACKGROUND: The gastrografin (GG) challenge is a diagnostic and therapeutic tool used to treat patients with small bowel obstruction (SBO); however, long-term data on SBO recurrence after the GG challenge remain limited. We hypothesized that patients treated with GG would have the same long-term recurrence as those treated before the implementation of the GG challenge protocol. METHODS: Patients ≥18 years who were treated for SBO between July 2009 and December 2012 were identified. We excluded patients with contraindications to the GG challenge (i.e., signs of strangulation), patients having SBO within 6-wk of previous abdominal or pelvic surgery and patients with malignant SBO. All patients had been followed a minimum of 1 y or until death. Kaplan-Meier method and Cox regression models were used to describe the time-dependent outcomes. RESULTS: A total of 202 patients were identified of whom 114 (56%) received the challenge. Mean patients age was 66 y (range, 19-99 y) with 110 being female (54%). A total of 184 patients (91%) were followed minimum of 1 year or death (18 patients lost to follow-up). Median follow-up of living patients was 3 y (range, 1-5 y). During follow-up, 50 patients (25%) experienced SBO recurrences, and 24 (12%) had exploration for SBO recurrence. The 3-year cumulative rate of SBO recurrence in patients who received the GG was 30% (95% confidence interval [CI], 21%-42%) compared to 27% (95% CI, 18%-38%) for those who did not (P = 0.4). The 3-year cumulative rate of exploration for SBO recurrence in patients who received the GG was 15% (95% CI, 8%-26%) compared to 12 % (95% CI, 6%-22%) for those who did not (P = 0.6). CONCLUSIONS: The GG challenge is a clinically useful tool in treating SBO patients with comparable long-term recurrence rates compared to traditional management of SBO.

Botulinum toxin A-induced paralysis of the lateral abdominal wall after damage-control laparotomy: A multi-institutional, prospective, randomized, placebo-controlled pilot study.

BACKGROUND: Damage-control laparotomy (DCL) is a lifesaving operation used in critically ill patients; however, interval primary fascial closure remains a challenge. We hypothesized that flaccid paralysis of the lateral abdominal wall musculature induced by botulinum toxin A (BTX) would improve rates of primary fascial closure, decrease duration of hospital stay, and enhance pain control. METHODS: Consenting adults who had undergone a DCL at two institutions were prospectively randomized to receive ultrasound-guided injections of their external oblique, internal oblique, and transversus abdominus muscles with either BTX (150 mL, 2 U/mL) or placebo (150-mL 0.9% NaCl). Patients were excluded if they had a body mass index of greater than 50, remained unstable or coagulopathic, were home O2 dependent, or had an existing neuromuscular disorder. Outcomes were assessed in a double-blinded manner. Univariate and Kaplan-Meier estimates of cumulative probability of abdominal closure were performed. RESULTS: We randomized 46 patients (24 BTX, 22 placebo). There were no significant differences in demographics, comorbidities, and physiologic status. Injections were performed on average 1.8 ± 2.8 days (range, 0-14 days) after DCL. The 10-day cumulative probability of primary fascial closure was similar between groups: 96% for BTX (95% confidence interval [CI], 72-99%) and 93% for placebo (95% CI, 61-99%) (HR, 1.0; 95% CI, 0.5-1.8). No difference between BTX and placebo groups was observed for hospital length of stay (37 days vs. 26 days, p = 0.30) or intensive care unit length of stay (17 days vs. 11 days, p = 0.27). There was no difference in median morphine equivalents following DCL. The overall complication rate was similar (63% vs. 68%, p = 0.69), with two deaths in the placebo group and none in the BTX group. No BTX or injection procedure complications were observed. CONCLUSION: The use of BTX after DCL was safe but did not seem to affect primary fascial closure, hospital length of stay, or pain modulation after DCL. Given higher-than-expected rates of primary fascial closure, Type II error may have occurred. LEVEL OF EVIDENCE: Therapeutic study, level III.

A prospective analysis of urinary tract infections among elderly trauma patients.

BACKGROUND: Catheter-associated urinary tract infections (CAUTIs) have been deemed "reasonably preventable" by the Centers for Medicare and Medicaid, thereby eliminating reimbursement. Elderly trauma patients, however, are at high risk for developing urinary tract infections (UTIs) given their extensive comorbidities, immobilization, and environmental changes in the urine, which provide the ideal environment for bacterial overgrowth. Whether these patients develop CAUTI as a complication of their hospitalization or have asymptomatic bacteriuria (ASB) or UTI at admission must be determined to justify the "reasonably preventable" classification. We hypothesize that a significant proportion of elderly patients will present with ASB or UTI at admission. METHODS: Institutional review board permission was obtained to perform a prospective, observational clinical trial of all elderly (≥65 years) patients admitted to our Level I trauma center as a result of injury. Urinalysis (UA) and culture (UCx) were obtained at admission, 72 hours, and, if diagnosed with UTI, at 2 weeks after injury. Mean cost of UTI was calculated based on Centers for Disease Control and Prevention estimates of $862 to $1,007 per UTI. RESULTS: Of 201 eligible patients, 129 agreed to participate (64%). Mean (SD) age was 81 (8.6) years. All patients had a blunt mechanism of injury (76% falls), with a mean Injury Severity Score (ISS) of 13.8 (7.6). Of the 18 patients (14%) diagnosed with CAUTI, 14 (78%) were present at admission. In addition, there were 18 patients (14%) with ASB at admission. The most common bacterial species present at admission urine culture were Escherichia coli (24%) and Enterococcus (16%). Clinical features associated with bacteriuria at admission included a history of UTI, positive Gram stain result, abnormal microscopy, and pyuria. The estimated loss of reimbursement for 18 UTIs at admission was $15,516 to $18,126; however, given an estimated cost of $1,981 to screen all patients with UA and UCx at admission, up to $16,144 savings was realized. CONCLUSION: Many elderly trauma patients present with UTI. Screening UA and UCx at admission for elderly trauma patients identifies these UTIs and is cost-effective. LEVEL OF EVIDENCE: Epidemiologic study, level II.

Early postoperative small bowel obstruction: open vs laparoscopic.

BACKGROUND: The window for safe reoperation in early postoperative (<6 weeks) small bowel obstruction (ESBO) is short and intimately dependent on elapsed time from the initial operation. Laparoscopic procedures create fewer inflammatory changes than open laparotomies. We hypothesize that it is safer to reoperate for ESBO after laparoscopic procedures than open. METHODS: Review of patients who underwent re-exploration for ESBO from 2003 to 2009 was performed. Based on the initial operation, patients were classified as "open" or "laparoscopic." The Revised Accordion Severity Grading System was used to define complications as minor (1 to 2) or severe (3 to 6). RESULTS: There were 189 patients identified (age 55 years, 48% male): 130 open and 59 laparoscopic. Adhesive disease was more common (65% vs 42%, P < .01), while strictures were less frequent (5% vs 14% P = .03), in the open group. The open group had a greater rate of malignancy, days to re-exploration, and severity of complications. There was no difference in the rates of minor complications, enterotomy, and mortality. ESBO after laparoscopic surgery was more commonly caused by a focal source (85% vs 63%). Eighty-three patients (64 open, 19 laparoscopic) underwent re-exploration at or beyond 14 days. Within this subgroup, there were more severe complications (25% vs 5%) after open procedures with equivalent mortality (4% vs 0%). CONCLUSIONS: Laparoscopic approaches confer a lower rate of adhesive disease and severity of complications in early SBO as compared with open surgery even if performed after 2 weeks of index procedure.

Successful laparoscopic cholecystectomy after percutaneous cholecystostomy tube placement.

BACKGROUND: Interval cholecystectomy (IC) after percutaneous cholecystostomy tube (PCT) placement is the definitive treatment for cholecystitis in patients who are operative candidates after optimization of medical comorbidities. It is not clear, however, which patients will be able to have a laparoscopic IC after PCT placement. We aimed to identify factors associated with successful laparoscopic IC in these patients. METHODS: This is a retrospective review of patients who had a PCT from 2009 to 2011. Patient's baseline demographics, clinical data, and outcomes were analyzed. Univariable and multivariable comparisons were performed between patients who did and did not undergo IC. A subgroup analysis of patients who had laparoscopic IC and open IC was performed. Data are presented as percentages, medians with interquartile ranges (IQRs), or odds ratios with 95% confidence interval as appropriate. RESULTS: A total of 245 patients had PCT placement, with a median age of 71 years (IQR, 59-80 years); 63% were male, of whom 72 (29%) underwent IC. The median time from PCT placement to IC was 55 days (IQR, 42-75 days). IC patients had a lower Charlson Comorbidity Index (5 [4-6] vs. 6 [4-8], p = 0.005) at the time of PCT placement. When controlling for other factors, lower Charlson Comorbidity Index and fewer previous abdominal operations were associated with performance of IC. Laparoscopic surgery was planned for 89% of the patients and completed successfully in 78%. The only factor associated with successful laparoscopic IC was fewer previous abdominal operations. CONCLUSION: Patients who have been medically optimized following PCT can undergo laparoscopic IC with a high rate of success. The degree of illness at the time of PCT placement did not seem to influence the rate of success of laparoscopic IC. LEVEL OF EVIDENCE: Therapeutic/care management study, level III.

Is the Centers for Medicare and Medicaid Service's lack of reimbursement for postoperative urinary tract infections in elderly emergency surgery patients justified?

BACKGROUND: Urinary tract infections, a risk factor for readmission, have been deemed a potentially preventable problem and, therefore, not reimbursable by the Centers for Medicare and Medicaid Services since 2008. Defining the risk factors for development of urinary tract infection in the postoperative period will provide risk stratification for development of urinary tract infection in these challenging patients. METHODS: Pre-, intra-, and postoperative characteristics were collected for patients ≥65 years who underwent an emergency abdominal operation from the 2005 to 2012 National Surgical Quality Improvement Program Participant User File, a database of 374 participating hospitals. In-hospital urinary tract infections occurring within 30 days of the operation were identified. Multivariable logistic regression analysis was conducted to identify risk factors of urinary tract infection. RESULTS: In total, 53,879 patients were included, 1,881 (3.5%) of whom were diagnosed with a postoperative urinary tract infection before discharge. In-hospital urinary tract infection was associated with a longer hospital stay (27 vs 13 days, P < .001) and greater 30-day mortality rates (18% vs 16%, P = .003). The rate of urinary tract infection decreased from 4.5% before the Centers for Medicare and Medicaid Services decree to 3.2% thereafter (P < .001). Multivariable logistic regression demonstrated advanced age, female sex, insulin-dependent diabetes mellitus, dependent functional status, open wound, hypoalbuminemia, increased American Society of Anesthesiologists class, operative approach, and prolonged operative time were independent risk factors for development of postoperative urinary tract infection. CONCLUSION: Although postoperative rates of urinary tract infection decreased after the Centers for Medicare and Medicaid Services decree, the lack of reimbursement is not justified, as few modifiable risk factors to further improve postoperative urinary tract infection rates in elderly emergency surgical patients were identified. Although targeted interventions may be developed, this complication is not easily preventable and will continue to plague acute care surgeons taking care of this challenging patient population.

Endoscopy in the early postoperative setting after primary gastrointestinal anastomosis.

INTRODUCTION: Gastrointestinal anastomoses may require early evaluation and treatment via flexible endoscopic techniques when complications arise. There is reticence, however, to perform endoscopy given the applied mechanical forces. We aimed to identify the incidence of gastrointestinal anastomotic perforation or disruption resulting from endoscopy performed ≤6 weeks of anastomoses. METHODS: Review of patients from 2002 to 2013 who underwent flexible endoscopy within 6 weeks of creation of gastrointestinal anastomosis. Exclusion criteria included intraoperative endoscopy, anastomotic perforation prior to endoscopy, and endoscopy remote from the anastomotic site. Data are presented as median (interquartile range; IQR) or percentages as appropriate. RESULTS: Twenty-four patients met our criteria (age 69 years [IQR 54-77], 54% men]). Endoscopy was performed at a median postoperative time of 18 days (IQR 8-30). Indications for endoscopy included bleeding (66%), obstruction (13%), pain (13%), concern for pancreatic duct leak (4%), and concern for ischemia (4%). Six patients underwent therapeutic endoscopic procedures including coagulation (8%), balloon dilation (8%), tube decompression (8%), and stent placement (4%). There were no anastomotic perforations or disruptions as a result of endoscopy. CONCLUSION: Despite theoretical risks of adverse events of flexible endoscopy in the early postoperative period, no endoscopic perforations or disruptions occurred in recently created surgical anastomoses.

Low tissue oxygen saturation is associated with requirements for transfusion in the rural trauma population.

BACKGROUND: Tissue O2 saturation (StO2) is a measure of tissue perfusion and should decrease during active hemorrhage. An initial StO2 value upon trauma center arrival measured concurrently with or prior to vitals, may predict hemorrhagic shock, requiring early blood product transfusion. Our aim was to identify the early StO2 threshold associated with a greater volume of packed red blood cell (PRBC) transfusion 24 h after injury. METHODS: All highest tier triage trauma patients from January 2011 to July 2012 were included in this study. The initial StO2 value upon arrival was used for comparison. RESULTS: A total of 632 patients were considered, 74% of them male with a mean age of 46 years. Initial StO2 values were available for 325 patients. An StO2 value of 65% was determined as the cutoff due to the marked increase in PRBC consumption in 24 h. There were 23 patients (7%) with an StO2 reading <65% compared to 302 patients with values ≥65%. Both groups had similar systolic blood pressure (118 vs. 126) and heart rate (99 vs. 95) in the trauma bay. In addition, there was no difference in the initial hemoglobin, pH, or base deficit. An early StO2 value <65% also led to a greater number of PRBC transfused in 24 h (6.4 vs. 1.7). Regression analysis demonstrated that an StO2 <65% was the only variable associated with a higher PRBC transfusion volume in 24 h (p = 0.01). CONCLUSIONS: An StO2 value <65% correlates with greater requirement for PRBC transfusion 24 h after injury. This suggests that StO2 can be used as an early marker of hemorrhage which may be superior to traditional vital signs in the trauma population.

Role of gastrografin challenge in early postoperative small bowel obstruction.

INTRODUCTION: Early small bowel obstruction following abdominal surgery presents a diagnostic and therapeutic challenge. Abdominal imaging using Gastrografin has been shown to have diagnostic and therapeutic properties when used in the setting of small bowel obstruction outside the early postoperative period (>6 weeks). We hypothesize that a GG challenge will reduce need for re-exploration. METHODS: Patients with early small bowel obstruction who underwent a Gastrografin challenge between 2010 and 2012 were case controlled, based on age ±5 years, sex, and operative approach to an equal number of patients that did not receive the challenge. RESULTS: One hundred sixteen patients received a Gastrografin challenge. There were 87 males in each group with an average age of 62 years. A laparoscopic approach in the index operation was done equally between groups (18 vs. 18 %). There was no difference between groups in operative re-exploration rates (14 vs. 10 %); however, hospital duration of stay was greater in patients who received Gastrografin challenge (17 vs. 13 days). Two in hospital deaths occurred, one in each group, both of infectious complications. CONCLUSION: Use of the Gastrografin challenge in the immediate postoperative period appeared to be safe. There was no difference, however, in the rate of re-exploration between groups.

Use of the Gastrografin challenge in patients with a history of abdominal or pelvic malignancy.

BACKGROUND: The Gastrografin (GG) challenge was developed to predict the need for operative management in patients with small bowel obstruction (SBO). Although clinical trials have demonstrated that it is an effective diagnostic and therapeutic modality, these studies excluded patients with a history of abdominal/pelvic malignancy. This study aims to examine the outcomes of the GG challenge for patients with a history of abdominal/pelvic malignancies. METHODS: Institutional review board approval was obtained to review retrospectively patients admitted with SBO in 3 separate categories: Group 1, patients presenting between 2010 and 2012 with SBO who received the GG challenge and had a concurrent history of abdominal or pelvic malignancy; group 2, patients presenting between 2010 and 2012 with SBO who underwent the GG challenge but did not have a concurrent history of abdominal or pelvic malignancy; and group 3, patients presenting between 2007 and 2010 (before our incorporation of the GG challenge protocol) with SBO and a concurrent history of abdominal or pelvic malignancy who did not receive GG . Two distinct comparisons were made. The first analysis was made between groups 1 and 2. The second comparison was performed comparing patients from groups 1 and 3. RESULTS: A total of 237 patients (74 group 1, 83 group 2, 80 group 3) were identified with a mean age of 69.1 years (range, 20-101); 115 were male (48%).There were no adverse events related to GG administration in our study. Analysis of groups 1 and 2 showed similar rates of exploration (25% vs 18%) and complications (32% vs 24%); however, mortality was greater among patients with history of malignancy at 12 months (26% vs 7%). Both groups had similar readmission rates for SBO, as well as exploration upon readmission. Analysis between groups 1 and 3 showed that the need for operative exploration at index admission was less in patients who underwent the GG challenge (26% vs 41%); however, hospital duration of stay was similar (8 vs 9 days). There was no difference in SBO recurrence at 12 months (28% vs 26%); however, mortality was significantly greater among patients not receiving GG (26% vs 41%). CONCLUSION: The GG challenge was safe and effective in patients presenting with SBO and a history of abdominal or pelvic malignancy. As a result, GG has the potential to improve these terminal patients' quality of life.