Analysis of Early Lower Extremity Re-amputation.

BACKGROUND: Data is scarce regarding the need for early re-amputation to a higher anatomic level. This study seeks to define outcomes and risk factors for re-amputation. METHODS: Patients undergoing primary major lower extremity amputation were identified within the 2012-2016 ACS-NSQIP database. Demographics, outcomes, and peri-operative characteristics were compared, and multivariable logistic regression model was used to determine association with early re-amputation. RESULTS: Over a 4-year period, 8306 below knee amputations and 6367 above knee amputations were identified. Thirty-day re-amputation occurred in 262 patients (1.8%) and was associated with increased length of stay (12.9 vs. 7.3 days, P < 0.001), higher rates of readmission (64.9% vs. 13.6%, P < 0.001), and overall complications (69.5% vs. 39.3%, P < 0.01). On multivariable analysis, advanced age (OR 1.02, CI 1.01-1.03), smoking (OR 1.75, CI 1.32-2.33), dialysis dependence (OR 1.67, CI 1.23-2.26), preoperative septic shock (OR 2.53, CI 1.29-4.97), and bleeding disorders (OR 1.72, CI 1.34-2.22) were associated with early re-amputation. CONCLUSIONS: Thirty-day re-amputation rates are low, but are associated with significant morbidity, prolonged hospitalization, and frequent readmissions.

Present-day analysis of early failure after forefoot amputation.

BACKGROUND: Forefoot transmetatarsal amputation is performed commonly to achieve limb salvage, but transmetatarsal amputations have a high rate of failure, requiring more proximal amputations. Few contemporary studies have examined the incidence of major amputation (transtibial or transfemoral) after transmetatarsal amputation. The goal of this study is to determine risk factors and outcomes for a more proximal amputation after forefoot amputation. METHODS: We queried the 2012 to 2016 database of the American College of Surgeons National Quality Improvement Program for patients undergoing a complete transmetatarsal amputation with wound closure by Current Procedural Terminology code. Patients requiring early (within 30 days) more proximal amputation after transmetatarsal amputation were compared with those who did not need further amputation. Characteristics of patients requiring more proximal amputation were examined, and a multivariable logistic regression model was created to identity risk factors for early more proximal amputation. RESULTS: In the study, 1,582 transmetatarsal amputation were identified. Most patients were male (70%), white (59%), and diabetic (74%), with a median age of 63 years. More proximal amputation occurred in 4.2% of patients within the first 30 days postoperatively. This early failure was associated with greater hospital stays postoperatively (10 days vs 7 days), more wound complications (29% vs 11%), pneumonia (8% vs 2%), stroke (3% vs 0.1%), and overall complications (50% vs 28%; P ≤ .025 each). Although there was no difference in 30-day mortality (P = .27), there was a marked increase in unplanned readmission (59% vs 14%; P < .0001) for those undergoing reamputation. On multivariable analysis, preoperative systemic inflammatory response, sepsis, or septic shock (odds ratio 2.1; 95% confidence interval, 1.2-3.6) were independent predictors of more proximal amputation. CONCLUSION: Early below-knee or above-knee amputation early after transmetatarsal amputation leads to increased morbidity. Because patients with preoperative sepsis may be at increased risk of failure after transmetatarsal amputation, the level of amputation should be considered carefully in these patients.

The changing role of endovascular stenting for blunt cerebrovascular injuries.

BACKGROUND: Few injuries have produced as much debate with respect to management as have blunt cerebrovascular injuries (BCVIs). Without question, early anticoagulation is the mainstay of therapy for these injuries. However, the role of endovascular stenting for BCVI remains controversial. Our purpose was to examine the use of endovascular stents for BCVI and outcomes and describe which injuries are being treated with stents. METHODS: Patients with BCVI from 2011 to 2016 were identified and stratified by age, sex, and injury severity. Patients were then divided into two groups (previous study [PS] = 2011-2012 and current study [CS] = 2013-2016) based on a paradigm shift in BCVI diagnosis and treatment at our institution. Beginning in 2013, a multidisciplinary team assumed care of patients with BCVI from interventional radiology. Digital subtraction angiography was used to confirmatory injuries in both groups and heparin used for initial therapy. RESULTS: In the CS, 237 patients were diagnosed with BCVI compared with 128 patients in the PS. Both groups were clinically similar with no difference in distribution of vessels injured. Beginning in 2013, there was a significant decrease in the use of stents for these injuries. In fact, in the CS, only 21 (8.9%) patients were treated with endovascular stenting compared to 44 (34%) patients in the PS. Of patients in the CS, 14 had grade III pseudoaneurysms and seven had grade II dissections. Despite this reduction in stenting, there was no significant change in the BCVI-related stroke rate between the CS and the PS (4.2% vs. 3.9%). CONCLUSION: Anticoagulation alone is adequate therapy for the majority of BCVI. Nevertheless, there is still a role for endovascular stents in the treatment of BCVI. Their use should be reserved for enlarging carotid pseudoaneurysms and dissections with significant narrowing. The prospect of determining which injuries benefit from stent placement warrants prospective investigation. LEVEL OF EVIDENCE: Therapuetic/care management, level IV.

Thirty-day outcomes after fenestrated endovascular repair are superior to open repair of abdominal aortic aneurysms involving visceral vessels.

OBJECTIVE: Although few studies have reported outcomes after branched or fenestrated endovascular aortic aneurysm repair (FEVAR) of abdominal aortic aneurysms involving visceral vessels (AAA-Vs), no multi-institutional study has compared FEVAR with open surgery (OS) for AAA-Vs. Our objective was to compare 30-day outcomes after FEVAR vs OS for AAA-Vs. METHODS: Patients who underwent FEVAR (n = 535) and OS (n = 1207) for elective AAA-Vs were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) 2008 to 2013 database. Thoracoabdominal aneurysms were excluded. Univariable and multivariable logistic regression analyses were performed. RESULTS: There were more men (82% vs 72%; P < .0001), diabetic patients (16% vs 11%; P = .005), patients with dependent functional status (4% vs 2%; P = .002), and nonsmokers (70% vs 56%; P < .0001) in the FEVAR group vs OS. There was no difference in rates of chronic obstructive pulmonary disease, cardiac history, peripheral artery disease, hypertension, and dialysis (P > .05). FEVAR had fewer major postoperative pulmonary complications (3.0% vs 19.0%; P < .0001), less renal failure requiring dialysis (1.9% vs 6.4%; P < .0001), less frequent cardiac arrest or myocardial infarction (2.2% vs 5.8%; P = .001), less bleeding with major transfusion (17.4% vs 50.2%; P < .0001), and decreased incidence of return to the operating room (4.5% vs 9.6%; P < .0001) and death (2.4% vs 4.7%; P = .02). The median length of stay was also significantly shorter for FEVAR (2 days vs 7 days; P < .0001). On multivariable analyses, OS was associated with higher risk than FEVAR for 30-day death (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.3-5.0), pulmonary complications (OR, 8.8; 95% CI, 5.1-15.0), cardiac complications (OR, 3.4; 95% CI, 1.8-6.6), renal failure needing dialysis (OR, 3.8; 95% CI, 1.9-7.7), and return to the operating room (OR 2.5; 95% CI, 1.6-4.0). CONCLUSIONS: FEVAR is associated with a lower risk for 30-day mortality and adverse events compared with OS for AAA-Vs.

Outcomes After Use of Aortouniiliac Endoprosthesis Versus Modular or Unibody Bifurcated Endoprostheses for Endovascular Repair of Ruptured Abdominal Aortic Aneurysms.

OBJECTIVES: Outcomes after endovascular repair (EVAR) of ruptured abdominal aortic aneurysms (rAAAs) have been widely published. There is, however, controversy on the role of the use of aortouniiliac endoprosthesis (AUI) versus modular or unibody bifurcated endoprosthesis (MUB) for repair of rAAAs. We study and compare 30-day outcomes after use of AUI and MUB for all rAAAs focusing specifically on patients with instability. MATERIALS AND METHODS: Patients who underwent EVAR for rAAA (n = 425) using AUI (n = 55; 12.9%) and MUB (n = 370; 87.1%) were identified from the American College of Surgeons' National Surgical Quality Improvement Program (2005-2010) database. Univariable and multivariable logistic regression analyses were performed. RESULTS: No significant difference ( P > .5) was seen in comorbidities between patients who underwent EVAR with AUI or MUB; there was also no change in endoprosthesis use from 2005 to 2010 ( P = .7). Patients who underwent EVAR with AUI more commonly had a history of peripheral arterial procedure (10.9% vs 4.6%; P = .053) and preoperative transfusion of >4 U packed red blood cells (18.2% vs 6.8%; P = .004). Use of AUI versus MUB was associated with more 30-day wound complications (16.4% vs 6.2%; P = .01), return to operating room (38.2% vs 20.0%; P = .003), and mortality (34.5% vs 21.4%; P = .03). On multivariable analysis, use of AUI was associated with an increased risk of 30-day mortality (odds ratio: 2.4; 95% confidence interval: 1.1-5.3). On subanalysis of the cohort for only the patients with unstable rAAA (n = 159; AUI = 29 and MUB = 130), 30-day mortality for AUI versus MUB was still higher but not statistically significant (44.8% vs 32.3%; P = .2). CONCLUSION: Endovascular repair for ruptured AAA using aortouniliac endoprosthesis is associated with higher 30-day mortality than using modular or unibody bifurcated endoprosthesis.

A safe and effective management strategy for blunt cerebrovascular injury: Avoiding unnecessary anticoagulation and eliminating stroke.

BACKGROUND: Few injuries have produced as much debate with respect to management as have blunt cerebrovascular injuries (BCVIs). Recent work (American Association for the Surgery of Trauma 2013) from our institution suggested that 64-channel multidetector computed tomographic angiography (CTA) could be the primary screening tool for BCVI. Consequently, our screening algorithm changed from digital subtraction angiography (DSA) to CTA, with DSA reserved for definitive diagnosis of BCVI following CTA-positive study results or unexplained neurologic findings. The current study was performed to evaluate outcomes, including the potential for missed clinically significant BCVI, since this new management algorithm was adopted. METHODS: Patients who underwent DSA (positive CTA finding or unexplained neurologic finding) over an 18-month period subsequent to the previous study were identified. Screening and confirmatory test results, complications, and BCVI-related strokes were reviewed and compared. RESULTS: A total of 228 patients underwent DSA: 64% were male, with mean age and Injury Severity Score (ISS) of 43 years and 22, respectively. A total of 189 patients (83%) had a positive screening CTA result. Of these, DSA confirmed injury in 104 patients (55%); the remaining 85 patients (45%) (false-positive results) were found to have no injury on DSA. Five patients (4.8%) experienced BCVI-related strokes, unchanged from the previous study (3.9%, p = 0.756); two were symptomatic at trauma center presentation, and three occurred while receiving appropriate therapy. No patient with a negative screening CTA result experienced a stroke. CONCLUSION: This management scheme using 64-channel CTA for screening coupled with DSA for definitive diagnosis was proven to be safe and effective in identifying clinically significant BCVIs and maintaining a low stroke rate. Definitive diagnosis by DSA led to avoidance of potentially harmful anticoagulation in 45% of CTA-positive patients (false-positive results). No strokes resulted from injuries missed by CTA. LEVEL OF EVIDENCE: Diagnostic study, level III.

Novel use of a gastrointestinal stapler for diaphragm division during thoracoabdominal aortic exposure.

A significant portion of the morbidity associated with a thoracoabdominal approach to the suprarenal aorta is due to postoperative pulmonary dysfunction. A contributing factor to this dysfunction is division of the diaphragm during surgical exposure and subsequent repair upon completion of the operation. In this brief technical report, we describe a novel technique using a gastrointestinal stapler to divide the diaphragm that is rapid, hemostatic, and aids with reapproximation at the completion of the case. This method of diaphragm division is quicker and less traumatic and has the potential to decrease the incidence of postoperative pulmonary dysfunction.

Impact of a defined management algorithm on outcome after traumatic pancreatic injury.

BACKGROUND: The optimal management of pancreatic injuries, specifically with respect to defining ductal integrity, remains controversial. Our previous experience suggested that decisions based on probability of ductal injury might improve outcome. Consequently, a management algorithm (ALG) was developed and implemented. The purpose of this study was to evaluate the impact of this ALG on outcomes. METHODS: Consecutive patients more than 13 years with pancreatic injuries subsequent to the development of the ALG were evaluated. Pancreatic injuries were defined as proximal or distal and ductal injuries classified as definite, high, low, or indeterminate (IND) probability. Pancreas-related morbidity (fistula, abscess, and pseudocyst) and mortality were recorded. Patients managed by the ALG were compared with the previous study (PS). RESULTS: In all, 245 patients were identified; 35 died within 12 hours and were excluded. Demographics and severity of shock (24-hour transfusions) were similar between groups. Pancreas-related morbidity for proximal injuries was 13.8% in the ALG group and 13.5% in the PS (p = 0.948). Pancreas-related morbidity was significantly reduced in the ALG group for distal injuries requiring drainage alone (11% vs. 25%, p = 0.05) and for distal injuries requiring resection + drainage (26% vs. 58%, p = 0.003) when compared with the PS. There was no pancreas-related mortality in the ALG group (1.6% in the PS group, p = 0.065). CONCLUSIONS: Adherence to a defined ALG simplified the management of traumatic pancreatic injuries and contributed to a reduction in both pancreas-related morbidity and mortality. The majority of all proximal pancreatic injuries can be treated with drainage alone. For distal injuries, a clinical decision based on defined parameters and suspicion of ductal injury dictates definitive management.

Regulated synthesis and functions of laminin 5 in polarized madin-darby canine kidney epithelial cells.

Renal tubular epithelial cells synthesize laminin (LN)5 during regeneration of the epithelium after ischemic injury. LN5 is a truncated laminin isoform of particular importance in the epidermis, but it is also constitutively expressed in a number of other epithelia. To investigate the role of LN5 in morphogenesis of a simple renal epithelium, we examined the synthesis and function of LN5 in the spreading, proliferation, wound-edge migration, and apical-basal polarization of Madin-Darby canine kidney (MDCK) cells. MDCK cells synthesize LN5 only when subconfluent, and they degrade the existing LN5 matrix when confluent. Through the use of small-interfering RNA to knockdown the LN5 alpha3 subunit, we were able to demonstrate that LN5 is necessary for cell proliferation and efficient wound-edge migration, but not apical-basal polarization. Surprisingly, suppression of LN5 production caused cells to spread much more extensively than normal on uncoated surfaces, and exogenous keratinocyte LN5 was unable to rescue this phenotype. MDCK cells also synthesized laminin alpha5, a component of LN10, that independent studies suggest may form an assembled basal lamina important for polarization. Overall, our findings indicate that LN5 is likely to play an important role in regulating cell spreading, migration, and proliferation during reconstitution of a continuous epithelium.