2014 Oral Presentations
SCIENTIFIC SESSION IX: SURGICAL POTPOURRI
A RETROSPECTIVE REVIEW OF DELAYED FAILURE OF NON-OPERATIVE
MANAGEMENT IN SPLENIC TRAUMA
Srinivasa, D, Love, J, McNutt, M, UT Houston
Background
The aim of this retrospective review was to find risk factors that could help identify which
patients can be considered “high risk” for delayed splenic rupture.
Methods
At our institution, we had 991 patients from 2008 to 2012 admitted with a splenic injury.
Of this group, 23 patients required surgical intervention for intra-abdominal hemorrhage
greater than 48 hours from injury. We further characterized the time to surgery, the
initial grade of injury, and the AAST injury grading at the time of takeback. We further
reviewed which patients had CT evidence of vascular injury.
Results
23 patients required a splenectomy greater than 48 hours from the time of admission.
19 of the 23 patients (82.6%) had AAST Grade ≤ III on admission. Although high grade
injuries have been associated with increased failure rates, it is important to note that
here, lower grade injuries were more prevalent. Admission CT scans revealed that only
10 of the 23 had evidence of extravasation or pseudoaneurysm on the admission. 3 of
the 19 patients proceeded to angiography given CT evidence of extravasation and all
three received embolization. Interestingly, all but three patients were noted to have a
“Shattered Spleen” on operative exploration. The average age of this group was 35
years.
Conclusion
AAST Grade I, II, and III splenic lacerations are traditionally considered lower risk for
failure of non-operative management (NOM). Low grade injuries, with no concomitant
vascular findings on CT, in younger individuals, were more likely to fail NOM in a
delayed fashion. Interestingly almost all of these patients had frank splenic rupture at
the time of failure. At our institution we see around 250 splenic injuries annually. We
would recommend a multi-center review to detect further patterns in patients who
present with delayed splenic rupture and failure of NOM.
FEASIBILITY OF SINGLE-INCISION LAPAROSCOPIC SURGERY IN THE SETTING
OF CHOLECYSTITIS
F.P. Buckley, J. Crosby, H. Vassaur, D. Jupiter, Texas A&M Health Science Center
Background
The feasibility of elective single-incision laparoscopic (SILS) cholecystectomy for biliary
colic and dyskinesia has been well-established in the literature, but limited data has
been published concerning the approach for more severe disease. A retrospective
chart review was conducted to assess the safety and feasibility of the SILS approach in
the setting of complicated gallbladder disease.
Methods
All SILS cholecystectomies performed at a single institution by three surgeons between
November 2008 and July 2012 were reviewed. Cases with indications of acute or
chronic cholecystitis were compared to the remaining cases. Statistical evaluation
included descriptive analysis of demographic data and bivariate analysis of operative
outcomes. Multivariate analyses were performed to control for other factors impacting
outcomes.
Results
90 SILS cholecystectomies were performed for complicated disease and 318 for
uncomplicated. The data set included 315 (71.21%) women, and the patients had a
mean age of 44.91 (16.84) (range 10-91) years. Mean BMI was 28.99 (6.04) (range
15.5-61). The mean operative time for complicated disease was 66.8 minutes versus
59.2 minutes for uncomplicated disease, which was significant (p=0.03). Neither
conversion nor overall complication rates differed statistically significantly between
complicated and uncomplicated cases (chi-squared p-values 0.33 and 0.94,
respectively). Abscess formation was higher in the complicated group (3.33% versus
0.31%), which was statistically significant (Fisher’s exact p-value = 0.04). There were
no common bile duct injuries in either cohort.
Conclusion
SILS cholecystectomy for complicated gallbladder disease appears to be a safe and
feasible option when compared to SILS cholecystectomy performed electively. Our
institution found a difference in operative length of about six minutes, but this is not
unreasonable given the expectation of increased difficulty in complicated cases.
Further prospective analyses comparing SILS cholecystectomy to traditional multiport
laparoscopy in both complicated and uncomplicated disease are required.
SYNTHETIC HERNIA MESH WITH NITRIC OXIDE INDUCED BACTERIACIDAL
PROPERTIES – A PARADIGM SHIFT
J.S.Fernandez-Moure MD MS, J Van Eps MD, S. Haddix, B.K. Weiner MD, N. Bryan
PhD., R. Olsen MD, E. Tasciotti PhD., B.J. Dunkin MD FACS, Houston Methodist
Hospital
Background
Mesh infection after ventral hernia repair results in significant morbidity. Management
includes re-operation with mesh excision and antibiotic therapy. Impregnating mesh with
antibiotics may decrease infection but is prone to resistance. Nitric Oxide (NO), a
diatomic free radical with no known resistance mechanism, plays a key role in the
natural immune response to fighting infection and may overcome these limitations. We
sought to create a NO-releasing mesh and study its antibacterial efficacy in vitro and in
vivo, hypothesizing that a NO-releasing polyester mesh would prevent MRSA
colonization and growth.
Methods
NO-Silica (NO-Si) nanoparticles were synthesized via a co-condensation of
tetraethoxysilane with aminoalkoxysilane with methanol and ammonia under high
pressure nitrous oxide. NO release was measured and confirmed using a
chemiluminescence NO analyzer. MRSA bactericidal efficacy of these nanoparticles
was quantified in vitro through tryptic soy broth assay. The NO-Si nanoparticles were
then bound to a commercially available polyester mesh, implanted in a rat model of
ventral hernia repair, and inoculated with MRSA. Bacterial growth was quantified using
colony forming unit assay.
Results
NO-Si, synthesized at 500nm, was capable of NO release for up to 12 hours. NO
release from the NO-silica polyester mesh was equivalent to NO-Si alone. MRSA CFUs
recovered relative to treatment demonstrated a dose dependent response to NO-Si with
100% bactericidal effect at 66mg NO-Si in vitro. The in vivo bactericidal effects of the
NO-releasing mesh correlated with in vitro results with 100% bacterial clearance at
66mg NO-Si.
Conclusion
This study created a NO-releasing synthetic mesh and demonstrated its MRSA
bactericidal efficacy both in vitro and in vivo. Creation of a novel polyester mesh with
enhanced non-antibiotic antibacterial activity using nanoparticles may lead to a
paradigm shift in treating not only abdominal wall defects in a contaminated
environment, but perhaps all surgeries that require use of a synthetic mesh.
HOSPITAL CHARACTERISTICS AFFECT CONSENT AND CONVERSION RATES
FOR POTENTIAL ORGAN DONORS
Ebadat A, Ali S, Brown C, University of Texas Southwestern - Austin
Background
Consent rates of potential organ donors in the United States do not parallel the steep
growth rate of the of number of individuals awaiting organ donation. Studies to date
have given little attention to characteristics of centers successfully improving
transplantation numbers.
Methods
Five years (2006 – 2011) of potential organ donors entered into our regional OPO
database. We categorized hospitals in our OPO region as academic centers vs. nonacademic centers, trauma centers vs. non-trauma centers, and large (>/= 400 beds)
centers vs. small (<400 beds) centers. For potential organ donors outcomes included
consent rate and conversion rates.
Results
There were 14,008 referrals to our OPO that resulted in 701 potential organ donors.
When comparing academic to non-academic hospitals, academic hospitals had higher
consent (72% vs. 58%, p = < 0.0001) and conversion (74% vs. 62%, p = 0.005)
rates.When comparing trauma centers to non-trauma centers, there was no difference
in consent rate (62% vs. 53%, p = 0.07) but trauma centers had a higher conversion
rate (66% vs. 51%, p = 0.02). When comparing larger hospitals to smaller hospitals
there was no difference in consent rates (58% vs. 64%, p = 0.09) but smaller hospitals
had a higher conversion rate (70% vs. 60%, p = 0.009). Small, academic, trauma
centers had the highest consent rates (82%) and conversion (82%) rates, while large,
non-academic, non-trauma hospitals had the lowest consent (37%) and conversion
(33%) rates, p < 0.0001.
Conclusion
Hospital characteristics such as academic involvement, trauma designation, and size
impact consent and conversion rates for potential organ donors. Small (< 400 bed),
academic, trauma centers have the highest consent and conversion rates. Successful
processes set up in these institutions should therefore be examined and applied to
assist in improving donor rates across all types of hospitals.