Endovascular Graft Repair for Blunt Traumatic Disruption of the Thoracic Aorta: Experience at a Nonuniversity Hospital

Blunt thoracic aortic injury (BAI) represents the second leading cause of death from blunt trauma. Admission rates for BAI are extremely low because instant fatality occurs in nearly 75 per cent of patients. Management strategies have transitioned from the more invasive immediate thoracotomy to delayed endograft repair with strict hemodynamic management. In this study, we assess outcomes and complications of open versus endograft repair for BAI at a nonuniversity hospital. Retrospective chart review was conducted on 49 patients admitted to a Level I trauma center who incurred BAI from 2004 to 2011. Collected data points included demographics, mortality, complication rates, and intensive care unit and hospital length of stay (LOS). Twenty-one patients underwent open thoracotomy (OPEN), whereas 28 patients were managed with thoracic endovascular aortic repair (TEVAR). The overall 30-day mortality rate was significantly lower comparing TEVAR to OPEN (7.1 vs 50%, P = 0.028); seven deaths occurred in the OPEN group versus two with TEVAR. Overall complications, including mortality, acute respiratory distress syndrome, renal failure, pneumonia, pulmonary embolism, and cardiac arrest, were fewer after TEVAR (32.1 vs 81.0%, P < 0.001) despite similar injury severity. Survivor hospital LOS (26.0 ± 15.3 vs 27.7 ± 18.7 days, P = 0.79), intensive care unit LOS (13.5 ± 10.9 vs 12.7 ± 8.8 days, P = 0.94), and ventilator days (11.4 ± 13.4 vs 16.4 ± 14.5 days, P = 0.25) were similar. Early nonoperative management with TEVAR for BAIs is a feasible and effective management strategy. Improved patient outcomes over traditional open thoracotomy in the presence of similar injury severity can be seen after TEVAR in the nonuniversity hospital setting.

The Green Operating Room: Simple Changes to Reduce Cost and Our Carbon Footprint

Generating over four billion pounds of waste each year, the healthcare system in the United States is the second largest contributor of trash with one-third produced by operating rooms. Our objective is to assess improvement in waste reduction and recycling after implementation of a Green Operating Room Committee (GORC) at our institution. A surgeon and nurse-initiated GORC was formed with members from corporate leadership, nursing, anesthesia, and OR staff. Initiatives for recycling opportunities, reduction of energy and water use as well as solid waste were implemented and the results were recorded. Since formation of GORC in 2008, our OR has diverted 6.5 tons of medical waste. An effort to recycle all single-use devices was implemented with annual solid waste reduction of approximately 12,860 lbs. Disposable OR foam padding was replaced with reusable gel pads at greater than $50,000 per year savings. Over 500 lbs of previously discarded batteries were salvaged from the OR and donated to charity or redistributed in the hospital ($9,000 annual savings). A “Power Down” initiative to turn off all anesthesia and OR lights and equipment not in use resulted in saving $33,000 and 234.3 metric tons of CO2 emissions reduced per year. Converting from soap to alcohol-based waterless scrub demonstrated a potential saving of 2.7 million liters of water annually. Formation of an OR committee dedicated to ecological initiatives can provide a significant opportunity to improve health care's impact on the environment and save money.

Home intravenous versus oral antibiotics following appendectomy for perforated appendicitis in children: a randomized controlled trial

PURPOSE

To compare the effect of home intravenous (IV) versus oral antibiotic therapy on complication rates and resource utilization following appendectomy for perforated appendicitis.

METHODS

This was a randomized controlled trial of patients aged 4-17 with surgically treated perforated appendicitis from January 2011 to November 2013. Perforation was defined intraoperatively and divided into three grades: I-contained perforation, II-localized contamination to right gutter/pelvis, and III-diffuse contamination. Patients were randomized to complete a ten-day course of home antibiotic therapy with either IV ertapenem or oral amoxicillin-clavulanate. Thirty-day postoperative complication rates including abscess, readmission, wound infection, and charges were compared.

RESULTS

Eighty-two patients were enrolled. Forty four (54%) were randomized to the IV group and 38 (46%) to the oral group. IV patients were older (12.3 ± 3.6 versus 10.1 ± 3.6, p < 0.05) with higher BMI (20.9 ± 5.8 versus 17.9 ± 3.5, p < 0.05). There were no differences in gender, comorbidities, or perforation grade (I-20.4% vs. 26.3%, II-36.4% vs. 34.2%, III-43.2% vs. 39.5%, all p > 0.05). Comparing IV to oral, there was no difference in length of stay (4.4 ± 1.5 versus 4.4 ± 2.0 days, p > 0.05), postoperative abscess rate (11.6% vs. 8.1%, p > 0.05), or readmission rate (14.0% vs. 16.2%, p > 0.05). Hospital and outpatient charges were higher in the IV group (p < 0.0001).

CONCLUSION

Oral antibiotics had equivalent outcomes and incurred fewer charges than IV antibiotics following appendectomy for perforated appendicitis.

Ileocolic and Jejunal Intussusceptions Requiring Surgical Intervention in a Pediatric Patient with Posttransplant Lymphoproliferative Disorder

Posttransplant lymphoproliferative disorder (PTLD) is not uncommon in pediatrics. This case report describes a case of intestinal intussusception that occurred secondary to lymphoid hyperplasia in a child with PTLD following a cardiac transplant. This case was unique in its presentation with multiple areas of intussusception and with need for surgical intervention. The diagnosis of intussusception secondary to lead points from PTLD should be strongly considered in pediatric transplant patients presenting with abdominal complaints.

Ileocolic and Jejunal Intussusceptions Requiring Surgical Intervention in a Pediatric Patient with Posttransplant Lymphoproliferative Disorder

Posttransplant lymphoproliferative disorder (PTLD) is not uncommon in pediatrics. This case report describes a case of intestinal intussusception that occurred secondary to lymphoid hyperplasia in a child with PTLD following a cardiac transplant. This case was unique in its presentation with multiple areas of intussusception and with need for surgical intervention. The diagnosis of intussusception secondary to lead points from PTLD should be strongly considered in pediatric transplant patients presenting with abdominal complaints.

Quality of Life Following Component Separation Versus Standard Open Ventral Hernia Repair for Large Hernias

Introduction. Component separation (CS) has become a viable alternative to repair large ventral defects when the fascia cannot be reapproximated. However, the impact of transecting the external oblique to facilitate closure of the abdomen on quality of life (QOL) has yet to be investigated. The study goal was to investigate QOL and outcomes after standard open ventral hernia repair (OVHR) versus CS for large ventral hernias. Study design. Prospective data for all CSs were reviewed and compared with matched OVHR controls. All defects were 100 to 1000 cm2 in size and repaired with mesh. Comorbidities, complications, outcomes, and Carolinas Comfort Scale (CCS) scores, were reviewed. Results. Seventy-four CS patients were compared with 154 patients undergoing standard OVHR with similar defect sizes. Age (56.7±13.0 vs 54.7 ± 12.3 years, P = .26), defect sizes (299 ± 160 vs 304 ± 210cm2, P = .87), and BMI (32.7 ± 6.9 vs 34.2 ± 9.0 kg/m2, P = .26) were similar in both groups, respectively. There were no differences in major postoperative complications (P = .22), mesh infections (P = 1.00), wound infections (P = .07), or hernia recurrence (P = .09), but wound breakdown increased after CS (10% vs 1%, P < .001) as did seroma interventions (15% vs 4%, P = .005). Postoperative CCS scores were similar at 1 month (P = .82) and 1 year (P = .14). Conclusions. In the first comparative study of its kind, it is found that patient undergoing CS with mesh reinforcement had equal short- and long-term QOL outcomes compared with similar patients who underwent standard OVHR. Whereas wound breakdown and seroma formation are higher, the overall complication, mesh infection, and recurrence rates are similar.

The green operating room: simple changes to reduce cost and our carbon footprint

Generating over four billion pounds of waste each year, the healthcare system in the United States is the second largest contributor of trash with one-third produced by operating rooms. Our objective is to assess improvement in waste reduction and recycling after implementation of a Green Operating Room Committee (GORC) at our institution. A surgeon and nurse-initiated GORC was formed with members from corporate leadership, nursing, anesthesia, and OR staff. Initiatives for recycling opportunities, reduction of energy and water use as well as solid waste were implemented and the results were recorded. Since formation of GORC in 2008, our OR has diverted 6.5 tons of medical waste. An effort to recycle all single-use devices was implemented with annual solid waste reduction of approximately 12,860 lbs. Disposable OR foam padding was replaced with reusable gel pads at greater than $50,000 per year savings. Over 500 lbs of previously discarded batteries were salvaged from the OR and donated to charity or redistributed in the hospital ($9,000 annual savings). A "Power Down" initiative to turn off all anesthesia and OR lights and equipment not in use resulted in saving $33,000 and 234.3 metric tons of CO2 emissions reduced per year. Converting from soap to alcohol-based waterless scrub demonstrated a potential saving of 2.7 million liters of water annually. Formation of an OR committee dedicated to ecological initiatives can provide a significant opportunity to improve health care's impact on the environment and save money.

Endovascular graft repair for blunt traumatic disruption of the thoracic aorta: experience at a nonuniversity hospital

Blunt thoracic aortic injury (BAI) represents the second leading cause of death from blunt trauma. Admission rates for BAI are extremely low because instant fatality occurs in nearly 75 per cent of patients. Management strategies have transitioned from the more invasive immediate thoracotomy to delayed endograft repair with strict hemodynamic management. In this study, we assess outcomes and complications of open versus endograft repair for BAI at a nonuniversity hospital. Retrospective chart review was conducted on 49 patients admitted to a Level I trauma center who incurred BAI from 2004 to 2011. Collected data points included demographics, mortality, complication rates, and intensive care unit and hospital length of stay (LOS). Twenty-one patients underwent open thoracotomy (OPEN), whereas 28 patients were managed with thoracic endovascular aortic repair (TEVAR). The overall 30-day mortality rate was significantly lower comparing TEVAR to OPEN (7.1 vs 50%, P = 0.028); seven deaths occurred in the OPEN group versus two with TEVAR. Overall complications, including mortality, acute respiratory distress syndrome, renal failure, pneumonia, pulmonary embolism, and cardiac arrest, were fewer after TEVAR (32.1 vs 81.0%, P < 0.001) despite similar injury severity. Survivor hospital LOS (26.0 ± 15.3 vs 27.7 ± 18.7 days, P = 0.79), intensive care unit LOS (13.5 ± 10.9 vs 12.7 ± 8.8 days, P = 0.94), and ventilator days (11.4 ± 13.4 vs 16.4 ± 14.5 days, P = 0.25) were similar. Early nonoperative management with TEVAR for BAIs is a feasible and effective management strategy. Improved patient outcomes over traditional open thoracotomy in the presence of similar injury severity can be seen after TEVAR in the nonuniversity hospital setting.

Application of Subcutaneous Talc in Hernia Repair and Wide Subcutaneous Dissection Dramatically Reduces Seroma formation and Postoperative Wound Complications

Wound complications after large ventral hernia repairs when combined with wide subcutaneous dissection (OVHR/WSD) are common (33 to 66%). We evaluate a novel technique of applying talc to wound subcutaneous tissues to decrease wound complications. We accessed our prospectively collected surgical outcomes database for OVHR/WSD procedures performed. Patients were divided into those that did and did not receive subcutaneous talc (TALC vs NOTALC). Demographics intraoperative and outcomes data were collected and analyzed. The study included 180 patients (n = 74 TALC, n = 106 NOTALC). Demographics were all similar, but hernias were larger in the TALC group. TALC patients had their drains removed earlier (14.6 vs 25.6 days; P < 0.001) with dramatic reduction in postoperative seromas requiring intervention (20.8 to 2.7%; P < 0.001) and cellulitis (39.0 to 20.6%; P = 0.007). Short-term follow-up demonstrates significantly higher recurrence rates in the NOTALC group with each recurrence related to infection. The use of talc in the subcutaneous space of OVHR/WSD results in significantly earlier removal of subcutaneous drains, fewer wound complications, and a decrease in early hernia recurrence. Use of talc in the subcutaneous space at the time of wound closure is an excellent technique to decrease wound complications in large subcutaneous dissections.

Application of subcutaneous talc in hernia repair and wide subcutaneous dissection dramatically reduces seroma formation and postoperative wound complications

Wound complications after large ventral hernia repairs when combined with wide subcutaneous dissection (OVHR/WSD) are common (33 to 66%). We evaluate a novel technique of applying talc to wound subcutaneous tissues to decrease wound complications. We accessed our prospectively collected surgical outcomes database for OVHR/WSD procedures performed. Patients were divided into those that did and did not receive subcutaneous talc (TALC vs NOTALC). Demographics intraoperative and outcomes data were collected and analyzed. The study included 180 patients (n = 74 TALC, n = 106 NOTALC). Demographics were all similar, but hernias were larger in the TALC group. TALC patients had their drains removed earlier (14.6 vs 25.6 days; P < 0.001) with dramatic reduction in postoperative seromas requiring intervention (20.8 to 2.7%; P < 0.001) and cellulitis (39.0 to 20.6%; P = 0.007). Short-term follow-up demonstrates significantly higher recurrence rates in the NOTALC group with each recurrence related to infection. The use of talc in the subcutaneous space of OVHR/WSD results in significantly earlier removal of subcutaneous drains, fewer wound complications, and a decrease in early hernia recurrence. Use of talc in the subcutaneous space at the time of wound closure is an excellent technique to decrease wound complications in large subcutaneous dissections.