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428 The Yield of Non-Invasive Testing in Post-Cholecystectomy Patients With Suspected Bile Duct Injury
429 Risk Stratification for Distal Pancreatectomy Utilizing ACS-NSQIP: Preoperative Factors Correlate With Morbidity Kaitlyn J. Kelly, Yin Wan, Robert J. Rettammel, Emily Winslow, Clifford S. Cho, Sharon M. Weber Background: Evaluation of risk factors following distal pancreatectomy (DP) has been limited by data collected from retrospective, primarily single-institution studies. Using a large, multi-institutional prospectively collected dataset, we sought to define the incidence of complications after DP, identify the preoperative and operative risk factors for the development of complications, and develop a risk score that can be utilized preoperatively. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant use file was utilized to identify patients who underwent DP from 2005 to 2008 by CPT codes. Multivariate logistic regression analysis was performed to identify variables associated with 30-day morbidity and mortality. A scoring system was developed to allow for preoperative identification of patients at risk for adverse events after DP. Results: Among 2,335 patients who underwent DP, 30-day morbidity and mortality were 28% and 1.2%, respectively. Serious complications occurred in 23%, and the most common complications included sepsis (11%), surgical site infection (11%), and pneumonia (5%). On multivariate analysis, variables associated with 30-day mortality included age (>60 yrs), neurologic disease or event, elevated BUN (>40 U/L), and high intraoperative transfusion requirement (≥ 3 units). Preoperative variables associated with serious complication included: male gender, BMI, poor functional status, current smoking, preoperative sepsis, and thrombocytosis. Operative variables associated with serious complication included high intraoperative transfusion requirement (≥ 3 units), and prolonged operation time (>360 minutes). A complication risk score consisting of 1 point for each of the preoperatively determined variables predicted the risk of serious complications (p<0.0001, Table 1). Discussion: The rate of serious complication after DP is 23%. A preoperatively-determined prognostic scoring system predicts the risk for serious complications after DP. This scoring system should be utilized when counseling patients preoperatively, obtaining informed consent, and comparing quality outcome measures between institutions.
427 Patients Admitted With Acute Abdominal Conditions are at High Risk for Development of Symptomatic Venous Thromboembolism (VTE) but Often Fail to Receive Adequate Prophylaxis Emily Pearsall, Ujash Sheth, Darlene Fenech, Marg McKenzie, J. Charles Victor, Robin S. McLeod
SSAT Abstracts
Introduction: There is Level I evidence supporting the use of venous thromboembolism (VTE) prophylaxis in patients admitted with acute medical conditions. Best Practice in General Surgery was initiated to standardize care based on best evidence at seven adult teaching hospitals in Toronto. The aim of this study was to determine the frequency with which VTE prophylaxis was administered appropriately as well as the frequency of symptomatic VTE in patients admitted with acute abdominal conditions. Methods: Charts of 350 patients (50 from each of the seven adult teaching hospitals) admitted with acute abdominal conditions and who did not have surgery for at least 24 hours following admission were audited to identify whether they received VTE prophylaxis, timing, type and factors affecting prescription of VTE prophylaxis. As well, the rate of symptomatic VTE was recorded. Results: Of 350 patients (173 males, 177 females, mean age 64.7), 152 (43.4%) were admitted for bowel obstruction, 9 (2.6%) for acute diverticulitis, 67 (19.1%) for biliary conditions and 122 (34.9%) for other conditions. Eighty (22.9%) patients had cancer. Sixty-one (17.4%) had a history of cancer. Fourteen (4%) had a history for VTE. One hundred and forty-two (40.6%) patients had surgery (mean time 5.44 days) following admission. Two hundred and forty seven (70.6%) received prophylaxis (174 unfractionated heparin, 73 low molecular weight heparin) at time of admission (96.8%) or prior to surgery (2.8%). VTE prophylaxis prescription varied according to hospital (range 46-84%), disease (range 63-75%), and surgery/no surgery (78.2 vs 64.2%). Overall, 12 patients (3.4%) developed symptomatic VTE. Two (16.7%) had a prior history of VTE. Eleven (91.7%) received prophylaxis. Conclusions: Patients admitted with acute abdominal conditions are at high risk for the development of symptomatic VTE. There is variation in the rate of VTE but a gap in care exists. Knowledge transfer strategies are required to ensure all patients receive adequate prophylaxis.
430 Multivisceral Transplantation With Preservation of Native Liver, Pancreaticoduodenal Complex and Spleen. Indications and Long-Term Outcome Ruy Cruz, Guilherme Costa, Geoffrey Bond, Kyle Soltys, William C. Stein, Guosheng Wu, Dolly Martin, Rakesh Sindhi, George V. Mazariegos, Kareem M. Abu-Elmagd
428 The Yield of Non-Invasive Testing in Post-Cholecystectomy Patients With Suspected Bile Duct Injury John M. Iskander, Gregory A. Cote, Riad R. Azar, J Christopher Eagon, Dayna S. Early, Steven A. Edmundowicz, Daniel Mullady, Faris Murad, Jerry Wallis, Sreenivasa S. Jonnalagadda
Due to scarcity of cadaveric liver donors, modification of the originally described multivisceral transplant (MVTx) operation was introduced at our Institution nearly 20 years ago. Native liver was preserved and donor stomach, duodenum, pancreas and intestine were transplanted en bloc with less extensive exenteration of the recipient left upper abdominal organs. This is the first report to outline proper indications, different recipient technical modifications, and long-term outcome. Methods: Out of a total of 279 adult visceral transplants, 29 (10%) patients received modified MVTx grafts between May 1990 and November 2009. Of the 29 modified MVTx recipients, 18 were female and 11 were male with a median age 36.3 years (range:19-58). Maintenance immunosuppression was with tacrolimus and induction was with Zenapax (14%), Thymoglobulin (24%) and Campath (62%). Results: Extensive pseudoobstruction syndrome was the main indication for the procedure with a prevalence of 55%. The second most common indication was Gardner's Syndrome and/or extensive desmoid tumors (28%). In the remaining recipients (17%), prior gastrectomy and/or duodenopancreatectomy were concomitant with the development of short bowel syndrome due to Crohn's disease (n=3) and vascular thrombosis (n=2). Preservation of native pancreaticoduodenal complex and spleen was performed in most of the pseudo-obstruction patients. Native duodenopancreatectomy with preservation of the splenic vascular system was technically feasible in 5 patients with exentensive pathology of the native duodenum and pancreas. With a mean follow-up of 46.1±34 months, 22 (76%) recipients are currently alive with fully functioning grafts. The retransplantation rate was 21% and causes of graft loss were chronic rejection (n=4), acute rejection (n=1) and vascular thrombosis (n=1). The KaplanMeier Patient survival rate was 92% at 1 year and 68% at 5-years with graft survival of 89% and 45%, respectively. Compared to historical controls, incidence of rejection was similar to the intestine-only allografts. Preservation of native spleen reduced risk of PTLD with slight increase in risk of graft versus host disease. Conclusion: In the absence of significant liver damage and portomesenteric venous thrombosis, a modified MVTx is a valid therapeutic option for patients with diffuse gastrointestinal disorders such as pseudo-obstruction, Gardner's Syndrome and other complex abdominal pathology. Preservation of the native duodenopancreatic complex and/or spleen is of added therapeutic benefits and should be performed when technically feasible.
Introduction: Cholecystectomy is associated with significant morbidity in patients who experience a bile duct injury. The incidence of bile duct injury (leak) with a laparoscopic technique is 0.5 to 3% as compared to open cholecystectomy rates of 0.1 to 0.5%. In this retrospective review, we determined the yield of non-invasive imaging in the diagnosis of bile leaks. Methods: A retrospective review of 137 post-cholecystectomy patients with clinical suspicion of bile duct injury was performed. Suspicion of injury was based on fever, pain, leukocytosis or elevated liver function tests. We included patients who had a cholecystectomy via an open or laparoscopic approach, post operative suspicion of bile duct injury with imaging (CT or HIDA) following cholecystectomy and/or ERCP between 2002 and 2009. Patient age, sex, duration to ERCP, radiologic method and findings, pre-ERCP liver function tests, operative indication, surgical method and the site of leak on those with positive ERCP were evaluated. The sensitivity and the positive predictive value (PPV) were calculated for CT scans, HIDA scans, and CT/HIDA scans combined. Results: 137 patients were included in this study, of which 97 (70.8%) had a bile leak and 40 (29.2%) had no evidence of extravasation on ERCP. 131 patients (95.6%) had a CT or HIDA scan or both and 6 had no imaging. Seventy-five of the 137 (54.7%) had a CT scan, 87 (63.5%) had a HIDA scan and 31 (34.1%) had both imaging studies. Using ERCP as the gold standard, the sensitivity for CT scans was 79.1%(CI 69.4 - 88.8%), HIDA scans 85.4%(CI 69.8 - 93.0%), and CT/ HIDA combined 81.5%(CI 73.0 - 89.9%). The false negative rates were 20.9% for CT, 14.6% for HIDA and 18.5% for combined CT/HIDA. The positive predictive value for CT scan was 93%, HIDA 94.6% and combined CT/HIDA 91.7%. Discussion: In the postcholecystectomy setting, non-invasive imaging studies, while providing a strong positive predictive value in appropriately selected patients, carry a significant false negative rate. In patients with a strong clinical suspicion of bile leak, consideration for a more definitive diagnostic approach such as ERCP should be undertaken even if non-invasive studies are unremarkable.
SSAT Abstracts
S-852
427 Patients Admitted With Acute Abdominal Conditions are at High Risk for Development of Symptomatic Venous Thromboembolism (VTE) but Often Fail to Receive Adequate Prophylaxis Emily Pearsall, Ujash Sheth, Darlene Fenech, Marg McKenzie, J. Charles Victor, Robin S. McLeod
SSAT Abstracts
Introduction: There is Level I evidence supporting the use of venous thromboembolism (VTE) prophylaxis in patients admitted with acute medical conditions. Best Practice in General Surgery was initiated to standardize care based on best evidence at seven adult teaching hospitals in Toronto. The aim of this study was to determine the frequency with which VTE prophylaxis was administered appropriately as well as the frequency of symptomatic VTE in patients admitted with acute abdominal conditions. Methods: Charts of 350 patients (50 from each of the seven adult teaching hospitals) admitted with acute abdominal conditions and who did not have surgery for at least 24 hours following admission were audited to identify whether they received VTE prophylaxis, timing, type and factors affecting prescription of VTE prophylaxis. As well, the rate of symptomatic VTE was recorded. Results: Of 350 patients (173 males, 177 females, mean age 64.7), 152 (43.4%) were admitted for bowel obstruction, 9 (2.6%) for acute diverticulitis, 67 (19.1%) for biliary conditions and 122 (34.9%) for other conditions. Eighty (22.9%) patients had cancer. Sixty-one (17.4%) had a history of cancer. Fourteen (4%) had a history for VTE. One hundred and forty-two (40.6%) patients had surgery (mean time 5.44 days) following admission. Two hundred and forty seven (70.6%) received prophylaxis (174 unfractionated heparin, 73 low molecular weight heparin) at time of admission (96.8%) or prior to surgery (2.8%). VTE prophylaxis prescription varied according to hospital (range 46-84%), disease (range 63-75%), and surgery/no surgery (78.2 vs 64.2%). Overall, 12 patients (3.4%) developed symptomatic VTE. Two (16.7%) had a prior history of VTE. Eleven (91.7%) received prophylaxis. Conclusions: Patients admitted with acute abdominal conditions are at high risk for the development of symptomatic VTE. There is variation in the rate of VTE but a gap in care exists. Knowledge transfer strategies are required to ensure all patients receive adequate prophylaxis.
430 Multivisceral Transplantation With Preservation of Native Liver, Pancreaticoduodenal Complex and Spleen. Indications and Long-Term Outcome Ruy Cruz, Guilherme Costa, Geoffrey Bond, Kyle Soltys, William C. Stein, Guosheng Wu, Dolly Martin, Rakesh Sindhi, George V. Mazariegos, Kareem M. Abu-Elmagd
428 The Yield of Non-Invasive Testing in Post-Cholecystectomy Patients With Suspected Bile Duct Injury John M. Iskander, Gregory A. Cote, Riad R. Azar, J Christopher Eagon, Dayna S. Early, Steven A. Edmundowicz, Daniel Mullady, Faris Murad, Jerry Wallis, Sreenivasa S. Jonnalagadda
Due to scarcity of cadaveric liver donors, modification of the originally described multivisceral transplant (MVTx) operation was introduced at our Institution nearly 20 years ago. Native liver was preserved and donor stomach, duodenum, pancreas and intestine were transplanted en bloc with less extensive exenteration of the recipient left upper abdominal organs. This is the first report to outline proper indications, different recipient technical modifications, and long-term outcome. Methods: Out of a total of 279 adult visceral transplants, 29 (10%) patients received modified MVTx grafts between May 1990 and November 2009. Of the 29 modified MVTx recipients, 18 were female and 11 were male with a median age 36.3 years (range:19-58). Maintenance immunosuppression was with tacrolimus and induction was with Zenapax (14%), Thymoglobulin (24%) and Campath (62%). Results: Extensive pseudoobstruction syndrome was the main indication for the procedure with a prevalence of 55%. The second most common indication was Gardner's Syndrome and/or extensive desmoid tumors (28%). In the remaining recipients (17%), prior gastrectomy and/or duodenopancreatectomy were concomitant with the development of short bowel syndrome due to Crohn's disease (n=3) and vascular thrombosis (n=2). Preservation of native pancreaticoduodenal complex and spleen was performed in most of the pseudo-obstruction patients. Native duodenopancreatectomy with preservation of the splenic vascular system was technically feasible in 5 patients with exentensive pathology of the native duodenum and pancreas. With a mean follow-up of 46.1±34 months, 22 (76%) recipients are currently alive with fully functioning grafts. The retransplantation rate was 21% and causes of graft loss were chronic rejection (n=4), acute rejection (n=1) and vascular thrombosis (n=1). The KaplanMeier Patient survival rate was 92% at 1 year and 68% at 5-years with graft survival of 89% and 45%, respectively. Compared to historical controls, incidence of rejection was similar to the intestine-only allografts. Preservation of native spleen reduced risk of PTLD with slight increase in risk of graft versus host disease. Conclusion: In the absence of significant liver damage and portomesenteric venous thrombosis, a modified MVTx is a valid therapeutic option for patients with diffuse gastrointestinal disorders such as pseudo-obstruction, Gardner's Syndrome and other complex abdominal pathology. Preservation of the native duodenopancreatic complex and/or spleen is of added therapeutic benefits and should be performed when technically feasible.
Introduction: Cholecystectomy is associated with significant morbidity in patients who experience a bile duct injury. The incidence of bile duct injury (leak) with a laparoscopic technique is 0.5 to 3% as compared to open cholecystectomy rates of 0.1 to 0.5%. In this retrospective review, we determined the yield of non-invasive imaging in the diagnosis of bile leaks. Methods: A retrospective review of 137 post-cholecystectomy patients with clinical suspicion of bile duct injury was performed. Suspicion of injury was based on fever, pain, leukocytosis or elevated liver function tests. We included patients who had a cholecystectomy via an open or laparoscopic approach, post operative suspicion of bile duct injury with imaging (CT or HIDA) following cholecystectomy and/or ERCP between 2002 and 2009. Patient age, sex, duration to ERCP, radiologic method and findings, pre-ERCP liver function tests, operative indication, surgical method and the site of leak on those with positive ERCP were evaluated. The sensitivity and the positive predictive value (PPV) were calculated for CT scans, HIDA scans, and CT/HIDA scans combined. Results: 137 patients were included in this study, of which 97 (70.8%) had a bile leak and 40 (29.2%) had no evidence of extravasation on ERCP. 131 patients (95.6%) had a CT or HIDA scan or both and 6 had no imaging. Seventy-five of the 137 (54.7%) had a CT scan, 87 (63.5%) had a HIDA scan and 31 (34.1%) had both imaging studies. Using ERCP as the gold standard, the sensitivity for CT scans was 79.1%(CI 69.4 - 88.8%), HIDA scans 85.4%(CI 69.8 - 93.0%), and CT/ HIDA combined 81.5%(CI 73.0 - 89.9%). The false negative rates were 20.9% for CT, 14.6% for HIDA and 18.5% for combined CT/HIDA. The positive predictive value for CT scan was 93%, HIDA 94.6% and combined CT/HIDA 91.7%. Discussion: In the postcholecystectomy setting, non-invasive imaging studies, while providing a strong positive predictive value in appropriately selected patients, carry a significant false negative rate. In patients with a strong clinical suspicion of bile leak, consideration for a more definitive diagnostic approach such as ERCP should be undertaken even if non-invasive studies are unremarkable.
SSAT Abstracts
S-852