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Laparoscopic Peritoneal Dialysis Catheter Placement is Associated with Decreased Risk of Perioperative Peritonitis and Reoperation
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ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS
51.8. Racial Disparities in Early Graft Failure following Infrainguinal Bypass Surgery: An Analysis of the ACS-NSQIP Database.. S. Selvarajah,1 J. H. Black,1 Y. Lum,1 B. W. Propper,1 A. H. Haider,1 C. J. Abularrage1; 1 Johns Hopkins University School Of Medicine - Department Of Surgery, Baltimore, MD, USA Introduction: National efforts to improve postoperative outcomes are being made in an effort to control the rising costs of healthcare. Racial and ethnic differences are found across an array of vascular surgical procedures, and have been shown to be responsible for disparate outcomes. We sought to identify racial disparities in 30-day post-operative graft failure following infrainguinal bypass in an effort to define targets for improved healthcare in minorities. Methods: We queried the American College of Surgeons - National Surgical Quality Improvement Program database from 2005-2011 for all patients undergoing infrainguinal bypass. Patients were stratified by race and a bivariate analysis was done to assess pre- and intraoperative risk factors for the primary outcome of 30-day graft failure. A multivariable logistic regression model was generated to assess the independent association of race with graft failure. Results: A total of 16,276 patients were identified, with 12,536 (77%) whites, 2,940 (18%) blacks, and 800 (5%) Hispanics. Black patients were more likely to be younger, female, current smokers, and on dialysis (p<.001, all). In addition, whites were less likely to present with critical limb ischemia (CLI) compared to blacks and Hispanics (44 vs. 55 vs. 53% respectively; p<.001). Similarly, fewer whites underwent femoral-tibial (31 vs. 35 vs. 39% respectively) or popliteal-tibial level bypasses (9 vs. 13 vs. 16%) than blacks and Hispanics, respectively (p<.001, all). There was no difference in the use of autogenous conduit across the groups (p¼.27). Unadjusted risk of early graft failure was greater in blacks (6.7 vs. 4.5%; p<.001) and Hispanics (6.0 vs. 4.5%; p¼.06) compared to whites. On multivariable analysis, only black race remained independently associated with early graft failure (Adjusted OR: 1.26; 95% CI [1.13-1.61]; p¼.009). The trend seen in Hispanics was driven by the higher prevalence of CLI and the need for tibial level revascularization. Conclusions: Both blacks and Hispanics present with more advanced peripheral vascular disease, requiring a more distal revascularization. Black race was independently associated with early graft failure after infrainguinal bypass. These results suggest the possible lack of early access and consistent utilization of healthcare for minorities, and should be a target for improved outcomes.
51.9. Laparoscopic Peritoneal Dialysis Catheter Placement is Associated with Decreased Risk of Perioperative Peritonitis and Reoperation. T. Tan,1 C. Chong,1 K. Abreo,1 M. E. Pahilan,1 W. W. Zhang,1 A. Farber3; 1 Louisiana State University Health Science Center Shreveport, Shreveport, LA, USA; 3Boston University Vascular Surgery, Boston, MA, USA Introduction: The optimal method for placement of peritoneal dialysis (PD) catheters is unclear. The objective of this study was to compare the outcomes of laparoscopic and open surgical placement of PD catheters. Methods: Patients who underwent open (OPD) and laparoscopic (LPD) surgical placement of PD catheters between 2005 and 2010 were identified from the American College of Surgeons - National Surgical Quality Initiative Project dataset using CPT and ICD codes. Perioperative outcomes including mortality, surgical site infection (SSI), peritonitis, reoperation, operative time, hospital length of
stay (LOS) were compared using student T test. Results: There were 1,577 PD catheter placement procedures in our study and most were performed laparoscopically (88.7%). Eighty three percent of PD catheter placement procedures were performed by general surgeons, mostly, under general anesthesia (94%). Although perioperative mortality and SSI were similar between these cohorts, OPD was associated with a higher rate of perioperative peritonitis (3.4% vs. 1.1%, p¼.02) and need for reoperation (11.2% vs. 5.1%, p¼.001). Operative time was significantly longer with LPD (54638 vs. 48649 minutes, p<.0001) but LOS was similar between both procedures (LPD:2611 vs.OPD: 3.462 days, p¼.10). In multivariate analysis, OPD was independently associated with increased risk of perioperative peritonitis (Odd ratio 2.4, 95% Confidence Interval 1.3-4.2, p¼.003). Conclusions: Laparoscopic peritoneal catheter placement is the most common current method of PD catheter placement and despite longer operative times, it is associated with lower risk of perioperative peritonitis and reoperation. When possible, PD catheters should be placed laparoscopically.
51.10. Preclinical Assessment of Host Remodeling of a Bioengineered Blood Vessel. J. H. Lawson,3,4 H. L. Prichard,2 R. J. Manson,3 S. M. Gage,3 M. SantiagoMaysonet,2 J. T. Strader,2 L. E. Niklason,1,2 S. L. Dahl2; 1 Yale University - Anesthesiology And Biomedical Engineering, New Haven, CT, USA; 2Humacyte, Inc., Durham, NC, USA; 3Duke University Medical Center Surgery, Durham, NC, USA; 4Duke University Medical Center - Pathology, Durham, NC, USA Introduction: Bioengineered human blood vessels (Humacyte, Inc.) are being studied as arterio-venous access conduits in patients on hemodialysis. The purpose of this study was to determine the remodeling events that occur in the bioengineered blood vessels, after implantation into large animal models as arterial or arterio-venous grafts. Methods: Bioengineered blood vessels are grown from human vascular cells that are cultured on a biocompatible polymer matrix inside of disposable bioreactors. After culture, engineered blood vessels are decellularized, creating an acellular conduit comprising human extracellular matrix proteins. These bioengineered blood vessels have been studied as end-to-end arterial grafts (vervet monkeys) and as arterio-venous grafts (baboons) for up to 6 months. Results: After implantation, the acellular grafts remodeled to incorporate host smooth muscle and endothelial cells. Repopulation was most rapid at the anastomoses, but was notably extensive in the mid-sections of long grafts after 3-6 months. The graft extracellular matrix was also remodeled, with evidence of new host-derived matrix, and improvements in the organization of extracellular matrix components (e.g., collagen). Bioengineered vessels explanted from primates showed significantly higher suture retention strengths than the original, implanted vessels. Lastly, studies in a porcine model showed that the grafts are resistant to anastomotic intimal hyperplasia, and display lower levels of mTOR pathway activation than do matched autologous vein grafts. Indeed, a total of > 25 implants in large animals has shown no evidence of hemodynamically significant intimal hyperplasia. Conclusions: In conclusion, there is extensive cellular repopulation and matrix remodeling of the bioengineered blood vessels in vivo. This remodeling transforms the graft into a living vascular structure. The remodeled vessel is mechanically stronger than the original implanted bioengineered vessel, indicating favorable remodeling in vivo.
ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS
51.8. Racial Disparities in Early Graft Failure following Infrainguinal Bypass Surgery: An Analysis of the ACS-NSQIP Database.. S. Selvarajah,1 J. H. Black,1 Y. Lum,1 B. W. Propper,1 A. H. Haider,1 C. J. Abularrage1; 1 Johns Hopkins University School Of Medicine - Department Of Surgery, Baltimore, MD, USA Introduction: National efforts to improve postoperative outcomes are being made in an effort to control the rising costs of healthcare. Racial and ethnic differences are found across an array of vascular surgical procedures, and have been shown to be responsible for disparate outcomes. We sought to identify racial disparities in 30-day post-operative graft failure following infrainguinal bypass in an effort to define targets for improved healthcare in minorities. Methods: We queried the American College of Surgeons - National Surgical Quality Improvement Program database from 2005-2011 for all patients undergoing infrainguinal bypass. Patients were stratified by race and a bivariate analysis was done to assess pre- and intraoperative risk factors for the primary outcome of 30-day graft failure. A multivariable logistic regression model was generated to assess the independent association of race with graft failure. Results: A total of 16,276 patients were identified, with 12,536 (77%) whites, 2,940 (18%) blacks, and 800 (5%) Hispanics. Black patients were more likely to be younger, female, current smokers, and on dialysis (p<.001, all). In addition, whites were less likely to present with critical limb ischemia (CLI) compared to blacks and Hispanics (44 vs. 55 vs. 53% respectively; p<.001). Similarly, fewer whites underwent femoral-tibial (31 vs. 35 vs. 39% respectively) or popliteal-tibial level bypasses (9 vs. 13 vs. 16%) than blacks and Hispanics, respectively (p<.001, all). There was no difference in the use of autogenous conduit across the groups (p¼.27). Unadjusted risk of early graft failure was greater in blacks (6.7 vs. 4.5%; p<.001) and Hispanics (6.0 vs. 4.5%; p¼.06) compared to whites. On multivariable analysis, only black race remained independently associated with early graft failure (Adjusted OR: 1.26; 95% CI [1.13-1.61]; p¼.009). The trend seen in Hispanics was driven by the higher prevalence of CLI and the need for tibial level revascularization. Conclusions: Both blacks and Hispanics present with more advanced peripheral vascular disease, requiring a more distal revascularization. Black race was independently associated with early graft failure after infrainguinal bypass. These results suggest the possible lack of early access and consistent utilization of healthcare for minorities, and should be a target for improved outcomes.
51.9. Laparoscopic Peritoneal Dialysis Catheter Placement is Associated with Decreased Risk of Perioperative Peritonitis and Reoperation. T. Tan,1 C. Chong,1 K. Abreo,1 M. E. Pahilan,1 W. W. Zhang,1 A. Farber3; 1 Louisiana State University Health Science Center Shreveport, Shreveport, LA, USA; 3Boston University Vascular Surgery, Boston, MA, USA Introduction: The optimal method for placement of peritoneal dialysis (PD) catheters is unclear. The objective of this study was to compare the outcomes of laparoscopic and open surgical placement of PD catheters. Methods: Patients who underwent open (OPD) and laparoscopic (LPD) surgical placement of PD catheters between 2005 and 2010 were identified from the American College of Surgeons - National Surgical Quality Initiative Project dataset using CPT and ICD codes. Perioperative outcomes including mortality, surgical site infection (SSI), peritonitis, reoperation, operative time, hospital length of
stay (LOS) were compared using student T test. Results: There were 1,577 PD catheter placement procedures in our study and most were performed laparoscopically (88.7%). Eighty three percent of PD catheter placement procedures were performed by general surgeons, mostly, under general anesthesia (94%). Although perioperative mortality and SSI were similar between these cohorts, OPD was associated with a higher rate of perioperative peritonitis (3.4% vs. 1.1%, p¼.02) and need for reoperation (11.2% vs. 5.1%, p¼.001). Operative time was significantly longer with LPD (54638 vs. 48649 minutes, p<.0001) but LOS was similar between both procedures (LPD:2611 vs.OPD: 3.462 days, p¼.10). In multivariate analysis, OPD was independently associated with increased risk of perioperative peritonitis (Odd ratio 2.4, 95% Confidence Interval 1.3-4.2, p¼.003). Conclusions: Laparoscopic peritoneal catheter placement is the most common current method of PD catheter placement and despite longer operative times, it is associated with lower risk of perioperative peritonitis and reoperation. When possible, PD catheters should be placed laparoscopically.
51.10. Preclinical Assessment of Host Remodeling of a Bioengineered Blood Vessel. J. H. Lawson,3,4 H. L. Prichard,2 R. J. Manson,3 S. M. Gage,3 M. SantiagoMaysonet,2 J. T. Strader,2 L. E. Niklason,1,2 S. L. Dahl2; 1 Yale University - Anesthesiology And Biomedical Engineering, New Haven, CT, USA; 2Humacyte, Inc., Durham, NC, USA; 3Duke University Medical Center Surgery, Durham, NC, USA; 4Duke University Medical Center - Pathology, Durham, NC, USA Introduction: Bioengineered human blood vessels (Humacyte, Inc.) are being studied as arterio-venous access conduits in patients on hemodialysis. The purpose of this study was to determine the remodeling events that occur in the bioengineered blood vessels, after implantation into large animal models as arterial or arterio-venous grafts. Methods: Bioengineered blood vessels are grown from human vascular cells that are cultured on a biocompatible polymer matrix inside of disposable bioreactors. After culture, engineered blood vessels are decellularized, creating an acellular conduit comprising human extracellular matrix proteins. These bioengineered blood vessels have been studied as end-to-end arterial grafts (vervet monkeys) and as arterio-venous grafts (baboons) for up to 6 months. Results: After implantation, the acellular grafts remodeled to incorporate host smooth muscle and endothelial cells. Repopulation was most rapid at the anastomoses, but was notably extensive in the mid-sections of long grafts after 3-6 months. The graft extracellular matrix was also remodeled, with evidence of new host-derived matrix, and improvements in the organization of extracellular matrix components (e.g., collagen). Bioengineered vessels explanted from primates showed significantly higher suture retention strengths than the original, implanted vessels. Lastly, studies in a porcine model showed that the grafts are resistant to anastomotic intimal hyperplasia, and display lower levels of mTOR pathway activation than do matched autologous vein grafts. Indeed, a total of > 25 implants in large animals has shown no evidence of hemodynamically significant intimal hyperplasia. Conclusions: In conclusion, there is extensive cellular repopulation and matrix remodeling of the bioengineered blood vessels in vivo. This remodeling transforms the graft into a living vascular structure. The remodeled vessel is mechanically stronger than the original implanted bioengineered vessel, indicating favorable remodeling in vivo.