Pedicled Flaps for High-Risk Open Vascular Procedures of the Lower Extremity: An Analysis of The National Surgical Quality Improvement Project Database

BACKGROUND

 Use of pedicled flaps in vascular procedures is associated with decreased infection and wound breakdown. We evaluated the risk profile and postoperative complications associated with lower extremity open vascular procedures with and without pedicled flaps.

METHODS

 The American College of Surgeons National Surgical Quality Improvement Program database (2010-2020) was queried for Current Procedural Terminology codes representing lower extremity open vascular procedures, including trunk and lower extremity pedicled flaps. Flap patients were compared with a randomized control group without flaps (1:3 cases to controls). Univariate and multivariate analyses were performed.

RESULTS

 We identified 132,934 adults who underwent lower extremity open vascular procedures. Concurrent pedicled flaps were rare (0.7%), and patients undergoing bypass procedures were more likely to receive a flap than nonbypass patients (69 vs. 64%, p < 0.0001). Flap patients had greater comorbidities. On univariate analysis, flap patients were more likely to experience wound (p = 0.0026), mild systemic (p < 0.0001), severe systemic (p = 0.0452), and all-cause complications (p < 0.0001). After adjusting for factors clinically suspected to be associated with increased risk (gender, body mass index, procedure type, American Society of Anesthesiologists classification, functional status, diabetes, smoking, and albumin < 3.5 mg/dL), wound (p = 0.096) and severe systemic complications (p = 0.0719) were no longer significantly associated with flap patients.

CONCLUSION

 Lower extremity vascular procedures are associated with a high risk of complications. Use of pedicled flaps remains uncommon and more often performed in patients with greater comorbid disease. However, after risk adjustment, use of a pedicled flap in high-risk patients may be associated with lower than expected wound and severe systemic complications.

Patient-Reported Outcomes on Subjective Nipple Sensation After Double-Incision and Periareolar Mastectomy for Chest Masculinization: Subjective Nipple Sensation After Chest Masculinization

ABSTRACT

We evaluated patient-reported outcomes to assess for patient and procedural factors associated with postchest masculinization subjective nipple sensation. Patients who underwent double-incision or periareolar mastectomies for chest masculinization by a single senior surgeon (2015-2019) were surveyed at 2 time points regarding postoperative nipple sensation and satisfaction, including patient-reported outcomes using BODY-Q modules (Q-Portfolio.org). Demographic, operative, and postoperative variables were obtained from medical records. Patients were stratified according to survey responses. Univariate and multivariate analyses were performed.Response rate was 42% for survey 1 and 22% for survey 2. Of the 151 survey 1 responders, 138 (91.4%) received double-incision mastectomies and 13 (8.6%) received periareolar mastectomies. Among Survey 1 responders, 84.6% periareolar patients and 69.6% double-incision patients reported "completely" or "a little" nipple sensation preservation, and the difference trended toward significance (P = 0.0719). There was a stepwise increase in proportion of patients reporting sensation with greater recovery time until response to survey 1. Obesity (P = 0.0080) and greater tissue removed (P = 0.0247) were significantly associated with decreased nipple sensation. Nipple satisfaction scores were significantly higher for patients reporting improved nipple sensation (P = 0.0235). Responders to survey 2 who reported greater satisfaction with nipple sensation were significantly more likely to report preserved sensitivity to light touch (P = 0.0277), pressure (P = 0.0046), and temperature (P = 0.0031). Preserved erogenous sensation was also significantly associated with greater satisfaction (P = 0.0018).In conclusion, we found that nipple sensation may be associated with postoperative nipple satisfaction. Operative techniques to optimize nipple sensation preservation may improve this population's postoperative satisfaction.

Is Diabetes a Contraindication to Lower Extremity Flap Reconstruction? An Analysis of Threatened Lower Extremities in the NSQIP Database (2010-2020)

Background  The impact of diabetes on complication rates following free flap (FF), pedicled flap (PF), and amputation (AMP) procedures on the lower extremity (LE) is examined. Methods  Patients who underwent LE PF, FF, and AMP procedures were identified from the 2010 to 2020 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP®) database using Current Procedural Terminology and International Classification of Diseases-9/10 codes, excluding cases for non-LE pathologies. The cohort was divided into diabetics and nondiabetics. Univariate and adjusted multivariable logistic regression analyses were performed. Results  Among 38,998 patients undergoing LE procedures, 58% were diabetic. Among diabetics, 95% underwent AMP, 5% underwent PF, and <1% underwent FF. Across all procedure types, noninsulin-dependent (NIDDM) and insulin-dependent diabetes mellitus (IDDM) were associated with significantly greater all-cause complication rates compared with absence of diabetes, and IDDM was generally higher risk than NIDDM. Among diabetics, complication rates were not significantly different across procedure types (IDDM: p  = 0.5969; NIDDM: p  = 0.1902). On adjusted subgroup analysis by diabetic status, flap procedures were not associated with higher odds of complications compared with amputation for IDDM and NIDDM patients. Length of stay > 30 days was statistically associated with IDDM, particularly those undergoing FF (AMP: 5%, PF: 7%, FF: 14%, p  = 0.0004). Conclusion  Our study highlights the importance of preoperative diabetic optimization prior to LE procedures. For diabetic patients, there were few significant differences in complication rates across procedure type, suggesting that diabetic patients are not at higher risk of complications when attempting limb salvage instead of amputation.

Does Frailty Predict Outcomes in Patients Undergoing Free or Pedicled Flap Procedures for Lower Extremity Limb Salvage? An Analysis of the American College of Surgeons National Surgical Quality Improvement Program Database

BACKGROUND

 Older and frailer patients are increasingly undergoing free or pedicled tissue transfer for lower extremity (LE) limb salvage. This novel study examines the impact of frailty on postoperative outcomes in LE limb salvage patients undergoing free or pedicled tissue transfer.

METHODS

 The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2010-2020) was queried for free and pedicled tissue transfer to the LE based on Current Procedural Terminology and the International Classification of Diseases9/10 codes. Demographic and clinical variables were extracted. The five-factor modified frailty index (mFI-5) was calculated using functional status, diabetes, chronic obstructive pulmonary disease, congestive heart failure, and hypertension. Patients were stratified by mFI-5 score: no frailty (0), intermediate frailty (1), and high frailty (2 + ). Univariate analysis and multivariate logistic regression were performed.

RESULTS

 In total, 5,196 patients underwent free or pedicled tissue transfer for LE limb salvage. A majority were intermediate (n = 1,977) or high (n = 1,466) frailty. High frailty patients had greater rates of comorbidities-including those not in the mFI-5 score. Higher frailty was associated with more systemic and all-cause complications. On multivariate analysis, the mFI-5 score remained the best predictor of all-cause complications-with high frailty associated with 1.74 increased adjusted odds when compared with no frailty (95% confidence interval: 1.47-2.05).

CONCLUSION

 While flap type, age, and diagnosis were independent predictors of outcomes in LE flap reconstruction, frailty (mFI-5) was the strongest predictor on adjusted analysis. This study validates the mFI-5 score for preoperative risk assessment for flap procedures in LE limb salvage. These results highlight the likely importance of prehabilitation and medical optimization prior to limb salvage.

Development of a risk score to predict occurrence of deep sternal dehiscence requiring operative debridement

OBJECTIVE

Severe deep sternal wound (DSW) complications after cardiac surgery are a source of cost, morbidity, and mortality. Our objective was to develop and validate a clinical risk score for predicting risk of DSW requiring operative bone debridement, the most severe form of sternal dehiscence.

METHODS

A retrospective review was conducted of patients who underwent open cardiac surgery at a single institution between October 2007 and March 2019. Primary outcome was DSW requiring sternal bone debridement. Potential risk factors were screened using Least Absolute Shrinkage and Selection Operator (LASSO) and significant covariates were included in a logistic regression prediction model. Interval validation was performed using 10-fold cross-validation. A novel sternal wound dehiscence risk score was derived from the relative parameterization estimates.

RESULTS

One hundred thirty-four of 8403 patients (1.6%) were identified as having a DSW. Female sex (odds ratio [OR], 2.75; 95% CI, 2.58-2.93), body mass index (OR, 1.0946; 95% CI, 1.09-1.09), percent glycated hemoglobin (OR, 1.31; 95% CI, 1.28-1.33), peripheral vascular disease (OR, 2.38; 95% CI, 2.2005-2.5752), smoking (OR, 1.66; 95% CI, 1.53-1.79) and elevated creatinine level (OR, 1.20; 95% CI, 1.18-1.22) were independent predictors of DSW. Patients were categorized as minimal risk (0%-1%), low risk (2%-3%), intermediate risk (4%-7%), and high risk (9%-64.0%) on the basis of risk score.

CONCLUSIONS

This risk stratification model for DSW requiring operative debridement might provide individualized estimates of risk, and guide counseling and potential risk mitigation strategies.

Impact of sternal notch-to-nipple distance and resection weight asymmetry on complication rates and patient reported outcomes in reduction mammaplasty

While there are numerous predictive models for estimating resection weight, their accuracy may not be strong. Through institutional data of patients who received reduction mammaplasty, this study demonstrates that preoperative sternal notch-to-nipple distance is not an optimal predictive factor for differences in final resection weight, complication rates, and patient reported outcomes. Our results showed that there is a weak correlation between preoperative sternal notch to nipple asymmetry and final resection weight asymmetry. Additionally, significant breast asymmetry is not tied to an increase in complication rates or poorer patient reported outcomes. There is an indication to reconsider the use of such absolute measures for determining who may benefit from reduction mammaplasty.

Sternal bone anatomy on preoperative imaging as an independent predictor of deep sternal dehiscence following median sternotomy

Complications following median sternotomy are associated with morbidity, mortality, and major healthcare costs. With plastic surgeons being increasingly consulted to close complex sternotomy wounds, a more accurate risk stratification tool for this comorbid patient population is warranted. This study examines the association of preoperative radiologic sternal measurements and deep sternal dehiscence, comparing this with other known clinical risk factors. A decreased manubrium sternal thickness relative to body weight (<0.13 mm/kg) and an absolute inferior sternal width ≤13.8 mm had a significant association with the development of deep sternal dehiscence, even with adjustment for known clinical risk factors. With such measurements assisting in further risk stratification, the opportunity to improve risk assessment holds value for plastic and reconstructive surgeons who are consulted to close extensive sternotomy wounds.

The Effect of Preoperative Diagnosis of Depression and/or Anxiety on Patient-Reported Outcomes Following Chest Wall Masculinization Surgery

BACKGROUND

Individuals with gender dysphoria have disproportionately high rates of depression and anxiety compared to the cisgender population. Although the benefits of gender affirmation surgery have been well documented, it is unclear whether depression and anxiety affect postoperative patient-reported outcomes (PRO).

OBJECTIVES

The authors evaluated the impact of preoperative anxiety or depression on clinical and PRO in patients undergoing chest masculinization surgery.

METHODS

Patients who underwent chest masculinization surgery within a 5-year period were reviewed. Demographics and clinical variables were abstracted from medical records. PRO of chest, nipple, and scar satisfaction were obtained postoperatively with the BODY-Q. Groups were stratified by preoperative anxiety, preoperative depression, both, or no history of mental health diagnosis. Univariate and multivariate analyses were performed.

RESULTS

Of 135 patients with complete survey responses, 10.4% had anxiety, 11.9% depression, 20.7% both diagnoses, and 57.0% no diagnosis. Clinical data and outcomes were similar. Patients with preoperative depression correlated with lower satisfaction scores for scar appearance (P = .006) and were significantly more likely to report feelings of depression postoperatively (P = .04). There were no significant differences in chest or nipple satisfaction among groups.

CONCLUSIONS

Although anxiety and depression are prevalent in gender minorities, we found no association with postoperative clinical outcomes. Patients with preoperative depression were more likely to report lower satisfaction with scar appearance and feelings of depression postoperatively. However, there were no differences in chest or nipple satisfaction. These results highlight the importance of perioperative mental health counseling but also suggest that patients can be satisfied with their results despite a coexisting mental health diagnosis.

LEVEL OF EVIDENCE: 4

Novel use of interosseous absorbable mattress sutures for secondary sternal fixation: A case series

There is currently no consensus on the treatment of median sternotomy patients presenting secondarily with deep sternal wound infection or symptomatic sternal nonunion. We have developed a novel approach to sternal bone fixation when concerns for open wounds or microbial colonization preclude the use of permanent hardware placement: (1) sternal closure with absorbable interosseous monocortical horizontal mattress sutures followed by (2) multilayered soft tissue closure with pectoralis major advancement or turnover flaps. Benefits of this technique include: closure of retrosternal dead-space, tension offloading of the soft tissue closure, repair of transverse sternal fractures, and preservation of internal mammary artery (IMA) perforators for potential pectoralis turnover flaps. In our early experience, this technique has been successful at promoting functional sternal union - even in secondary closure of high-risk patients contraindicated for permanent hardware placement.

The use of abdominal wall tissue expansion prior to herniorrhaphy in massive ventral hernia defects

BACKGROUND

Massive ventral hernias pose a challenging reconstructive problem. In comparison to bridging mesh repair, the primary fascial repair is associated with significantly reduced rates of hernia recurrence. This study will review our experience with massive ventral hernia repairs using tissue expansion and anterior component separation as well as present the largest case series to date.

METHODS

A retrospective review was conducted of 61 patients who underwent abdominal wall tissue expansion prior to herniorrhaphy at a single institution between 2011 and 2017. Demographics, perioperative co-variates, and outcomes were recorded. Univariate and subgroup analysis was performed. Kaplan-Meier survival analysis was used to assess the time to recurrence.

RESULTS

Sixty-one patients underwent abdominal wall expansion via tissue expanders (TE). Of these, 56 subsequently underwent staged anterior component separation for attempted closure of large ventral hernia. Major complications of TE placement included TE replacement (4,6.6%), TE leak (2,3.3%), and unplanned readmission (3,4.9%). Higher BMI groups were significantly associated with comorbid hypertension (BMI<30 kg/m², 22.7%; BMI 30-35 kg/m², 68.7%; BMI>35 kg/m², 64.7%; P = 0.004). 15 patients (32.6%) had hernia recurrence and 21 patients (34.4%) still required bridging mesh during herniorrhaphy after tissue expansion.

CONCLUSION

The use of tissue expansion prior to herniorrhaphy can be effective in achieving durable closure for most massive abdominal wall defects - especially those associated with musculofascial, soft tissue, or skin deficiencies. In this proof-of-concept analysis, we found that the efficacy and safety profile of this technique compares favorably to other methods for massive hernia repair in the literature.

Outpatient Prosthetic Based Reconstruction During COVID-19 Pandemic Possible in Selected Patients Without Increased Complications

BACKGROUND

Following the reopening of elective surgery, our division transitioned from inpatient admission to same-day discharge for immediate prosthetic breast reconstruction in an effort to decrease the hospital's clinical burden and minimize potential COVID-19 exposure. This study aims to compare complication rates following this acute transition for patients who had inpatient and outpatient mastectomy with immediate alloplastic reconstruction.

METHODS

A retrospective chart review was performed on patients who underwent mastectomy with immediate prosthetic reconstruction. The outcome of interest was 30-day morbidity. Descriptive statistics were compared for patients with outpatient and inpatient surgeries. Odds ratios were calculated to determine whether any pre-operative factors increased odds of 30-day complications.

RESULTS

A total of 115 patients were included in this study. Twenty-six patients had outpatient surgery and 89 stayed inpatient postoperatively. Same-day discharge did not significantly impact the odds of having one or more 30-day complications (OR: 0.275, 95% CI: 0.047-1.618, p = 0.153). Patients with complications had significantly longer median operating times (5.0, IQR 4.0 - 6.0 vs. 4.0, IQR 3.0 - 5.0, p = 0.05), and there was a statistically significant association between length of surgery and odds of complication (OR: 1.596, 95% CI: 1.039-2.451, p = 0.033). Age was independently associated with increased risk of 30-day complication (OR: 1.062, 95% CI: 1.010-1.117, p = 0.020).

CONCLUSIONS

Our findings support a continuation of same-day discharge strategy which could decrease costs for patients and hospitals without increasing complications.

An Algorithmic Approach to the Surgical Management of Sternal Dehiscence: A Single-Center Experience

Background Deep sternal wound complications following sternotomy represent a complex challenge. Management can involve debridement, flap reconstruction, and rigid sternal fixation (RSF). We present our 11-year experience in the surgical treatment of deep sternal wound dehiscence using a standardized treatment algorithm.

Methods A retrospective review was conducted of all 134 cardiac patients who required operative debridement after median sternotomy at a single institution between October 2007 and March 2019. Demographics, perioperative covariates, and outcomes were recorded. Univariate and subgroup analyses were performed.

Results One-hundred twelve patients (83.5%) with a deep sternal dehiscence underwent flap closure and 56 (50%) RSF. Of the patients who underwent flap closure, 87.5% received pectoralis advancement flaps. A 30-day mortality following reconstruction was 3.9%. Median length of stay after initial debridement was 8 days (interquartile range: 5–15). Of patients with flaps, 54 (48%) required multiple debridements prior to closure, and 30 (27%) underwent reoperation after flap closure. Patients who needed only a single debridement were significantly less likely to have a complication requiring reoperation (N = 10/58 vs. 20/54, 17 vs. 37%, p = 0.02), undergo a second flap (N = 6/58 vs. 17/54, 10 vs. 32%, p < 0.001), or, if plated, require removal of sternal plates (N = 6/34 vs. 11/22, 18 vs. 50%, p = 0.02).

Conclusion Although sternal dehiscence remains a complex challenge, an aggressive treatment algorithm, including debridement, flap closure, and consideration of RSF, can achieve good long-term outcomes. In low-risk patients, RSF does not appear to increase the likelihood of reoperation. We hypothesize that earlier surgical intervention, before the development of systemic symptoms, may be associated with improved outcomes.

Reconstruction of the Upper Extremity High-Voltage Electrical Injury: A Pediatric Burn Hospital's 13-Year Experience

High-voltage electrical injury is a rare yet destructive class of burn injury that persists as a serious public health issue. High-voltage exposure is commonly associated with complex wounds to the upper extremities, which can be a significant challenge for burn and plastic surgeons to reconstruct. This intensive and multistage reconstructive process is especially difficult in the growing child. Maximizing upper extremity function is a top priority, as it can have a significant impact on a patient's quality of life. Therefore, this retrospective review describes lessons learned during a 13-year experience at a specialized pediatric burn hospital with reconstruction of the upper extremity after severe high-voltage injury in 37 children. We found that adherence to the following principles can help promote meaningful functional recovery. These include: (1) frequent assessment during early acute care for the evolving need of decompression or amputation, (2) serial surgical debridement that follows a tissue-sparing technique, (3) wound closure by skin grafting or use of flaps (particularly groin or abdominal pedicled flaps) when deep musculoskeletal structures are involved, (4) early multidisciplinary intervention for contracture prevention and management including physical and occupational therapy, splinting, and fixation, (5) secondary reconstruction that focuses on the simplest possible techniques to repair chronic skin defects such as laser therapy, local tissue rearrangements, and skin grafting, (6) complex secondary reconstruction to address deeper tissue contractures or tendon and peripheral nerve deficits, and (7) amputation with preservation of growth plates, soft tissue transfer, and long-term prosthetic management when limb salvage is unlikely.

Temporoparietal Fascia Free Flap for a Large Nasal Septal Perforation

Reconstruction of large nasal septal perforations can be a considerable challenge for surgeons. Reconstructive modalities are often determined by the size of the defect and the quality of local tissue and vasculature. Local and regional flaps may not provide enough tissue to achieve successful closure in patients with large perforations and those with baseline compromise of the nasal mucosa and blood supply from prior intervention or underlying medical condition. Microvascular free tissue transfer is a possible approach to reconstruction in these patients. We report a case of a 30-year-old man who presented with a large, symptomatic, 4 × 3.5 cm perforation as a result of prior functional septoplasty at an outside hospital. Reconstruction of the defect was accomplished in this setting with a free temporoparietal fascia (TPF) flap anastomosed to the columellar branch of the labial artery and the angular vein. Postoperative follow-up visits showed successful closure of the perforation without complications. As illustrated by this case, TPF flap is a versatile tool for complex nasal reconstructions. With minimal donor-site morbidity and rich vascularity capable of promoting remucosalization without the need for prelamination, the TPF flap may be suited for the repair of large nasoseptal perforations.

Long term mortality in critically ill burn survivors

INTRODUCTION

Little is known about long term survival risk factors in critically ill burn patients who survive hospitalization. We hypothesized that patients with major burns who survive hospitalization would have favorable long term outcomes.

METHODS

We performed a two center observational cohort study in 365 critically ill adult burn patients who survived to hospital discharge. The exposure of interest was major burn defined a priori as >20% total body surface area burned [TBSA]. The modified Baux score was determined by age + %TBSA+ 17(inhalational injury). The primary outcome was all-cause 5year mortality based on the US Social Security Administration Death Master File. Adjusted associations were estimated through fitting of multivariable logistic regression models. Our final model included adjustment for inhalational injury, presence of 3rd degree burn, gender and the acute organ failure score, a validated ICU risk-prediction score derived from age, ethnicity, surgery vs. medical patient type, comorbidity, sepsis and acute organ failure covariates. Time-to-event analysis was performed using Cox proportional hazard regression.

RESULTS

Of the cohort patients studied, 76% were male, 29% were non white, 14% were over 65, 32% had TBSA >20%, and 45% had inhalational injury. The mean age was 45, 92% had 2nd degree burns, 60% had 3rd degree burns, 21% received vasopressors, and 26% had sepsis. The mean TBSA was 20.1%. The mean modified Baux score was 72.8. Post hospital discharge 5year mortality rate was 9.0%. The 30day hospital readmission rate was 4%. Patients with major burns were significantly younger (41 vs. 47 years) had a significantly higher modified Baux score (89 vs. 62), and had significantly higher comorbidity, acute organ failure, inhalational injury and sepsis (all P<0.05). There were no differences in gender and the acute organ failure score between major and non-major burns. In the multivariable logistic regression model, major burn was associated with a 3 fold decreased odds of 5year post-discharge mortality compared to patients with TBSA<20% [OR=0.29 (95%CI 0.11-0.78; P=0.014)]. The adjusted model showed good discrimination [AUC 0.81 (95%CI 0.74-0.89)] and calibration (Hosmer-Lemeshow χ² P=0.67). Cox proportional hazard multivariable regression modeling, adjusting for inhalational injury, presence of 3rd degree burn, gender and the acute organ failure score, showed that major burn was predictive of lower mortality following hospital admission [HR=0.34 (95% CI 0.15-0.76; P=0.009)]. The modified Baux score was not predictive for mortality following hospital discharge [OR 5year post-discharge mortality=1.00 (95%CI 0.99-1.02; P=0.74); HR for post-discharge mortality=1.00 (95% CI 0.99-1.02; P=0.55)].

CONCLUSIONS

Critically ill patients with major burns who survive to hospital discharge have decreased 5year mortality compared to those with less severe burns. ICU Burn unit patients who survive to hospital discharge are younger with less comorbidities. The observed relationship is likely due to the relatively higher physiological reserve present in those who survive a Burn ICU course which may provide for a survival advantage during recovery after major burn.

Reconstruction of the Adult and Pediatric Burned Hand

Thermal injuries of the hand can have a great impact on function. Initial treatment should focus on the prevention of contracture through the use of tissue-sparing techniques and optimized occupational therapy. Surgical intervention should follow the standard reconstructive ladder and can involve several techniques from simple to complex including minimally invasive techniques, such as laser and steroid injection, contracture release and skin grafting, and local tissue rearrangement and regional flaps as well as distant pedicled and free flaps. Reconstructive surgery of the hand, when performed well, can lead to meaningful functional improvement in severe burns.

Pulmonary support on day of life 30 is a strong predictor of increased 1 and 5-year morbidity in survivors of congenital diaphragmatic hernia

PURPOSE

Pulmonary support (PS) on day-of-life-30 (DOL-30) has been shown to be the strongest predictor of subsequent morbidity and in-patient mortality in congenital diaphragmatic hernia (CDH). We hypothesized that PS on DOL-30 can also predict long-term outcomes in CDH survivors.

METHODS

We analyzed records of 201 CDH survivors followed by a single multidisciplinary clinic (1995-2010). Follow-up was 83 and 70% at 1 and 5years respectively. PS was defined as: (1) invasive support (n=44), (2) noninvasive support (n=54), or (3) room air (n=103). Logistic regression was used to estimate the adjusted association of PS on DOL-30 with outcomes at 1 and 5-years.

RESULTS

Use of PS on DOL-30 was significantly associated with pulmonary and developmental morbidities at 1 and 5-years. Even after adjusting for defect-size and presence of ventilation/perfusion mismatch, greater PS on DOL-30 was associated with a significantly increased odds of requiring supplemental oxygen and developmental referral at 1-year, and asthma and developmental referral at 5-years.

CONCLUSION

CDH survivors continue to have significant long-term pulmonary and developmental morbidities. PS on DOL-30 is a strong independent predictor of morbidity at 1 and 5-years and may be used as a simple prognostic tool to identify high-risk infants.

The effect of graft type on mortality in liver transplantation for hepatocellular carcinoma

BACKGROUND

Liver transplantation (LT) with living-donor (LD-P) and deceased-donor (DD-P) partial grafts for hepatocellular carcinoma (HCC) may be associated with worse outcomes. Using the United Network for Organ Sharing (UNOS), we aimed to: (1) examine the risk of mortality in LT for HCC, (2) to establish if this risk is affected by partial graft use, and (3) to determine if this effect is mitigated by improved tumor-associated risk stratification.

MATERIAL AND METHODS

All first-time adult LT recipients were analyzed (3/2002-12/2012), including 2,353 LD-P, 727 DD-P, and 47,833 DD whole (DD-W) grafts. Cox proportional hazards models were used to examine the risk of mortality given HCC. Interaction/subset analyses were used to examine the effect of tumor-risk and graft-type on outcome. Presence of an HCC exception and low alpha-fetoprotein (AFP) level (<66 ng/mL) were considered favorable.

RESULTS

Overall, HCC was associated with an increased mortality risk compared to the absence of HCC (HR 1.21 [1.15-1.27]), and the use of partial grafts was noted to further intensify this risk. However, HCC with a favorable risk profile had more comparable outcomes to patients without HCC and this finding was similar across all graft-types (Given LD-P: HR 1.14 [0.76-1.73]; Given DD-P: HR1.05 [0.71-1.56]; Given DD-W: HR1.08 [1.02-1.14]). On subset analysis, all graft types had similar outcomes given either favorable-risk HCC or the absence of HCC.

CONCLUSIONS

There is no significant difference in outcomes between whole and partial grafts given (1) patients with HCC with a favorable risk-profile or (2) patients without HCC.

Nutritional outcomes in survivors of congenital diaphragmatic hernia (CDH)-factors associated with growth at one year

BACKGROUND

Malnutrition is prevalent among congenital diaphragmatic hernia (CDH) survivors. We aimed to describe the nutritional status and factors that impact growth over the 12-months following discharge from the pediatric intensive care unit (PICU) in this cohort.

METHODS

CDH survivors, who were discharged from the PICU from 2000 to 2010 with follow-up of at least 12months, were included. Nutritional intake, anthropometric, and clinical variables were recorded. Multivariable linear regression was used to determine factors associated with weight-for-age Z-scores (WAZ) at 12months.

RESULTS

Data from 110 infants, 67% male, 50% patch repair, were analyzed. Median (IQR) WAZ for the cohort was -1.4 (-2.4 to -0.3) at PICU discharge and -0.4 (-1.3 to 0.2) at 12-months. The percentage of infants with significant malnutrition (WAZ<-2) decreased from 26% to 8.5% (p<0.001). Patch repair (p=0.009), protein intake<2.3g/kg/day (p=0.014), and birth weight (BW)<2.5kg (p<0.001) were associated with lower WAZ at 12-months.

CONCLUSIONS

CDH survivors had a significantly improved nutritional status in the 12-months after PICU discharge. Patch repair, lower BW, and inadequate protein intake were significant predictors of lower WAZ at 12-months. A minimum protein intake in the PICU of 2.3g/kg/day was essential to ensure optimal growth in this cohort.

Immediate extubation after pediatric liver transplantation: a single-center experience

The care of pediatric liver transplant recipients has traditionally included postoperative mechanical ventilation. In 2005, we started extubating children undergoing liver transplantation in the operating room according to standard criteria for extubation used for general surgery cases. We reviewed our single-center experience to determine our rates of immediate extubation and practice since that time. The records of 84 children who underwent liver transplantation from 2005 to 2011 were retrospectively reviewed. The immediate extubation rate increased from 33% during 2005-2008 to 67% during 2009-2011. Immediate extubation did not result in an increased reintubation rate in comparison with delayed extubation in the intensive care unit (ICU). Patients undergoing immediate extubation had a trend toward a shorter mean ICU stay as well as a significantly decreased overall hospital length of stay. Our findings suggest that there is a learning curve for instituting immediate extubation in the operating room after liver transplantation and that the majority of pediatric liver recipients can safely undergo immediate extubation.

Deceased-donor split-liver transplantation in adult recipients: is the learning curve over?

BACKGROUND

Infants have the highest wait-list mortality of all liver transplantation candidates. Deceased-donor split-liver transplantation, a technique that provides both an adult and pediatric graft, might be the best way to decrease this disproportionate mortality. Yet concern for an increased risk to adult split recipients has discouraged its widespread adoption. We aimed to determine the current risk of graft failure in adult recipients after split-liver transplantation.

STUDY DESIGN

United Network for Organ Sharing data from 62,190 first-time adult recipients of deceased-donor liver transplants (1995-2010) were analyzed (889 split grafts). Bivariate risk factors (p < 0.2) were included in Cox proportional hazards models of the effect of transplant type on graft failure.

RESULTS

Split-liver recipients had an overall hazard ratio of graft failure of 1.26 (p < 0.001) compared with whole-liver recipients. The split-liver hazard ratio was 1.45 (p < 0.001) in the pre-Model for End-Stage Liver Disease era (1995-2002) and 1.10 (p = 0.28) in the Model for End-Stage Liver Disease era (2002-2010). Interaction analyses suggested an increased risk of split-graft failure in status 1 recipients and those given an exception for hepatocellular carcinoma. Excluding higher-risk recipients, split and whole grafts had similar outcomes (hazard ratio = 0.94; p = 0.59).

CONCLUSIONS

The risk of graft failure is now similar between split and whole-liver recipients in the vast majority of cases, which demonstrates that the expansion of split-liver allocation might be possible without increasing the overall risk of long-term graft failure in adult recipients. Additional prospective analysis should examine if selection bias might account for the possible increase in risk for recipients with hepatocellular carcinoma or designated status 1.

Deceased donor liver transplantation in infants and small children: are partial grafts riskier than whole organs?

Infants have the highest wait-list mortality of all liver transplant candidates. Although previous studies have demonstrated that young children may be at increased risk when they receive partial grafts from adult and adolescent deceased donors (DDs), with few size-matched organs available, these grafts have increasingly been used to expand the pediatric donor pool. We aimed to determine the current adjusted risks of graft failure and mortality in young pediatric recipients of partial DD livers and to determine whether these risks have changed over time. We analyzed 2683 first-time recipients of DD livers alone under the age of 24 months in the United Network for Organ Sharing database (1995-2010), which included 1118 partial DD livers and 1565 whole DD organs. Transplant factors associated with graft loss in bivariate analyses (P < 0.1) were included in multivariate proportional hazards models of graft and patient survival. Interaction analysis was used to examine risks over time (1995-2000, 2001-2005, and 2006-2010). Although there were significant differences in crude graft survival by the graft type in 1995-2000 (P < 0.001), graft survival rates with partial and whole grafts were comparable in 2001-2005 (P = 0.43) and 2006-2010 (P = 0.36). Furthermore, although the adjusted hazards for partial graft failure and mortality were 1.40 [95% confidence interval (CI) = 1.05-1.89] and 1.41 (95% CI = 0.95-2.09), respectively, in 1995-2000, the adjusted risks of graft failure and mortality were comparable for partial and whole organs in 2006-2010 [hazard ratio (HR) for graft failure = 0.81, 95% CI = 0.56-1.18; HR for mortality = 1.02, 95% CI = 0.66-1.71]. In conclusion, partial DD liver transplantation has become less risky over time and now has outcomes comparable to those of whole liver transplantation for infants and young children. This study supports the use of partial DD liver grafts in young children in an attempt to significantly increase the pediatric organ pool.

Pulmonary support on day 30 as a predictor of morbidity and mortality in congenital diaphragmatic hernia

PURPOSE

Congenital diaphragmatic hernia (CDH) is associated with significant in-hospital mortality, morbidity and length-of-stay (LOS). We hypothesized that the degree of pulmonary support on hospital day-30 may predict in-hospital mortality, LOS, and discharge oxygen needs and could be useful for risk prediction and counseling.

METHODS

862 patients in the CDH Study Group registry with a LOS ≥ 30 days were analyzed (2007-2010). Pulmonary support was defined as (1) room-air (n=320) (2) noninvasive supplementation (n=244) (3) mechanical ventilation (n=279) and (4) extracorporeal membrane oxygenation (ECMO, n=19). Cox Proportional hazards and logistic regression models were used to determine the case-mix adjusted association of oxygen requirements on day-30 with mortality and oxygen requirements at discharge.

RESULTS

On multivariate analysis, use of ventilator (HR 5.1, p=.003) or ECMO (HR 19.6, p<.001) was a significant predictor of in-patient mortality. Need for non-invasive supplementation or ventilator on day-30 was associated with a respective 22-fold (p<.001) and 43-fold (p<.001) increased odds of oxygen use at discharge compared to those on room-air.

CONCLUSIONS

Pulmonary support on Day-30 is a strong predictor of length of stay, oxygen requirements at discharge and in-patient mortality and may be used as a simple prognostic indicator for family counseling, discharge planning, and identification of high-risk infants.

Reno-portal anastomosis as an approach to pediatric kidney transplantation in the setting of inferior vena cava thrombosis

In pediatric renal transplantation in the setting of IVC thrombosis, the retrohepatic IVC or gonadal veins are often used for outflow. However, if use of systemic venous outflow is unsuccessful, options become limited. We report the use of the portal vein for venous outflow in kidney retransplantation in the setting of IVC thrombosis. The patient is a 19-month-old male who developed end-stage renal failure at seven months of age secondary to hypotension after spontaneous rupture of an accessory renal vein. The IVC was occluded during emergent laparotomy, and the patient developed extensive IVC thrombosis. The first two transplant attempts used the retrohepatic IVC for venous outflow. Despite good initial flow, in both instances the renal vein thrombosed on post-operative day 1. In an unsuccessful salvage attempt of the second transplant, a reno-portal anastomosis was performed. With few options for vascular access, a third transplant was attempted. The reno-portal stump from the second transplant was used for outflow. The patient recovered well from his third transplant (creatinine 0.6 mg/dL 35 months post-surgery), demonstrating that the portal vein can be used for outflow in cases of extensive IVC thrombosis.

Aorto-mesenteric and renal allograft transplant: a novel treatment for midaortic syndrome

Midaortic syndrome (MAS) is a rare condition characterized by stenosis of the aorta and often involving renal and visceral arteries. Current therapies include medical management of associated hypertension, and interventional procedures such as angioplasty or surgical bypass. We report a 2-year-old female with severe MAS who was initially treated with angioplasty and stents in both her aorta and superior mesenteric artery (SMA). Due to the presence of long segment stenoses, her renal arteries were not amenable to surgical reconstruction and she rapidly progressed to Stage V chronic kidney disease. The patient underwent bilateral nephrectomy and renal transplantation using a donor thoracoabdominal aorta allograft to provide inflow for the kidney as well as to bypass the nearly occluded aorta. The donor SMA was used to bypass the native SMA stenosis. Postoperatively, the patient had normalization of four limb blood pressures. She weaned from five anti-hypertensive agents to monotherapy with excellent renal function. This is the first reported case of thoracoabdominal aortic bypass using allograft aorta to address MAS. This approach allowed for successful kidney transplantation with revascularization of the mesenteric, and distal aortic circulation using allograft conduit that will grow with the child, obviating the need for repeated interventional or surgical procedures.

Multivisceral transplantation using a 2.9 kg neonatal donor

Prematurity and very low birthweight have often been considered relative contraindications to neonatal organ donation. Organ procurement from neonatal donors is further complicated by unclear guidelines regarding neonatal brain death. We report a successful case of multivisceral transplantation using a graft from a 10-day-old, 2.9 kg, neonatal donor born at 36 6/7 wk in a 3.2 kg, three month old with intestinal and liver failure secondary to midgut volvulus. There was immediate liver graft function with correction of recipient coagulopathy, but delayed normalization of laboratory values and delayed return of bowel function. At six-yr post-transplant follow-up, the patient has normal intestine and liver function. Her last histologically confirmed rejection episode was 30 months prior to last follow-up. This case suggests that multivisceral grafts from very young or small neonatal donors may be transplanted successfully in selected cases. We propose a re-examination of the brain death guidelines for premature and young infants to potentially increase the availability of organs for infant recipients.