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 impact of operative timing on outcomes of appendicitis: a National Surgical Quality Improvement Project analysis

BACKGROUND

Surgery is indicated for acute uncomplicated appendicitis but the optimal timing is controversial. Recent literature is conflicting on the effect of time to intervention.

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Project dataset for patients undergoing laparoscopic and open appendectomy between 2007 and 2012. Logistic regression was used to evaluate 30-day morbidity and mortality of intervention at different time periods, adjusting for preoperative risk factors.

RESULTS

A total of 69,926 patients undergoing appendectomy were identified. Groups were divided by time to intervention: group 1, less than 24 hours (n = 55,839; 79.9%); group 2, 24 to 48 hours (n = 13,409; 18.6%); and group 3, greater than 48 hours (n = 1,038; 1.5%). After adjustment, the risk of complication remained increased for group 3 versus group 1 or 2 (odds ratio 1.66, 95% confidence interval 1.34 to 2.07).

CONCLUSIONS

These data demonstrate equivalent outcomes between time to appendectomy of less than 24 and 24 to 48 hours. There was a 2-fold increase in complication rate for patients delayed longer than 48 hours.

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 Reward is Worth the Wait: A Prospective Analysis of 100 Consecutive Organ Donors

Aggressive donor management protocols have evolved to maximize the number of procured organs. Our study assessed donor management time and the number and types of organs procured with the hypothesis that shorter management time yields increased organ procurement and transplant rates. We prospectively analyzed 100 donors managed by a regional organ procurement organization (OPO) during 2007 to 2008. Data included patient demographics, number and types of organs procured and transplanted, patient management time by the OPO, and achievement of donor pre-procurement goals. One hundred consecutive organ donors were managed with a mean age 41 ± 18 years and mean management time 23 ± 9 hours; 376 organs were procured and 327 successfully transplanted. Donors managed greater than 20 hours yielded significantly more heart (5 vs 26, P < 0.01) and lung (6 vs 40, P < 0.01) procurements, more organs procured per donor (3.2 ± 1.4 vs 4.2 ± 1.6, P < 0.01), and more organs transplanted per donor (2.6 ± 1.5 vs 3.7 ± 1.8, P < 0.01) than those managed 20 hours or less. No difference in the attainment of donor management goals was observed between these populations. Contrary to our initial hypothesis, donor management times greater than 20 hours yielded increased organ procurement and transplant rates, particularly for hearts and lungs, despite no differences in the achievement of donor preprocurement management goals.

The reward is worth the wait: a prospective analysis of 100 consecutive organ donors

Aggressive donor management protocols have evolved to maximize the number of procured organs. Our study assessed donor management time and the number and types of organs procured with the hypothesis that shorter management time yields increased organ procurement and transplant rates. We prospectively analyzed 100 donors managed by a regional organ procurement organization (OPO) during 2007 to 2008. Data included patient demographics, number and types of organs procured and transplanted, patient management time by the OPO, and achievement of donor preprocurement goals. One hundred consecutive organ donors were managed with a mean age 41 ± 18 years and mean management time 23 ± 9 hours; 376 organs were procured and 327 successfully transplanted. Donors managed greater than 20 hours yielded significantly more heart (5 vs 26, P < 0.01) and lung (6 vs 40, P < 0.01) procurements, more organs procured per donor (3.2 ± 1.4 vs 4.2 ± 1.6, P < 0.01), and more organs transplanted per donor (2.6 ± 1.5 vs 3.7 ± 1.8, P < 0.01) than those managed 20 hours or less. No difference in the attainment of donor management goals was observed between these populations. Contrary to our initial hypothesis, donor management times greater than 20 hours yielded increased organ procurement and transplant rates, particularly for hearts and lungs, despite no differences in the achievement of donor preprocurement management goals.