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Poster # 1 COLON INJURY in DAMAGE CONTROL SURGERY: IS

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Poster # 1 COLON INJURY in DAMAGE CONTROL SURGERY: IS Poster # 1 COLON INJURY IN DAMAGE CONTROL SURGERY: IS IT SAFE TO DO A DELAYED ANASTOMOSIS? Leah C. Tatebe MD, Andrew Jennings MD, Michael Smith MD, MPH, Tai Do MD, Alexandra Handy BA, Ken Tatebe MD, Ph.D., Purvi Prajapati BS, Gerald Ogola Ph.D., Monica Bennett Ph.D., Rajesh R. Gandhi* MD, Ph.D., Stephen Luk* MD, Laura B. Petrey* MD, Baylor University Medical Center Introduction: Delayed colonic anastomosis with damage control laparotomy (DCL) has been considered as an alternative to colostomies during a single laparotomy (SL) in high-risk patients. The literature, however, suggests increased leak rates with DCL between 7-27%. Reported risk factors for anastomotic leak vary widely across studies. We sought to evaluate the regional experience to better elucidate risk for anastomotic leak in DCL. Methods: A multi-center retrospective cohort study was performed as a collaboration of 3 metropolitan Level I trauma centers. Traumatic colon injuries from January 2006 through June 2014 were included. Exclusion criteria included rectal injuries and death within 24 hours of presentation. Demographics, comorbidities, injury characteristics, complications, medical and operative interventions were compiled and compared between the SL and DCL groups. Logistic regression analysis was performed for any complication with a minimum of 20 occurrences. We utilized regional hospital council readmission data to identify patients who presented after discharge to any member hospital within 1 year of the index admission to better capture complications. Results: Out of 267 qualified patients, penetrating injuries accounted for 69%, and overall mortality rate was 4.9%. Fifty-six patients (21%) underwent DCL, many with multiple injuries. A total of 179 had a primary repair (26 in DCL), 89 had a resection and anastomosis (28 in DCL), 18 had an end colostomy (10 in DCL), and 9 had a diverting loop ileostomy (2 in DCL). One-third (19) of DCL patients had injuries repaired in a delayed manner during subsequent laparotomies. Patients selected for DCL were statistically more likely to be hypotensive, transfused >6 units of packed red blood cells, receive 3-4 liters more crystalloid, and suffer from adult respiratory distress syndrome, pneumonia, acute kidney injury, and death. Only 5 leaks were identified (1.8%), proportionately distributed between DCL and SL (p=1.00), along with 3 enterocutaneous fistulas (ECF, p=0.51). Given the small incidence, we were unable to perform meaningful analysis to determine risk factors for leaks. No difference was seen in the incidence of intraabdominal abscesses (p=0.13) or surgical site infection (SSI, p=0.70) between DCL and SL. DCL patients with concomitant liver injuries had a trend toward increased risk of abscess formation (p=0.06), whereas SL patients with pancreas injuries were at increased risk of abscess (p<0.01). No difference in complications was noted in DCL patients who underwent definitive colon repair at the initial operation compared to a subsequent operation. Conclusion: Our regional data do not suggest any increase in complication rate for anastomotic leaks, ECF, SSI, or intraabdominal abscesses within the DCL cohort despite one-third of patients having delayed repair. This is contrary to previous lower-powered studies, which demonstrated higher leak rates. A large multi-institution prospective trial would be indicated to further characterize the risks of DCL in colon trauma. Poster # 2 IS IT SAFE? NON-OPERATIVE MANAGEMENT OF BLUNT SPLENIC INJURIES IN GERIATRIC PATIENTS Marc D. Trust MD, Sadia Ali MPH, Lawrence Brown Ph.D., Adam Clark MBA, Jayson Aydelotte* MD, Ben Coopwood* MD, Pedro Teixeira* MD, Carlos V. Brown* MD, Dell Medical School At The University Of Texas At Austin Introduction:Previous surgical dogma dictated that older age was a contraindication to non-operative management (NOM) of blunt splenic injuries (BSI). This was based on documented increased failure rates and the concern for increased mortality associated with failure. As many studies have shown the efficacy of NOM, there has been an increased use of this treatment strategy in the geriatric population. However, no recent study has been published assessing the safety of NOM of BSI in this population. Methods:We performed a retrospective analysis of data from the National Trauma Databank (NTDB) from 2014 and identified young (age < 65) and geriatric (age ≥ 65) patients with a BSI. Patients who underwent immediate splenectomy (within 6 hours of admission) were excluded from the analysis. Outcomes were failure of NOM and mortality. Results:We identified 18,917 total patients with a BSI, 2,240 (12%) geriatric patients and 16,677 (88%) young patients. 14% of geriatric patients and 13% of young patients underwent immediate splenectomy and were excluded from further analysis. Geriatric patients failed NOM more often than younger patients (6% vs. 4%, p < 0.0001). On logistic regression analysis, high ( ≥16) ISS was the only independent risk factor associated with failure of NOM in geriatric patients (OR=2.8, CI=1.8 – 4.4, p < 0.0001). There was no difference in mortality in geriatric patients who had successful versus failed NOM (11% vs. 15%, p = 0.22). Independent risk factors for mortality in geriatric patients who underwent NOM included admission hypotension (OR=1.5, CI=1.0 – 2.4, p = 0.049), high ISS (OR=3.8, CI=2.6 – 5.8, p < 0.0001), low GCS (OR=5.0, CI=3.5 – 7.2, p < 0.0001), and pre-existing cardiac disease (OR=3.6, CI=2.0 – 6.6, p < 0.0001). However, failure of NOM was not independently associated with mortality (OR=1.4, CI=0.8 – 2.6, p = 0.25). Conclusion:When compared to younger patients, geriatric patients had a higher but acceptable rate of failed NOM of BSI, and failure rates in our geriatric population are lower than previously reported. Failure of NOM in geriatric patients is not associated with an increase in mortality. Based on our results, NOM of BSI in geriatric patients is safe. Poster # 3 REGIONALISTAION OF MAJOR TRAUMA IN ENGLAND IMPROVES THE OUTCOME OF SEVERE LIVER INJURIES. EYAD ISSA MD,Ph.D., Tina Gaarder* MD, Pal Aksel MD, Adam Brooks MD, East Midlands Major Trauma Centre Introduction: Regionalisation of major trauma in England in April 2012 re-directed severely injured patients to Major Trauma Centres (MTC) whilst less injured patients went to Trauma Units (TU). This has delivered an overall improvement in survival, however outcomes in specific injuries have not been evaluated. Severe liver trauma (Grade IV and V) is recognised to have high mortality although contemporary national outcome for patients in England with these injuries have not previously been reported. The aim of this study was to define the contemporary mortality associated with severe liver injury in England, as well as, to investigate the effect of the regionalisation of major trauma on outcome for patients with severe liver injuries. Methods: Trauma Audit Research Network (TARN) data for patients, who presented between April 2010 and March 2015, were between 16 and 65 years old, alive on admission and had injury severity score (ISS) ≥ 15 and at least liver injury, were retrieved. Outcome (mortality) was compared before and after regionalisation and also between MTCs and TUs. Results: A total of 1790 patients met the inclusion criteria. 449 patients had a liver injury of grade IV or above. The overall mortality for severe liver trauma in England since April 2012 is 19%, and this has improved significantly since regionalisation (19% vs 31%; Odds ratio [OR], 1.82; 95% confidence interval [CI], 1.16 -2.8; P=0.007). Similarly, the outcome of trauma patients with severe liver injury in MTCs has improved since regionalisation (16% vs 27 %; OR 0.51; 95% CI, 0.29-0.89; P=0.01). Patients with severe liver injury admitted to TUs after April 2012 had higher mortality compared to those admitted to a MTC (36% vs 16%; OR, 0.33; 95% CI, 0.17-0.65). Conclusion: The mortality of severe liver trauma remains high, however regionalisation of major trauma in England is associated with improved outcome in this patient group. Further improvements could be delivered with better triage to MTCs. Poster # 4 THE ROLE OF PROCALCITONIN IN THE DECISION TO CLOSE OPEN ABDOMENS AFTER DAMAGE CONTROL LAPAROTOMY Rondi B. Gelbard MD, Marcus Darrabie MD, Christopher Dente* MD, Bryan C. Morse MD, Stacy D. Dougherty MD, Neal N. Iwakoshi Ph.D., Timothy G. Buchman MD, Ph.D., Eric Elster MD, Emory University Introduction: Damage control laparotomy (DCL) followed by temporary abdominal closure, resuscitation and planned re-laparotomy is used to manage critically injured patients who cannot be closed primarily at the initial operation. Patients that undergo successful primary fascial closure at the initial operation may have a biomarker profile that is distinct from those who are managed with an open abdomen. The purpose of this study was to evaluate whether procalcitonin (PCT), as a modulator of immunologic function, is associated with delayed fascial closure after laparotomy. Methods: This is a prospective, observational study of patients requiring exploratory laparotomy for blunt or penetrating injury at an urban Level 1 trauma center. Serial tissue, serum and peritoneal effluent samples were collected during each operative intervention from initial laparotomy to abdominal closure. Demographic and physiologic data, as well as local and systemic biomarker and quantitative bacteriology data were analyzed and compared among patients that achieved definitive fascial closure at the initial operation versus those that did not. Outcome measures included overall survival, hospital length of stay, intensive care unit length of stay, ventilator days, time to abdominal wound closure, wound complications, and discharge disposition. Results: Sixty-one trauma patients met inclusion criteria for the study, 31 of these were managed with DCL while 30 underwent definitive primary fascial closure at the initial operation.
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