ASSOCIATION FOR ACADEMIC SURGERY—ABSTRACTS
did not affect postoperative outcome on the General and Vascular Surgery services in our facility.
P36. Is the Routine Use of Pacing Wires Necessary? A. Raiesdana, MD, T. Greco, MD, J. Brown, MD, Y. Mahomed, MD, D.R. Meldrum, MD. Indiana University. Introduction. Although temporary epicardial pacing wires are routinely placed following cardiac surgery, there are costs (⬃$200/ patient) and associated clinical risks such as bleeding/tamponade (wire removal) and mediastinitis (prolonged use). We examined the frequency of postoperative pacing and potential predictors of pacing wire use. Methods. Seventy-four patients [coronary artery bypass surgery (68%), valvular repair or replacement (15%), combination valvular surgery and bypass (10%), aneurysm repair (4%), or left atrial mass excision (3%)] were evaluated. The prevalence of pacing was determined and then the Mann--Whitney U test and Fisher exact test compared the mean values of continuous and categorical clinical variables between the paced and nonpaced groups. A multivariate logistic regression model was constructed using only the statistically significant univariate variables (P ⱕ 0.05). Results. Fifteen patients (20%) required pacing. The mean age of the patient population was 63 ⫾ 11 years, and 59% of the patients were male. Use of digoxin and a history of a previous arrhythmia or diabetes were statistically significant univariate predictors for postcardiac pacing wire use (P ⱕ 0.05). History of a previous arrhythmia (OR ⫽ 5.8, 95% CI, 1.6 –20.8, P ⫽ 0.02) was the strongest multivariate predictor for necessity of pacing after cardiac surgery. Although not statistically significant, length of stay for paced patients was longer compared to nonpaced patients (8.8 ⫾ 4.7 days versus 7.4 ⫾ 5.1 days, P ⫽ 0.06). Conclusions. These data suggest that pacing wires do not need to be routinely placed in all adult cardiac surgery patients and could possibly be used selectively in patient populations at increased risk. Continued refinement of our understanding of who is most likely to benefit will allow the most judicious use of this practice, which carries both cost and risk.
P37. Late Presentation of Malrotation: An Argument for Elective Repair. H. Broker, MD, A. Waltrip, MD, S. Megison, MD, S.G. Gregorcyk, MD, C.L. Simmang, MD, P. Huber, MD, H. Papaconstantinou, MD, D.R. Jeyarajah, MD. Southwestern Medical School. Introduction. Midgut malrotation is not commonly diagnosed in adults. We reviewed our experience and present one of the largest reported series of operative repair of malrotation in adolescents and adults. Methods. Retrospective review of medical records that carried the diagnosis of anomaly of intestinal fixation or malrotation was performed in our health system between September 1993 and February 2004. Results. Since 1993, we treated 32 patients with varying degrees of malrotation whether the presentation be acute, chronic, or incidental with a Ladd Procedure. Ages ranged from 11 to 83 years old (mean 33), with a slight male preponderance (56% male). Symptoms were present from less than one day to most of a lifetime. Patients presented with acute abdominal pain (50%), nausea and vomiting (59%), constipation (50%), abdominal distention (41%) and chronic abdominal pain (25%). Initial work-up included CAT scan (28%), UGI study (38%), and plain films (47%) prior to surgery. Twenty-eight percent of patients were found to have midgut malrotation incidentally during an operation for another reason. All patients underwent Ladd’s procedure. Complications occurred in 22% of the incidental group, 25% in the elective group, and 60% of the nonelective/nonincidental group. Prolonged postoperative ileus (4 days) occurred in 28% of patients; however, patients that had their malrotation repaired electively had a lower rate of prolonged ileus: 11% in the incidental group, 25% in the elective group, and 40% in
the nonelective/nonincidental group. Average length of stay was 7.6 days. Symptoms attributed to malrotation resolved in all cases. There were no second-look operations and no mortalities. Conclusion. Intestinal malrotation is an important entity to consider in nonpediatric patients with vague abdominal complaints. When symptoms progress to acute abdominal pain, postoperative complications are greater. Based on our experience with late presentation of intestinal malrotation, we recommend elective Ladd’s procedure, which can be performed safely.
P38. Predictive Factors and Outcomes in Patients with Gallbladder Perforation. D. Stefanidis, MD, PhD, J. Bingener, MD, PhD, K.R. Sirinek, MD, PhD. Uthscsa, Department of Surgery. Introduction. Gallbladder perforation is associated with significant morbidity and mortality. Preoperative diagnosis of perforation is difficult. This study investigates the outcome of patients with gallbladder perforation over a 20-year period and attempts to investigate predictors for perforation. Methods. From 1982 to 2002 all patients undergoing cholecystectomy for gallstone disease were prospectively entered into a database. A subgroup of patients with gallbladder perforation was identified and their outcome was compared with patients presenting with gangrenous cholecystitis. The Chi-square and Student’s t-test were used for statistical analysis where appropriate. Results. 238 patients underwent cholecystectomy for gangrenous cholecystitis. Of those, 30 patients were found to have gallbladder perforation; 9 with contained perforation (pericholecystic abscess) and 21 with free intraabdominal perforation. Gallbladder perforation was suspected in 3% of the patients preoperatively. Men outnumbered the women (23:7) and Hispanics outnumbered the Caucasians (26:4). Postoperative complications in pa-
Age (yrs) ASA Morbidity (37%) Mortality (%) Post-op stay (d)
Pat w/o perf
60 2.6 37 7 13
53 2.3 17 1.4 8
⬍0.05 ⫽0.07 ⬍0.05 ⬍0.05 ⬍0.001
tients with gallbladder perforation correlated with a significantly longer preoperative hospital stay (3.7 versus 0.8 days; P ⬍ 0.001). Eight patients underwent an attempted laparoscopic cholecystectomy; six patients (75%) required conversion to the open procedure. Conclusions. Gallbladder perforation is associated with high morbidity and mortality. Longer pre- and postoperative hospital stay, male gender, and advanced age correlated with perforation and postoperative complications in this study. Methods to improve preoperative diagnosis and early treatment are needed to improve the outcome of this disease. P39. Factors Affecting Outcomes Young Patients with Diverticulitis. L.S. Miranda, MD, K. Lee, MD FACS. Fairview Hospital Department of Surgery, Cleveland Clinic Health System, Cleveland, OH. Introduction. Young age has been identified in the literature as a risk factor for complications and emergency surgery among patients with acute diverticulitis. Our objective was to determine whether or not factors such as (1) duration of symptoms before admission to the hospital, (2) body mass index (BMI), and (3) smoking affected their outcome. Materials and methods. After IRB
ASSOCIATION FOR ACADEMIC SURGERY—ABSTRACTS approval, a retrospective review was conducted at a community teaching hospital. The study included 107 patients 45 years of age and younger admitted with diverticulitis between January 1997 and December 2001. Comparison was made between patients who either underwent surgery or received antibiotics alone upon first admission for diverticulitis. The results were evaluated using either a Mann-Whitney Rank Sum or Chi-Square test. Results. The mean age of the 107 patients was 38.5 years (22– 45), 64% males, and 36% females. There were a total of 126 admissions. Fourteen patients were excluded from this analysis since they were readmissions for elective surgery. Twenty-five patients (26.9%) required surgery during the first admission. Among this subgroup, the duration of symptoms was 5.1 days. Antibiotic management alone was successful in 73.1% of patients. Obesity was found in 86.3% (mean BMI 32.5 ⫾ 8.2 kg/m 2). Among the subgroup that required surgery during the first admission, the BMI was 28.5. Smoking history was present in 56% (1.25 ⫾ 0.6 packs a day ⫻ 18.4 ⫾ 6.1 years) of all study patients, and there was no significant difference in smoking history between the two outcome groups. Mortality was zero. Conclusions. Diverticulitis in
TABLE—ABSTRACT P39 Factor
Symptoms BMI Smoke
2.6 days 34.3 35 (53%)
5.1 days 28.5 14 (56%)
0.248 0.004 0.986
young patients can usually be managed at first presentation nonoperatively; patients that require surgery urgently tended to have a longer duration of symptoms. Obesity and smoking do not increase the risk for needing surgery at initial admission. P40. Pancreaticoduodenectomy with Closing the Pancreatic Stump versus Standard Whipple’s Procedure: A Nonanastomotic Technique in Surgery of Pancreatic Cancers. K. Ayazi, MD, S. Ayazi, MD, M. Davaei, MD, FACS, FAAP(S), Khatam-al-Anbia Hospital, Tehran, Iran. Background/Aims. Pancreaticoduodenectomy is commonly used for the surgical treatment of malignancies of the ampulla of Vater, duodenum, head of pancreas, and distal common bile duct (CBD). Pancreatic fistula and anastomotic leakage are the common fatal complications of the procedure. Management of the remained stump is the most important part of pancreaticoduodenectomy in the prevention of fistula and leakage. We describe a nonanastomotic procedure that has fewer complications. Methods. Wirsung’s duct was ligated with interrupted sutures after pancreaticoduodenectomy. The cut edge of the pancreatic stump was then sutured. Drainage of the stump field was performed with a Petzer drain. Results. Of the six patients who were studied, three were men and three were woman. The mean age was 59.19 years. There were no serious problems with pancreatic fistula, anastomotic leakage, significant weight loss, far elevation in serum amylase, pancreatitis, and oral intake within the follow-up months (median ⫽ 7 months, minimum ⫽ 2 months, maximum ⫽ 20 months). Conclusion. Such nonanastomotic options necessitate the use of pancreatic enzyme supplementation, but low rate of complications and simple procedure can present it as an operation of choice. P41. Totally Implanted Central Venous Access in a Designated Outpatient Line Clinic. D.K. Cunningham, MD, J. Kepple, MD, M. Rowe, RN, R. Henry-Tillman, MD, R. Layeeque, MD, V.S. Klimberg, MD. University of Arkansas for Medical Sciences.
Introduction. Totally implanted central venous access (TICVA) devices are the conduit of choice for administration of vesicant chemotherapy and have classically been placed in the operating room under direct fluoroscopic guidance. High-volume centers have been successful in placing TICVA catheters in ambulatory surgery. We hypothesized that TICVA devices could be safely and successfully placed in a designated, fully-staffed outpatient line clinic (DOLC). Methods. The DOLC is exclusively used for large volume placement of central venous catheters and TICVA. All patients analyzed required chemotherapy, and were referred to the DOLC for central venous access. Patients with indwelling electrical conduction devices, platelet count less than 50,000, or elevated prothrombin time and patients requiring conscious sedation were not appropriate candidates for DOLC. Results. Of 101 attempted TICVA in the DOLC, 97 were successfully placed: a technical success rate of 96% (97/101) without the aid of fluoroscopy or ultrasound. Inability to access the central vein occurred in four patients. Early complications include catheter malposition in 1% (1/97) and a 2% (2/97) incidence of pneumothorax. Late complications occurred in 2% (2/97) of patients requiring TICVA removal: one for infection and one for vessel thrombosis. Conclusions. Routine placement of totally implanted central venous catheters in a designated outpatient clinic, with personnel specifically trained to facilitate the procedure, is safe, efficient, and economical with appropriately selected patients.
P42. Surgical Management of Renal Cell Carcinoma with Level II Thrombus Through a Transabdominal Approach. T.C. Lee, MD, N.R. Barshes, MD, L. Nguyen, MD, J.A. Goss, MD. Baylor College of Medicine. Purpose. Surgery is still the mainstay of treatment for renal cell carcinoma (RCC) with extension into the inferior vena cava (IVC). However controversy still exists over the correct surgical management of tumors which extend into the retrohepatic IVC (level II). Herein, we report our experience of RCC with level II thrombus extension and discuss the application of a transabdominal approach without use of cardiopulmonary bypass or intraoperative anticoagulation. Method. Between 1999 and 2003, there were seven patients who presented with RCC and level II thrombus extension. All charts were retrospectively reviewed. All level II tumors were resected via a transabdominal approach. The liver was completely freed from its ligamentous attachments and mobilized off of the IVC, leaving the hepatic veins as the only attachments between the liver and IVC. Tumor thrombus was resected en bloc with the involved renal vein via an anterior cavotomy. The cavotomy was then closed primarily with a running monofilament suture. There was no use of any intraoperative anticoagulation or cardiopulmonary bypass. Results. In this study, there were six males and one female with a median age of 71 years (59 –76). All tumors were located retrohepatic and classified as level II tumors. Six of seven tumors were right sided. The median estimated blood loss was 3300 ml (2000 –14,000), and the median number of PRBC units transfused in the operating room was 7 (4 –28). There were no intraoperative deaths and one postoperative death from myocardial infarction. Of seven patients, four had complications: two myocardial infarctions, one pneumonia, and one cerebral vascular accident. The median ICU stay was 3 days (2– 6) and median time for ventilatory support was 2 days (1–3). Total median hospital stay was 11 days (5–21). Discussion. We conclude that the transabdominal approach is an acceptable operation for RCC with level II thrombus extension and that the thoracic cavity does not need to be entered for this operation. Furthermore, we believe that intraoperative anticoagulation or cardiopulmonary bypass is not necessary for this type of procedure.