Eugene Golts

A Comparison of Pancreaticogastrostomy and Pancreaticojejunostomy Following Pancreaticoduodenectomy

This retrospective study compares the results of pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ) in our institution, which has extensive experience in both techniques. Between the years of June 1995 and June 2001, 214 patients underwent pancreaticoduodenectomy (PD) at our institution. Of these 177 had PG and 97 had pancreatojejunostomy (PJ). There were 117 (54.6%) males and 97 (45.3%) females with a mean age of 64.2 ± 12.4 years. Indications for surgery were pancreatic adenocarcinoma in 101 (47.2%), ampullary adenocarcinoma in 36 (16.9%), distal bile duct adenocarcinoma in 22 (10.2%), duodenal adenocarcinoma in 9 (4.2%), and miscellaneous causes in 46 (21.4%) of patients. Preoperatively, significant differences in the groups were that the patients undergoing PJ were significantly younger than those undergoing PG. Also noted preoperatively, was that the patients undergoing PG had a significantly lower direct bilirubin than those undergoing PJ. With regard to intraoperative parameters, operative time was significantly shorter in the PJ group when compared to the PG group. When the patients who did not develop fistula (N = 186) were compared to those who developed fistula (N = 28) the significant differences were that the patients who developed fistula were more likely to have hypertension preoperatively and a higher alkaline phosphatase. They also showed a significantly higher drain amylase and were likely to have surgery for ampullary, distal bile duct or duodenal carcinoma rather than pancreatic adenocarinoma. In addition, those patients who developed fistula had a significantly longer postoperative stay, a larger number of intraabdominal abscesses and leaks at the biliary anastomosis. Thirty-day mortality was significantly higher in the PJ group compared to the PG (4 vs. 0, P = 0.041). There was a significantly larger number of bile leaks in the PJ group when compared to the PG (6 vs. 1, P = 0.048). In addition, the PJ group required a significantly larger number of new CT guided drains to control infection (8 vs. 2,P = 0.046) and the PJ group required a larger number of re-explorations to control infection or bleeding (5 vs. 0, P = 0.018). However, the pancreatic fistula rate was not different between the two groups (12% [PG] vs. 14% [PJ]). This retrospective analysis shows that safety of PG can be performed safely and is associated with less complications than PJ and proposes PG as a suitable and safe alternative to PJ for the management of the pancreatic remnant following PD.

Age is not a contraindication to pancreaticoduodenectomy

The incidence of pancreatic cancer has increased threefold over the last 40 years with the greatest rate of growth occurring in the elderly. In the past it was suggested that elderly patients tolerated pancreaticoduodenectomy less well than younger patients with higher mortality rates. This single-institution experience examines the question of whether age is a significant factor in relation to morbidity and mortality in patients undergoing pancreaticoduodenectomy. Between 1994 and 1999 outcomes of 122 patients who underwent pancreaticoduodenectomy were reviewed. There were 48 patients 70 years of age and older and 74 patients less than 70 years of age. Both groups were compared with respect to preoperative clinical prognostic determinates and perioperative factors affecting morbidity and mortality. There was no significant difference between the two groups comparing their comorbidities, use of preoperative antibiotics, intraoperative blood loss, or length of hospital stay (11.9 and 10.8 days respectively). The two groups were also similar with regard to pathologic diagnosis with pancreatic adenocarcinoma being the most frequently encountered neoplasm. There was one death in the less-than-70-year-old group and none in the older group. No significant difference in the rate of complications was appreciated. These data demonstrate that pancreaticoduodenectomy can be performed safely in patients 70 years of age and older with morbidity and mortality rates similar to those of younger individuals.

Major Positional Obstruction of the Trachea in a Patient With a Right-Sided Aortic Arch and Kommerell’s Diverticulum

TRACHEAL COMPRESSION in patients with a right-sided aortic arch and Kommerell’s diverticulum (classically defined as a bulbous configuration of the origin of an aberrant left subclavian artery in the setting of a right-sided aortic arch) previously has been described. In reported cases, clinically significant tracheal compression was noted preoperatively or soon after induction of anesthesia but prior to any change in the position of the patient. There has not been a case report in a patient with a right-sided aortic arch and Kommerell’s diverticulum in whom tracheal compression and/or obstruction was related only to surgical positioning and was otherwise absent. This case report describes a patient with a right-sided aortic arch and Kommerell’s diverticulum without any clinically significant symptoms during normal daily activities, exercise, or while sleeping in supine, lateral, or prone positions. Following tracheal intubation under general anesthesia in the supine position, no tracheal compression or difficulty with mechanical ventilation was encountered. However, complete tracheal obstruction was manifested in the right lateral decubitus position after placement of an axillary roll. This compression was relieved completely when the axillary roll was removed and the patient was returned to the supine position.

Heparin Induced Thrombocytopenia: A Novel Approach to Anticoagulation During Transcatheter Aortic Valve Replacement Utilizing Cangrelor

Transcatheter aortic valve replacement (TAVR) is a wellestablished therapy for patients with severe aortic stenosis who are at intermediate-high surgical risk. While the technical and procedural aspects of TAVR may vary, systemic anticoagulation with heparin or bivalirudin is universally used to reduce the risk of procedure-associated thromboembolic events. However, the optimal anticoagulation strategy for a patient with heparininduced thrombocytopenia (HIT) undergoing TAVR is unclear.

Severity of Acute Kidney Injury in the Post-Lung Transplant Patient Is Associated With Higher Healthcare Resources and Cost

OBJECTIVE Perioperative risk factors and the clinical impact of acute kidney injury (AKI) and failure after lung transplantation are not well described. The incidences of AKI and acute renal failure (ARF), potential perioperative contributors to their development, and postdischarge healthcare needs were evaluated. DESIGN Retrospective. SETTING University hospital. PARTICIPANTS Patients undergoing lung transplantation between January 1, 2011 and December 31, 2015. MEASURED DATA The incidences of AKI and ARF, as defined using the Risk, Injury, Failure, Loss, End-Stage Renal Disease criteria, were measured. Perioperative events were analyzed to identify risk factors for renal compromise. A comparison of ventilator days, intensive care unit (ICU) and hospital lengths of stay (LOS), 1-year readmissions, and emergency department visits was performed among AKI, ARF, and uninjured patients. MEASUREMENTS AND MAIN RESULTS Ninety-seven patients underwent lung transplantation; 22 patients developed AKI and 35 patients developed ARF. Patients with ARF had significantly longer ICU LOS (12 days v 4 days, p < 0.001); ventilator days (4.5 days v 1 day, p < 0.001); and hospital LOS (22.5 days v 14 days, p < 0.001) compared with uninjured patients. Patients with AKI also had significantly longer ICU and hospital LOS. Patients with ARF had significantly more emergency department visits and hospital readmissions (2 v 1 readmissions, p = 0.002) compared with uninjured patients. A univariable analysis suggested that prolonged surgical time, intraoperative vasopressor use, and cardiopulmonary bypass use were associated with the highest increased risk for AKI. Intraoperative vasopressor use and cardiopulmonary bypass mean arterial pressure <60 mmHg were identified as independent risk factors by multivariable analysis for AKI. CONCLUSION The severity of AKI was associated with an increase in the use of healthcare resources after surgery and discharge. Certain risk factors appeared modifiable and may reduce the incidence of AKI and ARF.

627: PERIOPERATIVE EVENTS AFFECTING ACUTE RENAL FAILURE IN POST-LUNG TRANSPLANT PATIENTS

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) 35% received living-related LTx while the rest received deceased organ grafts. The mean age was 4.6 y (6 m – 24y) and 55% were female. Almost one third of the 58 episodes met criteria for septic shock and 39% had multiple organ dysfunction syndrome. Approximately 52% of the patients required mechanical ventilation and 5% of the patients were placed on extracorporeal membrane oxygenation support. The primary sites of infection included blood (40%), respiratory tract (16%), peritonitis (14%). Culture results were documented as bacterial (68%), culture negative (13%), viral (7%), and fungal (2%). Of note, 36% of bacterial infections were due to MDROs, predominantly vancomycin resistant enterococcus and extend spectrum beta lactamase producers. No graft loss was attributable to sepsis. Mortality for this cohort was 5%. Conclusions: Compared to the general PICU population, liver transplant recipients are more likely to be septic but have lower mortality despite infection with MDROs. Knowledge about local bacterial epidemiology should guide initial empiric antibiotic therapy. Future studies are needed to identify potential risk factors in this cohort, including immunosuppression management.