Kerry Hitos

Mortality, morbidity and functional outcome after ileorectal anastomosis

Total colectomy with an ileorectal anastomosis (IRA) is a commonly performed operation. Postoperative mortality and morbidity are reported to be low and functional outcome is generally rated as good to excellent. The aim of this study was to review postoperative mortality, morbidity and functional results in an effort to identify risk factors predictive of a poor outcome.

Improved short-term outcomes of laparoscopic versus open resection for colon and rectal cancer in an area health service: a multicenter study.

BACKGROUND: Evidence demonstrates short-term benefits of laparoscopic surgery for colon cancer. The situation for rectal cancer is less clear. OBJECTIVES: This review assessed the use and short-term outcomes of elective open and laparoscopic colon and rectal cancer resections within an area health service. DESIGN: This was a multicenter, retrospective review of a prospective database. SETTINGS: All elective colon and rectal cancer resections in the western zone of Sydney South West Area Health Service from 2001 until 2008 were included. PATIENTS: Included were 1721 patients who underwent either a laparoscopic colon (n = 434) or rectal (n = 157) resection or an open colon (n = 742) or rectal (n = 388) resection. MAIN OUTCOME MEASURES: Outcome measures included operating time, blood loss, adequacy of resection, conversion rate, intensive care unit admission, length of stay, and 26 acute postoperative complications. RESULTS: Patients were matched for age, sex, ASA, BMI, and tumor stage. Laparoscopic surgery increased in frequency. Fewer patients experienced a complication in both the laparoscopic colon (28.8 vs 54.4%; p < 0.0001) and rectal (41.4 vs 60.3%; p < 0.0001) group irrespective of age. Laparoscopic operating time for colon and rectal cancer was 24.1 minutes (p < 0.0001) and 25.8 minutes (p < 0.0001) longer, with a low conversion-to-open rate (6.5% and 8.3%; p = 0.44). Laparoscopic surgery resulted in fewer transfusions (0.4 vs 0.7units; p = 0.0028) and length of stay (7 vs 10 days; p = 0.0011) for colon cancers, and reduced intraoperative hemoglobin drop (20.5 vs 24.8; p = 0.029) and intensive care unit admissions (26.8 vs 36.3%; p = 0.032) for rectal cancers. LIMITATIONS: This was a nonrandomized study with rectal cancers more often resected with the open technique (71.2 vs 28.8%; p < 0.001). CONCLUSIONS: Within an area health service, elective laparoscopic resection for colon and rectal cancer had improved short-term outcomes in comparison with open surgery.

Effect of leg exercises on popliteal venous blood flow during prolonged immobility of seated subjects: implications for prevention of travel-related deep vein thrombosis

Summary.  Background: Venous stasis is an important contributing factor in the development of travel‐related deep vein thrombosis. This study examined factors affecting popliteal venous blood flow in order to determine the most effective exercise regimen to prevent venous stasis. Methods: Twenty‐one healthy subjects were randomly assigned to various activities over a 9‐week period. Subjects remained seated throughout the investigation and 3660 duplex ultrasound examinations were performed by a single examiner using a SonoSite 180 Plus handheld ultrasound. Baseline popliteal vein blood flow velocity, cross‐sectional area and volume flow in subjects sitting motionless were assessed in the first 3 weeks.The remaining 6 weeks involved subjects performing airline‐recommended activities, foot exercises, foot exercises against moderate resistance and foot exercises against increased resistance in order to determine the most beneficial method for enhancing popliteal venous flow. Sitting with feet not touching the floor and the effect of sleeping were also assessed. Results: The median age of the subjects was 22 years (range: 18–25.5 years), height 171 cm (162.5–180.5 cm) and body mass index 25.3 kg m–2 (23.2–26.3 kg m–2). Blood volume flow in the popliteal vein was reduced by almost 40% with immobility of seated subjects and by almost 2‐fold when sitting motionless with feet not touching the floor. Foot exercises against increased resistance positively enhanced volume flow (P < 0.0001). Conclusion: Leg exercise regimens enhanced popliteal venous flow during prolonged immobility of seated subjects, reinforcing the importance of regular leg movement to prevent venous stasis during prolonged sitting, such as in long‐distance travel.

Improved Outcomes with Endovascular Stent Grafts for Thoracic Aorta Transections

OBJECTIVE To retrospectively assess the outcome of endovascular stent-graft implantation for thoracic aortic transections (ETAT). DESIGN Retrospective review. METHODS 16 patients median age 30 years, treated between May 2000 and April 2007. Median injury severity score was 33 (range 29 to 66) in 14 acute patients; 2 patients had thoracic pseudoaneurysms. The Cook-Zenith endograft was used in eight patients, Medtronic-Talent (6) and Gore-Excluder (2). Average procedure time was 90 minutes, blood loss 100 (range 40 to 3000) mls, screening time 10.8 (range 5.9 to 22.6) minutes, and contrast dose was 195 (range 60 to 400) mls. RESULTS Graft deployment was successful in all cases. There was one death within 30 days. The left subclavian artery was completely covered in one case, and partially in three. Two patients had Type I endoleak, and one delayed Type II endoleak. One patient had iatrogenic right coronary artery dissection. Two patients developed difficult to treat hypertension, and one acute renal failure. CONCLUSION Endovascular intervention is a safe and effective treatment for aortic transection in multiple trauma patients. ETAT reduces the major morbidity and mortality associated with open repair in multiple trauma patients. The majority of these patients are young and long-term follow up is necessary to assess graft durability.

Prospective observational study of the practice of endotracheal intubation in the emergency department of a tertiary hospital in Sydney, Australia

To describe the practice of endotracheal intubation in the ED of a tertiary hospital in Australia, with particular emphasis on the indication, staff seniority, technique, number of attempts required and the rate of complications.

Venous thromboembolism and fractured neck of femur

The post-operative incidence of venous thromboembolism (VTE) is high for patients undergoing hip fracture surgery. Proven prophylactic measures are available although underutilized due to concern on post-operative bleeding with use of anticoagulants. This study retrospectively reviewed the clinical incidence of VTE and utilisation of thromboprophylactic protocols over an eight year period. Demographic details, mechanism of injury, VTE risk factors, prophylactic modalities (mechanical and pharmacological), operation duration, mode of anaesthesia, hospital length of stay (LOS) and post-operative complications with particular attention to suspected deep vein thrombosis (DVT) and/or pulmonary embolism (PE) were analysed. Male to female ratio was 1:2.7 with a median age of 78 years (IQR: 70-86 years) and 83 years (IQR: 77-87 years) respectively (p<0.001). Median hospital LOS was 8 days (IQR: 5-13 days) and differed with mechanism of injury. The in-hospital incidence of VTE was 1.6% (95% CI: 1.1-2.5%) with a probably underestimated three month rate of 8.2% (95% CI: 5.3-12.4%). Non fatal PE was 0.5% (95% CI: 0.2-1.0%) in-hospital and 2.6% (95% CI: 1.2-5.5%) at three months. Fatal PE was 0.5% (95% CI: 0.2-1.0%) with a three month incidence of 0.4% (95% CI: 0.1-2.4%). The in-hospital VTE incidence was kept relatively low with use of prophylactic protocols with almost all patients receiving prophylaxis by the end of the study period. Given the five-fold out of hospital increase in incidence, consideration should be given to continue prophylaxis beyond hospital discharge in this high risk group of patients.

Identifying the bleeding trauma patient: predictive factors for massive transfusion in an Australasian trauma population.

BACKGROUND Military and civilian data would suggest that hemostatic resuscitation results in improved outcomes for exsanguinating patients. However, identification of those patients who are at risk of significant hemorrhage is not clearly defined. We attempted to identify factors that would predict the need for massive transfusion (MT) in an Australasian trauma population, by comparing those trauma patients who did receive massive transfusion with those who did not. METHODS Between 1985 and 2010, 1,686 trauma patients receiving at least 1 U of packed red blood cells were identified from our prospectively maintained trauma registry. Demographic, physiologic, laboratory, injury, and outcome variables were reviewed. Univariate analysis determined significant factors between those who received MT and those who did not. A predictive multivariate logistic regression model with backward conditional stepwise elimination was used for MT risk. Statistical analysis was performed using SPSS PASW. RESULTS MT patients had a higher pulse rate, lower Glasgow Coma Scale (GCS) score, lower systolic blood pressure, lower hemoglobin level, higher Injury Severity Score (ISS), higher international normalized ratio (INR), and longer stay. Initial logistic regression identified base deficit (BD), INR, and hemoperitoneum at laparotomy as independent predictive variables. After assigning cutoff points of BD being greater than 5 and an INR of 1.5 or greater, a further model was created. A BD greater than 5 and either INR of 1.5 or greater or hemoperitoneum was associated with 51 times increase in MT risk (odds ratio, 51.6; 95% confidence interval, 24.9–95.8). The area under the receiver operating characteristic curve for the model was 0.859. CONCLUSION From this study, a combination of BD, INR, and hemoperitoneum has demonstrated good predictability for MT. This tool may assist in the determination of those patients who might benefit from hemostatic resuscitation. LEVEL OF EVIDENCE Prognostic study, level III.

Comparison of the C‐MAC video laryngoscope with direct Macintosh laryngoscopy in the emergency department

To investigate the first pass success rate, airway grade and complications in two tertiary EDs with the C‐MAC video laryngoscope (VL), when compared with standard direct laryngoscopy (DL).

Utility of white cell count and ultrasound in the diagnosis of acute appendicitis

Background:  Despite considerable advances in imaging, the diagnosis of acute appendicitis remains a clinical one. Nonetheless, knowledge of the characteristics of commonly used investigations for appendicitis may aid surgical decision‐making.

A Structured Review of Antithrombotic Therapy in Peripheral Artery Disease With a Focus on Revascularization: A TASC (InterSociety Consensus for the Management of Peripheral Artery Disease) Initiative

Peripheral artery disease affects >200 million people worldwide and is associated with significant limb and cardiovascular morbidity and mortality. Limb revascularization is recommended to improve function and quality of life for symptomatic patients with peripheral artery disease with intermittent claudication who have not responded to medical treatment. For patients with critical limb ischemia, the goals of revascularization are to relieve pain, help wound healing, and prevent limb loss. The baseline risk of cardiovascular and limb-related events demonstrated among patients with stable peripheral artery disease is elevated after revascularization and related to atherothrombosis and restenosis. Both of these processes involve platelet activation and the coagulation cascade, forming the basis for the use of antiplatelet and anticoagulant therapies to optimize procedural success and reduce postprocedural cardiovascular risk. Unfortunately, few high-quality, randomized data to support use of these therapies after peripheral artery disease revascularization exist, and much of the rationale for the use of antiplatelet agents after endovascular peripheral revascularization is extrapolated from percutaneous coronary intervention literature. Consequently, guideline recommendations for antithrombotic therapy after lower limb revascularization are inconsistent and not always evidence-based. In this context, the purpose of this structured review is to assess the available randomized data for antithrombotic therapy after peripheral arterial revascularization, with a focus on clinical trial design issues that may affect interpretation of study results, and highlight areas that require further investigation.