Michael J. Anstadt

No consensus exists for use of anticoagulation for calf vein thrombosis.

The ideal treatment of calf vein thrombosis (CVT) remains undefined. We assessed practice patterns at a single institution for CVT. Physicians were sent an online survey with 8 multiple choice questions about management of CVT. A total of 99 physicians of varying specialties participated in the survey. A total of 48.5% anticoagulate patients with CVT and 51.5% do not. Of those who anticoagulate, 62.3% use low molecular weight heparin and 11% use IV heparin. Treatment duration is 3 months for 58% and 6 months for 30% of responders. Of those who do not anticoagulate, 71.2% reassess for clot propagation or resolution with a duplex exam. IVC filters are used by 46% when there is a contraindication to anticoagulation and 13.7% when clot propagation is noted on follow-up scan. These results suggest that there is no consensus treatment of CVT. There is a higher than expected rate of IVC filters placed for CVT.

Superusers: Drivers of health care resource utilization in the national trauma population

Background: Health care spending is driven by a very small percentage of Americans, many of whom are patients with prolonged durations of stay. The objective of this study was to characterize superusers in the trauma population. Methods: The National Trauma Data Bank for 2008–2012 was queried. Superusers were defined as those with a duration of stay in the top 0.06% of the population and were compared with the remainder of the population to determine differences in demographic characteristics, comorbidities, prehospital factors, and outcomes. Multivariate analysis was used to determine independent predictors of being classified as a superuser. Results: A total of 3,617,261 patients met inclusion criteria, with 34,728 qualifying as superusers. Mean duration of stay for superusers was 58.7 days compared with the average 4.6 days (P < .001). Superusers were more likely to be male, black, Medicaid insured, and have a higher Injury Severity Score and lower Glasgow Coma Scale score. The hospital course of superusers was likely to be complicated by pneumonia, acute respiratory distress syndrome, decubitus ulcer, and acute kidney injury. Conclusion: Age, sex, race, and insurance were associated with prolonged use of inpatient care in the trauma patient population. Specific comorbidities and complications are associated with being a superuser. This subset of the trauma population confers a disproportionate burden on the health care system and can serve as a potential target for intervention.

The National Trauma Data Bank story for emergency department thoracotomy: How old is too old?

Background. The fastest growing segment of the American population is the elderly (>65 years). This change in demographics also is being seen in trauma centers. Emergency department thoracotomy is utilized in an attempt to restore circulation for patients arriving in extremis. The purpose of this study was to investigate the relationship between clinical variables, particularly age, and outcomes for injured patients receiving an emergency department thoracotomy. Methods. Using the National Trauma Data Bank for years 2008–2012, observations with International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes for exploratory thoracotomy were identified. Emergency department thoracotomy was defined as any observation that occurred at a time to thoracotomy less than the total time spent in the emergency department thoracotomy, and within 15 minutes of arrival. Mechanisms of injury, demographic data, and injuries were analyzed for predictors of survival and mortality rates. Mortality rates were determined for each decade and year of life. Results. There were 11,380 observations for thoracotomy identified. Of these, 2,519 were emergency department thoracotomy, with the majority (n = 2,026, 80% observations) performed for penetrating wounds. Mortality rates ranged from 80% to 100% for each decade of life. Mortality was 100% for patients >57 years old with either penetrating or blunt mechanisms of injury. Conclusion. Emergency department thoracotomy offered no survival benefit for patients older than 57 years of age. These data suggest that emergency department thoracotomy performed in elderly patients may be futile.

Surgical Aspects of Thoracic and Abdominal Organ Procurement from Brain-Dead Donors

Over the past two decades, the procedure of synchronous multiple organ procurement has been standardized. This has enabled the utilization of organs from nearly 8,000 deceased donors each year in the USA. This chapter sheds light on the technical aspects of safe retrieval of abdominal and thoracic organs.

M1552 Intraoperative Blood Transfusion Is Associated with Worse Long-Term Survival in Patients with Pancreatic Cancer Undergoing Pancreaticoduodenectomy

determined using Students t-test. Results: All study patients completed a successful RFAassisted liver resection. They were compared to 6 patients who underwent similar resections using a standard crush and clamp liver parenchymal division technique. The study group included 2 segmentectomies and 4 bisegmentectomies. The control group included 1 wedge resection, 1 segmentectomy, 1 bisegmentectomy, and 2 lobectomies. The average age of the study group and of the control group was 48.3 years and 64.5 years, respectively. The mean EBL was significantly lower in the study group (91.7 vs. 1016.7 ml, p<0.01). Significantly reduced LOS was seen in the study group as well (4.5 vs. 9 days, p<0.05). The post-operative complications for the RFA-assisted group included one patient with biloma which required percutaneous drainage. Complications from the control group included wound infection, ileus, and pneumonia. Conclusion: Our initial experience with radiofrequency ablation assisted liver resection indicates that it can be performed safely with significantly less blood loss and a shorter hospital stay.