Minna K. Lee

Damage control as a strategy to manage postreperfusion hemodynamic instability and coagulopathy in liver transplant

IMPORTANCE Damage control (DC) with intra-abdominal packing and delayed reconstruction is an accepted strategy in trauma and acute care surgery but has not been evaluated in liver transplant. OBJECTIVE To evaluate the incidence, effect on survival, and predictors of the need for DC using intra-abdominal packing and delayed biliary reconstruction in patients with coagulopathy or hemodynamic instability after liver allograft reperfusion. DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective analysis of adults undergoing liver transplant at a large transplant center from February 1, 2002, through July 31, 2012. MAIN OUTCOMES AND MEASURES Predictors of DC, effects on graft, and patient survival. RESULTS Of 1813 patients, 150 (8.3%) underwent DC during liver transplant, with 84 (56.0%) requiring a single additional operation for biliary reconstruction and abdominal closure and 57 (38.0%) requiring multiple additional operations. Compared with recipients without DC, patients requiring DC had greater Model for End-stage Liver Disease scores (33 vs 27; P < .001); more frequent pretransplant hospitalization (72.0% vs 47.9%; P < .001), intubation (33.3% vs 19.9%; P < .001), vasopressors (23.2% vs 10.9%; P < .001), renal replacement therapy (49.6% vs 30.3%; P < .001), and prior major abdominal operations (48.3% vs 21.9%; P < .001), including prior liver transplant (29.3% vs 8.9%; P < .001); greater operative transfusion requirements (37 vs 13 units of packed red blood cells; P < .001); worse intraoperative base deficit (10.3 vs 8.4; P = .03); more frequent postreperfusion syndrome (56.2% vs 27.3%; P < .001); and longer cold (430 vs 404 minutes; P = .04) and warm (46 vs 41 minutes; P < .001) ischemia times. Patients who underwent DC followed by a single additional operation for biliary reconstruction and abdominal closure had similar 1-, 3-, and 5-year graft survival (71%, 62%, and 62% vs 81%, 71%, and 67%; P = .26) and patient survival (72%, 64%, and 64% vs 84%, 75%, and 70%; P = .15) compared with recipients not requiring DC. Multivariate predictors of DC included prior liver transplant or major abdominal operation, longer pretransplant recipient and donor length of stay, greater Model for End-stage Liver Disease score, and longer warm and cold ischemia times (C statistic, 0.75). CONCLUSIONS AND RELEVANCE To our knowledge, this study represents the first large report of DC as a viable strategy for liver transplant recipients with coagulopathy or hemodynamic instability after allograft reperfusion. In DC recipients not requiring additional operations, outcomes are excellent and comparable to 1-stage liver transplant.

794 Prophylactic Pancreatic Resection in Patients With IPMN Does Not Negatively Impact Patient Quality of Life: A Preliminary Study

Introduction: The use of proximal esophageal pH monitoring to diagnose laryngopharyngeal reflux (LPR) is disappointing. We hypothesized that failure to maintain adequate alkalization instead of acidification of the cervical esophagus may be a better indicator of proximal esophageal exposure to gastric juice. As currently performed, acidification of the proximal esophagus is defined by exposure to a pH 7 and to use the inability to maintain this as an indication of LPR. Material and methods: The normal subject group consisted of 59 asymptomatic volunteers who had a complete foregut evaluation including pH monitoring of the proximal esophagus. After analysis of proximal esophageal exposure to a pH 7. Results: The median percent time the pH was >7 was significantly less in LPR patients prior to surgery compared to normal subjects [10.4 (2.8-21.9) vs. 38.2(27-56), p 7 in normal subjects was 19.6%. In 84% of the LPR patients (43/51) the percent time pH was >7 was less than 19.6, indicating they were unable to maintain a pH>7. In contrast, 69% of the patients (35/51) had an abnormal test when the pH records from proximal esophagus were analyzed using the % time pH 7. Conclusion: Normal subjects are expected to have a pH>7 in cervical esophagus for at least 19.6% of the monitored period. Using the threshold value for pH>7 rather than 7 as the threshold to identify reflux as the cause of LPR symptoms. It identifies two third of the patients whose analysis of their pH records using pH<4 is falsely normal.

1040 127 Resections for Pancreatic Neuroendocrine Tumor: Evaluating the Impact of Minimally Invasive and Parenchymal-Sparing Surgical Techniques

Background: Gastro-gastric fistulae are a challenging complication of obesity surgery that often requires surgical revision. Performance of endoscopic fistula closure is increasing and may provide a less invasive alternative; nevertheless, the majority of fistulae ultimately require surgical revision. The impact of prior endoscopic intervention on surgical revision outcomes remains unknown. We present the largest series on surgical revision of gastro-gastric fistulae to date and perform cohort analysis to assess the impact of prior endoscopic therapy. Methods: A database of all bariatric surgical revisions performed at a single institution was searched for patients with gastro-gastric fistula. Electronic records and clinic charts were then reviewed. The cohort was divided between patients with attempted endoscopic fistula closure prior to surgical revision, and patients without endoscopic therapy prior to revision. 30-day morbidity and mortality was the primary outcome. Age, sex, initial surgery BMI, revision surgery BMI, type of initial surgery, type of revision surgery, number of prior surgeries, number of endoscopic fistula closure attempts, presence of dilated gastrojejunostomy, number of endoscopic clips placed, number of endoscopic sutures placed, fistula size, smoking status, thyroid disease, presence of diabetes, medical co-morbidities, OR time and 30-day minor and major post-operative complications were collected. Categorical and continuous data were analyzed with Fishers exact test and Wilcoxon signed-rank test respectively. Results: 68 total cases of surgical revision were reviewed. 35 cases were performed for gastro-gastric fistula. Of 35 cases, 22 had attempted endoscopic closure prior to surgical revision while 13 went directly to surgical revision. In the endoscopy group, 2 minor complications and 7 major complications occurred (total 9/22; 40.9%). In the surgery only group, 3 minor complications and 3 major complications occurred (total 6/13; 46.1%). No deaths occurred. No statistical difference existed in the demographic or primary outcome variables of interest between the two groups. Sub-group analysis of the endoscopy group did suggest a relationship between the number of sutures (p=0.04) and clips p=(0.04) placed at the gastrojejunostomy and major 30-day complications. Conclusion: In the largest study of surgical revision of gastro-gastric fistulae to date, there is no evidence that prior attempts at endoscopic fistula closure lead to increased complications at the time of surgical revision.