Abstracts from the 10th annual Baylor Scott & White Department of Surgery Research Day Harry T. Papaconstantinou, MD, James Fleshman, MD, J. Scott Thomas, MD, Marcin Czerwinski, MD, and M. Karen Newell-Rogers, PhD, editors
T
his year marks the 10th anniversary of the Department of Surgery Research Day. We want to begin by expressing gratitude to all who made this Research Day a success. This included a dedicated staff, including Dee Ann Gillam, Lynn Botts, and Kathleen McKee, the organizers of the 2015 Research Day, the founders and visionaries that established and maintained the tradition of having a yearly Department of Surgery Research Day, and the young physicians and physicianscientists whose scholarly activity and efforts were shared at our May 1, 2015, event. This year also marked our second year in existence as Baylor Scott & White Healthcare, and as such, we celebrate the collaborative effort of the Departments of Surgery at Scott & White Memorial Hospital and Baylor University Medical Center to make this a systemwide integrated event. Research Day started as a grassroots initiative to showcase the efforts of medical students, residents, and fellows in the areas of basic, translational, and clinical research. Each year for the last 10 years, surgical trainees within the Department of Surgery have worked to integrate the clinical problems they encounter into research projects aimed at offering new insights and knowledge with the potential of advancing medical knowledge and improving patient outcomes. The robust participation and quality of research presented at the Baylor Scott & White Department of Surgery Research Day highlight the importance of research to the residents, faculty, department, institution, and system. Many of the studies and presentations have been submitted and accepted for presentation at regional, national, and international specialty meetings. It is this level of participation that increases the awareness of quality education, research, and clinical/surgical care provided in our organizations. Many of these presentations will be submitted as manuscripts to peer-reviewed journals, such as Baylor Proceedings, and upon successful publication will be the basis for future patient care and the foundation for future research. This concept is powerful, as our surgical trainees and departments of surgery are shaping the standard of surgical patient care and developing innovative techniques to improve quality of care and patient outcomes. This year we had the opportunity to host two keynote speakers. Dr. Paul Kuo, chairman of surgery and director of the Oncology Research Institute at Loyola University Medical
24
Center, gave a talk entitled “Not knowing is part of the fun.” Dr. Lisa Poritz, an associate professor in the Department of Surgery and Section of Colon and Rectal Surgery from Pennsylvania State University Medical School, spoke about “Alteration of the tight junction complex in intestinal inflammation.” Presentations from these highly regarded surgeon scientists demonstrate how a lifetime of dedicated inquiry and research can lead to a productive and successful academic career. We are appreciative of their willingness to participate and be a critical participant in this important day. Together with Dr. Carl Tong, director of the Baylor Scott & White Heart Transplant Team, our invited guest speakers not only presented their inspiring work, but also reviewed the presentations and acted as judges for the awardees of the event. After strict review and careful deliberation, the judges distributed awards to the following recipients: • Trung Ho (Baylor Scott & White Central), Best Presentation, “The incidence of ocular injuries in isolated orbital fractures” • Anson Nguyen (Baylor Scott & White Central), Best Poster, “Safety of outpatient orbital fracture repair” • Philip Edmundson (Baylor Scott & White North), Second Place (tie), “Sarcopenia as a marker of frailty: PSOAS muscle size predicts functional outcome in mild to moderately injured trauma patients” • Mark Draoua (Baylor Scott & White North), Second Place (tie), “Signifi cance of measured intraoperative portal vein flows after thrombendvenectomy in deceased donor liver transplant recipients with portal vein thrombosis” Collectively, we are proud of our residents, faculty, and this important event. We look forward to continuing this tradition and expanding participation among surgical trainees within the Baylor Scott & White Healthcare System. From the Department of Surgery, Baylor Scott & White Health, Temple, Texas (Papaconstantinou, Thomas, Czerwinski, Newell-Rogers) and the Department of Surgery, Baylor University Medical Center at Dallas (Fleshman). Corresponding author: Harry T. Papaconstantinou, MD, Department of Surgery, Baylor Scott & White Health, 2401 South 31st Street, Temple, TX 76508 (e-mail: [email protected]).
Proc (Bayl Univ Med Cent) 2016;29(1):24–29
The incidence of ocular injuries in isolated orbital fractures Trung Ho,* Jonathan Tsai, and Marcin Czerwinski (e-mail: [email protected])
Orbital fractures are common and have the potential for an associated ocular globe injury. Prompt identification of significant ocular injuries is important to prevent any potential long-term visual sequelae; however, their true incidence in this patient population has not been determined due to the suboptimal design of previously conducted studies. As a consequence, most surgeons choose to have all such patients formally evaluated by an ophthalmologist. The objective of this study was to conclusively identify the incidence of significant ocular injuries in patients with isolated orbital fractures and to determine their predictors in order to guide more efficient patient care. A prospective cohort study, powered to detect a 15% incidence of ocular injuries, was designed. All patients presenting to our regional Level I trauma center with computed tomography findings of an isolated orbital fracture were included and followed a strict evaluation protocol. Plastic surgery examination included visual acuity, pupillary reactivity, ocular range of motion, and presence of visible injuries. Ophthalmology evaluation also included intraocular pressure and formal anterior chamber and posterior chamber exams. Significant ocular injury was defined as that requiring ophthalmologic intervention in an attempt to preserve or restore vision. Patients were followed for a minimum of 1 week to identify any delayed injuries. Eighty patients were enrolled from 2012 to 2014. There were 46 males and 34 females with a mean age of 42.8 years. Assault was the most common mechanism of injury. There were eight ocular injuries (10%): ruptured globe (1), uveal prolapse (1), retrobulbar hemorrhage (2), hyphema (3), and scleral tear (1). Four of the injuries were considered significant. Predictors for significant ocular injuries were grossly abnormal visual acuity and obvious lack of pupillary reactivity of the affected eye. The incidence of significant ocular injuries in isolated orbital fractures is much lower than previously reported. Therefore, not all patients with isolated orbital fractures require formal ophthalmologic evaluation. However, patients presenting with grossly abnormal visual acuity or abnormal pupillary reactivity are at high risk and likely require urgent ocular intervention. Significance of measured intraoperative portal vein flows after thrombendvenectomy in deceased donor liver transplant recipients with portal vein thrombosis Mark Draoua,* Nicole Titze, Amara Gupta, Hoylan Fernandez, Giovanna Saracino, Michael Ramsay, Giuliano Testa, Goran Klintmalm, and Peter Kim (e-mail: mark. [email protected])
Adequate portal vein (PV) flow, an important factor in liver transplantation, may still be compromised after thrombendvenectomy in patients with portal vein thrombosis (PVT). This study evaluated the impact on patient outcomes of measured intraoperative PV flow after PV thrombendvenectomy during deceased donor liver transplantation (DDLT). Eighty patients who underwent PV thrombendvenectomy during DDLT with available flow data over a 16-year period were included in the study. Patients were classified into two groups: high PV flow (>1300 mL/min, n = 57) and low PV flow (60 years (hazard ratio [HR] 3.03 [1.08–8.54], P = 0.04), male sex (HR 4.4 [1.45–13.3], P = 0.009), and PV flow 1300 mL/min after PV thrombendvenectomy for PVT during DDLT was associated with lower rates of biliary strictures and better long-term survival. Consideration should be given to identifying reasons for low flow and maneuvers to increase PV flow when PV is stage II) (55.6% vs 26.8%; P = 0.004), and myocardial infarction during hospitalization (20% vs 8.7%; P = 0.039). Among weaned patients, 18.8% were discharged home, 39.9% to a skilled nursing facility, 29.7% to an inpatient rehabilitation facility, 3.6% to hospice, and 2.2% to the intensive care unit. Failure to wean imparted a 14-fold increased mortality at 1 month (odds ratio, 14.23 [6.39–31.71]; P < 0.001). We report a higher weaning rate than in prior studies. Increased age, chronic obstructive pulmonary disease, renal failure, and myocardial infarction impact liberation from MV. Incorporating these variables can facilitate meaningful family discussions regarding weaning expectations.
Baylor University Medical Center Proceedings
Volume 29, Number 1
The benefits to pediatric trauma patients offered by freestanding pediatric hospitals with trauma centers Laura Harmon,* Matthew Davis, and Justin Regner (e-mail: [email protected])
Differences in the care of pediatric trauma patients at combined adult and pediatric trauma centers versus stand-alone pediatric trauma centers remains unclear with regard to complications and outcomes. While pediatric trauma centers are becoming more common, only 36% of states have designated pediatric trauma centers, and 70% stenosis or occlusion (75%). Mortality also occurred more frequently in injuries with >50% stenosis or occlusion (71%). For BCVI, the ISS, incidence of TBI, incidence of stroke, and mortality were higher for CA than VA injuries. Cervical fractures were much more common with VA injuries. Stroke occurred only in injuries with >70% luminal stenosis/occlusion or with persistent sciatic artery, and mortality occurred 6 times more frequently in injuries with >50% luminal stenosis/occlusion or with PSA. Due to this, the new Dallas modified BCVI grading scale gives better prognostic outcomes than the original grading scale. S100β induces blood-brain barrier endothelial cell hyperpermeability via caspase-3–mediated disruption of the tight junctions Chen Chen,* Himakarnika Alluri, Anasooya Shaji, Katie Wiggins-Dohlvik, Matthew Davis, and Binu Tharakan (e-mail: [email protected])
Traumatic brain injury (TBI) is a leading cause of death and disability in the younger population. Microvascular permeability that occurs due to breakdown of the blood-brain barrier (BBB) is one of the major contributors of the vasogenic brain edema and elevated intracranial pressure that occur following TBI. The BBB consists of endothelial cells linked together by tight junction proteins that are intracellularly linked to the actin cytoskeleton of the cell mainly by zonula occludens-I (ZO-I). S100β, a glial-specific protein expressed by astrocytes, is released during TBI and is a biomarker for it. However, it has not been determined whether the protein contributes to BBB breakdown. Our objective was to determine if S100β causes BBB breakdown and hyperpermeability and to determine if it occurs through tight junction protein disruption via caspase-3. TBI was induced in mice with a controlled cortical impactor, and serum S100β was measured using an antibody array technique. Rat brain microvascular endothelial cell (RBMEC) monolayers were exposed to S100β in the presence or absence of the caspase-3 inhibitor Z-DEVD-fmk. Monolayer permeability was measured fluorometrically. Changes in tight junction integrity and cytoskeletal assembly were studied using ZO-1 immunofluorescence and rhodamine phalloidin staining for F-actin, respectively. Serum S100β levels were increased following TBI injury in animals. Treatment of S100β caused a significant increase in RBMEC monolayer permeability at 1 ug/mL and 10 ug/mL concentrations (P < 0.05), while ZDEVD-fmk (10 uM; 1 hour) pretreatment attenuated S100β (1 ug/mL; 4 hours)–induced hyperpermeability significantly (P < 0.05). Z-DEVD-fmk prevented S100β-induced disruption of the tight junctions and resulted in cytoskeletal reorganization. S100β-induced BBB endothelial cell hyperpermeability may be mediated via caspase-3 disruption of tight junction proteins.
Abstracts from the 10th annual Baylor Scott & White Department of Surgery Research Day
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What risk factors within the first 24 hours of admission are associated with mortality after traumatic injury? Stephanie Joyce,* Geoffrey Funk, Stephanie Agrarap, Megan Reynolds, and Michael Foreman (e-mail: [email protected])
The Trauma Quality Improvement Program (TQIP) was created to provide risk-adjusted benchmarking in trauma centers. Currently, 9 variables in TQIP are used in risk adjustment. There are risk factors not yet validated by TQIP that are direct contributors to mortality. Looking specifically at variables within the first 24 hours of admission, we hoped to identify novel contributors predictive of overall mortality within trauma patients at our institution. A retrospective review of concurrently collected trauma registry data included all trauma patients admitted to the institution in the year 2013. Multiple variables were reviewed, including diagnostic and procedural processes during the first 24 hours following hospital arrival (i.e., age, Injury Severity Score [ISS], motor component of the Glasgow Coma Scale [GCS], initial systolic blood pressure and pulse rate, mechanism of injury, head injury severity, abdominal injury severity, and patient transfer status). Additional variables included time of arrival, operative vs minimally invasive interventions, volume of crystalloid and/or blood transfused, acidosis/base deficit, race, as well as scene time and vitals. For continuous variables (e.g., age and ISS), independent t tests were run; for categorical variables (e.g., sex, race, and trauma type), chi-squared tests were used to determine initial differences between those who survived and died. There were significant differences in initial pulse, systolic and diastolic blood pressure, GCS, and ISS (all P < 0.001). Additionally, there were significant differences for race (P = 0.003), sex (P = 0.01), hospital transfer (P = 0.002), and disposition from the emergency department, cause of injury, trauma type, comorbidities, and use of paralytics in the emergency department (all P < 0.001). These initial findings identify distinctive differences among variables of patients who survived traumatic injury and those who did not. This suggests that multiple factors within the first 24 hours, beyond the standard risk factors, are predictive of eventual mortality. Melatonin inhibits hemorrhagic shock-induced microvascular endothelial cell derangements Katie Wiggins-Dohlvik,* Himakarnika Alluir, Chinchusha Anasooya Shaji, Vivayak Govande, Madhava Beeram, Amin Mohammad, Matthew Davis, and Binu Tharakan (e-mail: [email protected])
Hemorrhagic shock (HS) induces global ischemia and reperfusion injuries, resulting in vascular hyperpermeability. The mechanisms that regulate this process are unclear. We hypothesized that matrix metalloproteinase-9 (MMP-9) is pivotal therein and that such damage can be attenuated with melatonin. Rats were divided into sham, HS, and HS plus melatonin groups (shock for 1 hour, n = 5). Laparotomy was performed and mesenteric postcapillary venules were examined with intravital microscopy. Fluorescent intensities were measured intravascularly and extravascularly to assess vessel permeability, vital signs and fluid requirements were recorded, and serum and tissue were collected. MMP activity was assayed in lung tissue homogenates (n = 8). In parallel, rat lung microvascular 28
endothelial cells (RLMEC) were grown and divided into the following groups: sham serum, HS serum, sham serum plus melatonin, and HS serum plus melatonin. Albumin flux across the monolayers was obtained as a marker of permeability (n = 6). RLMEC grown on chamber slides (n = 4) were stained for adherens junction protein β-catenin and the cytoskeletal protein F-actin, and protein degradation was examined with confocal microscopy. Statistical analysis was conducted using Student’s t test and analysis of variance. Intravital microscopy revealed an increase in vascular hyperpermeability following HS, which was attenuated with melatonin (P < 0.05). HS animals required more fluid to maintain normotension, and this was mitigated with melatonin (P < 0.05). MMP-9 activity was elevated in lung homogenates from HS animals, and levels were lower with melatonin treatment (P < 0.05). Monolayer permeability was increased with exposure to HS serum, and melatonin attenuated this (P < 0.05). Chamber slides showed that HS serum induced disruption of adherens junction proteins and incited formation of F-actin stress fibers; melatonin preserved the baseline configuration of both. In conclusion, HS induces microvascular hyperpermeability and clinical fluid derangements and causes alterations in endothelial cell structure; melatonin attenuates these changes. The effect of multidisciplinary teams for rectal cancer on delivery of care and patient outcome Bradford Richardson,* James Fleshman, John Preskitt, and Stephanie Peschka (e-mail: [email protected])
Baylor University Medical Center at Dallas initiated biweekly colorectal tumor multidisciplinary team (MDT) conferences in January 2013. All cases of colorectal cancer are presented to a team of specialists across disciplines. The complex treatment of rectal cancer requires an MDT approach. It is hypothesized that these MDTs will allow for 1) standardization of care and improved utilization of available resources to meet this standard; 2) improvements in the technical aspects of treatment; and 3) improvements in patient outcome. A retrospective chart review and review of prospectively collected MDT data was conducted for all patients treated for primary rectal adenocarcinoma at the institution in the past 5 years. The 130 patients were grouped by those discussed by the MDT in 2014 (n = 47) and 2013 (n = 41) and those treated before the initiation of MDT conferences (n = 42). Data on demographics, clinical stage, process evaluation, quality of surgery, and outcomes were collected. The National Comprehensive Cancer Network guidelines and College of American Pathologists protocol were used as standards. Clinical stage III was higher in 2013. Steady improvements were seen in 13 of the 15 preoperative process variables, 7 significantly. Improvement in an important technical aspect of surgery, the completeness of total mesorectal excision, was significant. The time to recurrence in the pre-MDT group was 27 months. The mean time since resection in the MDT groups was 6.5 and 14.5 months. It is too early to determine if recurrence rates and survival rates have improved. Since adopting the MDT approach, steady improvements have been made in preoperative clinical staging, multimodality treatment,
Baylor University Medical Center Proceedings
Volume 29, Number 1
pathologic staging, and technical aspects of surgery. There is still considerable room for improvement in some areas, especially the use of the rigid proctoscope and chest imaging for metastasis. Close follow-up of the 88 post-MDT patients will show whether these improvements in delivery of care result in improvements in patient outcomes. Tailoring surgical approach for elective ventral hernia repairs based on obesity and outcomes
in ventral hernia repairs. National data demonstrate that the laparoscopic approach is increasingly preferred as BMI increases when repairing elective reducible hernias. Early postoperative complications are more common as BMI increases in both open and laparoscopic repairs. The laparoscopic approach is associated with lower superficial and deep SSI complications for all BMI categories, in addition to lower organ space infections, reoperation, and wound dehiscence complications for higher obesity classes.
Mary Mrdutt* and Justin Regner (e-mail: [email protected])
Currently, a third of the US population is obese, and that percentage is projected to exceed 40% by 2030, involving approximately 140 million people. Obesity’s influence on postoperative complications in laparoscopic ventral hernia repairs (LVHR) versus open ventral hernia repairs (OVHR) has yet to be defined. While 30-day postoperative complications in both LVHR and OVHR are more frequent as body mass index (BMI) increases, we propose that the laparoscopic approach minimizes infectious complications for given BMI categories. A retrospective review was conducted of the American College of Surgeons National Surgical Quality Improvement Program database (2009–2012) for all patients ≥18 years undergoing elective repair of reducible ventral hernia. Exclusion criteria included immunosuppression, disseminated malignancy, advanced liver disease, or pregnancy. Patients were stratified by World Health Organization BMI categories of normal weight, overweight, and obesity classes I, II, and III (BMI 20–25, 25–30, 30–35, 35–40, and ≥40 respectively). Thirty-day postoperative complications were evaluated across BMI groups for LVHR vs OVHR using chi-squared test. Linear regression was adjusted for diabetes, smoking, gender, and age. A total of 75,168 patients met inclusion criteria, with nearly 55% of patients obese. The rate of LVHR increased with BMI (normal weight, 17.8%; BMI ≥40, 28.3%). Superficial and deep surgical site infections (SSIs) increased with increasing BMI for both techniques. However, LVHR minimized superficial and deep SSIs across all BMIs (odds ratio, open versus laparoscopic, specifically for BMI ≥40, superficial SSI, 5.34; deep infections, 4.76). Organ space infections, reoperation, and wound dehiscence increased with increasing BMI only in OVHR (P < 0.05). For organ space infections, reoperation, and wound dehiscence, only higher classes of obesity had a statistically significant difference (odds ratio, open versus laparoscopic at BMI 35–40: organ space, 1.98; reoperation, 1.86; wound dehiscence, 4.79; P < 0.05). Obese patients are overrepresented
January 2016
Do donor lifestyle choices and polysubstance abuse affect long-term survival in heart transplant recipients? Yazhini Ravi, Shelly Bansal, Kim Jeong, Sitaramesh Emani, Bryan A. Whitson, Carl Tong, and Chittoor B. Sai-Sudhakar (e-mail: [email protected])
High-risk behavior negatively impacts donor acceptance. We sought to evaluate the impact of donors’ negative lifestyle choices and substance abuse on long-term outcomes in heart transplant recipients. The registry of the United Network for Organ Sharing was queried for adult heart transplant recipients from 2000 to 2013. Donors were categorized into non–high risk and high-risk based upon the factors listed by the Centers for Disease Control and Prevention: a history of intravenous drug use, prostitution, high-risk sexual activity, HIV exposure, and hemophilia. We also sought to evaluate the impact of alcohol, tobacco, or cocaine abuse. A t test was used to analyze continuous variables, and a chi-square test was used to analyze categorical variables. Kaplan-Meier survival curves were created to analyze the impact of substance abuse on transplant recipient survival. A total of 17,546 heart transplant recipients were identified. In the high-risk donor group, 43% had type O blood, 78% were males, and 69% were Caucasians. In the non–high-risk donor group, 54% had type O blood, the mean donor age was 29.9 ± 9.5 years, body mass index was 26.2 ± 4.8 kg/m2, and 69% were Caucasians. There were no significant differences in age and body mass index between the two groups, but donor age and BMI were significantly lower in transplant recipients. Equivalent waiting times were seen in both groups. Rejection and graft failure secondary to acute or chronic rejection at 1 year were not statistically significantly different between groups. Posttransplant survival at 5 years was similar in both groups. In conclusion, high-risk donor behaviors and polysubstance abuse do not adversely affect outcomes in heart transplantation. Negative lifestyle choices should not deter organ acceptance.
Abstracts from the 10th annual Baylor Scott & White Department of Surgery Research Day
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T
his year marks the 10th anniversary of the Department of Surgery Research Day. We want to begin by expressing gratitude to all who made this Research Day a success. This included a dedicated staff, including Dee Ann Gillam, Lynn Botts, and Kathleen McKee, the organizers of the 2015 Research Day, the founders and visionaries that established and maintained the tradition of having a yearly Department of Surgery Research Day, and the young physicians and physicianscientists whose scholarly activity and efforts were shared at our May 1, 2015, event. This year also marked our second year in existence as Baylor Scott & White Healthcare, and as such, we celebrate the collaborative effort of the Departments of Surgery at Scott & White Memorial Hospital and Baylor University Medical Center to make this a systemwide integrated event. Research Day started as a grassroots initiative to showcase the efforts of medical students, residents, and fellows in the areas of basic, translational, and clinical research. Each year for the last 10 years, surgical trainees within the Department of Surgery have worked to integrate the clinical problems they encounter into research projects aimed at offering new insights and knowledge with the potential of advancing medical knowledge and improving patient outcomes. The robust participation and quality of research presented at the Baylor Scott & White Department of Surgery Research Day highlight the importance of research to the residents, faculty, department, institution, and system. Many of the studies and presentations have been submitted and accepted for presentation at regional, national, and international specialty meetings. It is this level of participation that increases the awareness of quality education, research, and clinical/surgical care provided in our organizations. Many of these presentations will be submitted as manuscripts to peer-reviewed journals, such as Baylor Proceedings, and upon successful publication will be the basis for future patient care and the foundation for future research. This concept is powerful, as our surgical trainees and departments of surgery are shaping the standard of surgical patient care and developing innovative techniques to improve quality of care and patient outcomes. This year we had the opportunity to host two keynote speakers. Dr. Paul Kuo, chairman of surgery and director of the Oncology Research Institute at Loyola University Medical
24
Center, gave a talk entitled “Not knowing is part of the fun.” Dr. Lisa Poritz, an associate professor in the Department of Surgery and Section of Colon and Rectal Surgery from Pennsylvania State University Medical School, spoke about “Alteration of the tight junction complex in intestinal inflammation.” Presentations from these highly regarded surgeon scientists demonstrate how a lifetime of dedicated inquiry and research can lead to a productive and successful academic career. We are appreciative of their willingness to participate and be a critical participant in this important day. Together with Dr. Carl Tong, director of the Baylor Scott & White Heart Transplant Team, our invited guest speakers not only presented their inspiring work, but also reviewed the presentations and acted as judges for the awardees of the event. After strict review and careful deliberation, the judges distributed awards to the following recipients: • Trung Ho (Baylor Scott & White Central), Best Presentation, “The incidence of ocular injuries in isolated orbital fractures” • Anson Nguyen (Baylor Scott & White Central), Best Poster, “Safety of outpatient orbital fracture repair” • Philip Edmundson (Baylor Scott & White North), Second Place (tie), “Sarcopenia as a marker of frailty: PSOAS muscle size predicts functional outcome in mild to moderately injured trauma patients” • Mark Draoua (Baylor Scott & White North), Second Place (tie), “Signifi cance of measured intraoperative portal vein flows after thrombendvenectomy in deceased donor liver transplant recipients with portal vein thrombosis” Collectively, we are proud of our residents, faculty, and this important event. We look forward to continuing this tradition and expanding participation among surgical trainees within the Baylor Scott & White Healthcare System. From the Department of Surgery, Baylor Scott & White Health, Temple, Texas (Papaconstantinou, Thomas, Czerwinski, Newell-Rogers) and the Department of Surgery, Baylor University Medical Center at Dallas (Fleshman). Corresponding author: Harry T. Papaconstantinou, MD, Department of Surgery, Baylor Scott & White Health, 2401 South 31st Street, Temple, TX 76508 (e-mail: [email protected]).
Proc (Bayl Univ Med Cent) 2016;29(1):24–29
The incidence of ocular injuries in isolated orbital fractures Trung Ho,* Jonathan Tsai, and Marcin Czerwinski (e-mail: [email protected])
Orbital fractures are common and have the potential for an associated ocular globe injury. Prompt identification of significant ocular injuries is important to prevent any potential long-term visual sequelae; however, their true incidence in this patient population has not been determined due to the suboptimal design of previously conducted studies. As a consequence, most surgeons choose to have all such patients formally evaluated by an ophthalmologist. The objective of this study was to conclusively identify the incidence of significant ocular injuries in patients with isolated orbital fractures and to determine their predictors in order to guide more efficient patient care. A prospective cohort study, powered to detect a 15% incidence of ocular injuries, was designed. All patients presenting to our regional Level I trauma center with computed tomography findings of an isolated orbital fracture were included and followed a strict evaluation protocol. Plastic surgery examination included visual acuity, pupillary reactivity, ocular range of motion, and presence of visible injuries. Ophthalmology evaluation also included intraocular pressure and formal anterior chamber and posterior chamber exams. Significant ocular injury was defined as that requiring ophthalmologic intervention in an attempt to preserve or restore vision. Patients were followed for a minimum of 1 week to identify any delayed injuries. Eighty patients were enrolled from 2012 to 2014. There were 46 males and 34 females with a mean age of 42.8 years. Assault was the most common mechanism of injury. There were eight ocular injuries (10%): ruptured globe (1), uveal prolapse (1), retrobulbar hemorrhage (2), hyphema (3), and scleral tear (1). Four of the injuries were considered significant. Predictors for significant ocular injuries were grossly abnormal visual acuity and obvious lack of pupillary reactivity of the affected eye. The incidence of significant ocular injuries in isolated orbital fractures is much lower than previously reported. Therefore, not all patients with isolated orbital fractures require formal ophthalmologic evaluation. However, patients presenting with grossly abnormal visual acuity or abnormal pupillary reactivity are at high risk and likely require urgent ocular intervention. Significance of measured intraoperative portal vein flows after thrombendvenectomy in deceased donor liver transplant recipients with portal vein thrombosis Mark Draoua,* Nicole Titze, Amara Gupta, Hoylan Fernandez, Giovanna Saracino, Michael Ramsay, Giuliano Testa, Goran Klintmalm, and Peter Kim (e-mail: mark. [email protected])
Adequate portal vein (PV) flow, an important factor in liver transplantation, may still be compromised after thrombendvenectomy in patients with portal vein thrombosis (PVT). This study evaluated the impact on patient outcomes of measured intraoperative PV flow after PV thrombendvenectomy during deceased donor liver transplantation (DDLT). Eighty patients who underwent PV thrombendvenectomy during DDLT with available flow data over a 16-year period were included in the study. Patients were classified into two groups: high PV flow (>1300 mL/min, n = 57) and low PV flow (60 years (hazard ratio [HR] 3.03 [1.08–8.54], P = 0.04), male sex (HR 4.4 [1.45–13.3], P = 0.009), and PV flow 1300 mL/min after PV thrombendvenectomy for PVT during DDLT was associated with lower rates of biliary strictures and better long-term survival. Consideration should be given to identifying reasons for low flow and maneuvers to increase PV flow when PV is stage II) (55.6% vs 26.8%; P = 0.004), and myocardial infarction during hospitalization (20% vs 8.7%; P = 0.039). Among weaned patients, 18.8% were discharged home, 39.9% to a skilled nursing facility, 29.7% to an inpatient rehabilitation facility, 3.6% to hospice, and 2.2% to the intensive care unit. Failure to wean imparted a 14-fold increased mortality at 1 month (odds ratio, 14.23 [6.39–31.71]; P < 0.001). We report a higher weaning rate than in prior studies. Increased age, chronic obstructive pulmonary disease, renal failure, and myocardial infarction impact liberation from MV. Incorporating these variables can facilitate meaningful family discussions regarding weaning expectations.
Baylor University Medical Center Proceedings
Volume 29, Number 1
The benefits to pediatric trauma patients offered by freestanding pediatric hospitals with trauma centers Laura Harmon,* Matthew Davis, and Justin Regner (e-mail: [email protected])
Differences in the care of pediatric trauma patients at combined adult and pediatric trauma centers versus stand-alone pediatric trauma centers remains unclear with regard to complications and outcomes. While pediatric trauma centers are becoming more common, only 36% of states have designated pediatric trauma centers, and 70% stenosis or occlusion (75%). Mortality also occurred more frequently in injuries with >50% stenosis or occlusion (71%). For BCVI, the ISS, incidence of TBI, incidence of stroke, and mortality were higher for CA than VA injuries. Cervical fractures were much more common with VA injuries. Stroke occurred only in injuries with >70% luminal stenosis/occlusion or with persistent sciatic artery, and mortality occurred 6 times more frequently in injuries with >50% luminal stenosis/occlusion or with PSA. Due to this, the new Dallas modified BCVI grading scale gives better prognostic outcomes than the original grading scale. S100β induces blood-brain barrier endothelial cell hyperpermeability via caspase-3–mediated disruption of the tight junctions Chen Chen,* Himakarnika Alluri, Anasooya Shaji, Katie Wiggins-Dohlvik, Matthew Davis, and Binu Tharakan (e-mail: [email protected])
Traumatic brain injury (TBI) is a leading cause of death and disability in the younger population. Microvascular permeability that occurs due to breakdown of the blood-brain barrier (BBB) is one of the major contributors of the vasogenic brain edema and elevated intracranial pressure that occur following TBI. The BBB consists of endothelial cells linked together by tight junction proteins that are intracellularly linked to the actin cytoskeleton of the cell mainly by zonula occludens-I (ZO-I). S100β, a glial-specific protein expressed by astrocytes, is released during TBI and is a biomarker for it. However, it has not been determined whether the protein contributes to BBB breakdown. Our objective was to determine if S100β causes BBB breakdown and hyperpermeability and to determine if it occurs through tight junction protein disruption via caspase-3. TBI was induced in mice with a controlled cortical impactor, and serum S100β was measured using an antibody array technique. Rat brain microvascular endothelial cell (RBMEC) monolayers were exposed to S100β in the presence or absence of the caspase-3 inhibitor Z-DEVD-fmk. Monolayer permeability was measured fluorometrically. Changes in tight junction integrity and cytoskeletal assembly were studied using ZO-1 immunofluorescence and rhodamine phalloidin staining for F-actin, respectively. Serum S100β levels were increased following TBI injury in animals. Treatment of S100β caused a significant increase in RBMEC monolayer permeability at 1 ug/mL and 10 ug/mL concentrations (P < 0.05), while ZDEVD-fmk (10 uM; 1 hour) pretreatment attenuated S100β (1 ug/mL; 4 hours)–induced hyperpermeability significantly (P < 0.05). Z-DEVD-fmk prevented S100β-induced disruption of the tight junctions and resulted in cytoskeletal reorganization. S100β-induced BBB endothelial cell hyperpermeability may be mediated via caspase-3 disruption of tight junction proteins.
Abstracts from the 10th annual Baylor Scott & White Department of Surgery Research Day
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What risk factors within the first 24 hours of admission are associated with mortality after traumatic injury? Stephanie Joyce,* Geoffrey Funk, Stephanie Agrarap, Megan Reynolds, and Michael Foreman (e-mail: [email protected])
The Trauma Quality Improvement Program (TQIP) was created to provide risk-adjusted benchmarking in trauma centers. Currently, 9 variables in TQIP are used in risk adjustment. There are risk factors not yet validated by TQIP that are direct contributors to mortality. Looking specifically at variables within the first 24 hours of admission, we hoped to identify novel contributors predictive of overall mortality within trauma patients at our institution. A retrospective review of concurrently collected trauma registry data included all trauma patients admitted to the institution in the year 2013. Multiple variables were reviewed, including diagnostic and procedural processes during the first 24 hours following hospital arrival (i.e., age, Injury Severity Score [ISS], motor component of the Glasgow Coma Scale [GCS], initial systolic blood pressure and pulse rate, mechanism of injury, head injury severity, abdominal injury severity, and patient transfer status). Additional variables included time of arrival, operative vs minimally invasive interventions, volume of crystalloid and/or blood transfused, acidosis/base deficit, race, as well as scene time and vitals. For continuous variables (e.g., age and ISS), independent t tests were run; for categorical variables (e.g., sex, race, and trauma type), chi-squared tests were used to determine initial differences between those who survived and died. There were significant differences in initial pulse, systolic and diastolic blood pressure, GCS, and ISS (all P < 0.001). Additionally, there were significant differences for race (P = 0.003), sex (P = 0.01), hospital transfer (P = 0.002), and disposition from the emergency department, cause of injury, trauma type, comorbidities, and use of paralytics in the emergency department (all P < 0.001). These initial findings identify distinctive differences among variables of patients who survived traumatic injury and those who did not. This suggests that multiple factors within the first 24 hours, beyond the standard risk factors, are predictive of eventual mortality. Melatonin inhibits hemorrhagic shock-induced microvascular endothelial cell derangements Katie Wiggins-Dohlvik,* Himakarnika Alluir, Chinchusha Anasooya Shaji, Vivayak Govande, Madhava Beeram, Amin Mohammad, Matthew Davis, and Binu Tharakan (e-mail: [email protected])
Hemorrhagic shock (HS) induces global ischemia and reperfusion injuries, resulting in vascular hyperpermeability. The mechanisms that regulate this process are unclear. We hypothesized that matrix metalloproteinase-9 (MMP-9) is pivotal therein and that such damage can be attenuated with melatonin. Rats were divided into sham, HS, and HS plus melatonin groups (shock for 1 hour, n = 5). Laparotomy was performed and mesenteric postcapillary venules were examined with intravital microscopy. Fluorescent intensities were measured intravascularly and extravascularly to assess vessel permeability, vital signs and fluid requirements were recorded, and serum and tissue were collected. MMP activity was assayed in lung tissue homogenates (n = 8). In parallel, rat lung microvascular 28
endothelial cells (RLMEC) were grown and divided into the following groups: sham serum, HS serum, sham serum plus melatonin, and HS serum plus melatonin. Albumin flux across the monolayers was obtained as a marker of permeability (n = 6). RLMEC grown on chamber slides (n = 4) were stained for adherens junction protein β-catenin and the cytoskeletal protein F-actin, and protein degradation was examined with confocal microscopy. Statistical analysis was conducted using Student’s t test and analysis of variance. Intravital microscopy revealed an increase in vascular hyperpermeability following HS, which was attenuated with melatonin (P < 0.05). HS animals required more fluid to maintain normotension, and this was mitigated with melatonin (P < 0.05). MMP-9 activity was elevated in lung homogenates from HS animals, and levels were lower with melatonin treatment (P < 0.05). Monolayer permeability was increased with exposure to HS serum, and melatonin attenuated this (P < 0.05). Chamber slides showed that HS serum induced disruption of adherens junction proteins and incited formation of F-actin stress fibers; melatonin preserved the baseline configuration of both. In conclusion, HS induces microvascular hyperpermeability and clinical fluid derangements and causes alterations in endothelial cell structure; melatonin attenuates these changes. The effect of multidisciplinary teams for rectal cancer on delivery of care and patient outcome Bradford Richardson,* James Fleshman, John Preskitt, and Stephanie Peschka (e-mail: [email protected])
Baylor University Medical Center at Dallas initiated biweekly colorectal tumor multidisciplinary team (MDT) conferences in January 2013. All cases of colorectal cancer are presented to a team of specialists across disciplines. The complex treatment of rectal cancer requires an MDT approach. It is hypothesized that these MDTs will allow for 1) standardization of care and improved utilization of available resources to meet this standard; 2) improvements in the technical aspects of treatment; and 3) improvements in patient outcome. A retrospective chart review and review of prospectively collected MDT data was conducted for all patients treated for primary rectal adenocarcinoma at the institution in the past 5 years. The 130 patients were grouped by those discussed by the MDT in 2014 (n = 47) and 2013 (n = 41) and those treated before the initiation of MDT conferences (n = 42). Data on demographics, clinical stage, process evaluation, quality of surgery, and outcomes were collected. The National Comprehensive Cancer Network guidelines and College of American Pathologists protocol were used as standards. Clinical stage III was higher in 2013. Steady improvements were seen in 13 of the 15 preoperative process variables, 7 significantly. Improvement in an important technical aspect of surgery, the completeness of total mesorectal excision, was significant. The time to recurrence in the pre-MDT group was 27 months. The mean time since resection in the MDT groups was 6.5 and 14.5 months. It is too early to determine if recurrence rates and survival rates have improved. Since adopting the MDT approach, steady improvements have been made in preoperative clinical staging, multimodality treatment,
Baylor University Medical Center Proceedings
Volume 29, Number 1
pathologic staging, and technical aspects of surgery. There is still considerable room for improvement in some areas, especially the use of the rigid proctoscope and chest imaging for metastasis. Close follow-up of the 88 post-MDT patients will show whether these improvements in delivery of care result in improvements in patient outcomes. Tailoring surgical approach for elective ventral hernia repairs based on obesity and outcomes
in ventral hernia repairs. National data demonstrate that the laparoscopic approach is increasingly preferred as BMI increases when repairing elective reducible hernias. Early postoperative complications are more common as BMI increases in both open and laparoscopic repairs. The laparoscopic approach is associated with lower superficial and deep SSI complications for all BMI categories, in addition to lower organ space infections, reoperation, and wound dehiscence complications for higher obesity classes.
Mary Mrdutt* and Justin Regner (e-mail: [email protected])
Currently, a third of the US population is obese, and that percentage is projected to exceed 40% by 2030, involving approximately 140 million people. Obesity’s influence on postoperative complications in laparoscopic ventral hernia repairs (LVHR) versus open ventral hernia repairs (OVHR) has yet to be defined. While 30-day postoperative complications in both LVHR and OVHR are more frequent as body mass index (BMI) increases, we propose that the laparoscopic approach minimizes infectious complications for given BMI categories. A retrospective review was conducted of the American College of Surgeons National Surgical Quality Improvement Program database (2009–2012) for all patients ≥18 years undergoing elective repair of reducible ventral hernia. Exclusion criteria included immunosuppression, disseminated malignancy, advanced liver disease, or pregnancy. Patients were stratified by World Health Organization BMI categories of normal weight, overweight, and obesity classes I, II, and III (BMI 20–25, 25–30, 30–35, 35–40, and ≥40 respectively). Thirty-day postoperative complications were evaluated across BMI groups for LVHR vs OVHR using chi-squared test. Linear regression was adjusted for diabetes, smoking, gender, and age. A total of 75,168 patients met inclusion criteria, with nearly 55% of patients obese. The rate of LVHR increased with BMI (normal weight, 17.8%; BMI ≥40, 28.3%). Superficial and deep surgical site infections (SSIs) increased with increasing BMI for both techniques. However, LVHR minimized superficial and deep SSIs across all BMIs (odds ratio, open versus laparoscopic, specifically for BMI ≥40, superficial SSI, 5.34; deep infections, 4.76). Organ space infections, reoperation, and wound dehiscence increased with increasing BMI only in OVHR (P < 0.05). For organ space infections, reoperation, and wound dehiscence, only higher classes of obesity had a statistically significant difference (odds ratio, open versus laparoscopic at BMI 35–40: organ space, 1.98; reoperation, 1.86; wound dehiscence, 4.79; P < 0.05). Obese patients are overrepresented
January 2016
Do donor lifestyle choices and polysubstance abuse affect long-term survival in heart transplant recipients? Yazhini Ravi, Shelly Bansal, Kim Jeong, Sitaramesh Emani, Bryan A. Whitson, Carl Tong, and Chittoor B. Sai-Sudhakar (e-mail: [email protected])
High-risk behavior negatively impacts donor acceptance. We sought to evaluate the impact of donors’ negative lifestyle choices and substance abuse on long-term outcomes in heart transplant recipients. The registry of the United Network for Organ Sharing was queried for adult heart transplant recipients from 2000 to 2013. Donors were categorized into non–high risk and high-risk based upon the factors listed by the Centers for Disease Control and Prevention: a history of intravenous drug use, prostitution, high-risk sexual activity, HIV exposure, and hemophilia. We also sought to evaluate the impact of alcohol, tobacco, or cocaine abuse. A t test was used to analyze continuous variables, and a chi-square test was used to analyze categorical variables. Kaplan-Meier survival curves were created to analyze the impact of substance abuse on transplant recipient survival. A total of 17,546 heart transplant recipients were identified. In the high-risk donor group, 43% had type O blood, 78% were males, and 69% were Caucasians. In the non–high-risk donor group, 54% had type O blood, the mean donor age was 29.9 ± 9.5 years, body mass index was 26.2 ± 4.8 kg/m2, and 69% were Caucasians. There were no significant differences in age and body mass index between the two groups, but donor age and BMI were significantly lower in transplant recipients. Equivalent waiting times were seen in both groups. Rejection and graft failure secondary to acute or chronic rejection at 1 year were not statistically significantly different between groups. Posttransplant survival at 5 years was similar in both groups. In conclusion, high-risk donor behaviors and polysubstance abuse do not adversely affect outcomes in heart transplantation. Negative lifestyle choices should not deter organ acceptance.
Abstracts from the 10th annual Baylor Scott & White Department of Surgery Research Day
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