Major Operative Trauma Research Articles

Acute Kidney Injury After Esophageal Cancer Surgery: Incidence, Risk Factors, and Impact on Oncologic Outcomes.

To determine the incidence, risk factors, and consequences of AKI in patients undergoing surgery for esophageal cancer. Esophageal cancer surgery is an exemplar of major operative trauma, with well-defined risks of respiratory, cardiac, anastomotic, and septic complications. However, there is a paucity of literature regarding AKI. consecutive patients undergoing curative-intent surgery for esophageal cancer from 2011 to 2017 in 3 high-volume centers were studied. AKI was defined according to the AKI Network criteria. AKI occurred if, within 48 hours postoperatively, serum creatinine rose by 50% or by 0.3 mg/dL (26.5 μmol/L) from preoperative baseline. Complications were recorded prospectively. Multivariable logistic regression determined factors independently predictive of AKI. A total of 1135 patients (24.7%:75.3% female:male, with a mean age of 64, a baseline BMI of 27 kg m-2, and dyslipidemia in 10.2%), underwent esophageal cancer surgery, 85% having an open thoracotomy. Overall in-hospital mortality was 2.1%. Postoperative AKI was observed in 208 (18.3%) patients, with AKI Network 1, 2, and 3 in 173 (15.2%), 28 (2.5%), and 7 (0.6%), respectively. Of these, 70.3% experienced improved renal function within 48 hours. Preoperative factors independently predictive of AKI were age [P = 0.027, odds ratio (OR) 1.02 (1.00-1.04)], male sex [P = 0.015, OR 1.77 (1.10-2.81)], BMI at diagnosis [P < 0.001, OR 1.10 (1.07-1.14)], and dyslipidemia [P = 0.002, OR 2.14 (1.34-3.44)]. Postoperatively, AKI was associated with atrial fibrillation (P = 0.013) and pneumonia (P = 0.005). Postoperative AKI did not impact survival outcomes. AKI is common but mostly self-limiting after esophageal cancer surgery. It is associated with age, male sex, increased BMI, dyslipidemia, and postoperative morbidity.

RA03.02: ACUTE KIDNEY INJURY AFTER ESOPHAGEAL CANCER SURGERY: INCIDENCE, RISK FACTORS, AND IMPACT ON ONCOLOGIC OUTCOMES

Abstract Background Surgery remains the cornerstone of treatment for esophageal cancer. Esophagectomy serves as an exemplar of major operative trauma, yet there is a paucity of literature regarding postoperative renal outcomes. We aimed to study the incidence of acute kidney injury (AKI) after esophageal cancer surgery, and to determine independent risk factors for postoperative renal impairment. Methods Consecutive patients undergoing potentially curative surgery for esophageal cancer from 2006–2016 were studied. AKI was defined according to AKIN criteria. Complications were recorded prospectively and comprehensive complications index (CCI) was determined. Multivariate linear and logistic regression were performed to determine factors independently predictive of postoperative AKI. Results 661 patients (72.9% male), a mean age of 63.5 ± 9.7 years, underwent surgery (2-stage esophagectomy, 307 [46.4%]; 3-stage esophagectomy, 117 [17.7%]; transhiatal esophagectomy, 112 [16.9%]; extended total gastrectomy, 122 [18.5%)], pharyngolaryngoesophagectomy, 3 [0.5%]), with a CCI of 21.3 ± 19.7 and an in-hospital mortality of 1.4%. Baseline prevalence of chronic kidney disease was 1.8%. Postoperative AKI occurred in 174 (26.3%) patients, with AKIN 1, 2 and 3 in 122 (18.5%), 41 (6.2%) and 11 (1.7%), respectively. Of these, 5 (2.9%) required renal replacement therapy during admission. Preoperatively, greater BMI (P = 0.02, OR 1.05 [95% CI 1.01–1.10]), male sex (P = 0.05, OR 1.68 [1.01–2.78]), age (P = 0.001, OR 1.04 [1.02–1.07]), hypertension (P = 0.005, OR 1.85 [1.20–2.84]), and transthoracic approach (P = 0.01, OR 1.82 [1.14–2.89]) independently predicted postoperative AKI. After surgery, while CCI was predictive of AKI on univariable analysis (P &lt; 0.001 OR 1.03 [1.02–1.04]), atrial fibrillation (P = 0.001 OR 3.25 [1.57–6.72]) and prolonged intubation (P = 0.016 OR 3.61 [1.28–10.21]) were independently associated with AKI on multivariable logistic regression. On multivariable linear regression, neoadjuvant treatment (surgery only, 13.5 ± 35.8%; chemotherapy, 25.3 ± 42.2%; chemoradiation 18.7 ± 31.9%, P = 0.02), transthoracic approach (P = 0.006), and baseline BMI (P = 0.02) predicted postoperative %Δcreatinine. Postoperative AKI did not impact survival outcome on univariable or multivariable analysis. Conclusion Major AKI is rare after esophageal cancer surgery, with risk independently associated with increasing age, features of the metabolic syndrome, and postoperative morbidity. Disclosure All authors have declared no conflicts of interest.

The changing face of trauma management and its impact on surgical resident training.

The management of trauma patients has become increasingly nonoperative, especially for solid abdominal organ injuries. However, the Residency Review Committee (RRC) still requires an operative trauma experience deemed essential for graduating general surgical residents. The purpose of this study was to review the trauma volume and mix of patients at two trauma centers and determine the major operative trauma cases available to residents involved in the care of these patients. A retrospective chart review was conducted at the two trauma centers used by the Michigan State University surgery residency. Both of the trauma centers are American College of Surgeons verified. Surgical residents are involved with the care of every trauma patient at each of the hospitals. Cumulative data were collected and analyzed from January 1, 1997, through December 31, 1999. Age, gender, mechanism of injury (blunt vs. penetrating), Injury Severity Score, length of stay, operative interventions, and patients managed nonoperatively were reviewed. There were 434 patients selected for this study from 2,340 patients admitted to the trauma services. Male patients accounted for 66% of patients and female patients accounted for 34% of patients. Blunt trauma was the mechanism in 89% of patients, with penetrating trauma accounting for the other 11% of patients. Of the total number of patients, motor vehicle crashes accounted for the majority of cases, 325 of 434 (75%). Overall, 85% (370 of 434) of patients were managed without an index trauma surgical procedure according to RRC guidelines. Only 14.7% (64 of 434) of patients underwent operative intervention that qualified as index trauma surgical cases identified by the RRC. The spleen and small bowel were the two most commonly injured organs found at laparotomy. Nonoperative intervention of many patients with solid abdominal organ injuries did not meet the operation requirements expected by the RRC. Our residency program had 10 graduating chief residents over the 3-year time period. With only 64 operative trauma cases, this yields an average of 6.4 trauma cases per resident. This falls significantly short of the 16-case minimum requirement in trauma surgery established by the RRC. The operative trauma requirements established by the RRC for graduating residents may be unattainable in many residency programs because of the high incidence of blunt trauma and the changing patterns of trauma management.

Down-regulation of surface monocyte lipopolysaccharide-receptor cd14 in patients on cardiopulmonary bypass undergoing aorta-coronary bypass operation

Objectives: Major operative trauma like aorta-coronary bypass operation may lead to postoperative immunodisturbance, putting the patient at an increased risk for infection and sepsis. The monocyte/macrophage system and the endotoxin receptor CD14 are important in the early recognition and elimination of invading bacteria. The aim of this study was to analyze changes in membrane-associated CD14 and soluble CD14 during and after cardiac involving cardiopulmonary bypass. Methods: We studied numbers of leukocytes, monocytes, and monocyte subpopulations, expression of monocyte membrane-associated CD14 and plasma levels of soluble CD14 in 10 patients (63 ± 8 years of age), who underwent elective cardiopulmonary bypass. Results: Cardiopulmonary bypass induced marked postoperative monocytosis, which was maximal 20 hours after the operation (485 ± 242 cells/μl before, 1080 ± 264 cells/μl 20 hours after surgery). Expression of membrane-associated CD14 on classical CD14++ monocytes decreased significantly by 40%, reaching a nadir 20 hours after surgery ( p < 0.05). At the time of maximal membrane-associated CD14 suppression, the levels of soluble CD14 measured by enzyme-linked immunosorbent assay were clearly increased (3.2 ± 1.0 μg/ml before versus 5.6 ± 1.0 μg/ml 20 hours after, p < 0.001). No significant change of the percentage of small (α) and large (β) forms of soluble CD14 was found. Conclusions: Cardiopulmonary bypass leads to reduced membrane-associated CD14 expression on peripheral blood monocytes and increased levels of soluble CD14 through shedding or secretion of membrane-associated CD14 from the cell surface. These findings indicate that bypass is associated with significant monocyte activation.(J Thorac Cardiovasc Surg 1998;115:1172-8)

Institutionally shared trauma rotations are viable solutions to deficiencies in trauma training.

Numerous national trauma leaders have expressed concern about the lack of uniformity of trauma training in this country. In 1984 we instituted a trauma rotation between the University of Louisville (U.L.), with a large trauma volume, and Loyola University (L.U.) in the planning stages of trauma center development. Third year L.U. residents rotated at U.L. in 3-month blocks with an increased level of responsibility monthly, culminating in major decision-making roles and operative treatment under the chief resident's direction. The L.U. residents functioned as full members of the team and not as passive observers. Fifteen L.U. residents and 12 U.L. residents rotated during this period. Yearly major trauma visits, helicopter flights, and trauma service admissions average 1,908, 700, and 1,520, respectively. U.L. chief residents averaged 136 major operative trauma cases and 115 nonoperative trauma cases each were managed during this time period (RRC records greater than 85th percentile for all U.L. residents). L.U. residents performed an average of 30 major operative cases, nine as teaching assistant, in 3 months. Each managed more than 75 nonoperative cases. Several elements are critical in such a multi-institutional rotation: 1) active communication among the program directors, 2) commitment to one sharing arrangement only, 3) financing and malpractice for off-site residents, 4) housing, and 5) the ability to assimilate off-site residents as true trauma team members. The resident-to-resident interplay is crucial and has succeeded because both residency staffs have had excellent early training.(ABSTRACT TRUNCATED AT 250 WORDS)

Insulin decreases muscle protein loss after operative trauma in man: Inculet RI, Finley RJ, Duff JH, et al. Surgery 99:752, 1986

Seventy-two hours after major operative trauma, nine patients receiving a constant infusion of calories (1460 kcal/m2/day) and protein (75 gm of amino acid/m2/day) showed a negative nitrogen balance, increased muscle catabolism, as measured by 3-methylhistidine excretion, increased amino acid efflux from muscle, and decreased circulating levels of insulin. When 5 U of insulin/hr were added to the infusate, arterial insulin levels rose significantly from 39.7 +/- 4.1 microU/ml to approximately the pretrauma levels (74.6 +/- 7.7 microU/ml). Despite this normalization of insulin levels, excretion of nitrogen and 3-methylhistidine and the efflux of amino acids from forearm muscle fell but did not return to pretraumatic levels, suggesting some insulin resistance. Visceral gluconeogenesis from amino acids appeared to decrease, since insulin infusion decreased the efflux of alanine from skeletal muscle with no change in its arterial level. Insulin also significantly reduced the efflux of isoleucine, tyrosine, phenylalanine, glutamine, and total amino acid nitrogen from forearm muscle. These findings, along with the partial reduction in the excretion of 3-methylhistidine and nitrogen, suggest that insulin, in combination with infused calories and protein, decreases the loss of muscle protein after trauma.

Major operative trauma increases peripheral amino acid release during the steady-state infusion of total parenteral nutrition in man.

The effect of major operative trauma on skeletal muscle metabolism was examined in nine patients receiving a constant infusion of calories (1460 kcal/m2/day) and protein (75 gm of amino acids/m2/day) for 5 days before and 4 days after an operation. Compared with the preoperative state, 72 hours after the operation there was a significant rise in arterial levels of glucagon, cortisol, norepinephrine, and inactive triiodothyronine and a drop in concentrations of insulin, active triiodothyronine, and amino acids. Forearm blood flow increased, as well as the efflux from forearm muscle of lactate, taurine, serine, glycine, valine, methionine, isoleucine, leucine, phenylalanine, lysine, arginine, and total amino acid nitrogen (440%). This loss of muscle protein after trauma is associated with increased muscle proteolysis, as measured by increased urinary 3-methylhistidine excretion (83%), and accounts for increased nitrogen loss (54%) from the body. Increased activity of the sympathetic nervous system is manifested by increased levels of epinephrine and norepinephrine, a relative lack of insulin, and increased levels of glucagon. This hormonal milieu plays an important role in the production of hypoaminoacidemia, increased efflux of amino acids and lactate from muscle, and negative nitrogen balance observed in these traumatized patients.

Correlation between anergy and a circulating immunosuppressive factor following major surgical trauma.

In order to clarify the relationship between anergy and immunosuppressive activity in the serum, we studied 46 previously well patients before and at three, five, seven and 28 days after surgery. Delayed hypersensitivity was measured by skin testing with four common recall antigens, and serum immunosuppressive activity was determined by the ability of the patient's serum in 10% concentration to suppress by 50% or more the phytohemagglutinin (PHA) stimulation of normal human lymphocytes as compared to pooled normal serum. Prior to surgery, all patients manifested delayed hypersensitivity to one or more antigens, and no patient had immunosuppressive serum. Fifteen patients underwent minor surgery under general anesthesia and did not develop anergy or immunosuppressive serum. Thirty-one patients underwent major cardiovascular surgery. Thirteen of these patients became anergic by day 3 after operation, and 11 of the 13 developed immunosuppressive serum. Eighteen patients maintained delayed hypersensitivity after major surgery, and only three developed immunosuppressive serum. The correlation between anergy and immunosuppressive serum was highly significant (p < 0.001). There was a significant difference in the degree of suppressive activity in the serum of the anergic and reactive patient groups for each postoperative day studied until day 28, when there was recovery of delayed hypersensitivity and lack of immunosuppressive serum. The occurrence of postoperative anergy and immunosuppressive serum was not related to the patient's age, sex, number of perioperative blood transfusions or duration of anesthesia but was associated with an increase in postoperative infectious complications (p < 0.05) and in postoperative days in the hospital (p < 0.01). Pooled immunosuppressive serum from anergic patients was fractionated by ion exchange chromatography, gel filtration and preparative high voltage electrophoresis. The majority of the immunosuppressive activity could be accounted for by an electrophoretically homogenous polypeptide-containing fraction not identified in the serum of patients undergoing minor surgery or in normal individuals. We conclude that anergy occurring after major operative trauma is associated with the appearance of a circulating immunosuppressive molecular species and that these events are in turn associated with increased patient morbidity and increased length of hospitalization.

Post-thyroidectomy laryngeal edema: A survey of fifty-four cases

1. 1. In a study of four hundred patients undergoing thyroid surgery for benign thyroid disease, laryngeal edema was noted laryngoscopically in fifty-four cases (13.5 per cent). 2. 2. The incidence of edema was higher in younger patients, in patients with toxic goiters, and in those undergoing more radical procedures. 3. 3. Edema developed in the majority of patients on the first and second postoperative day, was mainly supraglottic, and was severe in three cases. Emergency tracheostomy was performed in the three severe cases. 4. 4. Laryngeal edema is mainly the result of major operative trauma to the neck and occasionally of intubation difficulties.

USE OF LIVING DONORS FOR RENAL HOMOTRANSPLANTATION.

The use of volunteer living donors to provide kidneys for renal homotransplantation has many medical, social, and legal implications. The infliction of major operative trauma upon healthy well-motivated donors cannot be dismissed lightly since the chance for ultimate viability of the homograft in its new environment is highly speculative. In the long run, justification for continued use of volunteer donors depends upon the demonstration that the donor operation carries a negligible risk and that the benefit for the recipient patients is substantial and predictable. In this communication, data will be analyzed concerning the risk involved to the donor, based upon experience with 40 patients. In addition, a detailed account of the donor operation will be provided. In the existing literature on renal transplantation, this phase of technical care has never been fully described, although it is evident that both the operative risk and the quality of the homograft obtained are