Intrauterine Cleaning After Placental Delivery At Cesarean Section: A Randomized Controlled Trial
Ahizechukwu Eke, MD, MPH, FICS, PGY4 Obstetrics & Gynecology Resident, Clinical Instructor, Michigan State University, Lansing, MI
To test the hypothesis that omission of intrauterine cleaning during cesarean sections does not increase intraoperative and postoperative complications
We randomized 206 women undergoing primary elective cesarean deliveries to cleaning (103 women) or omission of cleaning (103 women) of the uterine cavity after placental delivery. Spontaneous rupture of membranes prior to cesarean section, chorioamnionitis, poorly controlled diabetes mellitus, patients on chronic steroid therapy and patients with immunosuppressive disorders were excluded. Primary outcome measure was postpartum endomyometritis. Secondary outcomes were postpartum hemorrhage, mean surgical time, retained products of conception, quantitative blood loss, length of hospital stay, return of gastrointestinal function, repeat surgery and hospital readmission rates. Analysis followed the intention-to-treat principle.
There were no statistically significant differences in the rate of endomyometritis between those who received intrauterine cleaning and those who did not (2.0 vs. 2.9%; RR = 0.60; 95% CI 0.40-1.32). No retained products of conception occurred in either group, and there were no statistically significant differences in postpartum hemorrhage (5.8% vs 7.7%, RR 0.75, 95% CI 0.6-1.2), hospital readmission rates (2.9% vs 3.8%, RR 0.75, 95% CI 0.8-1.5), mean surgical time, hospital length of stay, return of gastrointestinal function, repeat surgery, and quantitative blood loss between both groups.
Our randomized controlled trial provides evidence suggesting that in women at low risk for infection, omission of intrauterine cleaning during cesarean deliveries does not increase intraoperative or postoperative complications.
Efficacy and Cost Effectiveness of Iliac Stenting in the Operating Room and Cath Lab
Sooyeon Kim, BS, Medical Student, University of Kentucky, Lexington, KY
Iliac arterial stenting is routinely performed both in the operating room (OR) and in the catheterization lab (CL). To date, no analysis has been conducted to compare efficacy and resource utilization between these locations.
Consecutive patients (N=105) treated between 2006 and 2013 at a single center were retrospectively analyzed. Patients included adults with chronic, symptomatic iliac artery stenosis with a minimum Rutherford Score (RS) of 3. Patients were treated with stents of the unilateral or bilateral external iliac, internal iliac, or aortoiliac arteries. Exclusion criteria were prior stenting, acute ischemic presentation, or major concomitant procedures. Patient demographics, procedure details, hospital course, physician billings, and actual procedure room and total costs were recorded, the latter from the hospital cost accounting system. All variables were compared by procedure location. Multivariable regression was used to adjust costs by demographic and perioperative cost drivers. Immediate outcomes included technical success, length of stay, same-stay reintervention, and major complications. Two-year outcomes included reintervention, death, or loss to follow-up.
Fifty-one procedures (49%) were performed in the OR and 54 (51%) in the CL. Mean age was 57 and 44% were female. Diabetes (DM) was more prevalent in OR patients (49 vs. 26%, p=0.016), and hyperlipidemia (HLD) in CL patients (80 vs. 57%, p=0.020). DM and elevated creatinine were associated with increased total costs; HLD with increased procedure room costs. Severe cases (RS = 4) were more often performed in the OR (42 vs. 11%, p<0.001) and were associated with increased total costs (p<0.01). OR procedures more often utilized additional stents (stents = 2; 61 vs. 46%, p=0.214), thrombolysis (12 vs. 0%, p=0.011), cut-down approach (8 vs. 0%, p=0.052), and endotracheal anesthesia (80 vs. 0%, p<0.001): these were all associated with increased costs (p<0.05). There was no difference in procedure room costs (OR median $7,700 vs. $8,300, p=0.445) but OR procedures were associated with increased total hospital costs (OR median $13,500 vs $9,100, p<0.001). OR procedures also resulted in increased hospital length of stay (LOS > 1 day; 41% vs. 17%, p<0.01) and more often required admission to the ICU (37 vs. 2%, p<0.001). Subsequent multivariable regression revealed that OR location was not a predictor of either procedure room or total costs, but was associated with increased professional fees (exponentiated coefficient for log-transformed procedure room costs 0.95, 95% CI 0.89-1.02; total costs 1.09, 95% CI 0.98-1.21; physician billings 1.31, 95% CI 1.13-1.51). Same-stay reintervention (4.8%) and reintervention after discharge (33%, median follow-up 13 mos.) did not vary by location.
Stenting performed in the OR resulted in increased LOS, more frequent ICU admission, and ultimately increased total costs. However, patients brought to the OR had more severe disease at presentation and therefore often required more aggressive intervention. After controlling for these differences, procedure venue per se was not associated with increased costs but the OR was associated with increased professional fees. Given the similar outcomes between venues, it would therefore seem reasonable to perform most stenting in the CL, while judiciously sparing the OR for more severe cases.
Honorable Mention (Alphabetical Order)
Coil Embolization Of Bleeding Ileal Conduit Varices
Hassan Ahmed, MD, FICS, Surgery Resident, Texas Tech University Health Sciences Center, Lubbock TX
Ileal conduit stomal varices are rare and prone to significant, life threatening bleeding. There is no established standard treatment modality to mange this condition. Varices are a common complication of liver cirrhosis with portal hypertension. Typically, they are found in the gastro-esophageal region. Peristomal varices represent ectopic portosystemic shunts due to portal hypertension. Ectopic bypasses such as stomal varices cause only 1-5% of all variceal bleeding episodes. The site of bleeding is usually located at the vulnerable mucocutaneous junction of the stoma, between the high-pressure portal system and the low-pressure systemic venous system. Since the first report of peristomal hemorrhage in 1968, different therapies such as sclerotherapy, embolization, transjugular intrahepatic portocaval shunt (TIPS), or liver transplantation has been used to treat and prevent variceal bleeding. The scarce case reports in the literature of patients with ureteroileal conduit, liver cirrhosis and ectopic variceal bleeding unanimously recommend TIPS to prevent further bleeding. However, portocaval shunting reduces the hepatic clearance of ammonia leading to hepatic encephalopathy with neurocognitive impairment, stupor, and coma in extreme cases. To our knowledge there is only one case reported with percutaneous transhepatic endovascular embolization (PTEE) without the use of TIPS.
Case report with literature review. We present the case of a 55-year-old woman with copious, recurrent ileal conduit bleeding from stomal varices. Bleeding was successfully managed by PTEE. In view of absence of clinically significant other varices or ascites, attempts were made to visualize the peristomal varices with an 8-12 MHz linear array ultradsound probe Even though the presence of varices around the stoma where established they were not accessible for cannulation. A percutaneous transhepatic access to the right porta hepatis using AccuStick Kit was obtained. This led access to the portal vein and from there to the superior mesenteric vein. Venography confirmed the position of the varices, which then were coil embolized successfully using Tornado coils time 6.
After the successful coil emboiization, she was observed post procedure in the hospital for 2 days, did not require additional blood transfusion. She was discharged from the hospital in much better condition. The patient did not have further bleeding or ischemic complications and has been event free for the last 4 months.
Although rare, when a patient with ileal conduit stoma, hepatic dysfunction, and recurrent episodes of “macrohaematuria”?, bleeding peristomal varices should be considered. Percutaneous transhepatic endovascular embolization is a reasonably good approach.
Minimizing Ionizing Radiation in Pediatric Emergency Department Patients with Suspected Appendicitis
Liisa Bergmann, MD, Radiology Resident, PGY-3 / R2, Royal Oak, MI
Mounting evidence suggests that the ionizing radiation associated with computed tomography (CT) in pediatric patients is also associated with long-term negative health sequelae. Our immediate purpose is to evaluate changes in ordering frequency of ultrasonographic examination (US) and CT in pediatric emergency department (PED) patients with suspected appendicitis in a community setting. This is within the context of the long-term goal of attaining ionizing radiation “as low as reasonably achievable.”? (ALARA)
Retrospective review of all PED patients who underwent abdominal US and/or CT Abdomen / Pelvis (CTAP) was performed. Charts were reviewed for one year prior to and one year following the implementation of an electronic medical record (EMR) prompt reminding physicians ordering CT Abdomen / Pelvis in PED patients with suspected appendicitis to first order US. Multivariate regression analysis was performed.
Preliminary results suggest that although the likelihood a US examination would be performed on a PED patient with suspected appendicitis increased to nearly 100% after the implementation of the EMR prompt, CT was also ordered for nearly all patients.
It is well known that US is highly user dependent and the appendix is frequently not visualized on US examination. Our data suggest that US examination alone does not preclude the need for additional information for diagnosis, nor does US examination significantly reduce ionizing radiation exposure in PED patients with suspected appendicitis. Our findings support development of a standardized physical exam protocol developed and accepted by surgeons and emergency physicians in order to achieve ionizing radiation ALARA.
The Management Of Patients With Colorectal Cancer And Synchronous Liver Metastasis Or Indeterminate Liver Lesions: A Retrospective Review
Sunu Philip, MD, FICS, General Surgery Resident, Providence Hospital and Medical Centers, Southfield, MI
Between a third to one-half of patients with colorectal cancer develop liver metastases . Approximately 15-25% of these patients present with one or more liver metastases at the time of diagnosis. The management of patients with synchronous colorectal metastases limited to the liver remains controversial with much of thedata published from highly specialized academic centers. We proposed to review the management and outcomes of patients with colorectal cancer and synchronous liver metastases at a community teaching hospital.
In this institutional review board approved retrospective study, the medical records of all patients with a diagnosis of colorectal cancer identified in the cancer registry of the hospital were reviewed. The review was conducted over a five year period from 2008-2013. The study sample included all patients with a primary diagnosis of colorectal cancer and synchronous liver metastases who had undergone a colon or rectal resection. We also reviewed the records of all patients who had an indeterminate lesion noted on preoperative staging and then progressed to have liver metastases on follow up imaging after their colon resection. A total of 811 patients with colon or rectal cancer were entered in the cancer registry over the study period. Ninety patients met the criteria for inclusion in the study. This sample was divided into three subgroups based on the pattern of their liver metastases. Patients with diffuse bi-lobar disease were classified as multiple, those with a finite number of metastatic deposits were classified as discrete. Finally those those patients with indeterminate lesions that progressed to cancer were classified as indeterminate.
Of the 90 patients, 50(55%) had diffuse metastatic disease at diagnosis. Twenty five patients (27%) had discrete lesions and 15 (16%) had indeterminate lesions. Twenty seven patients in the diffuse group had presented with intestinal obstruction and had emergent colon surgery. Only 4 patients in this group were treated with primary chemotherapy. One patient in this group had a resection of hepatic metastases. In the discrete group, the number of liver secondaries ranged between 1 and 4 lesions with a size ranging between 0.9 and 7 cm. Ten of the 25 patients in this group had liver resections of which 4 were done synchronously at the time of their colon surgery. Only two patients in the group with indeterminate lesions had a liver resection. The time to liver resection in those patients who staged procedures ranged from 4 months to two years from their colon surgery. Progression of disease was noted in all patients with diffuse disease on serial imaging and in a large number of patients with discrete and indeterminate lesions who were treated without hepatic resection.
Only a small proportion of patients with synchronous colorectal liver metastases are candidates for a potentially curative resection. In this series only a small proportion of patients with diffuse unresectable metastatic disease were treated with primary chemotherapy. Patients with localized disease should be evaluated early for synchronous or early staged resection. Patients with suspicious indeterminate lesions may benefit from evaluation of these at the time of their of colon resection or alternatively will need careful followup imaging.