The American College of Surgeons 96th Annual Clinical Congress took place Oct. 3-7 in Washington, D.C., and attracted more than 13,000 participants from around the world. The conference focused on advances in the care of surgical patients. Presentations focused on novel surgical techniques, the impact of surgeon availability on survival rates, application of surgical techniques to expanding patient populations, and risk factors associated with trauma incidents.
In an effort to develop a new surgical approach to control diabetes without daily insulin injections, Claudius Conrad, M.D., Ph.D., of Massachusetts General Hospital in Boston, and colleagues created a novel matrix to mimic natural pancreatic tissue and serve as a scaffold to support pancreatic islet cell viability.
"The most physiologic control of blood glucose levels is achieved through pancreas or islet cell transplantation. Donor organ shortage makes these therapies available to too few patients. Further downsides are that pancreas transplantation requires lifelong immunosuppression with significant side effects and is surgically a very involved procedure. In addition, islet cell transplantation is not very efficient due to the fact that two to four pancreases are needed to obtain a sufficient number of islets," Conrad said.
In a proof of concept study, the investigators found that bioengineered pancreatic tissue may provide patients with the same physiologic blood glucose control as patients with an intact pancreas have.
"We have bioengineered an endocrine pancreas using a novel bioartificial matrix, which we created through perfusion decellularization from whole pancreases. This bioartificial scaffold was seeded with islet cells and supportive stem cells to re-create the pancreas-specific islet niche," Conrad said. "The functional results of our bioengineered endocrine pancreas are very convincing, and the technical aspects have been worked out. Therefore, I think we are not very far from clinical trials that could revolutionize this tremendous health care problem of diabetes."
In a study aimed at improving outcomes associated with ventricular assist device (VAD) implantation, William M. DeCampli, M.D., Ph.D., of the University of Central Florida in Orlando, and colleagues developed a mathematical model to direct VAD implantation among surgeons performing the procedure in patients with end-stage congestive heart failure.
"A lot of the incidence of stroke is in the hands of the surgeon, and we set out to reduce the risk of stroke up front in patients with VAD implants," DeCampli said.
The investigators found that if they can adjust the way they implant a VAD to align with a patient's cardiac output, they can modify blood flow patterns to avoid blood clots traveling to the brain and reduce incidence of stroke.
"Basically, what we attempted to do is to adjust the position of the VAD and graft to redirect the blood clots away from the brain toward the rest of the body, where the clots pose a lesser risk," DeCampli said. "We used a large computer program to calculate the position of the VAD placement, simulating the flow of blood, to calculate the risk of blood clots traveling to the brain. We were able to alter the position of the VAD to reduce the percentage of clots traveling to the brain to 7 percent, which is a huge reduction in the incidence of blood clots to the brain."
Edward Chin, M.D., of Mount Sinai Medical Center in New York City, and colleagues developed a scar-free surgical technique for gallbladder removal -- laparoendoscopic single-site surgery (LESS) -- which is less invasive than minimally invasive surgery and requires only a single incision.
"Minimally invasive gallbladder surgery requires the surgeon to make four small incisions in a half-moon pattern in the abdomen, but the LESS procedure requires one incision made through the navel. Moreover, laparoscopy leaves behind four visible, small scars in the abdomen following a procedure. LESS leaves virtually none," Chin said in a statement.
Outcomes associated with the LESS approach were found to be very similar to laparoscopic surgery, with the LESS approach associated with less pain medication postoperatively and higher patient satisfaction scores. The investigators recently expanded use of this approach to other organs in the abdomen, including the adrenal gland and spleen.
"These are more advanced and challenging procedures, but we were able to demonstrate in small numbers so far that these procedures can be safely done using a similar technique," Chin said in a statement.
Due to the increased morbidity associated with immunosuppression necessary to prevent graft rejection during hand transplantation, Vijay S. Gorantla, M.D., Ph.D., of the University of Pittsburgh in Pennsylvania, and colleagues developed a novel, cellular-based approach to minimize the risks of immunosuppressive therapy after hand transplantation. The investigators used donor bone marrow cell infusion to reduce the need for immunosuppressive drugs required to prevent rejection and achieve graft survival.
"In our approach, we use an antibody called CAMPATH-1H to eliminate the transplant recipient's T cells and B cells. T cells are the primary cells that attack the graft and cause acute rejection. Two weeks later we infuse the bone marrow of the hand transplant donor into the recipient. The strategy is to enable 'education' of the recipient immune cells to recognize the donor cells as 'self' and facilitate gradual lowering of drug therapy to minimal levels with negligible associated risk or complications," Gorantla said.
The investigators developed a protocol to minimize the dosing and number of drugs used to sustain hand transplants, thus reducing the risk and optimizing the benefits of the procedure.
"The past decade has offered us considerable insights into the effects of multidrug immunosuppression in hand transplantation. However, to enable its widespread application as a treatment option, we need to focus on minimizing the number, dose and duration of drugs used in order to improve the safety, efficacy and applicability of this reconstructive modality," Gorantla said.
In a study presented by Spiros Frangos, M.D., M.P.H., of Bellevue Hospital in New York City, the investigators found that risk factors including lack of helmet use, alcohol consumption, and earphone use may increase bicycling-related injuries in city traffic, especially among men. The investigators reported on preliminary results from the first year of a three-year study evaluating 143 bicyclists injured in traffic crashes.
"We found a number of distracting factors among cyclists. Approximately 13 percent of cyclists had alcohol on board; another 5 percent had electronic devices such as iPods in use. In addition, only one in four cyclists in our total sample were wearing helmets. Although we are not implying causality, these behaviors can certainly affect response times," Frangos said.
In addition, 41 percent of individuals in the sample were injured on the job (typified by bicycle delivery workers), and only one-third of them wore helmets. The investigators also found that 18 percent of the injured cyclists were using a bike lane and 17 percent collided with a vehicle door. Taxi cabs accounted for 35 percent of bicyclists' injuries.
"This is a big public health issue, as it undoubtedly uses up hospital resources and raises costs," Frangos said. "Identifying clear risk factors is vital towards optimizing injury prevention programs."
In another study looking at motor vehicle crash victims, David C. Chang, Ph.D., M.P.H., M.B.A., of the University of California-San Diego, and colleagues found that the availability of surgeons in a geographic area was significantly associated with the risk of deaths from motor vehicle crashes. The researchers evaluated public health data from 3,225 U.S. counties between 2001 and 2003 and found that each increase of one surgeon per 1 million in population was associated with 0.38 fewer motor vehicle crash deaths -- approximately 2.5 surgeons for one life. After adjusting for socioeconomic status and the degree to which a geographic area is urban, the researchers found that approximately six additional surgeons would increase motor vehicle crash survival by a factor of one life as compared with 25 general practitioners.
"The shortage of primary care physicians has been well documented and thoroughly discussed, especially recently as we determined the priorities for health care reform," Chang said in a statement. "Our paper will challenge the public to reexamine our definition of primary care, to actually include care such as trauma surgery, which has so far been considered tertiary care. It's important to realize that especially in low-resource areas, such as rural America, surgery is in the unique position of being at the intersection of medicine and public health."
In another study, researchers from the Johns Hopkins Center for Surgery Trials and Outcomes Research in Baltimore found that all-terrain vehicle (ATV) crash victims were more likely to die, require aggressive trauma care, and use intensive care unit resources than equivalently injured motorcyclists. The researchers compiled data on crash victims who received trauma care between 2002 and 2006; they used National Trauma Data Bank of the American College of Surgeons data on 13,749 patients who had an off-road motorcycle accident and 44,509 patients who had an accident involving an ATV. The researchers also found that even with helmet use, ATV accident victims were worse off than motorcyclists.
"We can't tell why [ATV riders are more at risk than motorcyclists] from this database. We think there are much more energy transfers when an ATV turns over, but we can't tell whether that is because of the stability of the vehicle or the weight of the vehicle as it rolls over on a rider," Adil Haider, M.D., M.P.H., one of the study's authors, said in a statement.
Riad Cachecho, M.D., M.B.A., of Crozer-Chester Medical Center in Pennsylvania, developed a multidisciplinary protocol to reduce rates of ventilator-associated pneumonia (VAP). The VAP bundle involves several steps, including elevating the patient's head, cleaning the patient's mouth every two hours, and rinsing the patient's mouth with a germicidal mouthwash every six hours. Data on 2,290 trauma patients from 2005 to 2009 was analyzed, including 1,006 patients who were on mechanical ventilation for more than 24 hours. The investigator found that the pneumonia rate dropped to 1.5 per 1,000 ventilator days when the protocol was fully implemented, as compared with 7.9 during the education period. In addition, the data revealed no VAP cases during the last eight months of 2009 and no cases during the first three months of 2010.
"Society today expects that when patients come to the hospital that they will not get an infection," Cachecho said in a statement. "One of the goals of the health care team should be to prevent any complications or side effects, whether it's a hospital-acquired infection or an injury. Hospital care should be looked at as a zero-defect system, just like going on an airplane."
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