Publications by authors named "William Stoll"

13 Publications

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Adult liver transplant anesthesiology practice patterns and resource utilization in the United States: Survey results from the society for the advancement of transplant anesthesia.

Clin Transplant 2021 Oct 12:e14504. Epub 2021 Oct 12.

Department of Anesthesiology, University of Colorado, Aurora, CO.

Introduction: Liver transplant anesthesiology is an evolving and expanding subspecialty, and programs have, in the past, exhibited significant variations of practice at transplant centers across the United States. In order to explore current practice patterns, the Quality & Standards Committee from the Society for the Advancement of Transplant Anesthesia (SATA) undertook a survey of liver transplant anesthesiology program directors.

Methods: Program directors were invited to participate in an online questionnaire. A total of 110 program directors were identified from the 2018 Scientific Registry of Transplant Recipients (SRTR) database. Replies were received from 65 programs (response rate of 59%).

Results: Our results indicate an increase in transplant anesthesia fellowship training and advanced training in transesophageal echocardiography (TEE). We also find that the use of intraoperative TEE and viscoelastic testing is more common. However, there has been a reduction in the use of veno-venous bypass, routine placement of pulmonary artery catheters and the intraoperative use of anti-fibrinolytics when compared to prior surveys.

Conclusion: The results show considerable heterogeneity in practice patterns across the country that continues to evolve. However, there appears to be a movement towards the adoption of specific structural and clinical practices. This article is protected by copyright. All rights reserved.
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http://dx.doi.org/10.1111/ctr.14504DOI Listing
October 2021

Conversion total knee arthroplasty: A case complexity between primary and revision total knee arthroplasty.

Knee 2021 Aug 10;31:180-187. Epub 2021 Jul 10.

Department of Orthopedic Surgery, George Washington Hospital, Washington, DC, USA.

Background: Conversion total knee arthroplasty (TKA) may represent a more complex procedure compared with primary TKA. The purpose of this study was to compare 30-day complications between conversion TKA and primary, non-conversion TKA as well as between conversion TKA and revision TKA on a national scale using a multi-center surgical registry.

Methods: Adult patients undergoing conversion TKA from 2006 to 2018 were identified in the National Surgical Quality Improvement Program database and were compared with patients who underwent primary TKA and aseptic revision TKA. In this analysis, 30-day complications were assessed. Bivariate analyses, including chi-squared and analysis of variance, and multivariate logistic regressions were performed.

Results: Of 299,065 total patients undergoing knee arthroplasty, 1,310 (0.4%) underwent conversion TKA, 275,470 (92.1%) underwent primary TKA, and 22,285 (7.5%) underwent revision TKA. Following adjustment, patients who underwent conversion TKA were more likely to have increased risks of any complications (P < 0.001), mortality (P = 0.021), wound complications (P < 0.001), cardiac issues (P = 0.018), bleeding requiring transfusion (P < 0.001), and reoperation (P = 0.002) relative to primary TKA patients. Compared with patients who underwent revision TKA, conversion TKA patients were less likely to have septic complications (P = 0.009).

Conclusion: Conversion TKA is associated with significantly higher rates of complications compared with primary, non-conversion TKA, but less risk of sepsis compared with revision TKA. Because current reimbursement classifications do not account for the case complexity of a conversion TKA, new classifications should be implemented with reimbursements for conversion TKA approximating reimbursements for revision TKA.
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http://dx.doi.org/10.1016/j.knee.2021.06.008DOI Listing
August 2021

Impact of Anesthesiologist Experience on Early Outcomes in Adult Orthotopic Liver Transplantation.

Transplant Proc 2021 Jun 18;53(5):1665-1669. Epub 2021 May 18.

Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina.

Background: Liver transplantation is a complex surgical procedure. The experience of the anesthesiologist, and its potential relationship to patient morbidity and mortality, is yet to be determined. We sought to explore this possible association using our institutional training patterns as the subject of study.

Methods: This is a single center retrospective analysis investigating the association of an anesthesiologist's experience with liver transplantation and its potential effect on early patient outcomes in adult liver transplant recipients from January 2010 to September 2016. Training of team members consisted of a 6-month period of clinical shadowing with a senior anesthesiologist and co-staffing 8 liver transplant procedures before solo staffing a liver transplant. Specifically, patient outcomes for the first 5 transplants after this training were investigated.

Results: The only independent risk factor for early death or early graft loss was the amount of packed red blood cells administered during transplantation. With respect to secondary outcomes, the amount of packed red blood cells and hospitalization at the time of transplant were associated with the number of days on a ventilator, length of intensive care unit stay, and overall hospital length of stay.

Conclusions: The results of this study conclude that the training model currently in place for our new team members has no negative impact on patient outcomes after liver transplantation.
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http://dx.doi.org/10.1016/j.transproceed.2021.04.004DOI Listing
June 2021

Intraoperative vasopressors in head and neck free flap reconstruction.

Microsurgery 2021 Jan 10;41(1):5-13. Epub 2020 Nov 10.

Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.

Introduction: Historically, there were concerns vasopressors impair free flap outcomes, but recent studies suggest vasopressors are safe. Here we investigate this controversy by (1) evaluating vasopressors' effect on head and neck free-flap survival and surgical complications, and (2) performing soft tissue and bony subset analysis.

Patients And Methods: Post hoc analysis was performed of a single-blinded, prospective, randomized clinical trial at a tertiary care academic medical center involving patients ≥18 years old undergoing head and neck free flap reconstruction over a 16-month period. Patients were excluded if factors prevented accurate FloTrac™ use. Patients were randomized to traditional volume-based support, or goal-directed support including vasopressor use. Primary data was obtained by study personnel through intraoperative data recording and postoperative medical record review.

Results: Forty-one and 38 patients were randomized to traditional and pressor-based algorithms, respectively. Flap survival was 95% (75/79). There was no significant difference between the pressor-based and traditional protocols' flap failure (1/38 [3%] vs. 3/41 [7%], RR 0.36, 95% CI of RR 0.04-3.31, p = .63) or flap-related complications (12/38 [32%] vs. 18/41 [44%], RR 0.72, 95% CI 0.40-1.29, p = .36) Soft tissue flaps had surgical complication rates of 12/30 (40%) and 9/27 (33%) for traditional and pressor-based protocols, respectively. Bony flaps had surgical complication rates of 6/11 (55%), and 3/11 (27%) for traditional and pressor-based protocols, respectively.

Conclusions: Intraoperative goal-directed vasopressor administration during head and neck free flap reconstruction does not appear to increase the rate of flap complications or failures.
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http://dx.doi.org/10.1002/micr.30677DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8396078PMC
January 2021

Total Hip Arthroplasty for the Sequelae of Femoral Neck Fractures in the Pediatric Patient.

Arthroplast Today 2020 Sep 1;6(3):296-304. Epub 2020 Jun 1.

Department of Orthopaedic Surgery, Georgetown University MedStar Health, Washington, DC, USA.

Although rare, total hip arthroplasty (THA) may be indicated in pediatric patients with degenerative changes of the hip joint after previous trauma. To illustrate management principles in this patient population, this study describes the case of a 15-year-old female who sustained bilateral femoral neck fractures after a generalized tonic-clonic seizure, an atypical, low-energy mechanism for this injury. These fractures were not diagnosed until 14 weeks after the seizure episode, at which point they had progressed to nonunion on the left side, malunion on the right side, and degenerative hip joint changes were developing bilaterally. Bilateral THA was ultimately performed, and the patient had favorable outcomes at 1 year postoperatively. In determining the optimal management strategy for such patients, a multidisciplinary approach should be used, with input from the patient's family, pediatrician, pediatric endocrinologist, pediatric orthopaedic surgeon, and adult reconstruction surgeon. From a surgical standpoint, this report highlights the importance of selecting the appropriate bearing surfaces, broaching technique, mode of implant fixation, and implant features when performing THA in the active pediatric patient.
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http://dx.doi.org/10.1016/j.artd.2020.04.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7264979PMC
September 2020

Service Requirements of Liver Transplant Anesthesia Teams: Society for the Advancement of Transplant Anesthesia Recommendations.

Liver Transpl 2020 04 10;26(4):582-590. Epub 2020 Mar 10.

Department of Anesthesiology, University of Colorado, Aurora, CO.

There are disparities in liver transplant anesthesia team (LTAT) care across the United States. However, no policies address essential resources for liver transplant anesthesia services similar to other specialists. In response, the Society for the Advancement of Transplant Anesthesia appointed a task force to develop national recommendations. The Conditions of Transplant Center Participation were adapted to anesthesia team care and used to develop Delphi statements. A Delphi panel was put together by enlisting 21 experts from the fields of liver transplant anesthesiology and surgery, hepatology, critical care, and transplant nursing. Each panelist rated their agreement with and the importance of 17 statements. Strong support for the necessity and importance of 13 final items were as follows: resources, including preprocedure anesthesia assessment, advanced monitoring, immediate availability of consultants, and the presence of a documented expert in liver transplant anesthesia credentialed at the site of practice; call coverage, including schedules to assure uninterrupted coverage and methods to communicate availability; and characteristics of the team, including membership criteria, credentials at the site of practice, and identification of who supervises patient care. Unstructured comments identified competing time obligations for anesthesia and transplant services as the principle reason that the remaining recommendations to attend integrative patient selection and quality review committees were reduced to a suggestion rather than being a requirement. This has important consequences because deficits in team integration cause higher failure rates in service quality, timeliness, and efficiency. Solutions are needed that remove the time-related financial constraints of competing service requirements for anesthesiologists. In conclusion, using a modified Delphi technique, 13 recommendations for the structure of LTATs were agreed upon by a multidisciplinary group of experts.
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http://dx.doi.org/10.1002/lt.25711DOI Listing
April 2020

Post-Reperfusion Syndrome in Liver Transplantation: Does a Caval Blood Flush Vent Help?

Ann Transplant 2019 Dec 13;24:631-638. Epub 2019 Dec 13.

Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA.

BACKGROUND Post-reperfusion syndrome (PRS) during liver transplantation can range from a benign event to a profound hemodynamic excursion from baseline with significant morbidity. Multiple variables can be responsible for the diverse presentations. Over time, our group noticed that a blood flush of the liver graft via a caval vent (in addition to a standard chilled flush via the portal vein) appeared to result in a milder reperfusion effect. Attenuation of PRS via caval vent seemed to minimize hemodynamic instability and reduce metabolic derangements associated with reperfusion. MATERIAL AND METHODS This was a prospective observational pilot study of standard practice with the addition of lab values and hemodynamic evaluations. We methodically observed normal clinical flow in 20 adult orthotopic liver transplant recipients. We analyzed blood and fluid samples at set time intervals during the peri-reperfusion phase. RESULTS Sixteen out of 20 patients received a blood flush via caval venting. Mean arterial pressure (MAP) and heart rate were better preserved in the patient population that received a caval blood flush vent. Elevations in central venous pressure (CVP) were similar between the 2 groups. Lab values (blood gas, electrolyte, and hemoglobin) of the patients' blood were similar, with no notable differences. Analysis of the initial blood flushed through the liver graft proved to be hypothermic, acidotic, and hyperkalemic. CONCLUSIONS Pre-reperfusion caval venting in liver transplantation (in addition to a portal vent and a chilled LR/albumin portal flush solution) appears to have favorable hemodynamic effects. The literature on this technique is sparse and larger studies are needed.
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http://dx.doi.org/10.12659/AOT.920193DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6930699PMC
December 2019

Two cases of combined patellar tendon avulsion from the tibia and patella.

SICOT J 2018 23;4:17. Epub 2018 May 23.

Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, USA - Division of Orthopaedic Surgery, Texas Children's Hospital, Houston, TX, USA.

Avulsion fractures of the inferior pole of the patella and proximal tibial apophysis are independently rare injuries. They occur in children due to the relative weakness of the apophyseal cartilage compared to the ligaments and tendons. The combination of these two fractures, is exceedingly rare, with only a few previously described cases in the literature. Due to the infrequent presentation of this injury, careful examination and consideration of advanced imaging is important for diagnosis and preoperative planning. Here we present two cases of combined sleeve fractures of the inferior pole of the patella and tibial apophysis, with discussion of the pathophysiology, classification, identification and management of the injury.
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http://dx.doi.org/10.1051/sicotj/2018014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5967859PMC
May 2018

Use of intra-aortic counterpulsation in cardiogenic shock post-liver transplantation.

Clin Transplant 2017 07 5;31(7). Epub 2017 Jun 5.

Department of Surgery, Case Western Reserve University, Cleveland, OH, USA.

Left ventricular dysfunction resulting in cardiogenic shock occurs infrequently following organ reperfusion in liver transplantation. The etiology of the cardiogenic shock is often multifactorial and difficult to manage due to the complex nature of the procedure and the patient's baseline physiology. Traditionally, this hemodynamic instability is managed medically using inotropic agents and vasopressor support. If medical treatment is insufficient, the use of an intra-aortic balloon pump for counterpulsation may be employed to improve the hemodynamics and stabilize the patient. Here, we analyze three cases and review the literature.
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http://dx.doi.org/10.1111/ctr.13002DOI Listing
July 2017

Utility of the Surgical Apgar Score in Kidney Transplantation: Is it Feasible to Predict ICU Admission, Hospital Readmission, Length of Stay, and Cost in This Patient Population?

Prog Transplant 2016 Jun 4;26(2):122-8. Epub 2016 Apr 4.

Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA.

Background: This study analyzed the utility of the Surgical Apgar Scoring (SAS) system in predicting morbidity in kidney transplantation. Recipient comorbidities were evaluated for any effect on the SAS and then globally assessed for any relationship with intensive care unit (ICU) admission, need for dialysis, creatinine at discharge, length of stay, incremental, and total cost of transplantation. The hypothesis for this study is that a low SAS will be a statistically significant predictor of postoperative morbidity and associated costs.

Methods: This was an institutional review board (IRB)-approved retrospective longitudinal cohort study on 204 solitary kidney transplant recipients (2009-2011). Patients were divided into 2 groups: low to moderate = SAS ≤ 7 and high = SAS ≥ 8. These groups were then analyzed against a host of variables.

Results: Sixty-five percent of patients had an SAS of 7 or lower, while 35% had an SAS of 8 and higher. Recipients with a history of stroke were 88% more likely to be in the low-moderate SAS group (P = .017). Patients with lower SASs trended toward having less extended criteria donors (0.097) but were more likely to be admitted to the ICU (P = .043), leading to significantly higher transplant event hospitalization costs. Higher SASs were more likely to be readmitted to the hospital within 30 days of discharge (P = .027), leading to higher 30-day postdischarge costs (P = .014). Readmission rates, however, and 30-day follow-up costs were similar between SAS groups after controlling for donor characteristics, specifically donor marginality and recipient estimated glomerular filtration rate (eGFR).

Conclusion: The findings of this study suggest that a history of stroke in the recipient may lend to a lower SAS and that a low SAS is associated with ICU admission following transplant, leading to higher hospital costs.
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http://dx.doi.org/10.1177/1526924816640948DOI Listing
June 2016

Motor/Prefrontal Transcranial Direct Current Stimulation (tDCS) Following Lumbar Surgery Reduces Postoperative Analgesia Use.

Spine (Phila Pa 1976) 2016 May;41(10):835-9

*Department of Orthopedic Surgery, Medical University of South Carolina, Charleston, SC †Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC ‡Menninger Clinic and Baylor College of Medicine, Houston, TX §Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC ¶Ralph H. Johnson VAMC, Charleston SC.

Study Design: Randomized, controlled pilot trial.

Objective: The present study is the first randomized, double-blind, sham-controlled pilot clinical trial of transcranial direct current stimulation (tDCS) for pain and patient-controlled analgesia (PCA) opioid usage among patients receiving spine surgery.

Summary Of Background Data: Lumbar spinal surgeries are common, and while pain is often a complaint that precedes surgical intervention, the procedures themselves are associated with considerable postoperative pain lasting days to weeks. Adequate postoperative pain control is an important factor in determining recovery and new analgesic strategies are needed that can be used adjunctively to existing strategies potentially to reduce reliance on opioid analgesia. Several novel brain stimulation technologies including tDCS are beginning to demonstrate promise as treatments for a variety of pain conditions.

Methods: Twenty-seven patients undergoing lumbar spine procedures at Medical University of South Carolina were randomly assigned to receive four 20-minute sessions of real or sham tDCS during their postsurgical hospital stay. Patient-administered hydromorphone usage was tracked along with numeric rating scale pain ratings.

Results: The effect of tDCS on the slope of the cumulative PCA curve was significant (P < 0.001) and tDCS was associated with a 23% reduction in PCA usage. In the real tDCS group a 31% reduction was observed in pain-at-its-least ratings from admission to discharge (P = 0.027), but no other changes in numeric rating scale pain ratings were significant in either group.

Conclusion: The present pilot trial is the first study to demonstrate an opioid sparing effect of tDCS after spine surgical procedures. Although this was a small pilot trial in a heterogeneous sample of spinal surgery patients, a moderate effect-size was observed for tDCS, suggesting that future work in this area is warranted.

Level Of Evidence: 2.
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http://dx.doi.org/10.1097/BRS.0000000000001525DOI Listing
May 2016

Intraoperative goal-directed hemodynamic management in free tissue transfer for head and neck cancer.

Head Neck 2016 04 1;38 Suppl 1:E1974-80. Epub 2016 Feb 1.

Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina.

Background: The purpose of this study was to determine the effect of algorithmic physiologic management on patients undergoing head and neck free tissue transfer and reconstruction.

Methods: Ninety-four adult patients were randomized to treatment and control groups. The blood pressure of the control group was managed consistent with contemporary standards. The treatment group was managed using an algorithm based on blood pressure and calculated physiologic values derived from arterial waveform analysis. Primary outcome was intensive care unit (ICU) length of stay.

Results: ICU length of stay was decreased in the treatment group (33.7 vs 58.3 hours; p = .026). The complication rate was not increased in the treatment group.

Conclusion: The goal-directed hemodynamic management algorithm decreased the ICU length of stay. Judicious use of vasoactive drugs and goal-directed fluid administration has a role in improving perioperative outcomes for patients undergoing head and neck free tissue transfer. © 2016 Wiley Periodicals, Inc. Head Neck 38: E1974-E1980, 2016.
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http://dx.doi.org/10.1002/hed.24362DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7179726PMC
April 2016

Right atrial compression due to diaphragmatic eventration after liver transplantation: successful treatment by diaphragmatic plication.

Liver Transpl 2014 Mar;20(3):394-6

Division of Transplant Surgery, Department of Surgery, University of South Carolina, Charleston, SC.

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http://dx.doi.org/10.1002/lt.23812DOI Listing
March 2014
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