12.14 Comparing Outcomes of Admission Patterns in Pediatric Trauma Patients with Isolated Injuries

Posted on December 22, 2014

S. M. Farach1, P. D. Danielson1, E. Amankwah2, N. M. Chandler1  1All Children’s Hospital Johns Hopkins Medicine,Pediatric Surgery,Saint Petersburg, FLORIDA, USA 2All Children’s Hospital Johns Hopkins Medicine,Clinical And Translational Research Organization,Saint Petersburg, FLORIDA, USA

Introduction:  Pediatric trauma patients presenting with stable, isolated injuries are often admitted to the trauma service for initial management. The purpose of this study was to evaluate admission patterns in trauma patients with isolated injuries and to compare outcomes based on admitting service.

Methods:  After Institutional Review Board approval, the institutional trauma registry was retrospectively reviewed for patients presenting from January 2007 to December 2012. A total of 3417 patients were admitted to a surgical service and were further reviewed. Patients were grouped by isolated or non-isolated injuries and further stratified into trauma service (TS) versus non-trauma service (NTS) admission. Significance was defined as p ≤ 0.05.

Results: Table 1 describes select demographic and outcomes data between the groups. Patients with isolated injuries admitted to a NTS were significantly younger, were more likely to present with Injury Severity Scores (ISS) ranging from 9-14, Glasgow Coma Scale (GCS) ≥ 13, had a shorter emergency room length of stay, were more likely to undergo surgery within 24 hours, and had significantly fewer computed tomography scans performed. Patients with isolated injuries admitted to the TS had a significantly lower GCS (3-12), were more likely to present with ISS ranging from 1-8, had longer emergency room length of stay, and were less likely to undergo surgery within 24 hours. There was no significant difference between the groups for ISS ≥ 15. Patients with isolated injuries following falls or sports related injuries were more likely to be admitted to NTS, while those presenting after motorized trauma were more likely to be admitted to the TS. Patients with isolated injuries admitted to NTS included: 54.4% orthopedic, 38.3% neurosurgery, and 7.3% other. There were no missed injuries noted in patients with isolated injuries admitted to NTS with 5% having a TS consult. Patients with isolated injuries admitted to a NTS were found to have significantly lower complication rates.

Conclusion: Pediatric trauma patients presenting with stable, isolated injuries may be efficiently and safety managed by non-trauma services without an increase in missed injuries or complications.
 

12.15 Post-operative analgesia after laparoscopic appendectomy in children

Posted on December 22, 2014

R. Baird1, R. Mujallid2, P. Ingelmo2, S. Emil1  1McGill University,Pediatric Surgery,Montreal, QC, Canada 2McGill University,Pediatric Anesthesia,Montreal, QC, Canada

Introduction: Appendicitis is the most common pediatric general surgery emergency procedure. The optimal analgesic strategy to minimize patient discomfort and adverse events while maximizing patient throughput has yet to be defined. Furthermore, the utility of ketorolac to minimize narcotic use has not previously been investigated.

Methods: A single-institution, retrospective review of a random sample of pediatric patients undergoing laparoscopic appendectomy for simple appendicitis (no evidence of perforation or gangrene) was performed over a two-year period. Analgesia administration was non-standardized. Demographics, analgesia use and outcomes were evaluated; pain was assessed using age appropriate Likert scores. Categorical and continuous variables were compared using the Fisher’s Exact and Student T test, respectively, with p=0.05 considered significant.

Results: One hundred and forty seven patients were included for analysis with a mean age of 11.7 years; 86 (58.5%) patients were male.  The median length of stay was 0.7 days (25%-75%ile: 0.54-1.18). Median pain score at ward admission was 2/10 (25%-75%ile: 0 – 5.5), which worsened during admission (median 5/10; 25%-75%ile: 3.75- 7). Patients received a median of 2 doses of 10 mg/kg of oral/rectal acetaminophen, and a median of 0.16mg/kg of intravenous morphine during admission.

Thirty-one patients received ketorolac after surgery. Compared to patients not receiving ketorolac, there was no difference in the number of individuals receiving opioids (13 [41.9%] vs. 51 [43.9%], p=1), nor in the overall morphine dose administered to each group (0.12 v 0.11mg/kg, p=0.82). The median maximal pain score with ketorolac was similar to without ketorolac: (5 [25%-75%ile: 3-7] vs. 5 [25%-75%ile: 4-7]).

Conclusion: Pain after laparoscopic appendectomy may worsen during hospital admission without a protocolized approach to post-operative analgesia. Ketorolac does not improve pain control in this patient population, likely due to the lack of associated inflammation and peritonitis associated with simple appendicitis alone. Efforts to optimize post-operative pain control through protocolized care appear warranted.
 

12.16 Parental & Volunteer Perception of Pyloric Scars: Comparing Lap, Open, & Non-Surgical Volunteers

Posted on December 22, 2014

S. R. Shah1, C. Archer2, D. J. Ostlie2, S. W. Sharp1, S. D. St. Peter1  1Children’s Mercy Hospital / University Of Missouri – Kansas City,Section Of Pediatric General And Thoracic Surgery,Kansas City, MO, USA 2American Family Children’s Hospital / University Of Wisconsin,Division Of Pediatric Surgery,Madison, WI, USA

Introduction:
Despite prospective trials and meta-analyses supporting laparoscopic pyloromyotomy (LP), the open technique (OP) is still utilized on the premise that there is minimal benefit to LP over OP. Despite the fact that the potential cosmetic benefit of LP over OP is often cited in reports, it has never been objectively evaluated.

Methods:
After IRB approval, the parents of patients from a previous prospective trial that had undergone LP (n=10) and OP (n=10) were contacted. After assent was obtained, the parents were asked to complete a validated scar scoring questionnaire which was compared between groups. Standardized photos were taken of study subjects and 5 controls with no abdominal procedures.  Blinded volunteers were recruited to view the photos, identify if scars were present, and complete questions if scar(s) was seen. Volunteers were also asked about degree of satisfaction if their child had this result on a 4 point scale from happy to unacceptable.

Results:
Mean age was 7 years in both groups. Parental scar assessment scores were superior in the LP group in every category (Table 1).  Blinded volunteers detected abdominal scars significantly more often in the OP group (98%) vs. the LP group (28%) (P<0.001).  The volunteers detected a scar in 16% of the controls, comparable to the 28% detected in the LP group (P=0.17). The degree of satisfaction estimate by volunteers was 1.78 for OP and 1.02 for LP and controls generating a Cohen’s d effect size of 5.1 standard deviation units comparing OP to either LP or controls (very large > 1.3).

Conclusion:
Parents of children scored LP scars superior to OP scars.  Scars are almost always identifiable with OP while the LP scars approach invisibility to the casual observer appearing similar to patients with no prior operation. 
 

12.17 Management of Appendiceal Carcinoid Tumors in Children

Posted on December 22, 2014

S. C. Fallon1, M. J. Hicks2, J. L. Beer1, S. A. Vasudevan1, J. G. Nuchtern1, D. L. Cass1  1Texas Children’s Hospital,Division Of Pediatric Surgery, Michael E. DeBakey Department Of Surgery, Baylor College Of Medicine,Houston, TX, USA 2Texas Children’s Hospital,Department Of Pathology,Houston, TX, USA

Introduction:

Appendiceal carcinoid tumors are rare lesions detected incidentally following appendectomy in children. There are limited data about the natural history of these tumors, and guidelines regarding family counseling and need for additional surgery or follow-up imaging are not established in the pediatric age group.  The purpose of this study was to review our institutional experience with appendiceal carcinoid tumors to provide data that might improve management.

Methods:

After IRB approval, the charts of all patients treated at our institution for an appendiceal carcinoid tumor between 2002 and 2014 were reviewed.  Data collected included patient demographics, pathologic details, postoperative management, and follow-up information.  Descriptive analyses were performed.

Results:

Twenty-eight patients were identified, which represents an incidence of 0.2% of children undergoing appendectomy during that time interval. The mean age at surgery was 13.8+2.1 years; 54% were females. Two patients had symptoms suspicious for carcinoid syndrome at presentation, though none had evidence of metastatic disease.  The mean tumor size was 0.8 (+0.4) cm.   Five patients (18%) underwent subsequent ileocecectomy or right hemicolectomy due to pathologic findings of invasion of the mesoappendix (n=4) or lymphovascular invasion and subserosal extension (n=1).  One child was found to have positive lymph nodes on pathologic examination. No recurrences have been detected at mean follow-up of 1.2 yrs.

Conclusion:

Appendiceal carcinoid tumors are discovered incidentally in about 0.2% of children undergoing appendectomy.  Based on findings from the largest series to date, we can conclude that these tumors are generally small, and demonstrate lymphovascular invasion or mesenteric extension in fewer than 20% of cases.  Prospective, multi-center studies are necessary to better define the indication for ileocecectomy and follow-up imaging protocols.

12.18 Management and Outcomes in Earlobe Keloids in Children

Posted on December 22, 2014

N. Drucker1, D. W. Kays1, S. D. Larson1, J. A. Taylor1, S. Islam1  1University Of Florida,Surgery,Gainesville, FL, USA

Introduction:  Earlobe keloids are challenging conditions to manage in children due to high recurrence rates.  There are a number of therapeutic alternatives available to treat these, which have not been reported in children.  The purpose of this study is to investigate the management and outcomes of keloids in a large cohort and attempt to understand the optimal way of treating them.

Methods:  We retrospectively analyzed all children who underwent surgical therapy for earlobe keloids over a 10-year period (2004-2014).  Clinical data including etiology, demographics, treatment, and outcome were collected. A follow up phone survey was attempted on all patients to assess for long term recurrence and satisfaction. Data was analyzed using student’s t test and Fischer’s exact test as appropriate. 

Results: A total of 95 patients with 135 keloids were identified.  Mean age was 14.0 years, 54.3% were female, and a majority (85%) were African American (AA).  The most common etiology was secondary to pierced earrings (88.4%).  Mean keloid size was 2.4 cm (0.25-11 cm) and they were more common on the left earlobe (73.7% including bilateral). Excision with (n=56) or without (n=24) steroid was the most common surgical management, with some cases also having compression earrings, and others radiation therapy(n=8).  Mean follow up of the entire cohort was 27 months. Recurrences were noted in 20 cases (21.1%), a majority of which were managed operatively (70%). The highest rate of recurrence was with those treated with radiation therapy (37.5%), while we found no difference in recurrence between excision alone vs. with steroid (20.8% vs. 19.6%). There have been 5 re recurrences as well. We found age less than 10 at surgery (p=0.015) to be a risk factor for recurrence, and all recurrences were in AA patients. Size of the lesion, gender, side, and nodular vs. pedunculated shape did not have any effect on recurrence. Phone follow up was achieved in 56% cases. 

Conclusion: This is the largest series of earlobe keloid treatment reported in children. Younger age at excision and AA race are associated with increased risk of recurrent keloid. Intraoperative administration of steroids did not seem to influence recurrence rates, and radiation therapy was associated with a higher recurrence. Longer duration follow up is needed for establishing true recurrence rates, and a larger multi center study would help in answering these questions.

 

12.20 Pediatric Non-Papillary Thyroid Carcinoma

Posted on December 22, 2014

E. A. Perez1, J. Tashiro1, S. Golpanian1, J. I. Lew2, H. I. Neville1, A. R. Hogan1, J. E. Sola1  1University Of Miami Miller School Of Medicine,DeWitt Daughtry Family, Department Of Surgery, Division Of Pediatric Surgery,Miami, FL, USA 2University Of Miami,Division Of Endocrine Surgery, DeWitt Daughtry Family, Department Of Surgery,,Miami, FL, USA

Introduction:   To update outcomes and predictors of survival on pediatric thyroid carcinoma, specifically examining pediatric patients with non-papillary thyroid carcinoma.

Methods:   Surveillance, Epidemiology, and End Results database was searched for pediatric cases (<20 yrs old) of non-papillary thyroid carcinoma diagnosed between 1973 and 2011.  Demographics, clinical characteristics, and survival outcomes were analyzed using standard statistical methods.   All follicular, medullary, Hurthle cell, and nonencapsulated sclerosing carcinoma types were included in the data set.

Results: A total of 504 cases were identified.  Overall incidence was 0.096/100,000 persons per year.  Mean age at diagnosis was 15 yrs old and highest incidence was found in white, female patients 15-19 yrs old. Most patients had regional (60%) or localized disease (35%) treated with surgery (98%) and less commonly radiation (38%). Of the surgical patients, subtotal/total thyroidectomy (83%) was the most common procedure performed and 47% had lymph node sampling. The most common histologies were follicular (54%) and medullary (28%) and most tumors were > 2 cm in size (63%). Overall 30 year survival was 91% but higher for females (94%, p=0.02) and for local disease (92%). Disease specific survival was highest for those with no lymph node sampling, and negative lymph nodes. On multivariate analysis only subtotal/total thyroidectomy was an independent prognostic indicator of survival. Neither gender, age, tumor size, histology, nor extent of disease were associated with increased risk of mortality.

Conclusions:  The incidence of non-pediatric papillary thyroid cancer is low.  Females have a higher incidence but similar survival to males. Subtotal/total thyroidectomy is the only independent prognostic indicator of survival. 

 

13.01 The Impact of Electronic Medical Record Implementation on Operating Room Efficiency

Posted on December 22, 2014

R. C. Frazee1, A. Carnes1, Y. Munoz Maldonado1, T. Bittenbinder1, H. Papaconstantinou1  1Scott & White Healthcare,Departments Of Surgery And Anesthesia,Temple, Texas, USA

Introduction:   First start delays in the operating room have a downstream effect on operating room efficiency and patient satisfaction.  In accordance with the American Recovery and Reinvestment Act, in February 2014, our institution adopted EPIC ™ as our electronic medical record (EMR) system.  The impact of the transition from paper to electronic documentation on operating room efficiency is not known.  This study analyzed first start data as a measure of overall operative suite efficiency, looking at the initial impact and the learning curve to return to baseline parameters.

 

Methods:   A retrospective review of on time start data was reviewed for three months prior and 4 months after implementation of the EMR.  A start was considered delayed if the patient arrived to the room after the 7:30 start time.  Patients transported from the intensive care unit were excluded from analysis.  Data was analyzed using control charts for the percentages, and comparisons of the average percentage of on time starts before EPIC implementation against each month percentage using Dunnet’s method.  Confidence intervals were calculated at 0.05 and 0.01 for significance.

 

Results:  On time starts for the three months leading into EPIC implementation averaged 64.1%.  After EPIC implementation, there was an initial drop in on time starts from to 41% (p<0.01).  There was a gradual return to baseline levels over the ensuing 4 months.

Conclusions:  Implementation of an EMR produced decreased efficiency in on time first starts in the operative suite, but the learning curve was brief, returning to baseline values in 4 months.  These findings can serve as a guide for other institutions that are undergoing transition from a paper to an electronic medical record.

 

 

 

13.02 Benefit of Hepatic Resection Versus Intra-Arterial Therapies for Neuro-Endocrine Liver Metastases

Posted on December 22, 2014

G. Spolverato1, A. Vitale1, A. Ejaz1, Y. Kim1, J. Geschwind1, C. Wolfgang1, M. Weiss1, T. M. Pawlik1  1Johns Hopkins University School Of Medicine,Baltimore, MD, USA

Introduction:  Management of patients with neuroendocrine liver metastasis (NELM) remains controversial. We sought to compare the survival benefit of hepatic resection (HR) versus intra-arterial therapy (IAT) among patients with NELM. 

Methods:  A decision analytic Markov model was created to estimate and compare life expectancy associated with different management strategies (HR vs. IAT) for a simulated cohort of patients with NELM. The primary (base-case) analysis was calculated based on a 57-year old male patient with metachronous, symptomatic NELM that involved < 25% of the liver in the absence of extrahepatic disease. A Monte Carlo simulation was performed to assess the effect on outcomes with variation in model/disease parameters.  

Results: In the base-case analysis, HR was strongly favored over IAT providing a survival benefit of 52 months. On the Monte Carlo simulation, the greatest survival benefit for HR was among patients with a smaller volume of disease (<25%) and functioning/symptomatic NELM.  While patients with large volume symptomatic disease (≥ 25%) benefited from HR over IAT, the effect was less pronounced (34 months).  In contrast, patients with large volume non-functioning/asymptomatic NELM did not seemingly derive a benefit from HR; instead, this cohort of patients had an anticipated 23 months better survival with IAT rather than HR. 

Conclusion: A Markov decision model demonstrated that HR was the preferred strategy among patients with symptomatic NELM, regardless of hepatic disease burden.  In contrast, IAT was associated with better outcomes among patients with large volume disease, especially among those patients with non-functioning/asymptomatic NELM.

 

13.03 Preventable Comorbidities (PCm) Effect on Open Ventral Hernia Repair (OVHR)

Posted on December 22, 2014

T. C. Cox1, L. J. Blair1, C. R. Huntington1, P. D. Colavita1, A. E. Lincourt1, B. T. Heniford1, V. A. Augenstein1  1Carolinas Medical Center,Division Of Gastrointestinal And Minimally Invasive Surgery,Charlotte, NC, USA

Introduction: Many patients with complex ventral hernias have comorbidities.  This study compared patients with PCm to those patients without such risks to evaluate the financial impact of PCm during elective surgery.

Methods: In this prospective study of OVHR at a single institution from 2007-2011, total hospital costs and outcomes for patients with PCm—diabetes, tobacco use, and obesity—were compared to patients without such risks.  Outcomes included total wound complications, wound infections, and mesh infections.  Cost evaluation included all hernia-related visits, interventions, or readmissions within one year. 

Results: The 249 OVHR patients were categorized into four groups: No PCm without complications(n=85), No PCm with complications(n=33), two or more PCm without complications(n=50), and two or more PCm with complications(n=81).  The majority were female(55.8%); mean age was 56.6 years, average defect size 202.01cm2.  BMI of the PCm group with complications was 40kg/m2 compared to 36kg/m2 in the PCm without complications(p<0.05).  There was no difference in BMI in the no PCm groups(p>0.05).  For all patients with wound complications, total hospital costs were $80,660 with PCm compared to $55,444 in those without PCm (p<0.05).  There was no difference in hospital costs in those with PCm without complications compared to no PCm with complications($65,453 vs$55,444, p>0.05). Even when no complications occurred, patients with PCm had higher costs than those without PCm for inpatient($61,269 vs$31,236, p<0.05), outpatient($4,185 vs$552, p<0.05), and total hospital costs($65,453 vs$31,788, p≤0.001). PCm vs no PCm did not impact number of office visits comparing the groups without complications(2.18 vs2.54, p>0.05) or those with complications(5.15 vs5.89, p>0.05). For all patients with wound complications, readmission in the PCm group was 37% compared to 21% in the no PCm group.

Conclusion: OVHR patients with PCm have higher hospital costs than those without PCm even when no complications occurred.  Furthermore, patients with PCm and no complications showed no difference in total hospital costs than those with no PCm that had complications.  Aggressive risk reduction can translate into saving tens of thousands of dollars in hospital care costs.  Novel tactics for preoperative optimization of patients prior to elective surgery are indicated.

 

13.04 Operating Room Material Costs: What Do Attending Surgeons and Surgical Residents Know?

Posted on December 22, 2014

A. D. Newton1, G. Savulionyte1, K. R. Dumon1, J. Anderson1, V. Salasky1, D. T. Dempsey1  1Hospital Of The University Of Pennsylvania,Surgery,Pennsylvania, PA, USA

Introduction: The American College of Surgeons’ 2009 Statement on Health Care Reform called for a reduction of health care costs and implementation of cost-effective care. Operating room (OR) materials are an important component of surgical health care costs. The purpose of this project was to measure surgeons’ knowledge of the cost of ten commonly used OR materials.

Methods: A questionnaire was designed to determine knowledge of actual (not billed) cost to the hospital of 10 common OR materials (Ligasure, Endoclip, Endodissect, Lap irrigator, GIA 60 Stapler, Endo GIA, Harmonic ACE, Marlex Mesh, Permacol, and packed red blood cells). It was completed by surgical attendings (n=12) and residents (n=44). All were familiar with all 10 OR items. Each multiple-choice question (1 per OR item) contained four distinct price range options, one of which contained the actual cost of the item. Differences were assessed by Chi Square.

Results: Attending surgeons scored significantly better on the overall survey than surgical residents (45% vs. 31% correct answers, p<0.05). On 6 out of 10 items, at least 50% of attendings and residents were wrong about the cost (Table 1).

Conclusion: Surgical attendings and residents demonstrate a lack of knowledge of the actual cost to the hospital of basic operating room materials. In an era of increased focus on cost-effectiveness and value in healthcare, medical centers and  residency programs should improve education to both attending and resident surgeons regarding the cost of OR supplies. 

 

13.05 Outpatient Versus Inpatient Thyroidectomy: A Cost minimization Analysis

Posted on December 22, 2014

E. Y. Cabrera Riascos1, A. E. Sanabria Quiroga1, L. C. Dominguez Torres1, P. A. Cifuentes Grillo1, A. E. Sanabria Quiroga1  1Universidad De La Sabana,General Surgery/Head And Neck Surgery,Chia, CUNDINAMARCA, Colombia

Introduction:

Traditionally, Patients Undergoing To Thyroidectomy Are Admitted Overnight To Monitor The Potential Complications As Hemorrhage, Airway Compromise And Severe Hypocalcemia. However, Current Evidence Has Shown That Outpatient Thyroidectomy Is Safe, And May Be More Cost-effective.  The Aim Of This Study Was To Determine The Costs And Safety Of Outpatient Versus Inpatient Thyroidectomy, Performed Routine In Low-risk Patients.

Methods:  

Patients Undergoing Thyroidectomy Between July 2013 And January 2014 Was Abstracted From The Surgical Department Databases From A Tertiary Care Center, Noting The Patient’s Age, Sex, American Society Of Anesthesiologists (Asa) Classification, Type Of Thyroidectomy, Indication, Operative Time, Hospital Stay, Postoperative Emergency Room Visit And Complications. The Main Factor Evaluated Were The Direct Costs Of The Intervention, So A Cost-minimization Analysis Was Designed From The Perspective Of The Payer. A Projection Of The Impact On The Budget Of The Health System Was Performed Taking Into Account The Number Approximate Thyroidectomies Per Year Performed.

Results:

A Total Of 44 Patients Were Included, Where 52.3% (N=23) Were Outpatients (Group 1) And 47.7% (N=21) Hospital Thyroidectomy (Group 2). There Were Not Statistically Significant Differences In Age, Type Of Thyroidectomy, Indication For Surgery, Asa And Surgical Time. The Overall Rate Of Complications Was Not Different Between The Groups (P = 0.82). The Overall Difference In Cost Was Usd$ 200.51 (Usd$ 1407.49 +- 247.48 In The Group 1 Versus Usd$ 1608.40 +- 1570.79 In The Group 2) (P <0.01). When Adjusted For Variables Of Resource Use, Implementation Of Ambulatory Thyroidectomy Guidelines, Can Decrease The Value Of The Procedure In 12.5%. 

Conclusion:

Outpatient Thyroidectomy Is A Feasible Option, That In Selected Patients Can Minimize The Costs Of The Procedure Safely.

 

Keywords: Thyroidectomy, Outpatient Surgery, Costs, Complications.

 

13.06 The Diagnostic Dilemma of Identifying Perforated Appendicitis

Posted on December 22, 2014

Z. Farzal1,2, Z. Farzal1,2, N. Khan2, A. Fischer3  1University Of Texas Southwestern Medical Center,Pediatric Surgery,Dallas, TX, USA 2Children’s Medical Center,Pediatric Surgery,Dallas, TX, USA 3Beaumont Children’s Hospital,Pediatric Surgery,Royal Oak, MI, USA

Introduction:  Despite decades of research, a best clinical pathway for classifying perforated versus nonperforated appendicitis remains undefined. The lack of accuracy in the classification of appendicitis can affect the therapeutic course and associated costs with the average cost per case of complicated appendicitis often being twice as much as that of a case of uncomplicated appendicitis. We hypothesized that there is variability in identification of perforated and nonperforated appendicitis across specialties due to lack of standardized criteria.

Methods:
An IRB-approved retrospective review of appendectomies (N=1311) allowed a comparison of classification as perforated appendicitis (PA) or nonperforated appendicitis (NPA) based on radiology (R), operative (O), and pathology (P) reports. For the radiology arm (R), only cases in which CTs were performed were included to use the most definitive radiologic diagnosis. Three groups: P+O (N=1241), P+R (N=516), O+R (N=512), were compared to identify the inter-group discordance in classification of appendicitis. The length of stay (LOS) served as a metric of clinical behavior and was compared to the designated classification of the case of appendicitis to test if the diagnosis was consistent with being clinically nonperforated (NPA) with a LOS less than or equal to 48 (LOS≤48) hours or perforated (PA) with a length of stay greater than 48 (LOS>48) hours.

Results:
The subsets P+O, P+R, O+R revealed a discordance of 11%, 15.7% and 16.6%, respectively. Operative and radiology (O+R) reports were the most discordant. In the O+R group, 35% of the cases that were operatively designated as perforated appendicitis (PA) were discordant with their radiologic diagnosis of nonperforated appendicitis (NPA). Cases designated as perforated appendicitis (PA) in all subsets (P+O, P+R, O+R) clinically behaved as perforated with an average LOS>48 hours (97, 95, 95, respectively), whereas the cases designated as nonperforated appendicitis (NPA) displayed greater variation from the expected LOS≤48 hours, with means of 35, 83, and 52 hours, respectively.

Conclusion:
There is significant variability in classifying perforated versus nonperforated appendicitis. With up to 16.6% discordance between operative and imaging findings, the absence of standardized classification criteria results in a continued lack of diagnostic accuracy, as confirmed by variation in clinical behavior. Standardizing the criteria for the classification of the type of appendicitis across specialties may improve diagnostic accuracy needed for meaningful clinical trials and to identify best practices for optimal use of hospital resources and health care costs.
 

13.07 Variation in Individual Surgeon Practice in the Treatment of Appendicitis

Posted on December 22, 2014

S. C. Fallon1, W. Zhang1, M. E. Lopez1, M. L. Brandt1, M. E. Kim1, J. R. Rodriguez1, M. V. Mazziotti1, D. E. Wesson1, J. G. Nuchtern1, E. S. Kim1  1Baylor College Of Medicine,Division Of Pediatric Surgery,Houston, TX, USA

Introduction:

Previous literature has shown that decreasing variation in medical care often leads to improved value by optimizing outcomes and decreasing cost. The purpose of this study was to determine variation between individual surgeons caring for children with appendicitis in a large, tertiary children’s hospital. 

Methods:

The records of all patients who underwent appendectomy during 2012 were retrospectively reviewed. Since 2011, patients in our institution have been managed using a standardized perioperative protocol, with >80% adherence to the protocol.  The primary outcome evaluated was variable direct cost of the patient’s initial hospitalization. Secondary outcomes included operating time, intra-abdominal abscess (IAA) rate, and LOS. Results were stratified by surgeon, and by simple and complex disease. Final diagnosis was based on intra-operative findings. Linear, logistic, and Poisson regression models, adjusting for patient age, gender, and simple vs. complex appendicitis, were used to analyze the differences between surgeons with respect to these outcomes.

Results:
1,089 appendectomies were performed by 15 surgeons. The average number of cases per surgeon was 71.8(+5.5). There were significant differences between surgeons for operative time (p=0.001), cost of treatment (p=0.001), and LOS (p=0.005) for simple appendicitis. For complex appendicitis, there were significant differences between surgeons for operative time (p=0.001), cost of treatment (p=0.045), and IAA rate (p=0.005), but not LOS (p=0.979). (Figure 1)

Conclusion:

Significant differences in operating time, cost, LOS, and IAA rates in pediatric appendicitis exist between surgeons at a single, high volume, tertiary hospital despite the use of a standardized pre and post-operative evidence-based protocol.  Future study to identify factors leading to these differences may allow further improvement in outcome while decreasing the cost of care. 

13.08 The Cost of Gastroschisis: Has Anything Changed ?

Posted on December 22, 2014

D. M. Hook-Dufresne1, X. Yu3, V. Bandla2, E. Imseis2, S. D. Moore-Olufemi1  1The University Of Texas Health Science Center Houston,Pediatric Surgery,Houston, TX, USA 2The University Of Texas Health Science Center Houston,Pediatric Gastroenterology,Houston, TEXAS, USA 3Baylor College Of Medicine,Pediatric Epidemiology,Houston, TEXAS, USA

Introduction:  Gastroschisis (GS) is a common, congenital abdominal wall defect that can cause significant morbidity associated with the development of intestinal dysfunction and feeding intolerance. The purpose of this study was to provide an update on the economic impact of pediatric patients diagnosed with gastroschisis on a national and state level.

Methods:  The Healthcare Cost and Utilization Project (HCUP) database was queried from 2007 -2011 for the following data: number of discharges, length of stay (LOS), costs and charges for all national pediatric (age < 1) hospital stays and all national pediatric (age < 1) hospital stays with the procedure code 54.71, designating repair of GS. The same data was collected for the state of Texas. The variation of differences in mean outcome between GS and normal infants over the years was negligible, thus we calculated the overall effect of having GS on LOS, cost and charges by the weighted average of the differences, where the weight was the reciprocal of the variance of the mean for each year. This value is represented by the combined estimate of difference (CED) and its standard error (SE). We performed a one-sample z test to compare the state CED against the national population CED.

Results: Pediatric patients under the age of 1 represent, on average, 11.86% of all national discharges. Pediatric patients with GS represent only 0.04% of all national pediatric discharges. Nationally, infants with GS had a significantly longer LOS (CED 38.5±0.9 days, p <0.0001). Infants with GS had significantly increased costs (CED $79,733±2,119, p <0.0001) and significantly increased charges (CED $249,999±9,652, p< 0.0001) for the national data. Data for the state of Texas reflected that of the national data. LOS was significantly longer for GS infants in the state of Texas (CED 41.6±2.5 days, p < 0.001). Texas infants with GS had significantly higher costs (CED $79,431±6,056, p <0.0001) and significantly higher charges (CED $252,611±27,752, p < 0.0001) when compared to non-GS infants. There were no significant differences between the state of Texas and the nation for LOS (p-value 0.22), costs (p-value 0.96), or charges (p-value 0.92).

Conclusion: While infants with GS represent a very small minority of both the national and Texas pediatric discharges, their LOS and costs greatly exceed their non-GS counterparts. Our findings reflect those of studies conducted more than 10 years ago, but interestingly, even when adjusting for the rate of inflation, the costs of caring for infants with GS continues to rise despite improved treatment strategies. Further investigation into the factors that promote the development of intestinal dysfunction and feeding intolerance in these patients is needed to significantly impact the economic burden of GS.

 

13.09 Bariatric Surgery and its Cost-Effectiveness in an Adolescent Population

Posted on December 22, 2014

S. Bairdain1, M. Samnaliev2  1Boston Children’s Hospital,Department Of Pediatric Surgery,Boston, MA, USA 2Boston Children’s Hospital,Harvard Medical School,Boston, MA, USA

Introduction:  The current estimates of the prevalence adolescent morbid obesity and severe morbid obesity are 21% and 6.6%, respectively.  Obesity, if left untreated, may result in a variety of comorbid conditions and earlier mortality. Adolescent bariatric surgery is expensive, but may be an effective means to ameliorate these conditions, and risk of earlier mortality.  We aimed to develop a model that can be used to evaluate the long term cost-effectiveness of bariatric surgery.

Methods:  All adolescents, who participated in our bariatric surgery multidisciplinary program from January 2010 to December of 2013 were included if they had at least 12 months follow-up following their surgery. A Markov cohort model was used to project costs, BMI and QALYs over a lifetime starting at age 18. Intervention costs included all operative as well as pre, and 12 month post-operative care costs. We estimated reductions in BMI after surgery and linked that information with the Medical Expenditures Panel Survey (MEPS) to estimate future savings from reduced medical care use. We used MEPS and other external data sources to estimate the association between BMI and health-related quality of life (HRQL). We linked BMI reductions with changes in life expectancy using publicly available data from the CDC. Incremental costs and quality-adjusted life years (QALYs) of surgery (vs. no surgery) were then estimated over different time periods. 

Results: From January 2010 to December 2013, data from 11 patients were analyzed. Ninety percent (n=10) were female. Median age at surgery was 17 (1.3) years. Median preoperative body mass index (BMI) was 48.7 (6.6) kg/m2.  All patients underwent a laparoscopic Roux-en-Y Gastric Bypass (RYGB) and 45% (n=5) had a concomitant hiatal hernia repair. Median length of stay was 3 days (range: 2-4 days). There were no complications. At 1 year follow-up, mean weight loss was 37.5 (13.5) kg and the corresponding BMI was 35.4(reduction of 13.2, p<0.01). Mean total intervention costs/person were $25,854 (sd=2,044). A unit change in BMI was associated with future medical care savings of $157 / year and with an increase in both quality of life and life expectancy. Bariatric surgery was not cost-effective in the first 3 years after surgery, but became cost-effective after that (e.g., $74,328/QALY in year 4 and 32,453/QALY and lower in year 7 and afterwards). 

Conclusion: Our results suggest that bariatric surgery among adolescents may be cost-effective when evaluated over a long period of time (e.g. 4 years). Future studies on a large scale are needed to show a continued improvement in QALYS and to evaluate earlier cost-effectiveness of the procedure.
 

13.10 DIEP Flaps Offer Lower Complication Rates, Shorter Hospitalizations at Higher Cost.

Posted on December 22, 2014

D. J. Gerth1, J. Tashiro1, S. R. Thaller1  1University Of Miami,DIvision Of Plastic Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA

Introduction:  Abdominal based breast reconstruction may be performed using several techniques, including pedicled transverse rectus abdominis myocutaneous (TRAM), free TRAM, and deep inferior epigastric perforator (DIEP) free flaps. DIEP flaps have the advantage of complete rectus abdominis sparing during the procedure, thus decreasing donor site morbidity. The aim of this study is to determine whether the surgical advantages of the DIEP flap impact postoperative outcomes vs. the free TRAM flap (fTRAM).

Methods:  We identified cases of DIEP (ICD-9-CM 85.74) and fTRAM (85.73) breast reconstruction within the Nationwide Inpatient Sample (NIS) database (2010-2011). Males were excluded from the analysis. Demographic and socioeconomic characteristics, comorbidities, postoperative complications (reoperation, hemorrhage, hematoma, seroma, pulmonary embolus, wound infection, and flap loss) were examined, along with endpoints of length of stay (LOS) and total charges (TC). Standard statistical methods and risk-adjusted multivariate analyses were used; all cases were weighted to project national estimates.

Results: Overall, 15,836 cases were identified, with 9,699 (61%) DIEP and 6,137 (39%) fTRAM reconstructions. Within the cohort, 70% were Caucasian, 97% were insured, and 83% of patients were treated in a teaching hospital setting. LOS was longer among fTRAM patients, whereas TC were lower, p<0.001. There were no in-hospital mortalities during the study period. DIEP patients were more likely to be obese (OR=1.2), p<0.001. The fTRAM cohort was more likely to suffer pneumonia (OR=3.7), wound infection (OR=1.7), and wound dehiscence (OR=4.3), p<0.001. Type of reconstruction did not affect risk of revision, hemorrhage, hematoma, seroma, or flap loss on bivariate analysis. Risk-adjusted multivariate analysis demonstrated that fTRAM was an independent risk factor for increased length of stay (OR=1.6) and postoperative complications (OR=1.3), p<0.001. DIEP was an independent risk factor for increased total charges (OR=1.5), p=0.001.

Conclusion: Patients undergoing fTRAM breast reconstruction were more likely to suffer postoperative complications and an increased length of stay; total charges however, were higher for the DIEP cohort. Additional research is necessary to elucidate patterns of technique availability to improve cost-utilization.

13.11 Free TRAM Flaps Have Higher Resource Utilization, More Complications vs. Pedicled Flaps.

Posted on December 22, 2014

D. J. Gerth1, J. Tashiro1, S. R. Thaller1  1University Of Miami,DIvision Of Plastic Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA

Introduction:  Conventionally, free transverse rectus abdominis myocutaneous (fTRAM) flap breast reconstruction has been associated with decreased donor site morbidity and improved flap inset, at the expense of higher requirements for technical expertise and advanced facilities. This study aims to characterize postoperative outcomes and their differences in patients undergoing free vs. pedicled TRAM (pTRAM) flap breast reconstruction.

Methods:  The Nationwide Inpatient Sample (NIS) database (2008-2011) was reviewed for cases of fTRAM (ICD-9-CM 85.73) and pTRAM (85.72) breast reconstruction. Inclusion criteria were female patients undergoing pTRAM or fTRAM total breast reconstruction; males were excluded from the analysis. We examined demographic characteristics, hospital setting, insurance information, patient income, comorbidities, with clinical endpoints of postoperative complications (including reoperation, hemorrhage, hematoma, seroma, myocardial infarction, pulmonary embolus, wound infection, and flap loss), length of stay (LOS), and total charges (TC). Bivariate and Multivariate analyses were performed to identify independent risk factors associated with increased complications and resource utilization. Cases were weighted to project national estimates.

Results: Overall, 21,655 cases were captured. Of the entire cohort, 70% were Caucasian, 95% were insured, and 72% of patients were treated in an urban teaching hospital. Of the 11,331 pTRAM and 10,328 (48%) fTRAM cases, there were 9 pTRAM and 6 fTRAM in-hospital mortalities. On bivariate analysis, the fTRAM cohort was more likely to be obese (OR=1.2), undergo revision (OR=5.9), require hemorrhage control (OR=5.7), suffer complications from a hematoma (OR=1.9), or wound infection (OR=1.8), p<0.003. The pTRAM cohort was more likely to suffer pneumonia (OR=1.6) and pulmonary embolism (OR=2.0), p<0.004. Type of reconstruction did not affect risk of flap loss or seroma. TC were higher in the fTRAM group (p<0.001), while LOS was not affected by procedure type. On a risk-adjusted multivariate analysis, fTRAM was found to be an independent risk factor for increased LOS (OR=1.6), TC (OR=1.8), and postoperative complication rate (OR=1.3), p<0.001.

Conclusion: Free TRAM breast reconstruction was found to have an increased risk of postoperative complications and resource utilization vs. pedicled TRAM on the largest risk-adjusted analysis to date. Further analyses are required to elucidate additional factors influencing outcomes following fTRAM and pTRAM reconstruction.

13.12 Financial Implications of Managing Penetrating Trauma Patients to an Acute Care Surgery Service

Posted on December 22, 2014

B. C. Branco1, P. Rhee1, B. Joseph1, A. L. Tang1, G. Vercruysse1, T. O’Keeffe1  1University Of Arizona,Trauma,Tucson, AZ, USA

Introduction:  Trauma centers often report unfavorable financial performance by caring for injured patients Penetrating trauma in particular has a significant impact on health care systems, with up to one third of these patients reported as uninsured. The financial impact on trauma surgery practice is unknown. The purpose of this study was to evaluate the financial implications of managing penetrating trauma patients in a level I trauma center.

Methods: All trauma patients admitted to a level I trauma center over a fiscal year (July 2011 to June 2012) were retrospectively identified. Demographics, clinical data and outcomes were extracted. Hospital and trauma surgeon financial data were also extracted. Outcomes were total charges, costs, net margin and reimbursements. Patients were compared according to injury mechanism. What stats did you use?

Results: 3,343 trauma patients were admitted of which 513 (15.3%) sustained penetrating trauma (51.3% GSW and 48.7% SW) and 2,830 (84.7%) blunt. Penetrating trauma patients had lower overall ISS (8.4 ± 11.3 vs. 9.2 ± 9.4, p<0.001) but were more likely to undergo an intra-cavitary procedure (39.3% vs. 26.7%, p<0.001). Patients who sustained penetrating trauma were more often uninsured (19.4% vs. 9.1%, p<0.001) and had Medicaid (55.8% vs. 36.9%, p<0.001). There were no significant differences in hospital LOS (penetrating: 4.2 ± 6.5 days vs. blunt: 4.7 ± 6.8 days, p=0.271). Overall, hospital net margin was $1.2 ± 1.3 k per trauma patient (1.9 ± 1.3 k for blunt vs. -2.4 ± 1.3 for penetrating, p<0.001). The average % hospital reimbursement was 25 ± 23% for blunt and 15 ± 18% for penetrating trauma (p<0.001). There were no differences in total hospital costs (10.4  ± 2.9 k vs. 10.1  ± 1.9 k, p=0.841) or patient charges (40.8 ± 8.1 k vs. 44.9 ± 7.4 k, p=0.302). Nevertheless, trauma surgeon professional charges were significantly higher for penetrating trauma (3.9 ± 7.3 k vs. 1.6 ± 3.2 k, p<0.001), in particular after GSWs (4.7 ± 8.9 k vs. 1.7 ± 3.4 k, p<0.001), as were surgeon’s reimbursement (1.4 ± 1.9 k vs. 0.6 ± 1.0 k, p<0.001.

Conclusions: Penetrating trauma was found to be a significant source of revenue loss for hospitals. This data may help inform mission support efforts in critical access hospitals that have high rates of penetrating trauma. Trauma surgeon reimbursement were however significantly higher after penetrating trauma, in particular after gunshot wounds, due to the associated operative interventions.

 

13.13 Do Healthcare Professionals Practice Evidence Based Medicine?

Posted on December 22, 2014

R. Kaur1, E. Chang1, P. Chung1, S. Hahn1, D. Chang1, A. Alfonso1, G. Sugiyama1  1SUNY Downstate,BROOKLYN, NY – NEW YORK, USA

Introduction:  Healthcare professionals (HCPs) have a duty to provide service for patients based on the best possible evidence available. However there is often little data available when novel approaches are first introduced. We conducted a survey of HCPs preferences for minimally invasive cholecystectomies with robotic cholecystectomy being the most recently introduced in available mainstream options for the procedure.   

Methods:  Non-surgical HCPs (attending and resident physicians, nurse practitioners, physician assistants and registered nurses) at our academic medical center were surveyed on their preferences for the following: multiport laparoscopic cholecystectomy (MLC), single incision laparoscopic cholecystectomy (SILC), single incision robotic cholecystectomy (SIRC), or no preference. HCPs were then provided educational material providing images of post-operative wounds, and expected outcomes based on currently available data. Only known parameters of patient outcomes in regards to SIRC were reported in the survey due to lack of currently available outcomes data.

Results: 100 HCPs completed the survey study. Prior to image and data presentation, reported preferences were SILC (48%), SIRC (21%), no preference (20%), and MLC (11%). After image and data presentation, preferences were SIRC (45%), SILC (33%), MLC 12%, and no preference (10%). The Stuart-Maxwell test showed a significant change (p < 0.0001) in preference for surgical approach between the paired groups. 

Conclusion:The plasticity displayed in HCPs’ preferences for surgical approach before and after data presentation shows the effects of information on HCPs’ choices. These results were surprising. Despite being provided incomplete outcomes data for SIRC, many HCPs chose SIRC over the more familiar options of MLC and SILC. These results suggest that HCPs are comfortable making decisions based on incomplete data. Further studies to explore the magnitude of the effects of marketing in the absence of concrete outcomes data as applied to robotic surgery is necessary.

 

13.14 Resource Utilization in Pediatric Skin and Soft Tissue Infections

Posted on December 22, 2014

M. Veenstra1,2, A. Hartner2, B. Kumar2, P. Mahajan2, B. Asmar2, M. Klein1,2  1Detroit Medical Center,Detroit, MI, USA 2Children’s Hospital Of Michigan,Pediatric Surgery,Detroit, MI, USA

Introduction:
Skin and soft tissue infections (SSTIs) have increased in the past 2 decades and are associated with increasing health care costs. We convened a multispecialty group of physicians from the departments of surgery, pediatrics, emergency medicine, and infectious disease to evaluate our experience and costs related to evaluation of pediatric SSTIs. 

Methods:
Patients (682) who presented to our ED with SSTIs during 6 consecutive months (July-December 2012) were reviewed for resource utilization and costs. This data was compared to current recommendations in the literature to identify evaluation tools that add resource consumption without benefit to the patient. ANOVA was used for statistical analysis.

Results:
Of the 682 patients presenting with a pediatric SSTI, 331 (49%) underwent incision and drainage for an abscess. Wound cultures were completed in 38% of patients, blood cultures in 29%, US in 16%, antibiotics prescribed to 97%, and 208 patients (30%) were admitted to the hospital. The mean direct cost per patient was $792.66 and mean length of stay was 15 hours. The total direct cost of care for 6 months was $540,593.  The use of ultrasound, wound culture, and blood culture increased the length of stay (p<0.01) and all resources increased cost for patients (p<0.01). Patients admitted to a surgical service had a shorter length of stay and lower cost than those admitted to a non-surgical service (p<0.01).

Conclusion:
We noted many resources that are being overutilized in the evaluation of pediatric patients with SSTI that are contributing to unnecessary costs when compared to recommendations in the literature. The include blood cultures, wound cultures, and the use of utrasound.
 

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