13.15 Indications And Outcomes For Nissen Fundoplication In Infants Less than 6 Months Of Age

Posted on December 22, 2014

J. Yoon1, J. Gross1, S. Burjonrappa1  1St.Jospeh’s Regional Medical Center,Surgery/Pediatric Surgery,Patterson, NJ, USA

Introduction:  Anti-reflux surgery is offered only to those who fail medical management for gastro-esophageal reflux (GERD) in the pediatric population. The general consensus is that most infants would grow out of their reflux with medical management only. A handful of studies show that those with neurologic impairment have benefited from these procedures; however, there are few studies that document the outcomes for infants less than 6 months of age.  This study investigates the short-term outcomes of Nissen Fundoplication (NF) in this population.

Methods:  We performed a retrospective analysis of children less than 6 months of age who underwent Nissen Fundoplication at our institution from December 2006 – June 2013.  The following factors were analyzed: surgical indications, co-morbidities, hospital course data, weight gain, length of stay, and complications.

Results: 23 patients were studied in this analysis (average age: 95.8 days, median 90 days).  Pre-surgery, these patients on average were in the 9.88 percentile for weight (median 0.9 percentile) and 21/23 (91.3%) patients were under the 50th percentile.  19/23 (82%) patients underwent NF for GERD and 16/23 (69%) patients had poor feeding prior to the surgery.  All patients had concomitant gastrostomy tube creation.  All patients had co-morbidities other than GERD/ poor feeding.    18/23 (78%) had anatomic or genetic abnormalities.  11/24 (45.8%) patients underwent an upper gastrointestinal contrast study that was positive for reflux.  Diet was advanced on average post-operative day 2.39 and the patients were tolerating their goal diet by post-operative day 6.45 (median 5.5).  All but 3 patients were discharged on diets more substantial (by volume) than their highest pre-operative diet. On average, these patients were on 1.9 GERD related medications before surgery (Pepcid most common), but decreased to 0.7 GERD related medications after surgery. Of the 15 patients who were still on GERD medications after surgery, only 2 were discharged with medications. Patients who were observed for longer than 2 weeks in an inpatient setting (10/23 patients) had an improvement in weight percentile (average 9.79 to 14.97 percentile; median 1.4 to 3.2). 7/24 (29.2%) patients had complications related to their g-tube, the main complaint being leakage around the tube.

Conclusion:Infants undergoing NF under the age of 6 months are very sick patients with multiple co-morbidities.  They have exhausted all options for weight gain due to excessive reflux and/or poor feeding.  Our study shows that NF in these patients improves their ability to gain weight and also decreases the overall need for GERD related medications.  
 

13.17 Temporal Variation of Non-Perforated and Perforated Appendicitis in the United States

Posted on December 22, 2014

A. A. Desai1, K. W. Schnell1, B. G. Dalton1, S. D. St. Peter1, C. L. Snyder1  1Children’s Mercy Hospital- University Of Missouri Kansas City,Kansas City, MO, USA

Introduction:   Seasonal variation in the incidence of acute appendicitis has been recognized.  The aim of this study was to determine whether children with non-perforated and perforated appendicitis were more likely to present during specific days of the week or seasons of the year in the United States.   Previously reported data demonstrates increased likelihood of presentation of perforated appendicitis on Mondays and increased rates of presentation during the fall and winter.

Methods:   A retrospective population-based study of patients was performed by querying The Pediatric Health Information System (PHIS) database over a 9-year period for de-identified patients with both ICD-9 code for appendicitis and procedure code for appendectomy.  Patients greater than 18 years of age were excluded.  Demographics and temporal data regarding day, quarter, and month were based on day of operation.  Chi square and odds ratio were performed where appropriate.

Results:  A total of 139,499 children were admitted during the study interval of which 34.1% were perforated.  The greatest incidence for non-perforated appendicitis was Tuesday (15.9%), and the greatest incidence for perforated appendicitis was Monday (15.8%).  Although the greatest incidence of perforated appendicitis was on Monday, this was not significant (p=0.72).  The weekends however were at higher odds (OR: 1.13; 95% CI1.102-1.16) for perforation.  Peak incidence of non-perforated appendicitis occurs in the summer (spring 25.9%, summer 27.1%, autumn: 23.8%, winter: 23.1%).  Peak presentation of perforated appendicitis occurs in the summer as well (spring: 8.8%, summer: 9.2%, autumn: 8.1%, winter: 7.9%)  However, the odds of perforated appendicitis during summer months (OR: 1, CI: 0.97-1.02) or winter months (OR 1.0, CI: 0.99-1.05) was not significant.

Conclusion:  Presentation with perforated appendicitis is more likely to occur on the weekends.  Seasonal variation supports previously reported data demonstrating peak presentation of non-perforated and perforated appendicitis in the summer, however increased odds of perforation in fall and winter months was not noted in this study.

 

13.18 Pediatric Ulcerative Colitis: Comparison of 30-day outcomes for laparoscopic and open colectomy

Posted on December 22, 2014

J. B. Mahida1,2, L. Asti1, P. C. Minneci1,2, K. J. Deans1,2, B. C. Nwomeh2  1Nationwide Children’s Hospital,Center For Surgical Outcomes Research,Columbus, OH, USA 2Nationwide Children’s Hospital,Division Of Pediatric Surgery,Columbus, OH, USA

Introduction:
For patients with ulcerative colitis, colectomy is considered curative treatment. Colectomy can resolve frequent disease flares and minimize the risk of colon cancer in patients with ulcerative colitis. The objective of this study was to compare 30-day outcomes between laparoscopic and open colectomy performed on pediatric patients with ulcerative colitis using a validated national database.

Methods:
We identified all total colectomies performed on patients with ulcerative colitis in the 2012 National Surgical Quality Improvement Program Pediatric (NSQIP Pediatric) database and compared demographic, clinical, and 30-day outcome characteristics between patients who underwent an open or laparoscopic resection. Minor complications included superficial and deep surgical site infections and urinary tract infections, whereas major complications included ventilator dependence for > 48 hours, unplanned reoperation within 30 days, and all other NSQIP Pediatric predefined 30-day complications.

Results:
Of the 69 patients who underwent colectomy, 21 (30%) were performed open and 48 (70%) laparoscopically. There were no significant differences in baseline characteristics between the groups with the exception of patients undergoing open procedures having  lower white blood cell counts (9,800 vs. 10,900 cells/mm3, p=0.041) and platelet counts (302,000 vs. 361,000 cells/mm3, p=0.026). There was no significant difference in the proportion of patients undergoing operations longer than 3 hours (open vs. laparoscopic, p-value) (67% vs. 81%, p=0.187), in postoperative length of stay (8 vs. 6 days, p=0.074), or in the rates of major and minor complications (Table).

Conclusion:
The majority of colectomies for pediatric ulcerative colitis are being performed laparoscopically with similar operative times, postoperative lengths of stay, and 30 day outcomes to open procedures. Additional patient accrual within NSQIP-Pediatric will allow for future risk-adjusted analyses to determine differences in outcomes.
 

13.19 Increased height associated with patients with pectus excavatum and pectus carinatum

Posted on December 22, 2014

A. A. Desai1, H. Alemayehu1, B. G. Dalton1, K. W. Schnell1, S. D. St. Peter1, C. L. Snyder1  1Children’s Mercy Hospital- University Of Missouri Kansas City,Kansas City, MO, USA

Introduction:   The underlying cause of most chest wall deformities is not clearly understood. A small fraction are associated with connective tissue diseases, with associated systemic skeletal abnormalities. Other than scoliosis, no other skeletal abnormalities are commonly associated with congenital chest wall deformities. We investigated the clinical observation that children with pectus defects appeared to be, on average, taller than unaffected children.

Methods:  A retrospective institutional review board approved review was conducted of all patients with pectus excavatum and pectus carinatum seen in our outpatient congenital wall deformity clinic from January 2011 to June 2013.   Demographic data including age at presentation, weight, height, body mass index (BMI) and gender were collected and compared to national cohort as published by the Center for Disease Control Clinical Growth Charts.  Two-tailed t-test was used for statistical analysis.   

Results:   A total of 360 patients (280 males and 80 females) were identified in the study period.   The mean and median percentile for height among males was 70.9 and 80.3, and the mean and median percentile for height among females was 67 and 69.5.  The mean and median percentile for weight among males was 56.6 and 54, and for females was 46 and 50 (Figure 1).  There was no significant difference between mean percentile height (p=0.1) or weight (p=0.12) between genders.  There was no significant difference in percentile of height (p=0.12) or weight (p=0.75) in patients with pectus carinatum and pectus excavatum.

Conclusions:  Patients with congenital chest wall deformity do have increased height when compared to the national cohort. The average weight of patients with congenital chest wall defects is similar to the national cohort, accounting for the lower BMI. The increased height and decreased BMI may be associated with general growth abnormalities seen with chest wall deformities.

14.01 Partnerships in Global Surgery: Do Short-Term Surgical Teams Increase Operative Volume?

Posted on December 22, 2014

S. R. Addington1, A. Matousek1,3, C. Exe2, R. R. Jean-Louis2, H. Sannon2, J. G. Meara3, R. Riviello1,3  1Brigham And Women’s Hospital,The Center Of Surgery And Public Health,Boston, MA, USA 2Hospital Albert Schweitzer,Surgery,Deschapelles, ARTIBONITE, Haiti 3Harvard Medical School,The Program In Global Surgery And Social Change, Department Of Global Health And Social Medicine,Boston, MA, USA

Introduction:  Short-term surgical teams (STSTs) offer the potential to increase surgical capacity, provide specialty services and create educational opportunities for local staff. They also often gain exposure to advanced pathology, improved physical examination skills and practice patterns with limited resources from experienced local providers.  In the absence of outcome data, STSTs often use productivity as a metric of impact.  We set out to determine whether STSTs increase operative volume at an NGO hospital in rural Haiti.

Methods:  We retrospectively reviewed the operative log at an NGO hospital in rural Haiti from Jan 1st, 2013 through July 1st, 2014. We compared the mean number of operations performed on weekdays when STSTs were present and absent. We also analyzed the relative contributions of STSTs and local staff surgeons to the operative volume.

Results: The sample included 1976 operations completed over 399 weekdays. During the study period, 53 individuals comprising 22 STSTs were present for 118 of the 399 weekdays (29.6%).  STSTs were associated with a modest increase in operative volume (5.83 vs. 4.58 operations/day, p= 0.0024) that accounted for approximately 100 additional procedures per year. STSTs did not perform as many operations as the local staff did during their stays (2.11 vs. 3.72 operations/day, p=0.0001). STSTs were also associated with a decrease in local staff productivity (3.72 vs. 4.58 operations/day, p=0.025).  

Conclusion: STSTs were associated with a modest increase in operative volume partially mitigated by a decrease in local staff productivity. STSTs offer many benefits to hospitals in LMICs, but must be well coordinated and integrated into existing systems to maximize potential benefits.

 

14.02 Measuring Surgical Outcomes in Rural Haiti: Choosing a Target for Quality Improvement

Posted on December 22, 2014

A. C. Matousek1,3, S. Addington1, C. Exe2, R. R. Jean-Louis2, J. G. Meara3,4, R. Riviello1,3  1The Center For Surgery And Public Health, Brigham And Women’s Hospital,Surgery,Boston, MA, USA 2Hospital Albert Schweitzer,Deschapelles, ARTIBONITE, Haiti 3Harvard Medical School,Program in Global Surgery And Social Change, Department Of Global Health And Social Medicine,Boston, MA, USA

Introduction:  The lack of outcome data is a barrier to quality improvement efforts in resource poor settings.  Most hospitals in LMICs endure several resource constraints and do not include outcome measurement in routine data collection.  We set out to systematically record inpatient surgical outcomes for an eight-month time period at a typical rural NGO hospital in rural Haiti to inform future quality improvement efforts.

Methods: A single data collector used a standard set of definitions to prospectively record outcomes during any admission or readmission for adult and pediatric general and orthopedic surgical patients from Sept 16th, 2013 to May 16th, 2014. Primary outcomes included all cause mortality, post-operative mortality, surgical site infection, and unplanned re-operation.  Secondary outcomes included length of stay and reasons for re-admission.

Results:  The cohort included 1088 patients and 1165 admissions.  The surgical caseload consisted of 1022 operations performed on 864 patients. All-cause mortality occurred in 1.52%, post-operative mortality in 1.45%, SSIs in 2.47%, and unplanned repeat operations in 1.40% of cases.  The 30-day readmission rate was 7.1%. Median Length of stay (LOS) for all patients was 4 days.  Median LOS for patients with diabetic foot ulcers was 30 days.  Readmissions were due to complications in 50% of cases.

Conclusions:  Measuring outcomes should precede attempts at quality improvement in order to identify the most relevant interventions.  For this hospital, we identify inpatient wound care as a target for quality improvement and encourage the development of outpatient metrics to more fully characterize surgical quality.

 

14.03 Estimating Global Access to Surgical Care with Geospatial Mapping of Surgical Providers

Posted on December 22, 2014

N. P. Raykar1,2,3, A. N. Bowder3,4, M. P. Vega3, J. Kim3,5, G. N. Boye2, S. L. Greenberg2,3,6, J. N. Riesel2,3,7, R. D. Gillies3, J. G. Meara2,3, N. Roy8  1Beth Israel Deaconess Medical Center,Boston, MA, USA 2Children’s Hospital Boston,Boston, MA, USA 3Harvard School Of Medicine,Program In Global Surgery And Social Change,Brookline, MA, USA 4University Of Nebraska College Of Medicine,Omaha, NE, USA 5Tufts Medical Center,Boston, MA, USA 6Medical College Of Wisconsin,Milwaukee, WI, USA 7Massachusetts General Hospital,Boston, MA, USA 8BARC Hospital,Mumbai, MH, India

Introduction: The Lancet Commission on Global Surgery calls for universal access to safe, affordable and timely surgical care.  Unfortunately, billions of people currently lack access to such care due to myriad factors including severe deficits in the surgical workforce.  Little is known, though, about the distribution of surgeons and their accessibility to patients in low-resource settings — this makes allocation of human and physical resources challenging.  Geospatial mapping can be used to (1) identify populations that lack timely access to surgical care (defined as living within two hours of a surgical provider) and (2) understand variations in surgeon-to-population density that can impact service availability.

Methods: The number and practice location of surgeons was obtained from Ministries of Health, professional societies, registration databases, personnel with in-country knowledge of surgeon distribution, and the published literature.  Spatial distribution of providers was mapped using online mapping software.  Two-hour driving zones were constructed around each provider location through analysis of roads and driving times calculated from Google Maps. The number of people living within these zones was estimated using the Socioeconomic Data and Applications Center Population Estimation Service.

Results:Analysis was completed on data from nine countries: Mongolia, Namibia, Papa New Guinea, Sierra Leone, Somaliland, Zimbabwe, nine states in Nigeria, six states in India, and one state in Ecuador.  Percentages of populations living within two hours of a surgical provider vary dramatically, ranging from 4.7% (Chhattisgarh state, India) to 88.6% (Ogun state, Nigeria).  Surgeon-to-population ratios ranged from 1:10,500 (Mongolia) to 1:1,360,000 (rural Kerala state, India).  Surgeon-to-population ratios also vary dramatically within the same country. In Sierra Leone, for example, the urban surgeon-to-population ratio was 1:80,900 compared to the rural surgeon-to-population ratio of 1:383,000.

Conclusion:Access to surgical care in the resource-limited setting is contingent upon multiple factors. The most fundamental of these is availability of and access to a surgeon. Geospatial mapping of surgical providers shows that regardless of national surgical numbers, many populations in the world still lack access to timely surgical care.  Wide variability in timely and available access exists between and within countries.  Geospatial mapping has the unique ability to illustrate coverage gaps in a meaningful way.  Understanding these access patterns can prove useful in addressing national deficits in surgical care. 

 

14.04 Improving Surgical Capacity in a Low Resource Setting: the Rwanda Human Resources for Health Program

Posted on December 22, 2014

A. Costas1,2,4, J. Kreshak2,3,4, G. Ntakiyiruta4, P. Kyamanywa4, R. Riviello2,3,4  1Children’s Hospital Boston,Department Of Plastic Surgery,Boston, MA, USA 2Harvard School Of Medicine,Brookline, MA, USA 3Brigham And Women’s Hospital,Surgery,Boston, MA, USA 4National University Of Rwanda,Surgery,Kigali, NONE, Rwanda

Introduction: There is an estimated shortage of approximately 7.2 million health care workers worldwide, with critical shortages in sub-Saharan Africa. These shortages are largely due to lack of sufficient quality medical education programs, limited faculty and infrastructure, and difficulty retaining trained professionals. This deficit is particularly noticeable in surgery, which is often forgotten in global health discussions. Surgical missions, isolated trainings by surgical volunteers, and task shifting have played important roles as short-term solutions. However, these vertical programs are unable to fill the workforce gap in resource-limited countries. For these countries to sustainably manage the volume of their unmet surgical need, an emphasis needs to be placed on capacity building.

Methods: Instead of small-scale cooperative efforts between stand-alone academic institutions or isolated individuals, the Human Resources for Health (HRH) program was created in Rwanda in 2012 as a long term plan to increase the quality and quantity of health care professionals in the country.  The HRH program is a seven-year partnership between the Rwandan Ministry of Health, the United States federal government, and a consortium of 23 US institutions (USI) dedicated to building sustainable health care capacity. USI faculty are recruited to work full-time for one year in Rwanda and are partnered directly with Rwandese colleagues. Since August 2012, 10 USI surgeons a year (including general, plastics, orthopedic and pediatric surgery) have been active participants in surgical clinical and didactic teaching, curriculum and residency program development, research support and trainee mentorship.

Results:The HRH program is unique in many ways but perhaps none more so than its attention to surgical education as a critical component of a thriving health care delivery system. The HRH faculty have been instrumental in the improvement of education practices including clinical bedside and operative teaching, establishing protected didactic time, regular educational lectures and conferences such as morbidity and mortality, and research mentoring.  Greater appreciation has developed as well for surgery as a complex system and the importance of the many components needed to run a successful surgical program. HRH surgeons have thus assisted in the creation of separate specialty surgical services, streamlining operating room efficiency, procuring necessary and adequate instruments, providing teaching to ancillary staff, and highlighting the importance of having adequate radiology and pathology services.

Conclusion:The HRH Program surgical faculty, in partnership with their Rwandan colleagues, have provided formal surgical instruction and mentoring in Rwanda since 2012. In doing so, they are helping to improve the quality and capacity of the Rwandese surgical workforce so that it may comprehensively and sustainably meet the country’s future healthcare needs.

 

14.05 A Nationwide Survey of Access to Surgical Facilities, Poverty, and Deaths from Acute Abdomen in India

Posted on December 22, 2014

J. S. Ng-Kamstra1,2, S. Fu1, A. J. Dare1, M. M. Hsiao1,2, P. Rodriguez1, J. Patra1, N. Correa1, P. Jha1  1University of Toronto,Centre For Global Health Research, Li Ka Shing Knowledge Institute, St Michael’s Hospital,Toronto, Ontario, Canada 2University of Toronto,Department Of Surgery,Toronto, Ontario, Canada

Introduction: Acute abdominal conditions, including appendicitis, peptic ulcer disease, and incarcerated hernias are associated with high mortality in the absence of timely surgical care. In India, limited country-specific data exists to quantify the burden and distribution of deaths from acute abdomen (DAA) and to guide the development of surgical services. In this study, we describe the spatial and socioeconomic distributions of DAA and quantify potential access to surgical facilities in relation to such deaths.

Methods: Data on DAA throughout India in 2001-2003 were obtained from the Million Death Study (MDS), a nationally representative, population-based mortality survey of 1.1 million Indian households using verbal autopsy methodology. We created a national spatial database of abdominal mortality by integrating data from the MDS with surgical provider and facility data from the District-Level Household and Facility Survey and household socioeconomic data from the Special Fertility and Mortality Survey. The spatial distribution of DAA was calculated using ordinary kriging, and cluster analysis was performed using the Getis-Ord Gi* statistic. This provided ‘hot’ and ‘cold’ clusters of DAA at the postal (PIN) code level. Spatial metrics of access and socioeconomic indicators were then evaluated to compare hot and cold spots of DAA.

Results: 923 of 85388 study deaths in those aged 0-69 years were identified as DAA, representing an estimated 1.1% proportional mortality. The majority of deaths occurred at home (71%) and in rural areas (87%). The mean age-standardized DAA mortality rate was 8.6 times higher in hot than in cold PIN codes. Hot spots were associated with poorer access to district-level hospitals (DH) with a full complement of surgical resources. The median distance to the nearest such hospital was 53 km [IQR 32-85] in hot spots versus 27 km [IQR 17-43] in cold spots. Poverty indicators were also associated with mortality. Median monthly total household expenditure was significantly lower in hot spots versus cold spots, as were adult literacy rates. The proportion of households belonging to a scheduled caste or tribe was significantly higher in hot versus cold spots.

Conclusions: DAA were concentrated in rural India and predominantly occurred outside of a health facility. Mortality was associated with poor geographic access to surgical care, poverty, and belonging to a scheduled caste or tribe. These findings support the need to improve timely access to well-resourced surgical facilities in India to prevent avertable mortality from common surgical conditions. Policies must also address the significant socioeconomic barriers to surgical care, especially for the rural poor in India.

11.06 Efficacy of a Single PTH Measurement Protocol for Prediction of Hypocalcaemia after Thyroidectomy

Posted on December 22, 2014

J. Y. Liu1, C. J. Weber1, M. McCullough1, J. Sharma1  1Emory University School Of Medicine,General Surgery,Atlanta, GA, USA

Introduction:  
The management of hypocalcaemia after total thyroidectomy (TTx) is a challenge as TTx is transitioned into a same-day surgery. Measurement of the parathyroid hormone (PTH) level following TTx allows for prediction of postoperative hypocalcaemia, defined as symptomatic hypocalcaemia or requiring intravenous calcium (IV Ca) supplementation, and may decrease the need for routine serum calcium (Ca) monitoring and lead to shorter hospital stays. 

Methods:
After implementing a standardized calcium management protocol based on PTH measurement and routine oral Ca supplementation, a retrospective database was queried to evaluate protocol efficacy and compliance for 169 patients undergoing TTx between 2012 and 2014. This was compared to a previous time period between 2010 and 2012 where 67 patients underwent TTx.  Patient demographics, extent of surgery, post-operative laboratory values, complications, IV Ca, and length of stay were analyzed. 

Results:
Of the 169 patients undergoing TTx, transient hypocalcaemia (TH) and permanent hypocalcaemia (PH) was reported in 17 and 0 patients respectively (10.1%, 0%). PTH was recorded in 81.7% (n=138) patients with 64.5% (n=89) >10 pg/ml and 35.5% (n=49) <10 pg/ml. In 2012-2014, there was a decrease in length of stay in the PTH<10 group compared to 2010-2012 (Table 1). However, in the PTH>10 group no significant change was observed between the two time periods (Table 1). From 2012-2014, patients with PTH<10 also had fewer calcium lab draws compared to 2010-2012 (Table 1). In the PTH>10 group, 3.4% (n=3) of patients had TH. However, in the PTH<10 group, 34.69% (n=17) of patients had TH. There were three readmissions for TH and all were in patients with PTH<10. 

Conclusion:
A PTH<10 can serve as a predictor for TH and readmissions in TTx. The implementation of a single PTH measurement protocol with a standardized calcium regimen has decreased the length of stay and the number of calcium draws for patients undergoing TTx and will make TTx a more cost effective procedure. 
 

11.07 High Volume of Emergency General Surgery Cases Is Associated With Better Outcomes.

Posted on December 22, 2014

V. Pandit1, P. Rhee1, B. Zangbar1, N. Kulvatunyou1, M. Khalil1, T. O’Keeffe1, A. Tang1, D. J. Green1, G. Vercruysse1, R. S. Friese1, B. Joseph1  1University Of Arizona,Trauma/Surgery/Medicine,Tucson, AZ, USA

Introduction:
The impact of trauma center volume on patient outcomes is well established. With regionalization of emergency general surgical (EGS) care, the association between EGS case volume and patient outcomes remains unknown. The aim of this study was to evaluate the association between EGS case volume and outcomes across the centers in the United States.

Methods:
We abstracted the national estimates for EGS procedures from the National Inpatient Sample database 2011 (representing 20% of all in-patient admissions).  Patients undergoing emergent procedures (appendectomy, cholecystectomy, hernia repair, small and large bowel resections) were included. Centers were divided into two groups based on the number of EGS cases performed per year: High volume (> 350 cases) centers (HVC) and low volume (<350 cases) centers (LVC). Outcome measures were: in-hospital complications, hospital length of stay, failure to rescue rate, and mortality.  Regression analysis was performed controlling for age, gender, Charlson comorbidity index, and type of surgical procedure.

Results:
A total of 167,698 patients that underwent EGS procedures across 825 centers were included.  22.8% (n=188) centers were HVC. Patients managed in HVC had a lower complication rate (16.8% vs.17.2%; OR [95%CI]: 0.96 [0.91- 0.97], p=0.032) and a shorter hospital length of stay (5.8±4.1 vs. 6.2±5.4; OR [95%CI]: 0.95 [0.89- 0.96], p=0.041) compared to patients managed in LVC. On sub-analysis of patients with major complications (n= 4,516), HVC had a lower failure to rescue rate compared to LVC (24.8% vs.36.1%; OR [95%CI]: 0.91 [0.85- 0.96], p=0.021). There was no difference in overall mortality rate between the two groups. (2.5% vs. 2.4%; OR [95%CI]: 1.13 [0.05- 1.21], p=0.71).

Conclusion:
A volume effect relationship exists among centers managing EGS patients. High volume EGS centers have a lower complications rate and a lower failure to rescue rate compared to low volume EGS centers. Understanding the reasoning behind the volume impact in EGS cases is critical as we move forward with expanding the acute care surgery model.

11.08 Do Probiotics/Synbiotics Reduce Postoperative Sepsis in Abdominal Surgery? – A Meta-analysis

Posted on December 22, 2014

S. Arumugam1, K. Mahendraraj1, R. S. Chamberlain1  1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA

Introduction: The gastrointestinal (GI) tract is intimately linked to the development of systemic anti-inflammatory response and sepsis following surgery. GI surgery significantly disrupts the natural microbiome environment by altering nutrient metabolism and deregulating immune function. The health benefits of probiotics and synbiotics is well established in healthy adults, but their role in preventing postoperative complications including sepsis remains controversial. This meta-analysis assesses the impact of probiotics and synbiotic preparations on the incidence of postoperative sepsis in GI surgical patients.

Methods: A comprehensive search of Pub Med, Google Scholar, and Cochrane Review (1966-2014) was performed seeking all published randomized controlled clinical trials (RCTs) assessing the impact of perioperative probiotics or synbiotics in elective GI surgery. Studies were included if patients underwent GI surgery with the addition of adjunct prebiotic, probiotic, or a synbiotic therapy and a control group receiving placebo or no therapy.16 potentially eligible studies were identified, of which 4 were excluded for lack of randomization, inadequate blinding and incomplete outcome data. Only RCTs which were completed and analyzed as level 1 studies were included. The primary outcome measured was postoperative sepsis within 1 month of surgery.

Results:12 RCTs involving 815 patients were included. 327 patients received synbiotics and 83 received probiotics, while 405 patients received placebo or no therapy. Overall, there was a 41% reduction in postoperative sepsis for patients treated with either a synbiotic or probiotic compared to the control group (RR 0.59; 95% CI=0.45-0.77; p<0.001). When assessing specific treatment, there was 76% reduction in the incidence of postoperative sepsis in the probiotic group (RR-0.24 ;95% CI=0.12-0.50; p  <0.001) and a 32% reduction in sepsis in the synbiotic group compared to the control group. (RR-0.68; 95% CI, 0.51-0.92 p = 0.014).

Conclusion:
Perioperative probiotic and synbiotic therapy significantly reduces the likelihood of post-operative sepsis in elective GI surgical patients. The adoption of this strategy is encouraged to optimize gut microbiota modulation after elective GI surgery. Additional studies are required to optimize duration, dose, and types of pro- and prebiotic regimens which yield the greatest benefit.
 

11.09 Disparities In Mangement Of Patients With Colorectal Disease: Impact Of Urbanization And Specialised Care

Posted on December 22, 2014

V. Pandit1, B. Joseph1, H. Aziz1, M. Iyoob1, V. Nfonsam1  1University Of Arizona,Surgical Oncology/Surgery/Medicine,Tucson, AZ, USA

Introduction:

Disparities in the management of patients with various medical conditions is well established. Colorectal diseases continue to remain one of the most common causes for surgical intervention. The aim of this study was to assess disparities (rural versus urban) in the surgical management of patients with colorectal diseases. We hypothesized that there is no difference among rural versus urban centers in the surgical management for colorectal diseases. 

Methods:

We abstracted the national estimates for colorectal procedures from the National Inpatient Sample database 2011 (representing 20% of all in-patient admissions).  Patients undergoing procedures (abscess drainage, hemmoroidectomy, fistulectomy, and bowel resections) were included. Patients with colon cancer were excluded. Patients were divided into two groups based on location: Urban and rural. Outcome measures were: in-hospital complications, mortality, and hospital costs.  Sub-analysis of urban centers was preformed: centers with colorectal surgeons and centers without colorectal surgeons. Regression analysis was performed.

Results:

A total of 20,617 patients that underwent colorectal surgery intervention across 496 (Urban: 342, Rural: 154) centers were included. Of the urban centers, 38.3% centers had colorectal surgeons.  Patients managed in urban centers had lower complication rate (7.6% vs. 10.2%, p=0.042), shorter hospital length of stay (4.7±3.1 days vs. 5.9±3.6 days, p=0.037) with higher hospital costs (56,820±27,691 vs. 49,341±2,598, p=0.046).  On sub-analysis, patients managed in centers with colorectal surgeons had a 11% lower incidence of in-hospital complications (OR: 0.90, 95%CI: 0.74-0.94) and 7.2% (OR: 0.072, 95%CI: 0.65-0.81) shorter hospital length of stay in comparison to patients managed in urban centers without colorectal specialization. 

Conclusion:

Disparities exit in patient outcomes managed in urban verses rural centers for colorectal surgery. Specialized care with colorectal surgeons at urban centers helps to reduce adverse patient outcomes. Steps to provide effective and safe surgical care in a cost effective manner across rural as well as urban centers is warranted.

 

11.10 Is Patient Satisfaction an Accurate Predictor of Patient Outcomes?

Posted on December 22, 2014

M. Garg1, K. Hu1, C. Davian1, D. Polk1, A. Sugiyama1, E. Chin1, S. Nguyen1, S. Nguyen1, L. Zhang1, C. M. Divino1  1Icahn School Of Medicine At Mount Sinai,General Surgery,New York, NY, USA

Introduction:

Medical insurance companies and healthcare systems are increasingly adopting value-based purchasing. This practice involves shifting patient care towards high-quality providers and away from practitioners and systems with poor clinical outcomes. Patient satisfaction is commonly utilized as a metric to determine clinical quality for value-based purchasing assessments. However, the validity of patient satisfaction as a measure of clinical outcomes has yet to be properly investigated. Our study aims to find a correlation between patient outcomes and satisfaction after commonly performed general surgical procedures.

Methods:
After receiving institutional review board approval, we conducted a retrospective chart review on patients that underwent commonly performed general surgical procedures. We then collected patient satisfaction data using Short Form 12 (SF12) and Surgical Satisfaction surveys (SSQ). Using SPSS we conducted, receiver operating curves (ROCs) to see how patient satisfaction can be used to predict clinical outcomes. We used the presence of any complication to the total satisfaction scores.

Results:

A total of 80 surveys were completed. Our patient population consists of 37 (46.3%) females, 53 (66.3%) Caucasians, and 10 (12.5%) African Americans with an average age of 54.12 ± 15.5 years. Most common religious preference was Christians 24 (30%), and English is the primary language for 69 (86.3%). Median ASA is 2, average body mass index 28.16 ±9.29, 28.16 % patients suffered from hypertension. Other comorbidities in our patient population included Diabetes Mellitus 5 (6.3%), Asthma/COPD 11(13.8%), and documented psychiatric issues in 12 (15%) patients. The average length of stay in this patient population was 1.29 days ± 2.29. On ROCs we found that area under the curve for SSQ survey was 0.465 (p= 0.722), and for SF12 was 0.467 (p= 0.738). 

Conclusion:

Using two validated surveys our study found no correlation between patient satisfaction and surgical outcomes.

 

11.11 Predictors of Morbidity and Mortality in Ambulatory Surgery

Posted on December 22, 2014

D. R. Cummings1, M. Garg1, C. Divino1  1Icahn School Of Medicine At Mount Sinai,Department Of Surgery,New York, NY, USA

Introduction:

The volume of ambulatory surgical procedures is increasing on a yearly basis in the United States, exceeding an estimated 34 million outpatient surgeries in the year 2006. As the US population continues to age, the burden of surgical illness will continue to fall upon an older cohort, with an increase in attendant comorbidities and perioperative morbidity and mortality. This study seeks to elucidate patient specific risk factors for perioperative morbidity and mortality in the outpatient setting.

Methods:
A retrospective analysis of the 2011 NSQIP data was used for this study. The most frequent general surgical procedures categorized as outpatient were analyzed. Univariate analysis of demographic information, comorbidities and complications were calculated.  The outcome variables of interest were 30-day morbidity and mortality. Multivariable logistic regression analyses were performed to identify predictors of the outcome variables.

Results:
Out of 442,149 surgical procedures registered in the NSQIP 2011 database, 88,256 were included in this study.  40% of the population was male (n=35,852) and 77% Caucasian (n=67,598). The most frequently represented cases were laparoscopic cholecystectomy (n=11,451), inguinal hernia repair (n=9,936), partial mastectomy (n=5,957), umbilical hernia repair (n=5,753) and laparoscopic appendectomy (n=5,714). There were 1,924 cases with a morbid outcome and 48 deaths. The most significant predictors of morbidity were ASA class, operative time in hours, female gender, BMI (mean 29.4), and dialysis dependence (p<0.0001).  The most significant predictors of mortality were ASA class (p<0.0001), functional status (p=0.0125), male gender (0.0131), and emphysema (0.0213).

Conclusion:

This study highlights several risk factors for perioperative morbidity and mortality in the outpatient surgical setting.  More investigation is necessary to identify ways to optimize these patients for surgery. 

 

11.12 Who's Ordering the CT Anyway? Frequency of CT Scan Use in Suspected Acute Appendicitis

Posted on December 22, 2014

W. Boyan1, A. Dinallo1, B. Protyniak1, M. Farr2, M. Goldfarb1  1Monmouth Medical Center,Surgery,Long Branch, NJ, USA 2Saint George’s University,Grenada, Grenada, Grenada

Introduction: Historically, acute appendicitis has been a clinical diagnosis made primarily on the basis of history and physical findings. The typical history is onset of abdominal pain followed by anorexia and nausea. Physical exam findings include right lower quadrant tenderness. Using solely clinical and laboratory variables, the rate of negative appendectomies has been approximately 20%. With the advent of the high resolution multi-slice computed tomography (CT), the aforementioned rate is now reported to be 6-13%. However, this has led to a liberal use of imaging regardless of a convincing clinical exam. The implications of additional radiation exposure are still unclear. We sought to quantify the number of CTs obtained for patients with suspected acute appendicitis and to identify the ordering physician group.

Methods: This is a single institution retrospective chart review of all patients presenting to the emergency department with a working diagnosis of acute appendicitis between January 2011 and December 2012. Patient demographics, history of presenting illness, physical exam, whether or not a CT was obtained, and CT ordering physician were identified. CT ordering physicians were grouped into three categories: emergency medicine, surgery, and primary care. All positive CT findings were confirmed by final pathology.

Results: Two thousand five hundred patients comprised the study group. A CT was obtained in 2400 patients (96%), confirming acute appendicitis in 440 (18%). CT findings other than acute appendicitis were responsible for abdominal pain in 200 patients (8%). One thousand seven hundred and sixty patients (73%) with a negative CT for appendicitis were either discharged or admitted for supportive care.  Emergency medicine physicians accounted for the majority (75%) of those ordering CT scans.

Conclusion: Emergency medicine physicians, primary care practitioners and even surgeons have become dependent on CT scanning to diagnose acute appendicitis. Recent literature states that diagnostic imaging can significantly increase an individual’s risk of developing cancer. The majority of patients in our study with a suspected diagnosis of appendicitis underwent a CT scan and did not have appendicitis. Although CT scans may prevent unnecessary surgery, their liberal use has potentially worrisome implications of developing future malignancy

11.13 Mini-Lap With Adjunctive Care Vs. Laparoscopy for Placement of Gastric Electrical Stimulation

Posted on December 22, 2014

M. G. Hughes1, B. Cacchione1, E. Miller2, L. McElmurray2, R. Allen3, A. Stocker2, T. L. Abell2  1University Of Louisville,Surgery,Louisville, KY, USA 2University Of Louisville,Medicine,Louisville, KY, USA 3KentuckyOne Health,Anesthesiology,Louisville, KY, USA

Introduction:  We have previously shown that implant hospital length of stay (LOS) for gastric electrical stimulation (GES) implantation varies with type of surgery and peri-operative care (JSLS. 2005; 9:305-310).  We now compare outcomes for GES via mini-laparotomy with adjuctive care (MLAC) vs. laparoscopy alone (LAPA) to measure equivalency. 

Methods:  Patients were evaluated with baseline solid gastric emptying tests (GET) and underwent pre-operative temporary endoscopic GES (Am Surg 79(5):457-64) in both groups prior to permanent implant. Patients with MLAC had pre-operative transvere abdominus plane (TAP) block with bupivacaine liposome of the lower abdomen to cover the area of generator placement.  Laparotomy was typically performed through a 2.5 – 3.0 cm midline incision above the area covered by TAP block.  Retraction was provided by disposable wound protector (Alexis Wound Protractor/Retractor, Applied Medical, Racho Santa Margarita, CA) that typically lengthened the wound to approximately 4 – 5 cm.  Pain control system was placed in the pre-peritoneal abdominal wall to both sides of midline wound (On-Q Pain Buster Post-Op Pain Relief System, I-Flow LLC, Irvine, CA).  This delivered 750 cc of 0.2% ropivacaine at 10 cc/hour (approximately 3 days) and then was removed and discarded by patients after discharge.  Patients with LAPA were treated with a similar post-operative oral and intravenous analgesia regimen but no adjunctive care (TAP or pain control system). Health related quality of life (HRQOL) was measured by IDIOMS (NGM  2005; 17: 35-43) at baseline. Follow up GI symptoms were recorded at last follow up. Results were reported as median or mean ± standard deviation and were compared by Wilcoxon rank-sum test or students t-test, respectively.

Results:  39 patients (87% female, mean age 43 years) with the symptoms of gastroparesis underwent MLAC and were compared with 36 patients (92% f, mean 42 years) who had LAPA. We aimed to compare the equivalency of MLAC to LAPA approach in terms of baseline and outcome measures. Baseline GI symptom scores (for nausea, vomiting, anorexia/early satiety, bloating/distention, and abdominal pain), solid GET and HRQOL were similar between the 2 groups (p>0.05). Median implant length of stay was significantly shorter in MLAC (2.0 days) than LAPA (3.0 days; p=0.02).  Follow up GI symptoms (were equivalent in the two groups (p>0.05).  

Conclusion:  For implantation of gastric electrical stimulators in this group of patients with gastroparesis, mini-laparotomy is as effective in improving symptoms as laparoscopic implantation and can result in shorter lengths of stay when coupled with adjunctive measures to limit incision size and relieve pain.

 

11.14 Continuous versus interrupted fascial closure of midline laparotomy incisions. A meta-analysis

Posted on December 22, 2014

V. Chakravorty1,2, R. S. Chamberlain1,2,3  1Saint Barnabas Medical Center,Department Of Surgery,Livingston, NJ, USA 2St. George’s University School Of Medicine,St. George’s, St. George’s, Grenada 3New Jersey Medical School,Department Of Surgery,Newark, NJ, USA

Introduction: Although fascial closure of a midline incision is a part of nearly all abdominal operations, the “ideal” or “best” method remains controversial. Numerous randomized controlled trials (RCT) have evaluated different methods of fascial closure with regards to time required and complications, but lack of consensus leads most surgeons to be guided by experience, anecdote, and training. This meta-analysis critically analyzes all existing RCTs to establish an evidence based approach to fascial closure which limits complications (dehiscence, surgical site infection, and incisional hernia).

Method: A comprehensive search of PubMed, Google Scholar, and the Cochrane and NIH registry of clinical trials assessing continuous or interrupted fascial suture closure of a midline laparotomy was performed. Outcomes analyzed were fascial dehiscence, surgical site infection, incisional hernia development, and time required for closure.

Results: 15 studies involving 9,539 patients were identified. No significant difference in fascial dehiscence (p=0.801) or incisional hernia rates (p=0.407) were observed between continuous and interrupted fascial closure. Wound infection rates were significantly higher with continuous compared to interrupted technique (RR 1.248, CI 1.074 to1.45; p=0.004). Time required for wound closure was significantly lower with continuous (14.1 min) compared to interrupted closure (22.3 min) (Z=-4.119; p<0.001). Subgroup analysis identified that a significantly lower rate of fascial dehiscence occurred with non-absorbable suture placed in a continuous fashion (1.37%) than with interrupted absorbable suture (5.18%) (p=0.02). Subgroup analysis of wound infection and incisional hernia rates showed no significant difference between the 4 different suture techniques (absorbable/non-absorbable and continuous and interrupted).

Conclusion: Continuous fascial closure required significantly less time than interrupted suture technique. Dehiscence and incisional hernia rates were not significantly affected by suturing technique; however analysis of different suture material identified a clear advantage for continuous non-absorbable closure over interrupted absorbable closure. Delayed or non-absorbable suture material placed in a continuous fashion offers significant advantages in terms of time, dehiscence rate, and a slightly lower incisional hernia rate  (7.3% vs. 8.82%, p=NS), but a slightly higher wound infection rate (8.1% vs. 6.36%, p=NS) compared to absorbable interrupted suture. Additional studies controlling for wound classification, # of prior laparotomies, suture type/size, ASA class, and co-morbidities are required for more precise recommendations on optimal laparotomy fascial closure technique.

11.15 Preoperative Biliary Drainage for Obstructive Jaundice Does Not Improve Outcomes: A Meta-Analysis

Posted on December 22, 2014

K. Mahendraraj1, R. S. Chamberlain1,2,3  1Saint Barnabas Medical Center,Department Of Surgery,Livingston, NJ, USA 2New Jersey Medical School,Department Of Surgery,Newark, NJ, USA 3Saint George’s University,Department Of Surgery,Grenada, Grenada, Grenada

Introduction:
Preoperative biliary drainage (PBD) was initially introduced to improve the postoperative outcome in patients with obstructive jaundice caused by pancreatic head and periampullary tumors, yet its benefits remain uncertain.This meta-analysis aimed to assess the benefits and risks of routine PBD in patients with obstructive jaundice compared to immediate surgery. 

Methods:
A comprehensive search of PUBMED, Embase, and both the Cochrane and NIH Registry of Clinical Trials was conducted using the keywords ‘preoperative biliary drainage’, ‘obstructive jaundice’ and ‘randomized controlled trial (RCT)’. Citations of relevant review articles were examined. 25 potentially eligible studies were identified, of which 18 were excluded for lack of randomization, inadequate blinding and incomplete outcome data. Only RCTs which were completed and analyzed as level 1 studies were included. Data on patient recruitment, intervention and complications were extracted from the included trials and analyzed. ‘Overall’ complications were defined as those associated with PBD (including pancreatitis, bleeding and bowel perforation) in addition to postoperative complications (which included reoperation, readmissions, technical, infectious and hepatobiliary complications). The risk ratio (RR) was calculated with 95% confidence intervals. 

Results:
7 RCTs involving 548 patients with obstructive jaundice were analyzed. 279 patients (50.9%) were randomized to receive PBD while 269 patients (49.1%) proceeded directly to surgery. Overall morbidity was 30% higher in the PBD group, although this difference was not statistically significant (RR 1.3, 95% CI 0.97-1.75; p=0.08). Overall postoperative morbidity was 6% lower with PBD, but not statistically significant (RR 0.94, 95% CI 0.74-1.20; p=0.62). Overall mortality was 10% higher in the preoperative biliary drainage group, but this finding was not significant (RR 1.1, 95% CI 0.72-1.68; p=0.65). Significant heterogeneity was found among the identified trials with regard to the definition and severity of complications, as well as the precise timing of PBD.

Conclusion:
The routine use of PBD in patients with obstructive jaundice did not significantly reduce overall complication rates or perioperative mortality. Current evidence suggests routine PBD does not improve patient outcomes. Further clarification of the effects of PBD is required in large, adequately powered randomized trials with low risk of bias.
 

11.16 Identifying Risk Factors for Complications Following Ventral Hernia Repair in the Elderly Patient

Posted on December 22, 2014

E. Ohlrogge1, K. O’Connell1, T. Webb1  1Medical College Of Wisconsin,Trauma/Critical Care,Milwaukee, WI, USA

Introduction: The aging population is on the rise in the United States, and general surgeons are increasingly operating on geriatric patients for repair of ventral hernias. This study investigates the risk factors associated with complications following both laparoscopic and open ventral hernia repairs in elderly patients. Specifically, we were interested if frailty markers predicted poorer outcomes.

Methods: This is a retrospective review of patients 65 years and older who underwent ventral hernia repair at a single institution from July 1 2004 to June 1, 2014. Patient demographics, comorbidities, frailty markers, and perioperative factors were analyzed. 

Results:The cohort consisted of seventy-three patients, of which 32 (43%) were performed laparoscopically and 41 (56%) were open ventral hernia repairs. 8 (11%) were emergent cases, and only 2 (25%) of these were completed laparoscopically. Overall, 23 (31%) patients developed post-operative complications, 11 (47%) following laparoscopic repairs and 12 (52%) following open repairs. The most common complications were urinary tract infections, wound complications, and early post-operative small bowel obstructions. Frailty markers were not associated with post operative complications; however, a history of heart disease (p=0.04), obesity (p=0.04), and prior percutaneous coronary intervention PCI (p=0.05) did predict complications. There were no deaths in the post-operative period.

Conclusion:This study suggests that laparoscopic ventral hernia repair in elderly patients is at least as safe as the traditional open approach and complications are common with either approach. Furthermore, history of heart disease, obesity, and PCI, but not currently used frailty markers predispose aging patients to post-operative complications following either laparoscopic or open ventral hernia repair. 

 

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