92.08 Quality of Life of in Geriatric Patients after Cholecystectomy

Posted on January 31, 2019

A. Z. Agathis1, J. J. Aalberg1, C. M. Divino1  1Mount Sinai School Of Medicine,New York, NY, USA

Introduction:  Gallbladder disease remains the most common cause of acute abdominal pain in older populations. Despite current recommendations, elderly patients undergo cholecystectomy procedure at lower rates. While literature demonstrates a relatively higher incidence of morbidity and mortality, the procedure is shown to be safe in older patients. However, few studies to date describe quality of life after cholecystectomy in elderly patients, and none within the American population. This study examines quality of life in geriatric patients after cholecystectomy.

Methods:  Patients ≥  65 years of age who underwent laparoscopic cholecystectomy at a single academic hospital were administered the 12-Item Short Form Survey (SF-12) and a gastrointestinal-specific survey. The surveys were administered pre-operatively (visit type 0) and post-operatively at two time points, once within 6 months and another within 18 months (visit type 1 and 2). A mixed model was used for statistical analysis. Pain severity, pain frequency, the SF-12 aggregate physical functioning score, and the SF-12 aggregate mental health score were compared amongst visit types using Wilcoxon tests in a univariate and multivariate setting. 

Results: The study population included n = 23 patients. In the multivariate analysis, visit type was significantly correlated with pain severity, pain frequency, and the SF-12 mental health aggregate score. Specifically, pain frequency improved from visit type 0 to 1 by a difference of 1.182 (p = 0.017) and from 0 to 2 by a difference of 1.424 (p = 0.018) on a scale of 1-5 (increasing frequency), but not significantly from visit type 1 to 2 (p > 0.05). Pain severity improved from visit 0 to 2 by a difference of 1.512 (p = 0.004) on a scale of 1-5 (increasing severity), but improvement was not statistically significant from visit 0 to 1 or from visit 1 to 2. The SF-12 mental health aggregate score worsened from visit 1 to 2 by a score of -6.015 (p = 0.014) of 100, with no other statistically significant differences in between visit types 0 and 1 and visit 0 and 2. The SF-12 physical aggregate was not found to be correlated with the visit type. 

Conclusion: Our results indicate that lifestyle in geriatric patients improves after cholecystectomy. The most progress is observed in relation to abdominal pain frequency and severity, specifically between pre-operative and the first research follow-up, as well as between pre-operative and second research follow-up. However, the SF-12 indicated an overall decrease in mental health from pre-operative to second research follow-up.
 

50.20 The Prognostic Value of CT Angiography in Endoscopic Intervention of Acute Lower GI Bleeds

Posted on January 31, 2019

A. Zhong1, C. Divino1  1Mount Sinai School Of Medicine,General Surgery,New York, NY, USA

Introduction:
Diagnostic modalities for lower gastrointestinal bleeds (LGIB) include endoscopy, mesenteric angiography, capsule endoscopy, nuclear RBC scans, and most recently CT angiography (CTA). The advantages of CTA include a sensitivity and specificity of 98.4% and 93.3%, visualization of the entire abdomen, and expediency. There are no clear guidelines to help providers decide on which diagnostic or interventional modality is optimal for their patient with a LGIB, often leading to confusion and unnecessary invasive workup. We propose that CTA’s can safely be used as an initial diagnostic modality in guiding intervention, specifically endoscopy, in acute LGIB’s.

Methods:
A single-institution retrospective chart review was performed of a cohort of patients who had procedure codes for endoscopy, abdominal CT angiography, and an ICD code for lower GI bleed over a period of 18 years (2000-2018).

Results:
185 patients were identified into the cohort. 51 of those patients had a CTA to diagnose an acute LGIB. A total of 69 CTA’s were performed in those 51 patients. 27/69 CTA’s had a subsequent endoscopic intervention. 22/27 CTA’s were negative for intraluminal contrast extravasation on arterial or venous phase, and 5 were positive. 17/22 (77.3%) negative CTA’s had subsequent diagnostically negative endoscopic procedures. 18/22 (81.8%) negative CTA’s had subsequent endoscopic procedures that resulted in unsuccessful intervention. Out of the 69 CTA’s, only 2 resulted in an AKI in dialysis dependent ESRD patients. No patients required surgical intervention. There were no mortalities.

Conclusion:
CTA should be the universal initial diagnostic modality in a patient with an acute LGIB when they present to an inpatient setting. It is fast, safe, and effective in identifying bleeds and potential sources. CTA’s can result within hours of presentation, have a better adverse event profile than other modalities, and have the highest sensitivity and specificity of all modalities. CTA’s have been shown to predict mesenteric angiographical diagnosis and intervention. A negative CTA is predictive of a negative endoscopic intervention, signifying that not all LIGB’s require additional attempts at diagnosis or intervention. A negative CTA can predict that a patient with a LGIB can be safely observed with transfusions as necessary. The results of the CTA should be used to guide clinical decision making in order avoid unnecessary work up, waste of healthcare resources, and potential risk from additional procedures.
 

19.13 Integration of Interactive Quiz Technology into Modern Surgical Education

Posted on January 31, 2019

D. Dolan1, J. Aalberg2, C. Divino1  1The Mount Sinai Hospital,General Surgery,New York, NEW YORK, USA 2Tufts University School of Medicine,School Of Medicine,Boston, MA, USA

Introduction:
The didactic lecture style used to teach residents hasn’t significantly changed since the beginning of the 20th century. Only in the last 20 years has problem-based learning begun to accompany lectures. Previously, questions were asked via PowerPoint© and Personal Digital Assistants (PDAs) during lectures. Now digital applications (apps) on smartphones have replaced PDAs. One example of an app is PollEverywhere© which allows audience response to questions, surveys, and images posted by the presenter. The presenter can then assess learners’ understanding and address problem areas. By using the app with the lectures given during surgical education, it was hypothesized that both subjective satisfaction with learning and objective scores on the American Board of Surgery In-Training Exam (ABSITE) would increase.

Methods:
The 31 categorical surgery residents at the Icahn School of Medicine of postgraduate year (PGY) 2 or higher in January 2017 were eligible to participate. PollEverywhere© was used to ask quiz questions in large group lectures from Fall 2016 to the 2017 ABSITE. After IRB approval and individual consent was obtained, the residents were surveyed before and after the 2017 ABSITE and data on previous test performance acquired including all ABSITE raw, calculated out of 800 total points, and percentile scores. Satisfaction score and raw score changes were then calculated.

Results:

19 of 31 residents (61%) completed the pre- and post-ABSITE surveys. 53% believed using the app contributed to their learning. 74% were satisfied with the current way the app was used. 84% were interested in continuing to use the app in the next academic year. ABSITE raw score change before PollEverywhere© in 2015-2016 was determined for each PGY level and then compared to the raw score change of the same PGY level from 2016-2017 to measure the app's effect. After PollEverywhere©, raw scores improved in the PGY 1-2 and 2-3 groups but this was not noted to be statistically significant (Table 1). Previous test performance, sleep prior to exam, and difficulty of rotation were not found to be modifying propensity factors.

Conclusion:

Most residents were satisfied with PollEverywhere© and believed it contributed to their learning. The ABSITE cannot test all concepts taught within the academic year and so sample error of the test itself will change the score changes seen. Despite this, scores generally improved with use of the app. This study lacked statistical power due to sample size. Further work is needed with a larger sample to determine statistical significance, refine how to better implement the technology to improve satisfaction and scores, and determine any propensity modifying factors.

09.12 Clinical Significance of Multifocal Primary Tumors in Small Bowel Neuroendorcrine Tumors

Posted on January 31, 2019

T. Khan1, S. Kelly1, J. Aalberg1, C. Divino1  1Mount Sinai School Of Medicine,Surgery,New York, NY, USA

Introduction: Multifocal primary tumors are known to occur in up to 30% of cases of small bowel neuroendocrine tumors. The clinical significance of multifocal disease remains to be established. Existing retrospective studies suggest that patients with multifocal disease are younger at time of diagnosis, have higher likelihood of experiencing carcinoid syndrome, have worse prognosis and/or disease burden at 36 months, and have shorter disease free survival. This study aims to contribute to the understanding of multifocal disease by presenting our experience with this phenomenon at a single academic medical center.  

Methods: Retrospective review of medical records of patients undergoing surgical resection of small bowel neuroendocrine tumor and with complete pathology reports between 2012 and 2017 at an urban, academic medical center with a dedicated center for neuroendocrine tumor management (The Mount Sinai Hospital, NY) was performed. Patients with multifocal disease were compared to those with single primary tumors.

Results: Data was abstracted from 62 patients. Multifocal disease was seen in 39% of patients. Patients with multifocal disease were of the same age as patients with single primary at time of diagnosis (59.5 vs 59.8 years) and surgical intervention (60.3 vs. 60.6 years). Abdominal pain, diarrhea, and carcinoid syndrome were the most common clinical symptoms in both groups. Interestingly, multifocal disease tended to be well differentiated and have lower Ki67 index. The average size of the primary tumor was similar in both groups (2.4 +/- 1.6 vs. 1.8 +/- 0.9 cm for multifocal vs. single primary). Finally, overall survival at the end of our study period was similar in both groups (79% vs 82%).

Conclusion: The prevalence of multifocal disease was higher at our institution/series than previously reported. No differences in the clinico-pathological features between multifocal and single disease were identified; however, the statistical significance of our findings is limited by small sample size.

06.20 Outcomes After Operative Management Of Anastomotic Leaks

Posted on January 31, 2019

S. Trinidad1, S. Haile2, S. Kelly2, H. Prince1, C. Divino1  1Mount Sinai Hospital,Surgery,New York, NY, USA 2Icahn School of Medicine at Mount Sinai,New York, NY, USA

Introduction:   Anastomotic leaks (AL) remain a highly morbid complication of colorectal surgery. This study sought to evaluate and compare outcomes between the two main operative approaches to AL: proximal diversion with loop ileostomy or anastomotic takedown with an end ostomy.

Methods:  A retrospective observational study was conducted on 79 patients presenting to the Mount Sinai Hospital between January 2009 and July 2016 who had an AL following ileocolic or colorectal surgery who were managed with either proximal diversion (n=50) or resection and end ostomy (n=29). Patient charts were data-mined for preoperative, operative and post-operative factors. Patients were followed for at least 6 months with a median of 2.5 years. Factors were compared with chi-square and t-test analyses.

Results:  The diverted group had a higher percentage of patients with a history of cancer (58% vs 31%, p=0.021) and though not statistically significant a seemingly higher percentage of pelvic anastomosis (84% vs 55%, p=0.086) and a higher rate of laparoscopic approach (70% vs 38%, p=0.055) while the end ostomy group seemed to have a higher percentage of patients with a history of IBD (55% vs 34%, p=0.066). Regarding outcomes, the mortality rate was seemingly higher in the end ostomy group (8% vs 2%, p=0.235) but this was not statistically significant and limited by small sample size (n =2 and 1 respectively). The diverted group had a shorter median LOS (14 vs 22 days, p<0.000). Though not statistically significant, the diverted group had a higher reversal rate (80% vs 65%, p=0.15) but also had a higher rate of stricture formation (12% vs 0%, p=0.052),) and higher rate of dehydration (8% vs 4%, p=0.12). The rates of SSI, recurrent abscess and reoperation were similar between the groups.

Conclusion:  Several preoperative factors were associated with which operation was ultimately chosen, particularly the location of the anastomosis and a history of cancer and IBD. There also seemed to be a difference in the approach to each operation, with a higher rate of laparoscopy in the proximal diversion group. Lastly, there were several notable differences in outcomes. Patients undergoing diversion had a shorter LOS and though only approaching statistical significance, also seemed to have a greater likelihood of reversal but higher rates of stricture formation and dehydration. These results are limited by the small sample size but nevertheless demonstrate key differences in outcomes between the two groups that can help guide operative management of AL.