78.06 Colon vs Rectal Surgery: A Comparison of Outcomes.

Posted on January 18, 2016

S. Groene1, C. Chandrasekera1, T. Prasad1, A. Lincourt1, B. T. Heniford1, V. Augenstein1 1Carolinas Medical Center,Division Of Gastrointestinal And Minimally Invasive Surgery,Charlotte, NC, USA

Introduction: Rectal resections are considered a challenging part of colorectal surgery due to anatomy and difficulties in obtaining critical views and angles during anastomoses. For this reason, it is felt that there is an increased risk of post-operative complications with rectal resections compared to only colon resections. The aim of this study was to compare outcomes of patients who underwent rectal resections versus colon resections.

Methods: Review of the Carolinas Medical Center (CMC) NSQIP data for colorectal resections performed from 2013 to 2015 was conducted. Procedures were categorized as rectal vs colon based on CPT codes. Demographics, pre-operative co-morbidities, minor and major complications were evaluated using standard statistical methods.

Results: There were 637 patients in the sample; 219 patients underwent rectal resections and 418 colon resections. Patients undergoing rectal resections were younger (58.9±12.2 vs 61.7±15; p=0.001) with no differences in BMI, gender or race. Those undergoing rectal resections had lower rates of diabetes (11.4% vs 19.4%; p=0.04), COPD (3.2% vs 7.9%; p=0.02), and fewer emergent cases (3.6% vs 15.8%; p<0.001). Pre-operatively, they had lower ventilator use (1.4% vs 5%; p=0.03), transfusions (1.8% vs 8.8%; p<0.001) and sepsis (2.3% vs 10.3%; p<0.001). Rectal resections were more often done laparoscopically (78.3% vs 59.6%; p<0.001). Post-operatively, those undergoing rectal resections had lower rates of pneumonia (PNA) (0.5 vs 2.9%; p=0.04), transfusions (12.3 vs 22%; p=0.003), sepsis (5% vs 10.5%; p=0.02), decreased 30 day mortality rate (1.4% vs 5.3%; p=0.02) and a shorter length of stay (8.7±8.3d vs 10.2±9.5d; p=0.02). After controlling for pre-op ventilator use and COPD, multivariate analysis (MV) indicated no significant difference in post-op PNA between the 2 groups. After controlling for pre-op transfusions and sepsis, MV analysis indicated no significant difference in post-op transfusions between the 2 groups. After controlling for pre-op sepsis, emergent case status and ASA class, MV analysis indicated no significant differences in post-op sepsis, 30 day mortality or LOS between the 2 groups. There were no significant differences in post-operative surgical site infections, deep infections, UTIs, cardiac or renal disease, DVTs/PEs, anastomotic leaks, unplanned returns to the OR, and death after 30 days between the 2 groups.

Conclusion: Patients undergoing rectal resections had fewer co-morbidities, underwent more laparoscopic and fewer emergent cases. They had fewer post-operative complications upon initial review of the data, though after controlling for ASA, pre-op sepsis and transfusions, emergent status and COPD, there were no significant differences between the groups. Rectal resections and colon resections appear to carry a similar risk of complications.

78.07 Effect of SCIP Guidelines on Outcomes of Colorectal Patients.

Posted on January 18, 2016

S. Groene1, C. Chandrasekera1, T. Prasad1, A. Lincourt1, B. T. Heniford1, V. Augenstein1 1Carolinas Medical Center,Division Of Gastrointestinal And Minimally Invasive Surgery,Charlotte, NC, USA

Introduction: The Surgical Care Improvement Project (SCIP) was instituted as a means to improve outcomes after surgery. One specific area of intended improvement was post-operative surgical site infections (SSI). The aim of this study was to compare the outcomes in colorectal patients who received antibiotics per SCIP guidelines versus those that did not.

Methods: A list of 44 patients at our institution where SCIP antibiotic measures were not followed between 2012-2014 was obtained. Twelve of these patients were in our NSQIP database and we used the results from NSQIP to determine demographics, pre-op co-morbidities and post-op outcomes. For the other 32 patients, a chart review was conducted to determine similar variables. We also excluded any NSQIP patients with sepsis or dirty wounds as they met SCIP exclusion criteria. Standard statistical methods were used to compare the data for the 44 non-compliant patients to the remaining SCIP-compliant patients in the NSQIP database.

Results: There were 563 patients in the sample and 44 did not receive antibiotics per SCIP guidelines. Of these 44 patients, 3 did not receive SCIP appropriate pre-op dosing of antibiotics within 1 hour of incision, 25 did not receive the SCIP appropriate antibiotic and 16 were non-compliant with post-op antibiotic duration. There were no significant differences between the groups in age, BMI, race, gender, hypertension, heart failure, ASA class, or ventilator use. There were no significant differences in superficial SSI, deep incisional SSI, organ space infection, pneumonia, UTIs, DVT/PEs, MIs, post-op transfusions or sepsis, unplanned return to the OR, 30 day mortality or length of stay between the 2 groups. Those in the non-adherent group had higher rates of pre-op diabetes (27.3% vs 15%; p=0.03), COPD (15.9% vs 5.2%; p=0.003) and pre-op renal failure (9.1% vs 0.2%; p<0.001). Post-operatively, those who were not SCIP adherent had higher rates of acute renal failure (6.8% vs 0.2%; p=0.002), unplanned intubations (9.1% vs 2.1%; p=0.02) and deaths after 30 days (4.6% vs 0.4%; p=0.03).

Conclusion: Overall, colorectal patients who were non-compliant with SCIP antibiotic measures had higher rates of diabetes, COPD and pre-op renal failure. They also had higher rates of post-op renal failure, unplanned intubations and death after 30 days. However, there were no differences in infectious outcomes between the groups, which may suggest that SCIP non-compliance with antibiotic measures may not lead to clinically significant differences in infectious outcomes.

68.08 Comparing Outcomes Following Colorectal Surgery in Patients with and without Diverticulitis.

Posted on January 18, 2016

S. Groene1, C. Chandrasekera1, T. Prasad1, A. Lincourt1, B. T. Heniford1, V. Augenstein1 1Carolinas Medical Center,Division Of Gastrointestinal And Minimally Invasive Surgery,Charlotte, NC, USA

Introduction: Colorectal diverticular disease occurs in about 3% of the population and at times it can result in significant complications such as perforations, abscesses or fistulae. Surgery is recommended for most complicated cases of diverticulitis. The aim of this study was to compare outcomes of patients with and without diverticular disease following colorectal surgery.

Methods: Review of the Carolinas Medical Center (CMC) NSQIP data for colorectal procedures performed from 2013 to 2015 was conducted. Patients were considered to have or had had diverticulitis based upon ICD-9 codes (562.11, 562.13). Demographics, pre-operative co-morbidities, minor and major complications were evaluated using standard statistical methods.

Results: There were 637 patients in the sample; 109 patients had the diagnosis of diverticulitis, 528 with other diagnoses, including neoplasms (63.2%), IBD (2.7%), infectious disease (3.2%), ischemia (4.7%) and obstruction (6.1%). There were no significant differences between the groups in terms of age, race, gender or other medical co-morbidities. Those with diverticulitis underwent laparoscopic surgery more often (75.2% vs 63.5%; p=0.02) than those with other diagnoses. However, those without the diagnosis of diverticulitis tended to have a higher rate of pre-operative steroid use (8.9% vs 1.8%; p=0.01), a higher rate of pre-operative transfusions (7.4% vs 1.8%; p=0.03) and a greater chance of pre-operative weight loss of ≥ 10 pounds (5.5% vs 0.9%; p=0.04). The proportion of emergent cases were similar between the 2 groups (10.1% vs 11.3%; p=0.59). Those with the diagnosis of diverticulitis had a lower rate of post-operative transfusions (3.7% vs 21.8%; p<0.001) and a shorter post-operative length of stay (6.7±5d vs 10.3±9.6d; p<0.001). After controlling for pre-op transfusions, ASA class and pre-op sepsis, multivariate analysis indicated patients with diverticulitis required fewer post-op transfusions with OR 0.17 (95% CI 0.06, 0.49) and had a shorter LOS (adjusted mean13.4d vs 15.3d; p=0.02). There were no significant differences in post-operative surgical site infections, pneumonia, UTIs, sepsis, anastomotic leaks, unplanned returns to the OR, cardiac or renal disease, DVTs/PEs and 30 day mortality between the 2 groups.

Conclusion: Patients with and without diverticulitis had similar demographic characteristics and pre-operative co-morbidities. Those with diverticulitis required fewer transfusions, both pre and post-operatively. They also had a shorter length of stay and did not require more emergent surgeries compared to those without diverticulitis. Surgery, including laparoscopy, can be performed on those with colorectal diverticular disease with similar outcomes to those requiring surgery for other reasons.

68.05 Comparison of Outcomes in Colorectal Resections Based on Surgical Technique.

Posted on January 18, 2016

S. Groene1, C. Chandrasekera1, T. Prasad1, A. Lincourt1, B. T. Heniford1, V. Augenstein1 1Carolinas Medical Center,Division Of Gastrointestinal And Minimally Invasive Surgery,Charlotte, NC, USA

Introduction: Laparoscopy has become a common technique for many colorectal resections. Robotic-assisted colorectal surgery is also gaining traction. The aim of this study was to compare outcomes following colorectal resections based on surgical technique.

Methods: Review of the Carolinas Medical Center (CMC) NSQIP data for colorectal resections performed from 2013 to 2015 was conducted. Data were classified as open (O), laparoscopic (L) and robot-assisted (R) cases based on CPT codes and chart review. Demographics, pre-operative co-morbidities, minor and major complications were evaluated using standard statistical methods.

Results: There were 616 patients: 371 in L, 212 in O and 33 in R groups. There were no differences in age, BMI, race or gender. The groups differed in rates of pre-op sepsis (20.8% vs 0.8% vs 0% for O, L and R, respectively; p<0.001), contaminated wounds (53.3% vs 11.9% vs 3%; p<0.001), ASA class 4-5 (29.7% vs 8.7% vs 0%; p<0.001), emergent cases (31.1% vs 1.9% vs 0%; p<0.001), smokers (25.9 vs 15.6 vs 15.2; p=0.001), pre-op ventilator use (11.3% vs 0% vs 0%; p<0.001), and pre-op transfusions (12.7% vs 3.2% vs 0%; p<0.001). Also, there was a significant difference among the groups in post-op transfusions (34% vs 10.2% vs 3%; p<0.001), superficial SSI (9% vs 4.9% vs 0%; p=0.05), post-op patients on ventilators at 48 hours (18.4% vs 1.1% vs 3%; p<0.001) acute renal failure (1.9% vs 0% vs 3%; p=0.001), UTI (9% vs 4% vs 0%; p=0.02), DVTs (3.8% vs 0.8% vs 0; p=0.04), 30 day mortality (10.4% vs 0.5% vs 0%; p<0.001), post-op sepsis (17% vs 4% vs 6.1%; p<0.001) and LOS (13.2±10.1 vs 7.4±7.3 vs 8.7±8.6d; p<0.001). After controlling for wound and ASA class and pre-op sepsis, multivariate analysis indicated that O cases had significantly higher rates of superficial SSI [OR 0.5 (95% CI 0.2,0.9)], organ space infection [OR 0.2 (95%CI 0.07,0.5)], post-op transfusions [OR 0.5(95%CI 0.3,0.8)] post-op ventilator use [OR0.3 (95%CI 0.7,0.8)], sepsis [OR0.4 (95%CI 0.2,0.8)] and LOS (p<0.001) compared to L cases. There was not a significant difference in anastomotic leaks among the groups.

Conclusion: Patients who undergo open colorectal resections are sicker and have more post-operative complications, even when controlling for ASA, wound classification and pre-op sepsis. Laparoscopic and robotic colorectal resections have similar outcomes.

67.09 Crohns Disease: Comparing Outcomes Following Colorectal Surgery.

Posted on January 18, 2016

S. Groene1, C. Chandrasekera1, T. Prasad1, A. Lincourt1, B. T. Heniford1, V. Augenstein1 1Carolinas Medical Center,Division Of Gastrointestinal And Minimally Invasive Surgery,Charlotte, NC, USA

Introduction: Given the pathophysiology of Crohns disease as well as the fact that patients undergoing surgery are often immunosuppressed, it is often felt that there are more adverse outcomes for patients with Crohns disease who undergo colorectal resections compared to those without the disease. The aim of this study was to compare outcomes of patients with and without Crohns disease following colorectal resections.

Methods: Review of the Carolinas Medical Center (CMC) NSQIP data for colorectal procedures performed from 2013 to 2015 was conducted. Patients were classified as having Crohns disease (CD) based upon ICD-9 codes (555.9, 555.2, 555.1). Demographics, pre-operative co-morbidities, minor and major complications were evaluated using standard statistical methods.

Results: There were 637 patients in the sample; 23 patients with the diagnosis of CD and 614 without CD. Mean age was 37.3±15.2 vs 61.2±13.4 (p<0.001) and the mean BMI was 23±6.2 vs 28.6±7.6 (p<0.001) for those with and without CD, respectfully. Those with CD were more likely to have a pre-operative weight loss of ≥10 pounds (17.4% vs 4.3%; p=0.02) and use pre-operative steroids (56.5% vs 5.9%; p<0.001). Those without CD had a higher rate of pre-operative hypertension (54.4% vs 8.7%; p<0.001). Post-operatively, patients with CD had a higher rate of wound disruptions (8.7% vs 0.7%; p=0.02). There were no significant differences in post-operative surgical site infections, pneumonia, UTIs, sepsis, anastomotic leaks, unplanned returns to the OR, cardiac or renal disease, length of stay and 30 day mortality between those with and without CD.

Conclusion: Patients with Crohns disease tended to be younger and leaner than those who underwent surgery without the disease. Furthermore, they had more pre-operative weight loss and used steroids. Although patients with CD had more post-operative wound disruptions, colorectal resections can be undertaken without otherwise-significantly increased risks.

67.02 The Perception of Diminished Surgical Outcomes Elderly Patients – Is it Really Age Related?

Posted on January 18, 2016

S. Groene1, C. Chandrasekera1, T. Prasad1, A. Lincourt1, B. T. Heniford1, V. Augenstein1 1Carolinas Medical Center,Division Of Gastrointestinal And Minimally Invasive Surgery,Charlotte, NC, USA

Introduction: The general belief concerning elderly patients undergoing surgery is that they are at higher risk for post-operative complications than their younger counterparts. Few studies, however, differentiate age from the associated co-morbidities of aging. The aim of this study was to compare outcomes of patients undergoing colorectal resection stratified by age.

Methods: An extensive review for colorectal procedures performed from 2013 to 2015 at a single institution was conducted utilizing a NSQIP database. Patients who were ≤60 years old were compared to those who were ≥75 years old. Demographics, pre-operative co-morbidities, minor and major complications, and mortality were evaluated using standard statistical methods.

Results: Over the 2 years, 373 patients qualified for the study; 278 were ≤60 years, and 95 were ≥75 years. Mean age for the younger group was 47.8±9.7 vs 80.8±4.4 for the older group. BMI was 28.8±8.3 vs 25.6±4.5 (p=0.003), respectively. Both groups were similar in gender and race. The older patients tended to be more hypertensive (72.6% vs 33.8%; p<0.001) with higher rates of diabetes (22.1% vs 8.6%; p<0.001) and COPD (14.7% vs 1.8%). In the older group, 81.1% were ASA class 3-4 vs 45% in the younger group (p<0.001). The younger group had a higher rate of smokers (26.3% vs 7.4%; p<0.001). There was no difference in the percentage of laparoscopic cases; however, the older group underwent more right-sided colectomies (55.7% vs 31.2%; p<0.001) and more emergent cases (16.8% vs 8.6%; p=0.03). The older group required more post-operative transfusions (24.2% vs 13.7%; p=0.02), had a higher rate of 30 day mortality (6.3% vs 1.1%; p=0.01) and had a longer post-operative length of stay (11.7±8.4 days vs 9.5±9.6 days; p<0.001). However, after controlling for ASA class and emergent surgery status, multivariate analysis indicated that there were no significant differences between the older or younger groups in terms of post-op transfusions or LOS. Given the low incidence of deaths (N=9), MV analysis was not feasible for this outcome. There were no differences in post-operative surgical site infections, pneumonia, urinary tract infection, myocardial infarction, renal failure, DVT/PE, unplanned intubations, anastomotic leak, unplanned return to the OR and mortality after 30 days between older and younger patients.

Conclusion: Patients who were ≥75 years old had a higher prevalence of pre-operative co-morbidities and required more emergent operations. After controlling for ASA class and emergent status, there was no significant difference in outcomes between patients ≤60 years old or those ≥75 years old. The perception of increased risk of surgery associated with elderly patients appears to related to their pre-op comorbidities rather than their age.

36.10 Prospective, Randomized, Controlled, Blinded Trial: ICG Angiography In Abdominal Wall Reconstruction

Posted on January 18, 2016

C. R. Huntington1, B. A. Wormer1, S. W. Ross1, P. D. Colavita1, T. Prasad1, A. E. Lincourt1, I. Belyansky2, S. B. Getz1, B. T. Heniford1, V. A. Augenstein1 1Carolinas Medical Center,Charlotte, NC, USA 2Anne Arundel Medical Center,Annapolis, MD, USA

Introduction: Indocynanine green angiography (ICG-A) has been utilized to measure tissue perfusion during surgical reconstruction procedures and intestinal anastomosis, despite a lack of high quality evidence to support its use. While unsubstantiated, ICG-A has also been proposed to reduce complications in abdominal wall reconstruction (AWR). Two tertiary referral hernia centers conducted a prospective, randomized, controlled, blinded trial to investigate the utility of ICG-A in reducing wound complications in complex AWR.

Methods: After IRB approval, all consented patients underwent ICG-A utilizing the SPY Elite deviceTM prior to flap/skin closure after AWR. In the control group, both the Hernia Surgeon and Plastic Surgeon were blinded to ICG-A images. In the experimental group, the surgery team viewed the images and modified tissue flaps if warranted. ICG-A videos were saved and reviewed by independent, blinded surgeons to ensure correct interpretation. Outcomes included medical, surgical and wound complications and reoperation over 3 months. Groups were compared with Chi square and Wilcoxon rank sum analysis.

Results: Among 95 patients, n=49 control and n=46 experimental, preoperative characteristics were similar: age (58.3vs.56.7years,p=0.4), BMI (34.9vs. 33.6kg/m2,p=0.8), tobacco use (8.2%vs. 8.7%,p=0.9), diabetes (30.6%vs.37.0%,p=0.5), and previous hernia repair (71.4%vs.60.9%,p=0.3). The mean hernia defect was 293cm2 and mesh size 1033cm2. Operative characteristics were also equivalent, including rate of panniculectomy (69.4% vs. 58.7%,p=0.3), component separation (73.5%vs. 69.6%,p=0.6), estimated blood loss (160vs.180mL,p=0.4) and mean operative time (204vs.217minutes,p=0.4). The experimental group was more likely to have skin and subcutaneous flaps modified (37%vs.4.1%,p<0.0001). However, there was no significant difference between control vs. experimental groups in wound infection (10.2%vs.21.7%,p=0.12), skin necrosis (6.1% vs. 2.2%,p=0.3), fat necrosis (10.2% vs. 13.0%,p=0.7), overall wound-related complications (32.7% vs. 37.0%,p=0.7), reoperation rates (14.3%vs. 26.1%,p=0.7), or long-term hernia recurrence (4.1% vs. 2.2%,p=0.6) with mean follow-up of 8.3 months. When limited to significantly at-risk patients (obese, diabetic, concomitant component separation, or panniculectomy), there was no significant difference in wound-related complications between groups. Patients with hypoperfusion on ICG-A (below a threshold of 10 units) had higher rates of wound infection (28%vs.9.4%,p<0.02), however flap modification after viewing images did not improve wound-related complications in these patients (15.6%vs.12.5%,p=0.99).

Conclusion: Though intra-operative ICG-A use during complex AWR may aid in identifying patients at risk of wound infection, it did not decrease wound-related complications or reoperation rates in complex abdominal wall reconstruction. The use of ICG-A in complex AWR is not warrented in ventral hernia repair.

22.08 Prospective, Randomized, Controlled, Blinded Trial: ICG Angiography In Abdominal Wall Reconstruction

Posted on January 18, 2016

C. R. Huntington1, B. A. Wormer1, S. W. Ross1, P. D. Colavita1, T. Prasad1, A. E. Lincourt1, I. Belyansky2, S. B. Getz1, B. T. Heniford1, V. A. Augenstein1 1Carolinas Medical Center,Charlotte, NC, USA 2Anne Arundel Medical Center,Annapolis, MD, USA

Introduction: Indocynanine green angiography (ICG-A) has been utilized to measure tissue perfusion during surgical reconstruction procedures and intestinal anastomosis, despite a lack of high quality evidence to support its use. While unsubstantiated, ICG-A has also been proposed to reduce complications in abdominal wall reconstruction (AWR). Two tertiary referral hernia centers conducted a prospective, randomized, controlled, blinded trial to investigate the utility of ICG-A in reducing wound complications in complex AWR.

Methods: After IRB approval, all consented patients underwent ICG-A utilizing the SPY Elite deviceTM prior to flap/skin closure after AWR. In the control group, both the Hernia Surgeon and Plastic Surgeon were blinded to ICG-A images. In the experimental group, the surgery team viewed the images and modified tissue flaps if warranted. ICG-A videos were saved and reviewed by independent, blinded surgeons to ensure correct interpretation. Outcomes included medical, surgical and wound complications and reoperation over 3 months. Groups were compared with Chi square and Wilcoxon rank sum analysis.

Results: Among 95 patients, n=49 control and n=46 experimental, preoperative characteristics were similar: age (58.3vs.56.7years,p=0.4), BMI (34.9vs. 33.6kg/m2,p=0.8), tobacco use (8.2%vs. 8.7%,p=0.9), diabetes (30.6%vs.37.0%,p=0.5), and previous hernia repair (71.4%vs.60.9%,p=0.3). The mean hernia defect was 293cm2 and mesh size 1033cm2. Operative characteristics were also equivalent, including rate of panniculectomy (69.4% vs. 58.7%,p=0.3), component separation (73.5%vs. 69.6%,p=0.6), estimated blood loss (160vs.180mL,p=0.4) and mean operative time (204vs.217minutes,p=0.4). The experimental group was more likely to have skin and subcutaneous flaps modified (37%vs.4.1%,p<0.0001). However, there was no significant difference between control vs. experimental groups in wound infection (10.2%vs.21.7%,p=0.12), skin necrosis (6.1% vs. 2.2%,p=0.3), fat necrosis (10.2% vs. 13.0%,p=0.7), overall wound-related complications (32.7% vs. 37.0%,p=0.7), reoperation rates (14.3%vs. 26.1%,p=0.7), or long-term hernia recurrence (4.1% vs. 2.2%,p=0.6) with mean follow-up of 8.3 months. When limited to significantly at-risk patients (obese, diabetic, concomitant component separation, or panniculectomy), there was no significant difference in wound-related complications between groups. Patients with hypoperfusion on ICG-A (below a threshold of 10 units) had higher rates of wound infection (28%vs.9.4%,p<0.02), however flap modification after viewing images did not improve wound-related complications in these patients (15.6%vs.12.5%,p=0.99).

Conclusion: Though intra-operative ICG-A use during complex AWR may aid in identifying patients at risk of wound infection, it did not decrease wound-related complications or reoperation rates in complex abdominal wall reconstruction. The use of ICG-A in complex AWR is not warrented in ventral hernia repair.