92.15 Satistfaction with Sedation in Colonoscopy: A Systematic Review and Meta-Analysis

Posted on January 18, 2018

F. Dossa1, B. Medeiros2, S. A. Acuna1, N. N. Baxter1  1University Of Toronto,Division Of General Surgery,Toronto, ON, Canada 2Western University,Department Of Biology,London, ON, Canada

Introduction:
The use of propofol for sedation in colonoscopy adds considerable expense to the procedure. Proponents of propofol defend its use through claims of increased patient and endoscopist satisfaction and greater procedural efficiency; however, these outcomes have not been formally compared between propofol and the commonly used alternative combination of midazolam/fentanyl. We aimed to compare satisfaction and efficiency outcomes between these agents.

Methods:
We systematically searched MEDLINE, Embase, and the Cochrane Library (to March 28, 2017) to identify randomized controlled trials comparing outcomes between propofol +/- short-acting opioids (fentanyl, remifentanil, alfentanil) and midazolam/fentanyl used for colonoscopy. Outcomes included post-procedure and delayed recall of patient pain and satisfaction, endoscopist satisfaction, procedural time, and recovery time. Standardized mean differences (SMD) were meta-analyzed using random effects models.

Results:
We identified 5 studies reporting at least one satisfaction or efficiency outcome of interest. There were no statistically significant differences in post-procedure (SMD 0.44; 95% CI: -0.03, 0.90) or delayed assessment (SMD 0.39; 95% CI: -0.34, 1.11) of patient satisfaction between propofol and midazolam/fentanyl. Similarly, there were no significant differences in post-procedure (SMD -0.31; 95%CI -0.88, 0.26) or delayed recall (SMD -0.12; 95%CI -0.33, 0.08) of patient pain between midazolam/fentanyl and propofol. We were unable to meta-analyze endoscopist satisfaction due to a lack of studies reporting this outcome. Procedural time was shorter with propofol use (SMD -0.22; 95%CI: -0.40, -0.04); however, the absolute differences in procedure time within studies ranged from only 0.5 to 1.7 minutes. There were no significant differences in recovery time between sedative combinations. Notably, for all outcomes assessed, we found greater differences between than within studies, suggesting a greater effect of endoscopic technique or depth of sedation used than sedative administered.

Conclusion:
Despite the beliefs of greater patient satisfaction and procedural efficiency with propofol versus midazolam/fentanyl in colonoscopy, we did not find evidence to support these claims. Given the large between study differences observed in this study, satisfaction and efficiency may depend more greatly on endoscopist technique and depth of sedation used than on sedative selection. Given the increased cost associated with propofol use, these findings should be considered when selecting sedative agents for lower gastrointestinal endoscopy. 

 

92.14 Acute Diverticulitis: Evolving trends in operative versus non-operative management

Posted on January 18, 2018

B. Zangbar1, S. Imtiaz1, V. Roudnitsky1, L. Dresner1, H. Talus1, A. Schwartzman1, F. Serafini1, R. Gruessner1  1State University Of New York Downstate Medical Center,Surgery,Brooklyn, NY, USA

Introduction:  Diverticular disease is among the most prevalent diseases in United States and imposes a vast healthcare burden to population. Treatment of diverticulitis has evolved over time with reportedly increasing primary anastomosis and non-operative treatment. The aim of our study was to assess these changes in patterns of practice over an 8 year period using a national database.

Methods:  We used the 2004 to 2011 nationwide inpatient sample (NIS) database to analyze the care received by 412,163 patients admitted with acute diverticulitis, and 47,574 patients operated for diverticulitis. Patient’s with Left hemicolectomy, Colostomy, Ileostomy, and percutaneous abscess drainage were identified and Jonckheere-Terpstra trend analysis and logistic regression analysis was used.

Results: Overall there was an increase in rate of admission for acute diverticulitis from 2004 to 2011. There was a decrease in rate of operations for diverticulitis from 5,832 (12.5%) to 5,823 (10.2%) per year during the same time period. The rate of primary anastomosis is decreased from 2,306 (5.0%) in 2004 to 1,660 (2.9%) in 2011 while patients admitted with acute diverticular disease were relatively younger during the same time period (64±16 in 2004 vs 63±16 in 2011, p=0.001). Gender, Race, and comorbidities was unchanged. Mortality during hospitalization decreased from 1.8% in 2004 to 1.5% in 2011.

Conclusion: Our study shows that non-operative management is clearly increasing over time with one main exception. In those that did receive operations  there is a significantly decreased rate of primary anastomosis. The cause of this change, contrary to the prior trend, is unknown. Further research is needed to investigate the role of non-operative management and more selective operative management for primary anastomosis.

 

92.12 Effectiveness of Liposomal Bupivacaine in Ostomy Reversal: A Retrospective Review

Posted on January 18, 2018

D. G. McKeown1, C. Sokas1, A. Nevler1, S. Goldstein1, G. Isenberg1, B. Phillips1  1Thomas Jefferson University Hospital,Colorectal Surgery,Philadelphia, PA, USA

Introduction:

Our objective was to assess the clinical efficacy of Liposomal Bupivacaine (LB) in patients undergoing ileostomy and colostomy reversal and its effect on average length of stay

Methods:

We conducted a single institution retrospective review of consecutive patients undergoing elective reversal and closure of either an ileostomy or colostomy from January 2012 to December 2016. Liposomal bupivacaine was approved for use at our institution between May 2013 to September 2016. The primary outcomes were postoperative hospital length of stay (LOS) and cumulative opioid usage calculated as morphine equivalents (MEQ)

Results:

A total of 154 patients were evaluated. 87 patients received LP and 67 patients received a standard dose of local anesthetic. There was no significant difference between the two cohorts. The mean length of stay for the non-LB group was 4.27 days compared to 3.45 days in the LB group (p=0.009). We then defined early discharge as a discharge less or equal to three days and we found that patients who received LB were more likely to receive an early discharge with an odds ratio of 2.1 (CI 1.13 – 4.13) p=0.23. Cumulative opioid use 78.8 morphine equivalents (meq) in the non-LB group versus 75.7 in the LP group (p=0.66). 32.8% of the LP group received a PCA vs 25.3% of the non-LBA group and there was no statistical difference in LOS between these two groups (p=0.36) Secondary outcomes looked at the effect of non-opioid analgesia and anti-emetics on length of stay. When we examined anti-emetic usage, we noted that patients who did not require the administration of anti-emetics were more likely to be discharged early (p=0.05, OR = 0.37 (CI = 0.19 – 0.72))  

Conclusion:

The usage of LB for local wound anesthesia after colostomy and ileostomy reversal is associated with decreased LOS, however opioid usage between the non-LB and LB groups were similar. Despite this, LB appears to offer the benefit of decreasing costs associated with longer hospital stay. A multi-institutional prospective randomized control trial would help to elucidate further. 

 

 

92.11 Differing Rates of C. Difficile Infection in Patients with Ostomy Reversal versus Colon Resection

Posted on January 18, 2018

C. L. Charlton1, D. Chen1, V. Pandit1, A. Cruz1, D. Sessinou1, P. Vij1, V. Nfonsam1  1University Of Arizona,Department Of Surgery,Tucson, AZ, USA

Introduction:

Colon resections and ostomies are commonly performed surgical procedures.  Clostridium difficile (C. diff) is a known disease process associated with worse outcomes but variations exists among patients developing C. diff. The aim of the study was to assess the prevalence of C. diff among patient with colon resection with primary anastomosis (CR), ileostomy (IS), and colostomy (CS).

Methods:

We queried the National Impatient Sample (NIS) for the year 2011 selecting patients with age ≥ 18. Patients were stratified into: large-large colon resection with primary anastomosis (CR), small-large colon resection with primary anastomosis (IR), ileostomy (IS), and colostomy (CS). The primary outcome measure was development of C. diff infection. Statistical analysis was performed.

Results:

A total of 6,013,105 patients were assessed of which 20,312 patients were included. 49.6% had CR, 21.9% had IS and 24.7% had CS. Patients with CS (OR: 1.4, p=1.43×10^-6) were more likely to develop C. diff compared to patients with CR, while patients with IS (OR: 0.74, p=0.52) were less likely to develop C. diff compared to patients with IR. On comparing CS to IS, patients with CS were more likely to develop C. diff (OR: 1.8, p=3.62×10^-8). There was no difference in developing C. diff between ostomy reversal and colon resection. 

Conclusion:

Patients with colostomy or large colon resection were more likely to develop C. diff than patients with ileostomies or small intestine resection. However, there did not appear to be any difference between the rates of C. diff infection when comparing whether a patient has ostomy reversal or a colon resection.

 

 

92.06 First Case Report of Rectal Cellular Angiofibroma

Posted on January 18, 2018

V. Kurbatov1, J. M. Bloom2, G. A. Yavorek1  1Yale University School Of Medicine,General Surgery,New Haven, CT, USA 2Southern Connecticut State University,New Haven, CT, USA

Introduction:

Cellular angiofibroma (CAF) was first described by Nucci et al in1997 as a distinctive mesenchymal neoplasm with 2 principal components: spindle cells and prominent vasculature. It was initially though to be a tumor of the vulva of middle-aged women. A histologically indistinguishable lesion called “angiomyofibroblastoma-like” tumor in the inguino-scrotal region of adult men was soon after described, broadening the WHO definition of CAF to include lesions in both genders. Extragenital locations have been described since, prompting Fletcher et al to publish a 51 case series of CAFs, describing a near equal distribution between men and women, with diverse distribution including spermatic cord, retroperitoneum, testis, urethra, perineum, vagina, vulva, and labium. One case of anal CAF was included. Median size was 2.7cm in females and 6.7cm in males. These cases followed benign course without recurrence after complete resection.

Subsequently, Fletcher et al described 13 cases of CAF with sarcomatous transformation. Patients were predominantly female with tumors of the vulva. Follow up information for 6 of 7 of the patients showed no evidence of recurrence after resection. One patient died 27 months after diagnosis of carcinoma of unknown primary. Cases with sarcomatous transformation appear to share p16 over-expression.

Methods:
We describe a case of 62 year old male with the first pathologic diagnosis of rectal CAF. We performed a review of clinical records and pathology, as well as extensive literature review.

Results:

The 62 year old male patient, with family history of prostate cancer, presented with a 1.4 cm submucosal rectal mass seen on surveillance MRI. EUS was performed, confirming the lesion, which increased in size to 1.6 cm in span of three months. A transanal excision was performed with resection of a 2cm mass.

Grossly, the tumor formed a well circumscribed nodule involving rectal submucosa and muscularis propria. Histologically, spindle cells were arranged in fascicles with intervening vessels and wispy collagen fibers. Immunostaining was positive for CD34 and ER and negative for Stat6, Cam5.2, S100, Desmin, PR, Dog1, SMA. Kit immunostain highlights numerous mast cells within the tumor. Mitotic activity was low. Immunohistochemical and morphologic features were consistent with CAF.

Conclusion:

The rectum is a potential site of CAF. Surgical resection with clear margins is the current treatment standard. Care needs to be taken to differentiate CAFs from angiomyofibroblastoma and aggressive angiomyxoma (AAM). These tumors share microscopic characteristics but have significantly different behavior. AAM is documented to be locally infiltrating with a 30% local recurrence rate despite wide local excision. Current literature suggests that this is not the case for CAF. Desmin can be used to distinguish between these lesions, as aggressive angiomyxoma, myofibroblastoma and angiomyofibroblastoma are positive for this antibody.

92.05 Advantage of Robotic Colorectal Surgery in Rates of Operative Conversion

Posted on January 18, 2018

L. Heidelberg1, E. Malone1, M. Morris1, D. Chu1, G. Kennedy1, J. Cannon1  1University Of Alabama at Birmingham,Division Of Gastrointestinal Surgery,Birmingham, Alabama, USA

Introduction:
Over the last 20 years, minimally invasive surgery has become the standard of care for most operations. While the laparoscopic approach offers demonstrable advantages over open approach, the benefit of robotic assistance in colorectal surgery is less well defined. Previous efforts comparing robotic and laparoscopic surgery have demonstrated equivocal short-term outcomes. However, the morbidly obese population is at particular risk for postoperative complication and is an area warranting further investigation. We hypothesized that robotic surgery would decrease conversion rates in the obese colorectal patient when compared to the standard laparoscopic approach.

Methods:
We conducted a retrospective review of patients undergoing elective colorectal surgery while following the Enhanced Recovery After Surgery (ERAS) protocol from 2014-2017. Patient data from the institutional ERAS database was obtained for all patients whose initial operation was performed with a laparoscopic or robotic approach. Patients were then stratified by body mass index (BMI) to normal or obese (BMI >30). Bivariate comparisons of patient clinical characteristics and comorbidities, surgical characteristics, and post-operative outcomes were made using χ2 or Fisher’s exact test and t-tests for categorical and continuous variables respectively. 

Results:
A total of 220 colorectal patients were included: 128 laparoscopic and 92 robotic. Patients were demographically matched between the groups. Mean age was 57 with at least 25% of patients on steroids, over 50% with hypertension, approaching 50% obesity, and with at least 79% having an ASA 3 classification. The overall rate of conversion to open operation was significantly lower in the robotic group compared to the laparoscopic group (1.1 vs. 15.6%, p < 0.05). The conversion rate, however, was not associated with BMI (44% for obese vs. 56% for normal BMI patients, p > 0. 05). Overall post-operative complication rate was higher in the robotic group (14.8% vs. 27.2%, p < 0.05), however no specific complication other than post-operative UTI were statistically significant (0% vs. 4.4%, p < 0.05). Operative time was also shorter in the laparoscopic approach (3.2 hours vs 3.9 hours, p < 0.05) by a mean of 42 minutes.

Conclusion:
Patients undergoing robotically assisted colorectal surgery were significantly less likely to require conversion to open operation. Higher BMI did not correlate with need for conversion in either group. More research is needed to stratify outcomes by BMI category and identify which patient populations benefit most from robotic surgery. 

92.03 Retrospective Review of TAP Block with Liposomal Bupivicaine During Laparoscopic Enterocolectomy

Posted on January 18, 2018

L. M. Deppe2, C. Kasal2, K. Mathis1, D. W. Larson1  1Mayo Clinic Rochester,Colon And Rectal Surgery,Rochester, MN, USA 2Mayo Clinic Health System,Red Wing, MN, USA

Introduction:
Data has suggested value of TAP (transversus abdominus plane) neural blockade in
procedure related pain management as part of an enhanced recovery surgical program. Our goal was to
retrospectively analyze pain management using combined bupivacaine and liposomal bupivacaine as
part of a rural community laparoscopic colorectal and surgical program.

Methods:
Records of consecutive laparoscopic segmental colectomy and enterectomy patients
managed with an enhanced recovery program whose procedures were performed by four community
surgeons over an eighteen month period were reviewed under IRB approval. Patients who returned to
the operating room within thirty days were excluded from analysis. In place of an intrathecal block, an
ultrasound (US) guided bilateral TAP block was performed by the operating surgeon using 266 mg of
liposomal bupivacaine and 50 mg of 0.25% bupivacaine with epinephrine using the technique previously
described. Comparison was performed to previously published results of an enhanced recovery program
(which we also adopted) utilized by our Rochester, Minnesota based colorectal surgical system
colleagues.

Results:
Twenty four patients were included in analysis. Two patients were excluded; one requiring reexploration
for hemorrhage after anticoagulation and another with an anastomotic leak (who eventually
succumbed to respiratory failure). Three enterectomies were included (for malignancy and
inflammatory bowel disease) as well as twelve right hemicolectomies and nine sigmoid/left
hemicolectomies (eighteen for neoplasia and the remainder for diverticulitis). We found compliance
with enhanced recovery elements varied greatly and was generally surgeon dependent. No TAP block
site related reactions were noted. Median length of stay was three days, consistent with previously
published academic institutional results. Our ASA 1-2 population was 58%, comparing favorably with
published experience by our colorectal team which was 81%. Mean body mass index and median oral
morphine equivalents were 30.6 kg/m2 versus 26.9 kg/m2 and 4.5 mg versus 37.5 mg respectively.
Forty-six percent of patients never took an opiate versus a rate of 26% by our academic colleagues. There
were no readmissions within thirty days, although one patient did develop a deep incisional surgical site
infection. Though not formally timed, performing the above block was felt to add approximately five minutes to case length.

Conclusion:

Incorporating a surgeon performed US guided TAP block as part of an enhanced recovery
program resulted in similar length of stay, favorable oral morphine equivalent utilization and avoidance
of narcotic compared to published data utilizing an intrathecal block. Further study is indicated to
directly compare surgeon directed TAP block versus intrathecal injection for post-operative pain
management.

89.19 Liver Resection for Metastatic Colon Cancer: During or Separate from Colon Surgery??

Posted on January 18, 2018

L. G. Leijssen1,2, A. M. Dinaux1,2, C. R. Ferrone1,2, H. Kunitake1,2, L. G. Bordeianou1,2, D. L. Berger1,2  1Massachusetts General Hospital,General And Gastrointestinal Surgery,Boston, MA, USA 2Harvard School Of Medicine,Brookline, MA, USA

Introduction:  ?Concomitant hepatectomy in patients with primary colon cancer and synchronous liver metastasis is feasible. The aim of this study is to assess the impact of combined hepatectomy and colectomy compared to separate procedures on both short- and long-term outcomes.?

Methods:  All patients who underwent a hepatectomy for metastatic colon cancer at our tertiary center from 2004 to 2014 were included. We compared patients who underwent hepatectomy during (DC) with before or after colectomy (BAC) and partial (PH) against extended hepatectomy (EH). ?

Results: We included 18 DC and 44 BAC patients (6.3% before and 63.5% after colectomy). DC patients had more transverse tumors (P=0.009), less sigmoid cancer (P=0.047), and a higher readmission rate (P<0.001). EH was performed in a comparable numbers of patients (DC 61.1% vs. BAC 61.4%). Mean survival duration was non-significantly shorter for DC patients (36 vs. 48 months; P0.075). R0 resection was achieved in 91.7% of PH and 97.4% of EH patients (P=0.308). Mean survival duration was non-significantly shorter for EH patients (49 vs. 42 months; P0.298). In adjusted analyses, there was no difference in overall survival between DC and BAC patients (HR 1.126 [95% CI: 0.46-2.76] P=0.795), or PH and EH patients (HR 1.042 [95% CI: 0.46-2.36] P=0.921).?

Conclusion: This study underscores the oncologic safety of simultaneous hepatectomy in patients with primary colon cancer and synchronous liver metastasis.?

 

81.20 RACIAL DISPARITIES AND GENDER DIFFERENCES IN ANAL CANCER

Posted on January 18, 2018

A. Cruz1, D. Chen1, V. Pandit1, C. L. Charlton1, D. Sessinou1, P. Vij1, V. N. Nfonsam1  1University Of Arizona,Department Of Surgery,Tucson, AZ, USA

Introduction:
Racial and gender disparities have been shown in other gastrointestinal cancers. However, there is a paucity of data on racial and gender disparities in anal cancer. The aim of this study was to assess racial and gender disparities among patients with anal cancer (AC). 

Methods:
We analyzed data from the National Inpatient Sample (NIS) 2011 database of patients diagnosed with AC with age ≥ 18. Demographic data including age, race and gender were assessed. Patients were stratified based on race and gender.  Fisher’s exact test and Odds Ratio Statistical analysis was performed to assess disparities. 

Results:
A total of 6,013,105 patients were assessed and 1,956,  (0.03% ) patients had AC.  Patient with AC were more likely to be female (58% vs 42%, p=0.001). Whites and Blacks had the highest incidence followed by Asians/Pacific Islanders. Black males had the highest proportion of anal cancer (0.04%) and had an OR of 1.64 compared to Whites (p-value = 0.00045). On the other hand, in Whites, females had the highest proportion of individuals with anal cancer (0.04%) and had an OR of 1.21 (p-value = 0.02). 

Conclusion:
Racial disparities and gender differences exist in incidence of anal cancer. Potential causes for this disparity are disparate access to healthcare, lack of education, and lack of awareness. Greater understanding of this disease will result in earlier detection, prevention methods, improved treatment, and better prognosis.
 

81.18 Racial Disparities in Incidence of Colon Cancer in Patients with IBD

Posted on January 18, 2018

P. Vij1, D. Chen1, V. Pandit1, D. Sessinou1, A. Cruz1, C. Charlton1, V. Nfonsam1  1University Of Arizona,Tucson, AZ, USA

Introduction:  Many studies have explored the relationship between inflammatory bowel disease (IBD) (ulcerative colitis (UC) and Crohn’s disease (CD)) and colon cancer (CC). However, the impact of racial diversity remains unclear. The aim of this study was to assess the impact of racial diversity in patients with IBD developing CC.

Methods:  Using the National Impatient Sample (NIS) database from the year 2011, we included patients with age ≥ 18 and IBD and CC. Patients were stratified by race (Whites, Blacks, Hispanics, Asians/Pacific Islanders, and Native Americans). The primary outcome measure was racial disparities in patients with IBD and CC.  Statistical analysis was performed to compare the groups.

Results: A total of 6,013,105 patients were analyzed of which, 57,358 patients were included (CD: 36,357, UC: 21,001). CD had the highest proportion among whites followed by blacks. Among blacks, 0.48% had CD and 0.22% had UC. 0.56% total had colon cancer.  Patients with UC were more likely to get CC (p=0.059). Among patients with CC and CD, Hispanic patients (0.63%) had the highest proportion followed by whites (0.46%). 

Conclusion: Our results demonstrate racial disparities among patients with IBD and their developing CC. Although IBD is common in white patients, Hispanics are more likely to develop CC after IBD. This can be attributed to the social and economic variability among racial groups. Further national studies are warranted to better understand these disparities. 

81.19 30-Day Hospital Readmission after surgery for colon cancer: Who is at risk of coming back?

Posted on January 18, 2018

V. Pandit1, F. S. Jehan1, C. Martinez1, M. Khan1, M. Zeeshan1, V. N. Nfonsam1  1University Of Arizona,Division Of Colorectal Surgery,Tucson, AZ, USA

Introduction:  The recent era has seen a change of focus from simple mortality and complications to the quality of healthcare delivery. Hospital readmission within 30 days of an index hospitalization is recognized as a marker of poor-quality patient care. The aim of our study was to identify the patient related factors associated with 30-day readmission after colon surgery.

Methods:  We performed a four year (2012-2015) analysis of the National Surgical Quality improvement program (NSQIP) and included all adult patients who underwent colon surgery for colon cancer. Outcome measures were to identify factors related factors associated with 30-day readmission after discharge. We performed regression analysis to control for confounding variables. 

Results: A total of 95,055 patients were analyzed of which 36,279 patients had colon surgery for colon cancer and were included in our analysis. Mean age was 65+13 years, 51% were males and 72% were white. Overall mortality was 2.7% and 16% patients developed one or more complications. The 30-day readmission rate was 10%. On regression analysis, after controlling for confounders, age (OR: 1.4; 95%CI [1.2-2.1], p=0.03), presence of comorbidity (DM, HTN) (OR: 3.2; 95%CI [1.9-4.5], p=0.02), BMI > 30 kg/m2 (OR: 2.1; 95%CI [1.6-4.5], p=0.02), post-operative complication (OR: 5.5; 95%CI [3.2-8.9], p=0.01) and OR time (OR: 1.4; 95%CI [1.2-2.2], p=0.04) were independent predictors of 30-day readmission. 

Conclusion: Risk factors for readmission after colon surgery are multifactorial; however, pre-surgery comorbidities and postoperative complications appear to drive readmissions in colon surgery for colon cancer. Identifying patients at risk of readmission and optimization and decreasing postoperative complications will decrease the risk of postoperative readmissions.

 

81.17 Morbidity and Mortality in Patients Undergoing Fecal Diversion as an Adjunct to Wound Healing

Posted on January 18, 2018

R. J. Kucejko1, M. E. Pontell1, D. Scantling1, M. Weingarten1, D. E. Stein1  1Drexel University College Of Medicine,Surgery,Philadelphia, PA, USA

Introduction:  Stomas are routinely created for fecal diversion in chronic, non-healing wounds of the sacrum, ischium and perineum. Aside from re-routing stool from the wound bed, they also improve quality of life and prepare the patient for future reconstructive surgery. While these procedures are commonplace, little is published about their safety, with only two studies in the last twenty years. This study aims to analyze patients from our institutional database as well as the NSQIP national database who underwent fecal diversion for non-healing wounds to clarify the safety of fecal diversion in this group of patients and to identify factors that contribute to elevations in perioperative risk.

Methods:  A retrospective analysis was performed using data from the American College of Surgeons National Surgical Quality Improvement Project database between 2005 and 2015. Patients were selected based on a postoperative diagnosis of chronic ulcer of the skin. Patients were considered to have undergone diversion if the entry contained the procedure code for ileostomy or colostomy. Propensity score matching was conducted based on the NSQIP morbidity score. An additional retrospective analysis was performed on our institutions patient database spanning from 2000 until 2017. All patients who underwent fecal diversion for chronic, non-healing wounds were included. 

Results: 4,849 patients meeting inclusion criteria were identified in the NSQIP database. 859 underwent diversion compared to 3,990 patients who did not. In unmatched data, comparison of the two groups revealed no significant differences in mortality rate, postoperative stroke, need for cardiopulmonary resuscitation, myocardial infarction, need for blood transfusion, deep venous thrombosis, renal failure, organ space or superficial surgical site infection. In matched data, diverted patients had a significantly lower 30 day mortality. 56 patients were identified at our institution that underwent fecal diversion for non-healing wounds. 50% of patients with a preoperative ejection fraction of less than 30% died within 30 days of surgery (p = 0.045, likelihood ratio 6.58).

Conclusion: Fecal diversion in patients with chronic non-healing sacral wounds does not increase 30 day morbidity and mortality, based on NSQIP data.  While the 30 day morbidity does remain high, the subgroup of patients with severe cardiac dysfunction likely represent the majority of these cases and remain at a disproportionately elevated risk, based on our institutional data. It is reasonable to suggest that patients with cardiac risk factors undergoing fecal diversion for chronic wounds should undergo preoperative echocardiography. We propose that a preoperative ejection fraction less than 30% should be seen as a relative contraindication to immediate diversion without further optimization.

81.16 Does Umbilical Cleanliness Correlate with Colorectal Surgery Patient Outcomes?

Posted on January 18, 2018

J. T. Brady2, A. R. Althans2, M. Nishtala2, S. L. Stein2, E. Steinhagen2, H. L. Reynolds2, C. P. Delaney4, S. R. Steele3  2University Hospitals Cleveland Medical Center,Surgery,Cleveland, OH, USA 3Cleveland Clinic,Colorectal Surgery,Cleveland, OH, USA 4Cleveland Clinic,Digestive Disease And Surgery Institute,Cleveland, OH, USA

Introduction:  Patient risk assessment can aid in stratification, preoperative intervention, and improvement in patient outcomes. While frailty and sarcopenia correlate with outcomes, these can be cumbersome to measure, and a simple objective bedside assessment of patient risk for postoperative complications would be useful. We hypothesized that umbilical cleanliness may be a surrogate for social or hygiene factors that reflect the risk of postoperative complications and discharge disposition. 

Methods:  A prospective, observational pilot study of patients > 18 years old undergoing colorectal surgery was performed over a two-year period at a tertiary academic medical center. Patients were excluded if they had an abdominal surgery in the prior 90 days, a protruding umbilicus, or prior umbilical excision. A scoring system to characterize the cleanliness of a patient’s umbilicus during routine sterile preparation of the abdomen consisted of a 0 to 5 point scoring system (see table).

Results: We enrolled 200 patients (mean age 58.1±14.8; 56% female). The mean BMI was 28.6±7.4. Indications for surgery included colon cancer (24%), rectal cancer (18%), diverticulitis (13.5%) and Crohn’s disease (12.5%). Umbilical scores were 0 (23%), 1 (26%), 2 (21%), 3 (24%), 4 (6%), and 5 (0%). Postoperative complications occurred in 116 (58%) patients. Increasing umbilical score correlated weakly with postoperative complications (Spearman’s rho=0.15, p=0.04) and increasing modified frailty index (Spearman’s rho=0.14, p=0.05). There was also a correlation with length of stay (Spearman’s rho=0.2, p=0.006), umbilical depth (Spearman’s rho=0.23, p=0.001) and ASA score (Spearman’s rho=0.25, p=0.0005). Umbilical score did not correlate with BMI (Spearman’s rho=0.09, p=0.2), surgical site infection (Spearman’s rho=0.05, p=0.5) or 30-day readmission (Spearman’s rho=0.2, p=0.3). There was no correlation between umbilical score and discharge disposition on univariate analysis (p>0.1). 

Conclusion:  Although sterile preparation of the abdomen is an important component of proper surgical technique, umbilical cleanliness does not correlate with patient outcomes.
 

81.15 “Practice Patterns and Outcomes of Splenic Flexure Mobilization During Laparoscopic Left Colectomy.”

Posted on January 18, 2018

B. Resio1, K. Y. Pei1  1Yale University School Of Medicine,Surgery,New Haven, CT, USA

Introduction: Historically, splenic flexure mobilization (SFM) was recommended for left colectomies to ensure adequate length for a tension free anastomosis and thus potentially mitigate the incidence of anastomotic complications. Despite the exponential increase in the adoption of the laparoscopic approach to colectomies, the national practice pattern and outcomes of SFM among this group are unknown. This study investigates the use of and outcomes associated with SFM for laparoscopic, partial colectomies with anastomosis for left colon and rectal cancers.

Methods:  The American College of Surgeons NSQIP database from 2007-2015 was queried for elective, laparoscopic, partial colectomies with anastomosis (CPT 44204, 44207, 44208) with/without SFM (CPT 44213) for colon cancer of the left colon or rectum (ICD9 153.2, 153.3, 154.0, 154.1) or (ICD10 C18.6, C18.7, C19, C20). Only cases labeled as elective were included and cases labeled as emergency or ASA 4/5 (life-threatening/ moribund) were excluded.  Primary outcome measures included all complications, superficial, deep and organ space infections, anastomotic leaks, postoperative ileus, return to operating room, death, hospital length of stay (HLOS) and operative time. Logistic regression models were used to compare outcomes, adjusting for patient and operative characteristics.

Results: 17,319 cases were identified of which 39.2% underwent SFM. Specifically, the proportion of SFM for left colon, sigmoid, recto-sigmoid and rectum were 49.3%, 33.3%, 36.9% and 46.9%, respectively. There was an increase in the overall proportion of cases with SFM during the study period (10.9% increase from 2007 to 2015). Compared to colectomies without SFM, patients undergoing SFM had an increase in: all complications (17.6% vs 15.6%, risk adjusted OR 1.11, 95%CI: 1.02-1.20); organ space SSI (4.6% vs 3.4%, risk adjusted OR 1.22, 95%CI: 1.04-1.43); prolonged ileus (10.7% vs 8.1%, risk adjusted OR 1.23 95%CI: 1.05-1.44) and operative time (mean time 234 vs 197 min, p<0.0001, 95%CI: 231.3-236.3 vs 195.4-198.9). There was no significant difference after risk adjustment for superficial SSI, deep SSI, return to operating room, anastomotic leak, death and HLOS.

Conclusion: Splenic flexure mobilization is performed in less than 50% of elective, laparoscopic, left, partial colectomies for colon and rectal cancer and is associated with increased complications, prolonged ileus, and operative time. Study findings support selective splenic flexure mobilization.

 

81.14 Laparoscopic Radical Right Hemicolectomy Using Caudal -to-Cranial Versus Medial-to-Lateral Approach

Posted on January 18, 2018

L. Zou1, B. Zheng1, L. Zou1  1Guangdong Provincial Hospital Of Chinese Medicine,Department Of Gastrointestinal Surgery,Guangzhou, GUANGDONG, China

Introduction:
The aim of this study is to compare the safety and feasibility of laparoscopic radical right hemicolectomy using caudal -to-cranial (CtC) approach versus medial-to-lateral (MtL) approach.

Methods:
Using data from a clinical database in our department, we retrospectively analyzed data of 78 cases undergoing laparoscopic radical right hemicolectomy using CtC approach, matching with using MtL approach from January 2013 and October 2015. The matching factors consisted of gender, age, ASA score, BMI, tumor size, tumor location and TNM stage. Data of intraoperative and postoperative characteristics were reviewed. 

Results:
The data of clinicopathological characteristics were similar in both groups. In the intraoperative and postoperative characteristics, there are no significant differences in average time of ambulation, time to first flatus, hospital stay between two groups, but there are significantly shorter operation time (173.9±25.39 min vs.193.5±39.55 min. P = 0.0002) and less blood loss (92.0±21.21ml vs. 107.3±24.67ml. P < 0.0001) in the CtC group than that in the MtL group. The number of lymph nodes dissected in the CtC group is more (26.3±10.92 vs.22±8.93. P = 0.007). The rate of hemorrhage of the major vessels (SMA, SMV, ICV/ICA, RCV/RCA, Henle’s trunk, MCV/MCA) in the CtC group was significantly lower (14.1% vs. 3.8%. P = 0.025). 

Conclusion:
Laparoscopic radical right hemicolectomy using CtC approach is technically feasible for curable right-sided colon cancer with less blood loss compared with MtL approach, especially in the major vessel injury.
 

81.13 Effect of BMI on Outcomes after Surgery for Perforated Diverticulitis

Posted on January 18, 2018

K. T. Weber1, P. Chung2, M. Sfakianos1, V. Patel1, A. Alfonso1, J. Nicastro1, G. Coppa1, G. Sugiyama1  1Hofstra Northwell School Of Medicine,Department Of Surgery,Hempstead, NY, USA 2Coney Island Hospital,Department Of Surgery,Brooklyn, NY, USA

Introduction: For perforated diverticulitis, an open resection with ostomy creation has endured as the standard treatment, despite trends toward laparoscopic lavage in diverticulitis and increasing utilization of minimally invasive techniques in colorectal surgery. With rising rates of both morbid obesity and diverticular disease in the US, we sought to evaluate if findings in the literature suggesting similar outcomes between obese and non-obese patients are substantiated among patients who have open, emergent procedures for diverticulitis.

Methods:  Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2010-2015, we identified cases of emergent admission for diverticulitis (ICD 9 code 562.11) with evidence of preoperative sepsis and intraoperative contaminated/dirty wound classification in which a resection with ostomy (CPT 44141, 44143, 44144) was performed. We excluded cases with age <18 years, ventilator dependence, evidence of disseminated cancer and missing sex, race, BMI, functional status, ASA class, length of stay (LOS), and operative time data. We defined morbid obesity as BMI>35 m2/kg. Risk variables of interest included age, sex, race, medical comorbidities, requirement for preoperative transfusion, preoperative sepsis, and operative time. Outcomes of interest included LOS, 30-day postoperative complications and mortality. Univariate and propensity score analyses were performed.

Results: A total of 2,019 patients met inclusion/exclusion criteria, of which 413 (20.5%) were morbidly obese. Morbidly obese patients tended to be younger (mean 57.2 vs 62.6 years, p<0.001), have higher rate of insulin-dependent diabetes (8.0% vs 4.2%, p<0.0001), and have ASA class 4 (23.5% vs 19.6%, p<0.0001). Morbidly obese patients also had higher rates of postoperative septic shock (17.7% vs 12.1%, p=0.0040), return to operating room (11.1% vs 6.4%, p=0.0015), and surgical site infection (SSI), both superficial SSI (8.9% vs 5.8%, p=0.026) and deep SSI (4.4% vs 1.9%, p=0.0073). We identified 397 morbidly obese patients that were well-matched by propensity score to 397 non-morbidly obese patients. Conditional logistic regression showed increased risk of postoperative septic shock (OR 1.60, 95% CI [1.09, 2.34], p=0.015), however there was no difference in LOS (mean 12.8 vs 12.3 days, p=0.46) and no increased risk of 30-day mortality (p=0.947).

Conclusion: This analysis of a large national clinical database demonstrates that patients presenting with perforated diverticulitis undergoing a Hartmann’s procedure, after adjusting for the effects of morbid obesity, do not have increased mortality or LOS. Among morbidly obese patients, only increased risk of 30-day postoperative septic shock was found to be significant. Further prospective studies identifying risk factors associated with these adverse outcomes are warranted to guide clinicians when faced with these difficult cases.
 

81.12 Robotic vs Laparoscopic Resection for Colorectal Disease

Posted on January 18, 2018

T. K. Kleinschmidt1, M. Ferrara1, J. Rosser1, M. Parker1  1Brookwood Baptist Health System,Department Of General Surgery,Birmingham, AL, USA

Introduction: The aim of this study is to compare the results of robotic versus laparoscopic colon resection for all causes performed by two high-volume private practice colon and rectal surgeons.  Current recommendations are at least 150-250 cases on the da Vinci platform are needed to become adept.  This study bears significance as current research shows inconsistent results in comparing the two modalities which could be in part because many of the current literature are meta-analyses incorporating multiple centers, surgeons and disparate patient populations. 

Methods:  Retrospective analysis was performed for all patients who had either robotic or laparoscopic colon resection over a 10 month period.  Outpatient records were reviewed to ascertain demographic data such as: age, BMI, tobacco use, comorbidities and prior surgeries.  Hospital records were accessed to determine: case length in OR, estimated blood loss (EBL), need for conversion of case, length of postoperative stay and complication rates.  Complication rates were defined as: surgical site infections (SSI), need for reoperation and/or loss in quality of life as recorded in follow up office visits.  Statistical analysis of data was performed using R software.

Results: The study included 166 patients (109 in the Robotic surgery (RS) and 57 patients in the Laparoscopic surgery (LS) groups). For RS patients: mean age was 57.8 years of age, 57% were female, mean BMI was 29.9 and the most common procedure performed was LAR (67%) and most common indication was diverticulitis (36.7%). For LS patients: mean age was 64.0 years of age, 47.4% were female, mean BMI was 27.5 and the most common procedure performed and indications were also LAR (50.9%) and diverticulitis (36.1%). Mean operative time was longer in RS group (138.3 versus 125.4 minutes, respectively [p=0.0380]). Estimated blood loss was less in RS (59.6 versus 106.3cc, respectively [p=0.0282]). Mean postoperative length of stay was shorter for RS than LS (2.85 versus 4.0 days [p=0.0046]). Complication rates were similar in LS (26.3%) and RS (20.2%) [p=0.3681], and the most common LS complication was SSI (32.3%%) and most common complication for RS was SSI (42.1%). Conversion of operative technique was similar in RS and in LS (19.3% versus 13.8%, respectively [p=0.3524]).

Conclusion: Robotic surgery for colon resection had decreased EBL, and significantly shorter postoperative hospital stay.  Laparoscopic surgery had shorter operating time.  Similar results were found between postoperative complications and conversion rates of surgery.  In the hands of surgeons who have performed the reported amount of surgeries needed to become adept with the da Vinci Surgical System, robotic surgery has significant advantages for colon resection.

 

81.11 Virtual Postoperative Visits for New Ostomates

Posted on January 18, 2018

T. L. White1, J. Moss1, P. Watts1, J. Cannon1, D. Chu1, G. Kennedy1, S. Vickers1, M. Morris1  1University Of Alabama At Birmingham,Birmingham, AL, USA

Introduction: Post-operative education, discharge instructions, and follow-up appointments provide a foundation for new ostomates leaving the hospital, but a gap in care remains.  Studies show that having a stoma is an independent predictor of hospital readmission. Patients with new stomas utilize resources, including hospital based acute care, twice as much as colorectal patients without an ostomy. Telehealth has an emerging role post-operatively, allowing visual inspection of the patient while providing verbal support during virtual visits before clinic follow-up.  The purposes of this project are to determine the feasibility of Virtual Postoperative Visits (VPOVs), to define specific issues patients want addressed during VPOVs, and to assess whether patients are satisfied with a virtual format. Our hypothesis is that virtual post-operative visits will be feasible and will address patient centered goals of care following discharge with a new stoma.  

Methods: In this pilot project, we recruited 10 patients who attended 2 VPOVs following hospital discharge in addition to routine post-operative WOCN education and a post-operative clinic appointment. The VPOVs were conducted and recorded using UAB approved, HIPAA compliant video conferencing software. Descriptive statistics were used to analyze data gathered from a survey assessing patient satisfaction.     

Results: The mean age of our 10 patients recruited was 40 and 80% were women. Surgical procedures included robotic, laparoscopic, and open colectomies with 80% resulting in an ileostomy and 20% in a colostomy. Of the patients enrolled, 90% successfully completed two VPOVs. The mean time to the first VPOV was 9 days post-discharge (range 2-7 days) and none of the patients enrolled were readmitted.  Ninety percent of patients felt VPOVs helped manage the ostomy and agreed that VPOVs should be part of the discharge plan. All patients felt comfortable with the virtual format. Common themes addressed during VPOVs included pouching issues and skin irritation.  Barriers to enrolling patients into our VPOV pilot study included lack of access to technology and HIPPA compliant software for smart phones. 

 

Conclusion: The immediate post-operative period is a tenuous time for new ostomates. Overall, VPOVs are feasible and patients are very satisfied with VPOVs in addressing their patient centered goals of care.  Bridging the period between hospital discharge and initial clinic follow-up by using culturally sensitive, educational, and timely interventions should be a priority in this population. Future work will focus on large scale implementation of VPOVs for patients with new stomas.

 

81.10 Racial Disparities in Opioid Utilization in Patients Undergoing Colorectal Surgery: Does It Exist?

Posted on January 18, 2018

P. K. Patel1, R. K. Burton1, K. E. Hudak1, L. E. Goss1, E. A. Dasinger1, M. Morris1, J. Richman1, G. Kennedy1, J. A. Cannon1, D. I. Chu1  1University Of Alabama at Birmingham,Gastrointestinal Division,Birmingham, Alabama, USA

Introduction: Racial disparities exist in surgical outcomes. Enhanced Recovery After Surgery (ERAS) protocols lead to improved outcomes and may reduce disparities. It is unclear, however, what the effect of ERAS is on post-discharge opioid utilization and whether racial disparities exist in opioid-specific outcomes. We hypothesized that there would be variations in opioid use between racial/ethnic groups with black patients prescribed more opioids and that this disparity would be reduced with ERAS.

Methods: This was a single institution study of patients undergoing ERAS for colorectal surgery in 2015, matched by race, age, sex, and procedure to a pre-ERAS group from 2010 to 2014. Patient, procedure, and opioid use characteristics were included. Each prescribed opioid was converted into standardized Oral Morphine Equivalents (OMEs). The primary outcome was the prescribed OMEs on discharge, OMEs over 1-year, and OME’s per pill (OME/P). Univariate and bivariate comparisons were performed using Chi-square and t-tests as appropriate. A p-value of less than 0.05 determined significance.

Results: Of the 395 patients (198 ERAS and 197 pre-ERAS) included, 28.3% were black. In the pre-ERAS group, a similar proportion of black and white patients were discharged with an opioid prescription (92.7% vs 92.3%, p=0.92). Within 1 year after surgery, opioid use decreased for both black and white patients (50.9% vs 49.3%, p=0.84). In the ERAS group, fewer patients were discharged with an opioid prescription but no difference was seen by race (89.3% for blacks, 85.9% for whites, p=0.53). Both black and white ERAS patients decreased opioid usage within 1 year (42.8% vs. 50.7%, p=0.32). At discharge, there was no difference in the OME/P between white and black patients under pre-ERAS (7.6 vs. 7.5, p=0.86) or ERAS (7.0 vs. 6.6, p=0.41) pathways. ERAS patients, however, did have significantly lower overall OME/P compared to pre-ERAS patients (p<.01). No differences in OME/P between racial groups were observed at 1-year post-discharge.

Conclusion: No racial disparities were observed in post-discharge opioid utilization in either the pre-ERAS or ERAS cohorts. ERAS did reduce overall opioid use, and possibly more for blacks than whites. However, a larger cohort is needed to confirm this hypothesis.

 

81.09 Proximal Intestinal Diversion for Colorectal Anastomoses: What Are We Preventing?

Posted on January 18, 2018

A. Sunkerneni1, R. J. Kucejko1, D. E. Stein1, J. L. Poggio1  1Drexel University College Of Medicine,Surgery,Philadelphia, PA, USA

Introduction:  Proximal intestinal diversion is often thought to protect colorectal anastomoses from leak, and reduce leak-related morbidity.  While data for rectal cancer convincingly shows improvement in outcomes, the results for abdominal anastomoses are mixed.  Yet, patients are being diverted, incurring the increased morbidity and mortality surrounding the reversal of stomas without clinical benefit.  Prior studies of abdominal anastomoses have been done on limited patient numbers, and did not control for pre-operative morbidity.  The American College of Surgeons’ (ACS) National Surgical Quality Improvement Program (NSQIP) has collected the largest dataset on anastomotic leak to date.  Our aim is to determine risk-adjusted post-operative outcomes including anastomotic leak on patients undergoing colorectal anastomosis to determine which patients receive the most benefit from diversion.

Methods:  A retrospective analysis of the ACS NSQIP Procedure Targeted Colectomy database from 2012 to 2015 was performed. All patients 18 to 90+ years old in the targeted colectomy database were included.  Patients were excluded if any CPT code corresponded to a surgery that did not have an anastomosis, or a surgery with a pelvic anastomosis, or if their leak status was unknown.  Post-operative outcomes were analyzed using chi-squared and Mann-Whitney U tests.   Propensity score-matched cohorts were developed using the NSQIP morbidity score.  The primary outcomes were 30-day mortality, 30-day reoperation rate, and anastomotic leak.

Results: 61,161 patients underwent abdominal colorectal anastomosis over the 4-year period. 8,352 (13.7%) underwent emergent surgery, and were diverted 30.5% of the time, compared to the non-emergent diversion rate of 11.4%.  Matched patients who were emergently diverted had significant improvements in prolonged intubation, septic shock, 30-day return to OR, mortality rate, and operative leak rate, with no significant difference in other outcome measures.  Matched patients who were non-emergently diverted were only noted to have significant improvements in post-operative pneumonia, rate of reintubation, mortality and operative leak rate.  More importantly, these patients had significantly worse rates of organ space infections, AKI, UTI, DVT, sepsis, return to OR and 30-day readmission. 

Conclusion: Proximal fecal diversion for abdominal colorectal anastomosis is a known trade-off between immediate protection and long-term morbidity.  In emergent cases, significant improvements in mortality and leak rate are seen without significant rises of other complications, suggesting the right patients are being diverted.  But, in non-emergent cases, many operative sequela are made worse by diversion, with only modest improvements in leak rates and 30-day mortality.  Surgeons would benefit from a decision tool to better stratify patients undergoing non-emergent abdominal anastomoses to aid in optimal patient selection.

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