83.17 Review of the Current State of Orthopedic Specialists in Japan

Posted on January 18, 2018

Y. Yatabe1, k. Ikeda1  1Ichihara Hospital,Dept. Of Orthop. Surg.,Tsukuba, IBARAKI, Japan

?Background and Purpose? To date, academic medical society was responsible for certifying its members as specialists in their respective fields; however, the Japanese Medical Speciality Board has now been established, and it was decided that it would handle specialist certification. Meanwhile, the Japanese Orthopaedic Association (JOA) has been training specialists for over 30 years. This study examined the current situation of orthopedic surgeons in comparison with other specialists. ?Methods? In August 2016, we examined the number of existing academic societies and specialists, with respect to 18 basic areas of medicine requiring specialists, according to the guidelines of the Japanese Medical Speciality Board, and compared the information. ?Results? The number of members with respect to the 18 basic areas of the Japanese Medical Speciality Board was 3,032 to 108,232 (average: 18,597.1), the number of specialists was 666 to 21, 275 (average: 8,567.4), and the acquisition rate was 14.0% to 79.7% (average: 56.0%). Meanwhile, JOA had 24,443 members and 18,489 specialists, with 79.7% of the members having acquired a specialist designation. ?Discussion? It is estimated that the demand for orthopedic medical treatment will increase at an exponential rate in Japan, which is amassing a super-aged society unparalleled elsewhere in the world. To do this, an orthopedic surgeon who understands diseases related to exerciser disease, and who has high level of practical ability, is indispensable. Currently, the number of members, the number of specialists, and the acquisition rate in academic societies exceed the average specified according to the 18 basic regions. Among them, for the specialist acquisition rate, about 80% of the total number of members of the JOA have acquired a specialist designation, the highest acquisition rate among the basic 18 areas put forth by the Japanese Medical Speciality Board. In the future, it is considered necessary to maintain the current number of specialists during the transition to following the specialist guidelines of the Japanese Medical Speciality Board. ?Conclusion? In order to improve orthopedic practice in Japan, it seems necessary to maintain the current number of orthopedic specialists.

82.19 Lipomatous Mass with Highrisk Radiographic Features:Is Routine Corebiopsy Warranted before Excision?

Posted on January 18, 2018

V. Satyananda1, C. Dauphine1, D. Hari1, K. Chen1, J. Ozao-Choy1  1Harbor UCLA Medical Center,General Surgery,Los Angeles, CALIFORNIA, USA

Introduction:  

Lipomatous masses are the most frequent non-cutaneous soft tissue masses encountered in clinical practice. Benign Lipomas comprise the majority,however,it is necessary to differentiate these from malignant lesions for which adequate surgical margins are important. In the abscence of suspicious clinical features, such as overlying skin changes,rapid growth,pain and firmness on examination, radiographic features have traditionally been to determine which patients should undergo core needle biopsy (CNB) prior to excision. We sought to examine whether CNB should be routinely performed in all lipomatous masses that demonstrate high -risk radiographic features

Methods:
A retrospective chart review of all patients who underwent excision of extremity or truncal lipomatous masses at a single institution between October 2014 to July 2017. Patients were divided into three groups-those who did not undergo pre-operative imaging or CNB(Group 1), those who underwent imaging (ultraosund, CT or MRI)without  CNB (Group 2) and those who underwent both imaging and CNB(Group 3). High risk radiographic features were defined as size > 5 cm , intramuscular location, presence of septationa (either < 2mm or > 2mm) and presence of areas of non -fat nodularity within the lesion. the number of high risk features present, pathologic results of surgical excision were evaluated to determine the subset of patients most likely to benefit from CNB.

Results:
In the 58 month study period, 182 patients underwent excision of lipomatous mass. Of these, 57 patients (Group1) had no preoperative imaging or CNB, and all were found to have benign lipotamous masses. In the remianing 125, 70 had imaging only(Group 2) and 55 had both imaging and CNB performed (Group 3). Overall, 2 patients (1.1%) were found to have atypical or malignant lipomatous lesions. Both had > 3 high risk features (thick/thin septations, intramuscular location, size >5cm)and both had undergone CNB( Table 1).

Conclusions:
Few recommendations exist regarding management of lipomatous masses; current guideline suggest imaging and CNB should be performed on large (> 5cm ) and /or high risk radiological features. Nonetheless, the rate of malignancy in these lesions appears to be low. Only 1% of our patients had an atypical or malignant final pathology. Our data suggests that patients who have small lipomatous masses (< 5 cm) may undergo excisional biopsy without further imaging or CNB. in additiona, our study suggests that routine performance of CNB based upon size alone is not warranted , but presence of 3 or more high-risk radiographic features should indicate pre operative CNB to ensure proper surgical approach at the time of excision. 

82.17 Impact of Prescription Drug Monitoring System on Prescribing Practices after Out Patient Procedures

Posted on January 18, 2018

J. L. Philip1, J. R. Imbus1, J. S. Danobetia1, N. Zaborek1, D. F. Schneider1, D. M. Melnick1  1University Of Wisconsin,Madison, WI, USA

Introduction:

The opioid epidemic continues. Overprescribing of opioids contributes to excess opioid supply for diversion and abuse. Recent data demonstrates wide variation in prescribing and significant over-prescribing following outpatient general surgery procedures. Many states have implemented prescription drug monitoring programs (PDMP) as a tool to help prevent and monitor prescription drug misuse and abuse. Beginning on April 1, 2017 Wisconsin law requires prescribers to review the WI electronic PDMP (ePDMP) prior to issuing most controlled substance prescriptions to their patients. Our aim was to investigate trends in opioid prescription amounts and to evaluate the impact of the ePDMP requirement on surgeon prescribing practices.

Methods:

We collected prescription data retrospectively for three months before and after implementation of the law, as well as for two months one year prior. Eligible procedures included outpatient inguinal hernia repair, umbilical hernia repair, laparoscopic cholecystectomy, and breast lumpectomy +/- sentinel lymph node biopsy.  All opioid prescriptions were converted to standard morphine milligram equivalents (MME).  We compared mean MMEs prescribed for different time periods. To estimate the effect of mandatory ePDMP review in Wisconsin on weekly mean MMEs prescribed, we performed an interrupted time-series analysis using an autoregressive integrated moving average (ARIMA) model with weekly intervals.

Results:

In January-March of 2017, the mean MME prescribed following outpatient operations was 135 ± 4.0 (~27 5mg hydrocodone pills). The amount in January 2016 was significantly higher (216 ± 10.2, ~43 5mg hydrocodone pills, p<0.001).  There was a significant decrease in the mean MME prescribed in the three months following the implementation of the ePDMP requirement (114 ± 3.6 MME, ~23 5mg hydrocodone pills, p<0.001 vs. January-March 2017 & vs. January 2016).  There was no difference in the procedure make-up across time periods. Figure 1 demonstrates a downward trend of opioids prescribed over time. Time-series analysis did not reveal a significant intervention effect (intervention parameter -1.84, t-value = -0.99, p = 0.335) for the implementation of the mandatory ePDMP review.

Conclusion:

We demonstrate a decrease in the amount of opioids prescribed by general surgeons for outpatient operations from January to June 2017 and a significant decrease compared to 2016. The implementation of mandatory ePDMP requirements for opioid prescribers does not appear to have had an effect on the amount of opioid prescribed in the early post-intervention period suggesting that additional factors have contributed to decreased prescription amounts. 

 

82.18 Assessing Coding Practices for Surgical Operations over Time in the United States

Posted on January 18, 2018

F. Gani1, A. Z. Paredes2, J. K. Canner1, F. M. Johnston1, E. B. Schneider2, T. M. Pawlik2  1Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA 2Ohio State University,Surgery,Columbus, OH, USA

Introduction:  Variations in hospital billing practices may reflect differences in patient risk or may represent the “up-coding” of patients in response to payer incentives / polices. Given that modifications in hospital billing practices remain largely unknown for surgical services, the current study sought to assess whether coding practices on claims for surgical services have changed over time. 

Methods:  Patients >18 years undergoing a general surgery operation (colorectal, hepato-pancreatico-biliary or upper gastrointestinal surgery) were identified using the Nationwide Inpatient Sample from 2002-2011. Coding practices were compared by hospital and patient characteristics over time.

Results: A total of 1,339,654 patients were identified who met inclusion criteria. Among all patients, the mean number of billing codes was 8.8 codes/record (SD=4.6) with the number of “up-coded” patients (≥9 codes/record) increasing from 41.5% in 2001 to 63.4% in 2011 (p<0.001). While greater patient comorbidity, elective surgery and being enrolled in Medicare were all associated with a greater proportion of up-coded patients (all p<0.001), an increase in the number of “up-coded” patients was also observed among patients presenting without comorbidity who underwent an elective operation. This pattern in coding practices was also observed when this sub-population of patients was stratified by the primary payer (Figure). Coding practices were also observed to be variable by hospital characteristics, with the proportion of up-coded patients consistently higher at non-teaching hospitals compared with rural and teaching hospitals (both p<0.001). Median total charges were 61.1% higher among patients who were up-coded (mean number of codes/record: ≥9 vs. <9: $43,905 [23,259-86,992] vs. $27,247 [16,925 vs. 44,019]).

Conclusion: The number of “up-coded” patients was observed to increase with time; this increase was not explained by patient severity and was associated with higher total charges among patients.

 

82.15 Surgical Performance Dashboard Analysis Affirms that Hypertension is a Biomarker of Surgical Risk

Posted on January 18, 2018

L. A. Gurien1, J. Ra1, H. Kendall1, L. Palmer1, A. J. Kerwin1, J. J. Tepas1  1University Of Florida College Of Medicine – Jacksonville,General Surgery,Jacksonville, FL, USA

Introduction:
The NSQIP dataset tracks specific patient comorbid conditions (CM) and post-operative adverse events (AE). While CM do not always cause AE, analysis of a matrix of concurrent CM and AE demonstrates interaction of CM and AE to define risk from a population perspective. Using our surgical performance dashboard which tracks population risk, categorizes effect of AE using the Clavien-Dindo (C-D) system, and ranks individual provider performance, we evaluated the effect of our surgical quality program over a four year period. We hypothesized that the dashboard would document dominant risk factors, guide analysis of “unexpected” AE occurring with no CM, track AE effect, and define specific procedures and providers for focused assistance in managing risk.

Methods:

Two 12-month cohorts of general-vascular cases from 2013-14 and 2016-17 were evaluated. We analyzed concomitant occurrence of CM and AE to define most common CM with highest AE rate, and most common AE and associated CM. “Unexpected” AE without CM were analyzed by CPT and type of AE. The impact of AE regarding additional resource consumption was compared across study periods using Wilcoxon matched pairs test accepting p<.05 as significant. Reflecting a “march to zero”, individual performance was measured as a surgeon’s proportion of AE divided by proportion of cases performed. Scores within the group mean ±1 SD were classified as “expected” and lower outliers as “exceptional”.

Results:

The 2013-14 cohort consisted of 651 cases with 21% (n=137) incidence of AE. The 2016-17 cohort consisted of 596 cases with 20% (n=120) incidence of AE. For both groups, hypertension was associated with highest incidence and severity of AE, and transfusion within 72 hr. was the most common AE. C-D effect analysis demonstrated a shift over time to less severe AE (Figure), although not statistically significant (p=.625). Of cases with unexpected AE based on no CM, 90% were elective oncologic procedures with infection and sepsis as the most common AE. Provider performance over time identified the same surgeons with the highest AE/volume; however scores improved over time for >50% of participants.

Conclusion:

This dashboard analysis demonstrates that hypertension, which is often clinically silent, is a population time bomb for adverse surgical outcome.  Review of cases with unexpected AE illustrated the primacy of optimization and infection control as major adjuncts in these mostly elective complex cases. Individual provider and group performance identified quality improvement over time and a consistent provider cohort whose case mix mandates more aggressive preemptive strategies for avoidance of adverse events.

82.16 Revised Cardiac Risk Index Poorly Predicts Cardiovascular Complications after Adhesiolysis for SBO

Posted on January 18, 2018

D. Asuzu1, G. Chao1, K. Y. Pei1  1Yale University School Of Medicine,Department Of General Surgery,New Haven, CT, USA

Introduction:

The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) universal surgical risk calculator estimates risk of postoperative cardiovascular complications with a good to excellent overall accuracy in the NSQIP dataset (c-statistic 0.895). However, the NSQIP calculator requires up to 21 variables for prediction including intraoperative details, and its retrospective use is limited by unavailability of individual regression coefficients. The Revised Cardiac Risk Index (RCRI) can be readily estimated prospectively or retrospectively using only six clinical variables, however its accuracy in large surgical datasets has not been tested. Our objective was to determine accuracy of the RCRI for predicting cardiovascular complications after adhesiolysis for small bowel obstruction (SBO) using the NSQIP dataset. 

Methods:
8,196 cases of open or laparoscopic adhesiolysis (Current Procedural Terminology codes 44005 and 44180) for SBO (International Classification of Diseases, tenth edition 560.81 and 560.9) were analyzed from 2005 to 2013 using the NSQIP dataset. RCRI estimates were calculated for each case and compared to reported cardiovascular complications (myocardial infarction or cardiac arrest) using univariable logistic regression. Overall predictive accuracy was assessed by measuring model discrimination (c-statistics) and model calibration (Hosmer-Lemeshow Chi-squared statistics).  

Results:

RCRI predicted cardiovascular complications with odds ratio 1.96, 95% confidence interval (CI) 1.54 – 2.50, P < 0.001. However, c-statistic was poor (0.64, 95% CI 0.59 – 0.68), and Hosmer-Lemeshow Chi-square did not reach statistical significance (X2 35.49, P < 0.001, 3 groups) indicating low model discrimination and calibration.

 

Conclusion:

Despite its relative computational simplicity, the RCRI performed poorly as a predictor of cardiovascular complications after adhesiolysis for SBO. These findings call into question the utility of the RCRI in this patient population. Future studies should aim to develop models that are computationally simple while retaining predictive accuracy. 

82.13 Is Intraoperative Assessment of Small Bowel Resection Accurate?

Posted on January 18, 2018

W. I. McKinley1, B. Strollo1, M. Benns1, A. Motameni1, N. Nash1, M. Bozeman1, K. Miller1  1University Of Louisville,Department Of Surgery,Louisville, KENTUCKY, USA

Introduction: Enterectomy is a commonly performed procedure in trauma and acute care surgery but the term is nebulous in regard to the extent of bowel resected.  There is wide variation in practice between intraoperative assessment of bowel length and the accuracy of that assessment is unknown.  The aim of this study is to determine the accuracy and frequency of intraoperative assessment of bowel length.

Methods: After obtaining IRB approval retrospective chart review was performed of patients from three centers in Louisville, KY having undergone enterectomy (CPT codes 44120, 44202) from 2012-2016.  Patients were excluded if lacking pathology or an operative report.  Subgroups (0 to <10cm, 10 to <30cm, 30 to <50cm, and >50cm) were created based on length dictated by the operative surgeon.  Groups were compared using a 2-tailed Student’s t-test.

Results: 174 patients were included in the study (219 bowel resections) of whom 106 did have an estimate of bowel length resected (48.4%). 24 patients had <10cm removed, 47 patients had 10-30cm removed, 18 patients had 30-50cm removed, and 17 patients had >50cm removed.  Estimated bowel length <10cm showed a statistically significant underestimation in comparison to pathologic specimen, and larger resections tended to be overestimated.

Conclusion: Documentation regarding extent of bowel resected at our institution was poor, as surgeons dictated estimated length in less than half of cases.  Surgeons underestimate short segment resections while overestimating on extensive (>50cm) enterectomy.  Documentation of extent of enterectomy should be standardized and can have future clinical implications.

 

82.14 Outcomes of Femoral Hernias in Veteran Patients

Posted on January 18, 2018

L. R. Taveras Morales1, S. Huerta1,2  1University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA 2VA North Texas Health Care System,Department Of Surgery,Dallas, TX, USA

Introduction: Femoral hernias are much less common than inguinal hernias (2-4% of all groin hernias).  An analysis of 3,980 femoral hernias showed that femoral hernias were more common in women compared to men (63% vs. 37%) and are more likely to present with a hernia complication compared to inguinal hernias (36% vs. 4.9%).  The aim of the present study is to determine incidence and outcomes in patients with groin hernias at a veteran affairs hospital. 

Methods: A retrospective analysis of a prospectively maintained database of a single surgeon’s practice over 12 years (2005-2017) at the VA North Texas Health Care System (VANTHCS). The database included 1153 consecutive groin hernias in 1062 patients. Wilcoxon rank-sum test and Fisher’s exact test were used to compare the continuous and categorical outcomes, respectively. Patient postoperative morbidity was explored in a multivariable logistic regression model. The model was constructed using a forward stepwise technique.

Results:  Of 1153 inguinal hernias performed by the same surgeon over a 12-year period, 15 were femoral (1.3%).  The hernia sac contained an inflamed appendix in one of them (0.09%).  Patients with femoral hernias were older (64.7 ± 17.7 vs. 63.0 ± 5.9; p = 0.03), more likely to present with an incarcerated groin hernia, and would require a small bowel resection more frequently.  Complications following a femoral hernia were higher compared to inguinal hernias (Table). 

Conclusion: Femoral hernias are uncommon in veteran patients. A veteran patient presenting with an incarcerated groin hernia is likely to have a femoral hernia. 

82.12 Laparoscopic versus Open Bowel Resection for Small Intestine Diverticulitis

Posted on January 18, 2018

M. P. DeWane1, A. S. Chiu1, I. Rezek1, K. Y. Pei1  1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA

Introduction: Small intestine diverticulitis is rare and individual surgeon operative experience is generally limited.  As such, optimal surgical management is unknown. This study addresses this knowledge gap by comparing outcomes of laparoscopic versus open operative management of small intestine diverticulitis.

Methods:

This analysis was a retrospective review of the prospectively gathered American College of Surgeons National Surgical Quality Improvement Project from a 5 year period (2010-2014). Patients included for analysis had a primary diagnosis of small intestine diverticulitis (ICD-9 code 562.01) and a primary or secondary procedure listing that indicated bowel resection. Patients were stratified as having undergone either laparoscopic versus open management.

Multivariable logistic regression models controlling for patient variables and comorbidities were constructed to examine risk factors for undergoing extended hospital length of stay (5 days), prolonged operation time (3 hours) or presence of any postoperative complication (including neurologic, cardiac, respiratory, bleeding, renal, infectious, thromboembolic, or wound complications). These models were constructed in a backwards fashion and utilized an inclusion value of 0.1 and significance value p<0.05.

Results: A total of 295 patients were included in this analysis, 22.4% of whom underwent laparoscopic operations. Selected variables and outcomes stratified by cohort are shown in Table I. Emergency cases were more likely to be completed in an open fashion but there were no significant differences in mortality between the operation types. Reoperations were more prevalent in the open cohort. Patients undergoing laparoscopic versus open operation had lower odds of having an extended length of stay (Odds Ratio [OR]: 0.28, p<0.001) and developing any complication (OR: 0.31, p=0.039) and increased odds of undergoing a prolonged operation (OR: 3.67, p<0.001). 

Conclusion: Surgical experience for small bowel diverticulitis is rare. Laparoscopic resection performed for small bowel diverticulitis is associated with decreased length of stay and complications. The laparoscopic approach should be considered a safe option in appropriate patients who can tolerate prolonged operations.
 

82.09 GASTROINTESTINAL BLEEDING IN THE 21st CENTURY: NO LONGER A SURGICAL DISEASE?

Posted on January 18, 2018

D. A. Hill1, L. Khoury1, M. Kopp1, M. Panzo1, T. Bajaj1, C. Schell1, A. Corrigan1, R. Rodriguez1, S. Cohn1  1Northwell Health At Staten Island University Hospital,Department Of Surgery,Staten Island, NEW YORK, USA

Objective: With the advent of proton pump inhibitors and H. Pylori treatment, the old dogma “the most common cause of lower gastrointestinal (GI) bleeding is upper GI bleeding” may no longer be accurate. Similarly the 1994 publication by McGuire describing the correlation between a transfusion requirement of > 4 units of packed red blood cells (PRBCs) requiring operative intervention 60% of the time may also no longer be valid. We sought to determine the most common causes of GI bleeding in patients without an obvious source and the likelihood of transfusion, and endoscopic or surgical intervention.

Method: We queried our hospital database for GI hemorrhage during 2015, excluding patients with obvious upper GI source (hematemesis), or anal pathology. We collected data from patients with GI bleeding defined as bright red blood per rectum, melena or a positive fecal occult blood test. The primary endpoints were etiology of GI bleed, amount of transfusions required and operative, endoscopic or angiographic interventions performed.

Results: 93 patients were admitted with GI bleeding: mean age was 74 years old (range 19 to 95), 52% were male, and mean hemoglobin was 8.2 (range 3.5 to 14.2).  74% received blood transfusions with an average of 2 units transfused per patient (range 0 to 9); 22% received ≥ 3 units of packed red blood cells. The etiology of bleeding was: 17% upper GI source; 15% lower GI source; and in 68% the source remained unknown.  Bleeding stopped spontaneously in 86% of patients and 9% died (deaths were related to refusal of transfusions, requests for comfort care measures or withdrawal of care). 71% underwent inpatient endoscopy with only 6% undergoing a therapeutic endoscopic intervention (none of those undergoing intervention were transfused ≥ 3 units). No patient had surgical or interventional radiologic procedures related to their GI bleed.

Conclusion: Gastrointestinal bleeding, without an obvious source on presentation, rarely requires operative or interventional radiologic intervention. Blood transfusions were not predictive of the need for therapeutic endoscopic intervention which was required in only 6% of patients.

82.10 Opioid Prescriptions in General Surgery: Perception vs Reality

Posted on January 18, 2018

J. S. Danobeitia1, J. R. Imbus1, J. L. Philip1, D. F. Schneider1, D. Melnick1  1University Of Wisconsin,Surgery,Madison, WI, USA

Introduction:

Opioid prescription is a common practice following common general surgical operations. However, over-prescription is a major factor influencing opioid-related mortality. The objective of this study was to compare the general perceptions, beliefs and actual prescribing practices of general surgery physicians in an academic setting.

Methods:

We queried our electronic medical record to identify prescriptions written by physicians at our institution over a three-month period. We evaluated the quantity of pills prescribed after common ambulatory procedures: laparoscopic cholecystectomy (LC, n=62), laparoscopic inguinal hernia repair (LIHR, n=80), open umbilical hernia repair (UHR, n=42) and lumpectomy (LUMP, n=126). We also distributed a survey assessing education in pain evaluation and control, opioid prescription habits and expectation of pain in patients undergoing these operations. We compared prescriber perceptions to actual practices by estimating a perceived to prescribed pill ratio (P:P) for the management of post-operative pain.

Results:

A total of 58 surveys were completed by attending (43.1%) and resident (56.9%) physicians at our institution. Approximately 25% of respondents rated their education regarding pain evaluation/treatment during training as adequate while 22.0% considered it inadequate. Overall, the majority of respondents (72.2%) considered opioids necessary for post-operative pain management. When asked about appropriate duration of opioid treatment post-operatively, the most often selected duration was 3-5 days for LC (19.7%) and LIHR (18.8%). A longer duration (7-10 days) was more often selected for UHR (20.7%) and a shorter duration (1-3 days) was preferred for lumpectomies (28.9%). Further analysis revealed that the P:P ratio for attending physicians for LC and LIHR was higher (+34% each), while residents showed a +37% ratio for LUMP (Table 1). Participants cited procedure type (26%), history of chronic pain (23.8%), anticipated need for refills (17.7%) and patient age (16.6%) as the main variables driving pill quantity per prescription. Respondents reported discussing the details of each opioid prescription with senior residents and/or attending physicians less than half the time.

Conclusion:

The majority of physicians consider opioid medication necessary for management of post-operative pain, but only 25% rate their education regarding pain management as adequate. In addition, there appears to be a tangible discrepancy between provider beliefs and actual opioid prescribing practices. Implementation of educational programs and enhancing communication among care providers regarding best opioid prescription practices may constitute simple approaches to reduce narcotic over-prescription after surgery.

82.11 Outcomes of GI Operations in Neutropenic Patients

Posted on January 18, 2018

M. Harary1,2, J. S. Jolissaint2, A. Tavakkoli1,2  1Harvard Medical School,Boston, MA, USA 2Brigham And Women’s Hospital,Department Of Surgery,Boston, MA, USA

Introduction:  Surgery in neutropenic patients is often avoided due to presumed increased morbidity and mortality although limited data on actual outcomes is available. Here, we report on post-operative outcomes in neutropenic patients undergoing abdominal surgery, stratifying the severity of neutropenia to examine whether there is a critical number below which surgical risks are significantly different.

Methods:  We performed an institutional database search between 1988-2017 to identify patients who were neutropenic in the 24-hours prior to undergoing abdominal surgery. Endoscopic and percutaneous procedures were excluded. Neutropenia was defined as an Absolute Neutrophil Count (ANC) of <1500, determined either via direct measurement or extrapolation from leukocyte values. Patient outcomes were extracted by chart review. Severity of neutropenia was stratified as mild (1,000<ANC≤1,500), moderate (500<ANC≤1,000) or severe (ANC≤500). Comparisons were made using two-sided ANOVA, Kruskall-Wallis test, Chi-Squared test and binary logistic regression on SPSS.  

Results: A total of 134 patients were identified with a mean age of 56 years (SD 15.8); 41% were male. Of these, 69, 37, and 29, were mildly, moderately, and severely neutropenic, respectively (see Table). These subgroups did not vary significantly in age or gender distribution (F(2,131,) p=0.821, p=0.388).  Rates of 30-day mortality significantly vary among the subgroups (p=0.02) with 2.9%, 16.2% and 27.6%, in the mild, moderate and severe neutropenic respectively. The presence of severe neutropenia and urgency of procedure were both independent predictors of 30-day mortality (p=0.013, p=0.02). Severity of neutropenia was not a predictor of 30-day morbidity, ICU stay, disposition status, length of stay or likelihood of 30-day readmission. Overall, 61.2% of procedures were performed as an emergency.  These cases were associated with significantly higher rates of 30 days morbidity in the moderate and severe neutropenia subpopulations (p=0.028, p=0.026) and higher rates of ICU stay in the moderate group (p=0.032), compared to non-urgent cases in the same neutropenia group

Conclusion: Abdominal surgery in neutropenic patients, particularly in those with ANC<1,000, is associated with high rates of mortality regardless of etiology of the neutropenia. Ideally, surgery should be delayed whenever possible in order to allow ANC to rise, however this needs to be balanced against the possibility of an acute worsening and need for emergency surgery which is associated with a significant further increase in mortality.
 

82.07 Significant Proportion of Small Bowel Obstructions Require > 48 Hours to Resolve after Gastrografin

Posted on January 18, 2018

M. B. Mulder1, M. D. Ray-Zack2, M. Hernandez2, D. Cullinane4, D. Turay5, S. Wydo3, M. Zielinski2, D. Yeh1  5Loma Linda University School Of Medicine,Department Of Surgery,Loma Linda, CA, USA 1University Of Miami,Ryder Trauma Center: Division Of Trauma And Surgical Critical Care,Miami, FL, USA 2Mayo Clinic,Division Of Trauma, Critical Care, And General Surgery,Rochester, MN, USA 3Cooper University Hospital,Department Of Trauma Surgery,Camden, NJ, USA 4University Of Wisconsin,Department Of Surgery Marshfield Clinic,Madison, WI, USA

Introduction:  Gastrografin (GG)-based non-operative approach is both diagnostic and therapeutic for partial small bowel obstruction (SBO).  Absence of x-ray evidence of GG in the colon after 8 hours (h) is predictive of the need for operation and a recent trial used 48 h to prompt operation.  We hypothesize that a significant number of patients receiving the GG challenge require >48 h before an effect is seen.

 

Methods: In this post-hoc analysis of a multi-institutional SBO database, only patients receiving the GG Challenge were included. We excluded those without a nasogastric tube (NGT), NGT removal on the same day as insertion, and flatus before NGT insertion. Date of NGT insertion and removal were used to calculate the number of days of NGT decompression.  Passage of flatus and NGT removal were used as surrogate endpoints for evidence of passing the GG Challenge. “Hard” preoperative signs for operation included: closed loop obstruction, septic shock, and peritonitis. Multiple logistic regression analysis controlling for age, prior abdominal operation, and prior SBO exploration was performed to identify predictors of delayed (>48 h) GG Challenge effect.

 

Results: Of 319 patients receiving GG, 225 patients (71%) were successfully managed non-operatively (mean age 64  ±  16 years; 56% female).  X-ray was performed after a median 8 [4-8.5] h and GG was observed in the colon in 179 (80%). A total of 64 patients (28%) had NGT decompression for >48 h (n=58) or required >48 h to pass flatus (n=37), with some requiring both (n=21).  By 4 days, 215 (96%) of those who successfully passed the GG challenge had passed flatus.  Regression analysis demonstrated that previous abdominal surgery was predictive (OR 0.37 [0.16-0.88], p=0.024) of a delayed GG Challenge effect.  Ninety-four patients (29%) receiving GG underwent operative exploration (mean age 63 ±  17 years; 61% female).  X-ray was performed after a median 8 [6-9] h and GG was observed in the colon in 17 (18%).  Of the 94 undergoing operation, 24 (25%) underwent operation before day 4 without “hard” signs and also did not have intraoperative findings of strangulation, perforation, or require bowel resection.  In these 24 subjects, x-ray was performed after a median 8 [6-9] h and GG was observed in the colon in 6 (25%). 

 

Conclusion: A significant proportion of patients (20%) “failed” the 8 h GG Challenge but were successfully managed non-operatively.  At 48 h, a large proportion (28%) still required NGT or had not yet passed flatus, but were nevertheless successfully managed non-operatively.  Extending the GG Challenge to 96 h may help avoid operation in some patients, especially those without previous abdominal surgery.

82.08 Microbiological Patterns and Sensitivity in Necrotizing Soft Tissue Infections in Rwanda

Posted on January 18, 2018

M. CHRISTOPHE1, J. Rickard2,3, F. Charles1,4, N. Faustin1,3  1University Of Rwanda,College Of Medicine And Health Sciences,Kigali, KIGALI, Rwanda 2University Of Minnesota,Surgery And Critical Care,Minneapolis, MN, USA 3University Teaching Hospital Of Kigali,Surgery,Kigali, KIGALI, Rwanda 4Rwanda Military Hospital,Plastic And Reconstructive Surgery,Kigali, KIGALI, Rwanda

Introduction: Necrotizing soft tissue infections (NSTI) remains a challenging emergency surgical condition with rapid clinical deterioration, microbiological variability and increased morbidity and mortality

Methods: This prospective cohort study includes all patients managed in Department of Surgery, University Teaching Hospital of Kigali (CHUK) from April 2016 to January 2017 with NSTI. The objective was to describe patients’ demographics, involved tissue planes, bacterial pathogens involved, antimicrobial sensitivity patterns and outcome of care. Analyses were conducted using student t-test for continuous variables and Pearson chi-square test for categorical variables. P-value < 0.05 was considered significant

Results:A cohort of 175 patients with confirmed diagnosis of NSTI was recruited during the study period. Monomicrobial organisms were identified in 57% of cases: Klebsiella spp (n=28, 16%), Escherichia coli (n=22, 13%, Proteus spp (n=20, 11%, and Staphylococcus aureus (n= 19, 11%. Fifty one (29 %) patients had no bacterial growth. The overall isolated germs were gram negative (n=121, 81%) with predominance of klebsiella spp (n=38, 25%).  Third generation cephalosporins were prescribed in 136 (78%) patients. Forty to sixty five (40-65%) of commonly isolated organisms (klebsiella spp, Escherichia coli) were resistant to most used antibiotics (third generation cephalosporins). The overall mortality was 26%.  The median length of hospital stay was 23days (IQR: 8-41). 

Conclusion:NSTIs are found to be predominantly mono-microbial with high resistance to 3rd generation cepahalosporins. A large scale antibiogram study is needed to guide clinician decision making for empirical antibiotic coverage in NSTI in order to improve patients’ outcomes.

 

82.05 Timing of Post-Operative Complications after Major Abdominal Surgery Varies by Age

Posted on January 18, 2018

C. Bierema1, A. J. Sinnamon1, C. E. Sharoky1, C. J. Wirtalla1, R. E. Roses1, D. L. Fraker1, R. R. Kelz1, G. C. Karakousis1  1University Of Pennsylvania,Philadelphia, PA, USA

Introduction:  The relationship between patient age and timing of postoperative complication is unknown. We hypothesized that advanced patient age may be associated with later presentation of certain common complications following major abdominal surgery.

Methods:  

The American College of Surgeons National Surgical Quality Improvement Program (2001-2011) was used to evaluate timing of postoperative complications in patients undergoing elective major abdominal surgery (colectomy, gastrectomy, hepatectomy, and pancreatectomy). The Jonckheere-Terpstra test was used to assess for significant trends in age and later median postoperative day of complications. Multivariable linear regression adjusting for patient factors was then performed to examine the association between older age and timing of postoperative complications.

Results: 

A total of 108,689 patients met inclusion criteria. There were 8,834 patients <40y (8%), 54,040 patients 40-65y (50%), 36,834 patients 66-80y (34%), and 8,891 patients >80 y (8%). More than half the patients (58%, n=63,004) underwent colectomy. The remainder of the cohort underwent pancreatectomy (26% n=28,388), hepatectomy (10% n=10,687), and gastrectomy (6% n=6,610).  Significant differences in comorbid status by age group were observed. Before adjustment for patient factors, the median number of days to complication for urinary tract infection (p<0.001), pneumonia (p<0.001), superficial surgical site infection (p<0.001) and deep/organ space surgical site infection (p=0.046) was significantly longer with increasing age (see figure). There was no significant difference between median days to complication and age for venous thromboembolism, cardiac or renal complications. After adjustment for patient factors, a significant association between older age and later median day of complication presentation was only observed for urinary tract infection (p<0.001) and pneumonia (p<0.001). Other patient factors being equal, patients >80 years of age presented on average 2.56 days later with urinary tract infection and 1.46 days later with pneumonia than patients <40 years of age.

 

Conclusion: Urinary tract infection and pneumonia present later postoperatively with increasing age. Further study is needed to delineate whether these represent biological differences or delay in diagnosis, as elderly patients may not present with the same classic symptoms as younger patients. Recognition of these trends is important in the postoperative care of elderly patients, which is particularly relevant with the aging population. 

82.06 Staphylococcus aureus Nares Colonization Rates and Decolonization Efficacy of Povidone-Iodine

Posted on January 18, 2018

D. S. Urias1, J. Di Como1, K. Curfman1, M. Marley1, W. Carney1, D. Duke1, R. Dumire1, S. Morrissey1  1Conemaugh Memorial Medical Center,Johnstown, PA, USA

Introduction:
Surgical site infections (SSIs) are the most common hospital acquired infections (HAIs), although rare in abdominal wall hernia repair it is one of the most dreaded complications. Bundle protocols using chlorhexidine-gluconate (CHG) bath, nasal S. aureus decolonization with povidone iodine, and standard preoperative antibiotics have been proven in multiple trials to decrease SSIs. Because of these findings, we added a nasal decolonization bundle protocol to most surgical procedures with similar results. To better understand the impact of this key portion to the bundle protocol, we investigated colonization prevalence to provide insight as to the actual (practical) decolonization efficacy.

Methods:
A prospective observational study enrolling patients undergoing elective abdominal wall hernia repair with mesh. All patients were instructed to bathe with CHG the night before and morning of surgery, preoperatively a nasal culture for S. aureus was obtained from the nares, the nares were then swabbed with povidone-iodine nasal swabs, standard preoperative antibiotics were administered and the patient underwent the procedure. Postoperative nasal cultures for S. aureus were also obtained. Pre and post colonization prevalence were compared, thereby providing an estimate of the actual efficacy of our decolonization protocol in eliminating S. aureus in the nares.

Results:
To date, 80 patients have been consented and enrolled, with 54 patients completing all steps of the bundle and culture series. The study sample demographics include 91% males, mean age 59, mean BMI 29 and mean ASA was 2. The mean length of surgery was 47 minutes and the mean time from end of surgery to obtaining the post decolonization s. aureus nasal culture was 105 minutes.  For our study sample, the estimated prevalence of colonization with MRSA and/or MSSA is 22.2% (12/54) pre decontamination (11 MSSA, 1 MRSA, 0 positive for both) and 9.25% (5/54) after decontamination and surgery (5 MSSA and 0 MRSA), yielding an approximate 68% decontamination efficacy.

Conclusion:
Decreasing the rate of SSIs is a task assumed by a variety of departments within the health system using numerous methods. Evidence based decontamination protocols such as the one we have implemented are being successfully used to decrease SSIs. We have used our protocol in orthopedic and neurosurgical procedures and now have successfully expanded the protocol to repairs of abdominal wall hernias with mesh. The efficacy of povidone iodine in our study population although not as high as stated in recent literature, it does provide evidence for its use in a bundle protocol to decrease SSIs.
 

82.03 Epidurals are Associated with Increased Morbidity and Length of Stay in Open Ventral Hernia Repairs

Posted on January 18, 2018

S. L. Zhou1, M. C. Helm1, J. H. Helm1, M. I. Goldblatt1  1Medical College Of Wisconsin,Department Of Surgery,Milwaukee, WI, USA

Introduction:

Open ventral hernia repair is a common surgical procedure with multiple options for post-operative pain control.   Intravenous narcotics or epidural anesthesia are commonly used options. The primary objective of this study was to determine the morbidity and mortality associated with the use of epidurals for post-operative pain control.

Methods:
This study was a retrospective review of patients who underwent open ventral hernia repair. Data was abstracted from the National Surgical Quality Improvement Program 2015 dataset. Outpatient procedures, emergency cases, patients who did not receive mesh, or patients who remained inpatient for less than two days were excluded from analyses to identify only complex hernias. 

Results:
In total, 1943 patients met inclusion criteria of which 1009 (51.93%) received any combination of non-epidural post-operative pain relief and 934 (48.07%) received an epidural. The patients who received an epidural had a higher incidence of pulmonary embolism, urinary tract infection and had a longer operative time and length of stay compared to those patients without an epidural (Table 1).

Conclusion:
The use of epidurals was associated with in an increased incidence of pulmonary embolism and urinary tract infections.  In addition, epidural use was associated with an increased operative time and length of stay.  The use of epidurals was not associated with an increased incidence of surgical site infections suggesting that the complexity of hernias between the groups was similar. 

82.04 Thyroidectomy In Older Adults: An ACS-NSQIP Study Of Outcomes

Posted on January 18, 2018

Z. T. Sahli1, G. Ansari1, J. K. Canner1, D. Segev1, M. A. Zeiger1, A. Mathur1  1Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA

Introduction:  The rise in the geriatric population in the US along with the increasing prevalence of thyroid nodular disease and cancer will lead to a higher number of thyroidectomies performed in this age group.  The impact of thyroidectomy in older adults is not well defined. The aim of our study was to evaluate surgical outcomes after thyroidectomy in older adults as compared to younger adults.

Methods:  We conducted a retrospective cohort study using the American College of Surgeons National Surgery Quality Improvement Program database from 2012-2015. We included and categorized thyroidectomy patients into three age groups (18-64 years, 65-79 years, and ≥80 years) and analyzed 30-day perioperative outcomes using the bivariate X2 test and multivariate logistic regression to estimate risk of outcomes.

Results: Our study identified 39,859 patients who underwent thyroidectomy. Among our cohort, 31,315 (78.56%) patients were between 18-64 years, 8,544 (21.44%) were between 65-79 years, and 904 (2.27%) were ≥80 years. Compared to younger patients, patients ≥80 years were 2.25 times more likely to develop a complication (95% confidence interval [CI]: 1.58-3.20, p<0.001), 1.52 times more likely to have a longer hospital stay (95% CI: 1.18-1.96, p=0.001) and were associated with higher rates of hematoma (16.67%, p<0.001). Compared to younger patients, patients 65-79 years were 1.36 times more likely to develop a complication (95% CI: 1.12-1.64, p<0.001), 1.31 times more likely to have a reoperation (95% CI: 1.07-1.62, p=0.011), and 0.64 times more likely to have a lower rates of related readmission (95% CI: 0.47-0.87, p=0.004).

Conclusion: Patients ≥80 years have significantly higher rates of complications, longer lengths of stay, and incidence of neck hematomas. Patients 65-79 years have higher rates of complications and reoperation rates and lower rates of related readmission. Further studies are needed to risk stratify individuals within the aging population to counsel patients and potentially mitigate these risks.

 

82.02 Perioperative Factors Associated With Postoperative Pain Following Open Ventral Hernia Repair

Posted on January 18, 2018

W. R. Ueland1, M. Plymale1, D. Davenport1, J. Roth1  1University Of Kentucky,Lexington, KY, USA

Introduction: Effective pain control following open ventral and incisional hernia repair (VHR) impacts all aspects of patient recovery. To reduce opioids and enhance pain control, multimodal pain management including use of epidural analgesia, muscle relaxants, and non-opioid analgesics are thought to be beneficial. The purpose of this study was to identify perioperative characteristics associated with patient-reported pain scores.

Methods: After obtaining IRB approval, surgical databases were searched for open VHR cases performed by one surgeon over three years. Modes of pain management and visual analog scale (VAS) pain scores were recorded in twelve-hour intervals to hospital discharge or up to eight days post-operation. Patient characteristics were determined by medical record review. Forward stepwise multivariable regression (p for entry < .05; exit > .10) was used to assess the independent contribution to VAS scores of the preoperative, operative and postoperative factors.

Results: One hundred and seventy-five patients underwent elective open VHR with mesh implantation and were included in the analyses. Average patient age was 55.1 years (+/- 12.8 years) and slightly over half of the patients were female (50.9%). Just over one in ten patients were morbidly obese (BMI ≥40 kg/m2). No significant (p < .01) associations were found between VAS pain scores at any time point based on gender, ASA class, BMI, smoking status, history of cancer, heart disease or COPD. Patient factors independently associated with increased preoperative VAS scores included: preoperative opioid use, open wound, CDC Wound Class II and prior hernia repair(s). Patients with epidural for postoperative pain had significantly decreased VAS pain scores across the time continuum. Operative factors significantly associated with increased preoperative VAS pain score included: median hernia defect size, concomitantly performed procedure(s), duration of operation and estimated blood loss (EBL). Hospital length of stay and postoperative surgical site occurrence were associated with increased VAS pain scores at the preoperative and 0-11 hour postoperative time points. Greater preoperative VAS pain score predicted increased pain at each postoperative time point (all p < .05). 

Conclusion: Preoperative pain status and opioid use are associated with increased VAS pain scores postoperatively. Epidural analgesia effectively results in decreased patient-reported pain. Increased preoperative VAS pain scores are reflected in increased operative complexity measured by operative duration and EBL. 
 

82.01 Emergency General Surgery Patients With Psychiatric Comorbidities and Increased Resource Utilization

Posted on January 18, 2018

A. Lauria2, V. Haney1, J. S. Kim1, A. Kulaylat1, S. Armen1, M. Boltz1, S. Allen1  1Milton S. Hershey Medical Center,Hershey, PA, USA 2Walter Reed Medical Center,Bethesda, MARYLAND, USA

Introduction: Mental health disorders offer a challenge to the care of patients across medical and surgical specialties. The impact of mental health disorders on the emergency general surgery (EGS) population is largely unstudied. We aimed to identify the prevalence of psychiatric disorders in EGS patients, and hypothesized that those with mental health comorbidities who underwent emergent procedures would have worse postoperative outcomes and require more intensive resource utilization.

Methods: Using standard NSQIP practices, data were collected on adult patients admitted for emergent cholecystectomy or appendectomy at a single academic center between 04/01/07 and 01/01/16. Charts were reviewed for psychiatric comorbidities and psychotropic medications. Logistic regression was used to determine the impact of psychiatric comorbidities on postoperative complications, ED visits, and readmission within 30 days.

Results: Of the 641 patients identified (appendectomy n=491 and cholecystectomy n=150), 115 patients (17.9%) had psychiatric comorbidities. Mood disorders were most common (76.5%), followed by anxiety or adjustment disorders (41.7%). Patients with psychiatric comorbidities experienced longer hospitalizations (median 2 vs. 1 days, p<0.001) and required more subsequent ED visits (18.3% vs. 10.3%, p=0.016) compared to those without a psychiatric diagnosis. On multivariable analysis, the presence of psychiatric comorbidities was associated with nearly twice the odds of ED visits within 30 days (OR 1.92, 95% CI 1.01 to 3.68).

Conclusions: Patients with mental health comorbidities who undergo emergency general surgery burden the healthcare system with longer lengths of stay and more ED visits. Protocols and patient education focused on those with mental health disorders may improve these outcomes.

 

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