73.06 The True Cost of Laparoscopic Cholecystectomy with Routine Intraoperative Cholangiography

Posted on January 18, 2018

N. Cortolillo1, J. Parreco1, R. Rattan1, A. Castillo1, R. Kozol1  1University Of Miami,General Surgery Residency Program,Miami, FL, USA

Introduction:

Many prior comparisons of outcomes and costs associated with intraoperative cholangiography (IOC) have been reported. However, prior studies have been limited to initial hospitalizations or readmissions to single institutions. The purpose of this study was to compare outcomes and costs of hospitals performing routine IOC to hospitals performing non-routine IOC including readmission cost across hospitals in the US.

Methods:
The Healthcare Cost and Utilization Project’s (HCUP) Nationwide Readmission Database for 2013-2014 was queried for all patients aged 18 years or older undergoing laparoscopic cholecystectomy. Hospitals performing intraoperative cholangiography in 90% or more of cases were identified as routine and compared to non-routine hospitals. Total charges and costs were calculated according to HCUP standards. Univariable logistic regression was performed for the outcomes of interest using ten different hospital and patient variables. The variables with p<0.05 were used for multivariable logistic regression. Results were weighted for national estimates.

Results:
There were 628,280 inpatient laparoscopic cholecystectomies during the study period with 2.0% occurring in hospitals performing routine IOC. The mortality rate was 0.4%, length of stay was >7 days in 11.0%, and readmission within 30 days occurred in 6.9%. Multivariable logistic regression revealed there was no statistically significant different risk for these outcomes between routine and non-routine IOC hospitals. Table 1 shows the mean age of patients at hospitals performing routine IOC was older, but had a lower Charlson Comorbidity Index and shorter length of stay. Non-routine IOC hospitals had higher mean index total charges but lower mean index total cost. Readmission charges were similar between the groups while readmission cost was higher in routine-IOC hospitals.

Conclusion:
While outcomes are similar, non-routine IOC hospitals charge more than routine IOC hospitals. Despite this, the costs are higher in routine IOC hospitals suggesting an unnecessary cost burden placed on hospitals performing routine IOC.

73.04 Perforated Peptic Ulcer Surgery: No Difference in Mortality Between Laparoscopic and Open Repair.

Posted on January 18, 2018

V. Gabriel1, A. Grigorian1, S. Schubl1, M. Pejcinovska1, E. Won1, M. Lekawa1, N. Bernal1, J. Nahmias1  1University Of California – Irvine,Division Of Trauma, Burns & Surgical Critical Care,Orange, CA, USA

Introduction:  The lifetime prevalence of perforated peptic ulcer (PPU) in patients with peptic ulcer disease is estimated at 5%. Reported mortality rates after surgery for PPU have ranged from 1 to 24%. A recent meta-analysis by Tan et al demonstrated equivalent morbidity and mortality when comparing laparoscopic repair (LR) to open repair (OR).  However, LR was shown to have lower operative time, less pain, shorter length of stay (LOS), and a lower rate of surgical site infection. We hypothesized a decrease in morbidity and mortality with LR from 2011-2015 compared to 2005-2010. Additionally, we hypothesized a decrease in morbidity and mortality for LR versus OR for the entire duration of 2005-2015.

Methods:  Patients undergoing operative repair of PPU between 2005- 2015 were identified in the NSQIP database by CPT code. Patients with definitive acid-reducing operations were excluded. A comparison of OR from 2005-2010 versus 2011-2015 was performed. A similar comparison was performed for LR. Additionally, a comparison between LR and OR for the entire duration (2005-2015) was conducted. Primary outcomes were the differences in 30-day mortality and overall morbidity. After controlling for significant covariables such as age, American Society of Anesthesiologists class, functional status, pre-operative albumin and creatinine, steroid use, liver disease, time to surgery, and presence of malignancy, a multivariate regression analysis was performed.

Results: 5,413 patients between 2005-2015 were included in the study. From 2005-2010 there were 86 LR cases and 1,924 OR cases.  Between 2011-2015 there were 221 LR cases and 3,182 OR cases. LR demonstrated no difference in 30-day mortality or overall morbidity between the two time periods (p>0.05). There was no significant difference in 30-day mortality for patients undergoing OR between the two time periods. However, overall morbidity (odds ratio (OR), 1.99; 95% CI, 1.71-2.33, p<0.05), development of sepsis (p<0.05), and septic shock (p<0.05) were all more prevalent in patients undergoing OR from 2011-2015. Comparing LR versus OR from 2005-2015, patients undergoing LR had a shorter length of stay (p<0.05), and were less likely to exhibit failure to wean from the ventilator at 2 days (OR, 0.34; 95% CI, 0.18-0.65, p<0.05). 

Conclusion: While a 2.5% increase LR utilization was seen, there was not a decreased morbidity and mortality associated with more recent LR from 2011-2015. This may be secondary to increasing utilization of LR in more debilitated patients over time. When LR was compared to OR there was a significant decrease in LOS. Future prospective research is needed to confirm this finding and evaluate the safety of more widespread adoption of LR for PPU.

 

73.02 Percutaneous Cholecystostomy in Acute Cholecystitis – Predictors of Recurrence & Cholecystectomy

Posted on January 18, 2018

M. N. Bhatt1, M. Ghio1, L. Sadri1, S. Sarkar1, G. Kasotakis1, C. Nasrsule1, B. Sarkar1  1Boston Medical Center,Department Of Trauma And Acute Care Surgery,Boston, MA, USA

Introduction:  Acute cholecystitis (AC) is a common acute illness, with the preferred treatment being cholecystectomy. However, in high-risk patients, a less invasive option of percutaneous cholecystostomy tube placement (PC) is preferable. Patients can subsequently either undergo interval cholecystectomy (IC) or PC can be utilized as definitive treatment. Currently, there is little evidence to guide patient care after PC. We sought to demonstrate the clinical outcomes of PC and identify the predictors of recurrent disease as well as successful IC.

Methods:  A retrospective chart review of patients undergoing PC for AC between 2008 and 2016 at a single tertiary care center was performed. Basic patient demographics, laboratory & imaging findings, and patient outcomes including mortality, readmissions, hospital length of stay (LOS), Intensive Care Unit (ICU) LOS, recurrence, and IC were collected. Univariate and multivariate analyses were performed using logistic regression, Wilcoxon Rank, and multi-variable logistic regression models.

Results: Of 145 patients, 96 (67%) had calculous and 47 (33%) had acalculous cholecystitis. PCs were performed in these patients due to their high preoperative risks; 72 (49%) had chronic prohibitive risks and 73 (51%) had acute prohibitive risks. There were 55 (38%) peri-procedural complications, 44 of which were PC dislodgment. Mean duration of PC was 93 days. Recurrence rate for AC was 18%; median duration to recurrence was 65 days. Patients with calculous cholecystitis were more likely to have AC recurrence (OR = 3.24, p = 0.018), whereas length of antibiotics course or duration of PC had no significant correlation with AC recurrence. 41 (28%) patients underwent IC. Patients with acute prohibitive risks and shorter antibiotics course (≤ 7 days) were more likely to undergo IC (OR = 6.66 & 2.10, p = <0.001 & 0.048), and most were completed laparoscopically (OR = 6.84, p = <0.0001). There were only two peri-operative complications and no peri-operative mortality. Mean hospital and ICU LOS were longer for patients with acalculous cholecystitis compared to calculous (22 vs. 11 days, p = <0.0001). 30-day readmission rate was 29%. Patients with acalculous cholecystitis had higher 30-day readmission rate (OR = 2.42, p = 0.020). 30-day mortality after PC was 9%. The follow up was for 26(3-53) months and survival analysis revealed that patients receiving IC had greater survival compared to PC as a definitive option.

Conclusion: PCs are a viable option for high-risk patients with AC. Calculous cholecystitis is a strong predictor of AC recurrence after PC. A longer (>7 days) antibiotics course is not associated with lower recurrence and should be avoided. Patients undergoing IC have better overall survival. PCs, although safe, should not be considered as a definitive treatment, especially in patients with acute critical illness where a successful IC can be performed laparoscopically with minimal complications.

 

73.03 Opioid Use after Surgery among Preoperative Intermittent Users

Posted on January 18, 2018

E. Harker1, C. A. Keilin1, R. Ahmed1, C. Katzman1, D. C. Cron1, T. Yao3, H. Hu1, J. S. Lee1, C. M. Brummett2, M. J. Englesbe1, J. F. Waljee1  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,Department Of Anesthesiology,Ann Arbor, MI, USA 3University Of Michigan,School Of Public Health,Ann Arbor, MI, USA

Introduction:  A significant number of surgical patients intermittently take opioids prior to elective surgery. Understanding the clinical trajectory of this large number of patients is critical to optimizing their care. We hypothesize that a longer duration of preoperative opioid use will be correlated with a longer duration of postoperative use.

Methods:  We used a national employer-based insurance claims dataset to identify adults age 18 to 64 who were preoperatively either opioid-naïve or intermittent opioid users and who underwent a general, gynecologic, or urologic surgical procedure between January 2010 and March 2014 (N= 309,096). We defined preoperative intermittent opioid users as patients who filled ≤120 days’ supply of opioids between 365 and 31 days before surgery. Our primary explanatory variable was preoperative opioid exposure, measured as the number of months during which an opioid prescription was filled in the year prior to surgery (opioid-naïve, 1 month, 2-3 months, 4-6 months, 7-9 months, >9 months). Our outcome was time until last postoperative opioid script (considered the date of opioid discontinuation). We used survival analysis techniques, including Kaplan-Meier curves to compute estimated proportion of patients continuing to fill opioids postoperatively.

Results: In this cohort, 27% of patients used opioids intermittently in the year before surgery, and the majority of these patients (62%) filled opioids during 1 month preoperatively. Patients with a longer duration of preoperative opioid exposure continued to fill opioids for longer durations postoperatively (Figure). Most patients discontinued opioids after the initial prescription, but the remaining patients continued filling opioids long after surgery. Compared to patients with 1 month of opioid fills preoperatively, patients with >9 months of preoperative opioid fills had a 4-fold longer adjusted mean time until opioid discontinuation (326 vs. 84 days, P<0.001). The estimated proportion of patients continuing to fill ≥1 opioid script beyond 180 days was 90% among patients with >9 months of preoperative opioid use, 23% among patients with 1 month of preoperative use, and 15% among opioid-naïve.

Conclusion: Patients who intermittently use opioids prior to surgery are particularly vulnerable to prolonged postoperative opioid use. The surgical event should be considered an opportunity to wean opioid users postoperatively. Such strategies may have significant positive impact on the overall health and wellness of these surgical patients.

73.01 A 3 year Follow-up of Nonoperative Management in Ventral Hernia Patients With Comorbidities

Posted on January 18, 2018

K. Bernardi1, J. L. Holihan1, D. V. Cherla1, J. R. Flores1, L. S. Kao1, T. C. Ko1, M. K. Liang1  1University Of Texas Health Science Center At Houston,General Surgery,Houston, TX, USA

Introduction:
Individuals with comorbid conditions (e.g. obesity or smoking) are not only at increased risk to develop a ventral hernia but are at markedly increased risk for complications (including recurrence) following repair.  There is limited high-quality prospective data on the safety and efficacy of non-operative management of patients with ventral hernias.  Our objective was to determine the long term clinical and patient reported outcomes of non-operative management of patients with comorbidities also suffering from ventral hernias.
 

Methods:
This is the 3-year follow-up to a prospective observational single institution study of patient with comorbidities and ventral hernias.  Patients were contacted by phone to complete a standardized interview. Primary outcome was proportion of patients who underwent urgent or emergency surgery. Secondary outcomes were the change in quality of life (QoL) from their baseline interview and proportion of patients undergoing elective or emergent repair.  QoL was measured utilizing the modified activities assessment scale (AAS), a validated, hernia-specific QoL survey.  The minimal clinically important difference was considered a change of 7 points on a scale of 1-100 where 1=poor QOL and 100=perfect QOL.
 

Results:
Overall, 60 patients were followed to completion (Table below).  At the end of 3 years, 3 (5%) patients had died due to non-hernia related causes, 16 (26.7%) patients had at least one emergency room visit related to their hernia, 4 (6.7%) patients underwent urgent/emergent ventral hernia repair, and 15 (25%) patients underwent elective ventral hernia repair.  On average, non-operatively managed patients experienced no change in their QoL, while those who crossed over to operative management experienced a substantial improvement in their QoL.
 

Conclusion:
Non-operative management for patients with ventral hernias appears to be safe; however, there was a substantial crossover to operative intervention. For most patients who successfully completed non-operative management, their QoL did not change over 3 years.  On the other hand, patients who underwent ventral hernia repair had a major improvement in their QoL.

70.10 A Decade of Components Separation Technique; An Increasing Trend in Open Ventral Hernia Repair.

Posted on January 18, 2018

M. R. Arnold1, J. Otero1, K. A. Schlosser1, A. M. Kao1, T. Prasad1, A. Lincourt1, P. D. Colavita1, B. T. Heniford1  1Carolinas Medical Center,General Surgery,Charlotte, NC, USA

Introduction:

Components separation technique (CST), a complex surgical adjunct to ventral hernia repair (VHR), was originally described by Ramirez et al. greater than 25 years ago. Reports of CST have increased over the last several years, but no studies to date have examined the trends of CST utilization and associated complications over time. This purpose of this study is to examine the trends on CST over the past 10 years.

Methods:

The ACS-NSQIP database identified open VHR with components separation from 2005 to 2014. Preoperative risk factors, operative characteristics, outcomes, and morbidity trends were compared. Univariate analysis of outcomes and morbidity was performed. Multivariate analysis was performed to control for potential confounding variables.

Results:

A total of 129,532 patients underwent open VHR during the study period. CST was performed as part of 8,317 ventral hernia repairs. Use of CST increased from 39 cases in 2005, to 2,275 cases in 2014 (2.6% vs10.2%; p<0.0001). Over the past decade, preoperative smoking and dyspnea significantly decreased (p<0.05). A decrease was seen in superficial and deep wound infection (10.3% vs 5.7%;p<0.05) and (7.7% vs. 3.4%;p<0.05), and all wound related complications (18.0% vs 10.2%;p< 0.05), minor complications (18.0% vs. 13.4%; p<0.0001), and major complications (25.6% vs 12.8%;p<0.0001). Hospital length of stay decreased (11.0 vs. 6.3;p<0.05), and hospital readmissions decreased from 2011 to 2014 (14.4% vs. 11.1%;p<0.05). There was no significant change in thirty-day mortality (Range 0-1.42%;p=0.28). Multivariate regression was performed to control for pre-operative comorbidities; there was an overall decrease in wound dehiscence for 2011 (OR0.3, 95%CI 0.1-0.9), 2012 (OR0.2, 95%CI 0.1-0.7), 2013 (OR0.2, 95%CI 0.0-0.6), and 2014 (OR0.2, 95%CI 0.1-0.7). There was no significant change in major or minor complications, wound infection, or mortality.

Conclusion:

CST in VHR has significantly increased in frequency over 10 years. As experience with CST increased, there has been a significant decrease in the rate of associated complications. When adjusted for preoperative risk factors, the risk of wound dehiscence decreased. However, the rate of other complications has remained unchanged. This suggests preoperative patient optimization, and improvement in patient selection and modifiable risk factors, such as smoking, rather than changes in surgical technique, have led to improved outcomes. Due to the limitations of the NSQIP database, changes in chronic disease management, such as diabetes, may be overlooked. Additional studies are needed to further elucidate the reason for this decrease in complications.

 

70.07 The Effect of Trainee Involvment on Patient Outcomes in General Surgery Cases over Time

Posted on January 18, 2018

T. Feeney2, J. Havens1  1Brigham And Women’s Hospital,Trauma,Boston, MA, USA 2Harvard School Of Public Health,Boston, MA, USA

Introduction:  Resident duty hour reform was implemented in 2003 and further modified in 2011. The effect of these changes on patient outcomes remains unclear. We investigated the effect on outcomes of resident involvement in surgical procedures over time since these changes have been implemented. We hypothesized that there has been no change in outcomes since implementation of the resident work hours restrictions.

Methods:  We utilized the ACS-NSQIP database (2005-2012). General surgery were identified by common procedural terminology code, and were restricted to ages ≥18. Using 2005/2006 as reference logistic and linear regression analysis was performed.

Results:There were 422,733 procedures analyzed. In the attending only group there was no difference in the odds of major morbidity in 2012 (Odds Ratio (OR) (0.67 (95% Confidence Interval 0.35-1.31;p=0.247)), overall morbidity (0.86 (0.63-1.18;p=0.354)) or all-cause mortality(0.40(0.09-1.87;p=0.246)). In cases that included a trainee there was no change in the odds of major morbidity in 2012(OR 1.42(0.77-2.62;p=0.264)), the odds of overall morbidity (OR 1.12(0.81-1.53;p=0.495)) or the odds of all-cause mortality (OR 2.20(0.46-10.49;p=0.322)) over the same time period. There was an increase in mean operative time the attending only cases from 2005 to 2012 (14.7 min(10.8- 18.6;p<0.001), but there was a decrease of 7.48 min(11.0-3.9;p<0.001)in the mean operating time in the cases that included a trainee.

Conclusion: Between 2005-2012 there were no changes in the odds of overall complications, major complications, or all-cause mortality in surgeries involving attending surgeons only or involving trainees. There has been a significant change in the mean operative time in both groups. Attending surgeons operating alone had an increase in operative time while cases that included a trainee had a decrease in operative time. These data suggest that while operative time has changed, surgical outcomes for patients have not changed between 2005 and 2012.

 

70.05 Path to the OR: When are the Delays and How does it Impact Outcomes in Emergency Abdominal Surgery?

Posted on January 18, 2018

C. M. Dickinson1, N. A. Coppersmith1, H. Huber1, A. Stephen1, D. T. Harrington1  1Brown University School Of Medicine,Surgery,Providence, RI, USA

Introduction: Current recommendations state that patients with peritonitis should be operated on within 1-2 hours. However, there is limited literature that support time-based recommendations or identify where delays exist from the emergency room (ER) to the operating room (OR). We investigated the time course for patients that needed emergency abdominal surgery and evaluated whether time to operation impacted outcomes. 

Methods: A retrospective review was done of all non-transferred adult patients over a 5-year period who were admitted from the ER and underwent a non-trauma exploratory laparotomy within 24 hours of admission. To limit the study group to patients with clear emergent indications for surgery, small bowel obstructions without perforations, appendicitis, cholecystitis, GI bleeds, and malignant obstructions were excluded. Demographics, comorbidities, vitals, labs, and operative details were reviewed. Times were noted for presentation(PR) to ER, time of ER physician evaluation(EREval), timing of diagnostic imaging(SCAN), time of signed surgical consult note(SC), and time of case start(OR). Adverse outcomes were identified using ICD-9 codes for infectious complications, wound complications, kidney injury, ileus, cardiovascular complications, and respiratory failure. Chi-square, t-tests, ANOVA and discriminant function analysis were used.

Results: One hundred forty-one patients were reviewed. Mean age was 60.8 years, 55.3% were male, and mean APACHE II was 8.5. Mean time from PR to OR was 597 minutes, PR to EREval 91 minutes, EREval to SCAN 156 minutes, SCAN to SC 147 minutes and SC to OR 205 minutes. Patients that did not develop a complication had a shorter time from EREval to SCAN compared to those who developed complications (113.8 vs 176.8 minutes, p<0.05). Shorter total time to OR (543.7 vs 702.3 minutes, p<0.05) was associated with lower rates of complications. There was no significant difference in time to EREval based on the shift that the patient presented on, however those who had an image obtained during the first shift (7AM-3PM) had longer delays to SCAN (1st shift 204 minutes, 2nd shift 152 minutes, 3rd shift 130 minutes, p<0.05). There were no significant differences based on shift when evaluating time from SCAN to OR. However, those who had a case start time during first shift experienced significantly longer total delays to operation (1st shift 779 min, 2nd shift 527 min, 3rd shift 491 min from arrival to OR, p<0.05). 

Conclusion: Increased time to OR was associated with a higher number of complications in patients undergoing emergency abdominal surgery. These delays are spread out over a patient's course, from arriving to the ER, to obtaining imaging and surgical team evaluation. Interestingly it appears that during the first shift patients experience the most delays. Further investigation into the cause for these delays is critical to expediting patient care for those who need emergent abdominal surgery.

69.07 Regional Variation in Laparoscopic and Open Inguinal Hernia Repair Across Michigan

Posted on January 18, 2018

J. V. Vu1, V. Gunaseelan1,2, E. Seese2, M. J. Englesbe1,2, G. L. Krapohl1,2, D. A. Campbell1,2, D. Telem1  2Michigan Surgical Quality Collaborative,Ann Arbor, MICHIGAN, USA 1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Background: Despite the benefits of minimally invasive surgery (MIS) for inguinal hernia repair, adoption of this technique has been suboptimal compared to other operations (e.g., colectomy, hysterectomy, cholecystectomy). To better understand the clinical, demographic, and provider factors associated with uptake of MIS for inguinal hernia, we characterized the variation in utilization rate across a statewide population.

Methods: A retrospective cohort study was performed in patients undergoing open and MIS inguinal hernia repair from 2012 to 2016, using data from the Michigan Surgical Quality Collaborative, a statewide surgical collaborative of 73 hospitals. Operations for recurrent hernia, strangulation, or gangrene were excluded. Primary outcome was MIS utilization rate by Dartmouth hospital referral region. Secondary outcomes were provider, patient, and hospital characteristics associated with MIS utilization. Data were evaluated using a weighted hierarchical logistic regression model.

Results: A total of 6,185 inguinal hernia repairs were identified. Utilization of MIS ranged from 13.5% to 42.8% of all repairs across six geographic regions, as demonstrated in Figure 1 (p<0.001). Hospital site accounted for 41% of the variation in utilization; MIS repair was associated with higher hospital volume (p<0.001), but not with teaching status. Out of the 558 total surgeons, 322 (58%) performed no MIS repairs. After controlling for clinical, demographic, and geographic factors, patients aged 18 – 44 (OR 1.68, p<0.001) and patients aged 45 – 64 (OR 1.49, p<0.001) were more likely to receive MIS than patients aged 65 and older. Black patients were less likely to receive MIS than white patients (OR 0.72, p=0.017). Patients with COPD, hypertension, and in American Society of Anesthesiologists Class III or IV were also significantly less likely to undergo MIS repair. There were no differences in MIS utilization with respect to gender, obesity, and tobacco use.

Conclusion: Utilization of MIS for inguinal hernia repair is widely variable by region across a statewide population. Causes of this variation are likely multifactorial and are attributable to hospital, provider, and patient factors. Over half of the surgeons sampled do not perform MIS repair. Additionally, variation in MIS utilization was independently associated with patient age, race, and comorbid conditions. These findings support the presence of a practice gap in the delivery of MIS care. Exploratory, in-depth qualitative work investigating provider and patient-level barriers to MIS inguinal hernia repair is needed to develop evidence-based implementation intervention strategies.

67.09 The Effect of Insurance Type on Access to Inguinal Hernia Repair Under the Affordable Care Act

Posted on January 18, 2018

W. Hsiang1, S. Lee1, C. McGeoch1, W. Cheung1, R. Becher1, K. A. Davis1, K. Schuster1  1Yale University School Of Medicine,General Surgery, Trauma And Surgical Critical Care,New Haven, CT, USA

Introduction:
The expansion of Medicaid under the Affordable Care Act (ACA) extended coverage to any individual with incomes up to 138% of the federal poverty level. As of January 2017, 31 states and the District of Columbia have elected to expand Medicaid. Our study investigated the impact of the type of insurance on access to elective inguinal hernia repair and the disparities in access between expansion and non-expansion states.

Methods:
Using the Amercian College of Surgeons directory, 240 hernia repair surgeons across eight states (four which have expanded Medicaid [NY, CA, OH, IL] and four which have not [TX, FL. NC, GA]) were randomly selected. Investigators posed as simulated patients seeking an evaluation for an inguinal hernia and phoned selected surgeons. Physician offices were contacted using a standardized script from a caller ID-blocked phone number at three separate occasions to assess responses to three different insurance types (Blue Cross, Medicaid, Medicare). Appointment success rates and waiting periods were compared between published Medicaid and Blue Cross or Medicare scenarios.

Results:
Of 240 surgeons contacted, 75.4% scheduled appointments for Medicaid patients, compared to 98.8% for Medicare patients and 98.3% for those with Blue Cross (p<0.001). In states that expanded Medicaid, fewer offices accepted Medicaid patients compared to those in non-expanded States (68.3% vs 82.5%, P=0.011). No differences in wait times between expanded and non-expanded states were observed. Surgeons in urban settings were less likely to accept Medicaid patients than non-urban offices (70.6% vs 82.5%, P=0.036) while solo practices were less likely to accept Medicaid patients than group practices (50.0% vs 79.0%, P<0.001). No differences in the acceptance of Medicaid patients between academic and private practice surgeons were noted (P=0.516).

Conclusion:
Simulated Medicaid patients were less successful at scheduling appointments for surgical consultation than Blue Cross or Medicare patients. Despite expanded Medicaid, fewer surgeons in expansion states accepted Medicaid patients. These findings should be further investigated with future changes in Medicaid to understand impact on access to surgical care.
 

67.10 A Comparison of Index and Redo Operations in Crohn's Patients Following Bowel Surgery.

Posted on January 18, 2018

B. Sherman2, A. Harzman1, A. Traugott1, S. Husain1  1Ohio State University,Division Of Colon And Rectal Surgery,Columbus, OH, USA 2Ohio Health,Doctor’s Hospital,Columbus, OH, USA

Introduction: Due to chronic, recurrent nature of Crohn’s disease, many patients undergo repeat operations. These “redo” surgeries can be technically difficult due to the presence of adhesive disease and inflammatory / fibrotic changes. Thus, subsequent operative interventions are commonly perceived to be wrought with worse outcomes. While there is a plethora of literature on outcomes after index operations for Crohn’s disease, there is a scarcity of articles describing outcomes of redo operations and how they compare with index operations. An in-depth knowledge of these variables is critical for managing patient expectations and optimal perioperative planning from the surgeon’s perspective.

Methods: All Crohn’s patients undergoing surgery with the two participating surgeons over a period of six years were included. A retrospective chart review was conducted including patient demographics, comorbidities, postoperative complications, operative time, length of stay, and estimated blood loss. A comparison of in index versus redo operations was performed utilizing t-test for continuous variables and Fisher's exact test for categorical variables.

Results: We identified a total of 118 patients during the approved study period. Out of these 66 (55%) underwent index operation and 52 (45%) were redo operations. Overall complication rate was 29.66% (n=35), mean operative time was 220 minutes, average length of hospital stay was 8.36 days and EBL was 189.62 ml. There was no statistically significant difference between index and redo operations in terms of complication rates (27.27% vs 32.69%, p=0.55), EBL (211 vs 231 ml, p=0.85) and operative time (211 vs 231 min, p=0.28). However, the difference in length of stay between index operations (mean=6.79 days) and redo surgeries (mean=10.93 days) was statistically significant (p=0.0005). Laparoscopic approach was utilized at a significantly higher rate for index operations (61/66, 92.42%) compared to redo operations (35/52, 67.30%, p=0.007). Conversion rates were much higher for redo operations (3/35, 8.57%) than index operations (3/61, 4.91%). Use of laparoscopic approach narrowed the gap in length of stay between the index and redo groups from 4.14 days for the entire group to 1.8 days in patients who were treated laparoscopically.

Conclusion: Contrary to common perception, repeat operations in Crohn’s disease have similar outcomes as index operations however redo surgeries are associated with a much longer length of stay compared to initial surgeries. Utilization of laparoscopic technique reduces the gap in length of stay between index and redo operations however laparoscopy is associated with higher a conversion rate in redo operations.

67.06 The costs of complications on post-acute care spending after major surgery

Posted on January 18, 2018

A. E. Kanters1, A. Cain-Nielsen2, S. Regenbogen1  1University Of Michigan,General Surgery,Ann Arbor, MI, USA 2University Of Michigan,Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA

Introduction:  With increasing scrutiny on total spending for episodes of care, it is recognized that post-acute care (PAC) is the principal source of variation in payments around surgery. Studies have demonstrated that hospital quality is associated with episode spending, however the extent to which quality improvement measures to decrease postoperative complications can affect PAC costs has not been quantified. 

Methods:  This cross-sectional cohort study included Medicare beneficiaries undergoing colectomy, coronary artery bypass grafting (CABG), or total hip replacement (THR) between January 2009 and June 2012. Each patient with a recorded postoperative complication was matched 1:1 with one who underwent the same operation, but without complication, according to preoperative predictors of PAC spending (including Elixhauser comorbidities, age and type of admission). We computed average prize-standardized PAC spending within 90 days from index operation and compared adjusted payments and rates of use of each type of PAC between those with and without complications. PACs were dichotomized as inpatient (skilled nursing facility [SNF], inpatient rehabilitation [IPR], or long term acute care [LTAC]) versus outpatient settings (outpatient rehabilitation [OPR] or home health [HH]).

Results: After risk-matching, 73,858 CABG patients, 62,948 colectomy patients, and 3,192 THR patients were included. Price-standardized PAC payments increased $5,590 for CABG (p<0.001), $6,600 for colectomy (p<0.001), and $2,051 for THR patients (p<0.001) with postoperative complications. Among patients with complications, the likelihood of inpatient PAC was increased by 9.6% after CABG (p<0.001), 7.3% after colectomy (p<0.001), and 5.3% after THR (p=0.001); accordingly, there was a decrease in likelihood of outpatient PAC by 10.4% after CABG (p<0.001) and 6.2% after colectomy (p<0.001). There was no significant change in outpatient PAC utilization for THR patients (Figure).

Conclusion: Postoperative complications after major surgery are associated with significantly greater PAC spending, and increased use of high-cost, inpatient care settings. Reductions in PAC spending will be central to hospitals’ efforts to reduce episode costs around major surgery. Thus, quality improvement efforts that reduce postoperative complications will be a key component of success in emerging payment reform.

 

67.07 Needlescopic analgesia of abdominal wall for laparoscopic surgery

Posted on January 18, 2018

J. Nagata1, Y. Sawatsubashi1, M. Akiyama1, Y. Akiyama2, K. Arase2, N. Minagawa2, T. Torigoe2, Y. Nakayama1, K. Hirata2  1Wakamatsu Hospital Of University Of Occupational And Environmental Health, Japan,Surgery,Kitakyushu, FUKUOKA, Japan 2University Of Occupational And Environmental Health, Japan,Surgery,Kitakyushu, FUKUOKA, Japan

Introduction: Ultrasound-guided percutaneous rectus sheath block and transversus abdominis plane block have become increasingly popular and used to provide analgesia for laparoscopic surgery. We report a novel transperitoneal approach of analgesia for laparoscopic abdominal surgery.

Methods: Observation was performed retrospectively. Two groups were compaired. One is the group with only conventional anesthesia, and the other was patients with novel nerve block. Under general anesthesia, a laparoscopic puncture needle was inserted via 3 or 5mm abdominal port, and 10 – 20mL levobupivacaine was injected into the correct plane through the peritoneum. This procedure was performed under combined images of laparoscopy and ultrasound. Postoperatively, the patient’s pain intensity assessed by the numeric rating scale.

Results: A total of 100 consecutive patients were enrolled. Colorectal surgery was 50 cases, gastric surgery was 15 cases, repair of inguinal hernia was 25 cases and other was 10. All operation was performed successfully and a novel laparoscopic anesthesia did not prevent completing operative procedure. Postoperatively, the patient’s mean pain intensity by the scale was measured. Numeric rating scale was smaller in the group of novel anesthesia (0.4 vs 0.8 at 6hrs postoperative on moving, p=0.29). Total volume of intravenous fentanyl?(10mL vs 5mL/2days) and frequency of pain killer was reduced?(1.5 vs 2.8?times/day, p=0.03). The mean time of novel block technique was 4.5 minutes

Conclusion: This novel analgesia technique would be considered as an optional regimen in laparoscopic surgery. Additional prospective studies are required to evaluate the benefit of this new laparoscopic block.
 

67.08 Patient Education Materials Among Surgical Subspecialties Lack Readability

Posted on January 18, 2018

C. A. Perkins1, A. Liwo1, C. A. Gamuko2, J. A. Cannon1, J. Grams1, G. Kennedy1, M. Morris1, J. Richman1, D. I. Chu1  1University Of Alabama At Birmingham,Department Of Surgery,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,School Of Nursing,Birmingham, Alabama, USA

Introduction:  Health literacy is a major determinant of health outcomes through its influence on patient understanding of their care and aftercare instructions.  Patients’ understanding can be affected by the readability of health education material, which the American Medical Association (AMA) and National Institute of Health (NIH) recommends to be at a 6th grade reading level or lower. It is unclear whether surgical education materials follow this recommendation. We hypothesized that surgical patient education materials across surgical specialties are written above a 6th grade reading level. 

Methods:  Routine patient education materials were collected from surgical specialty clinics at a single, tertiary-care referral center. The Flesch-Kincaid Grade Level (FKGL) instrument was used to analyze the texts to generate a FKGL score without any correction of misspellings or grammatical errors. We averaged the FKGL for each sample to obtain a mean for each surgical specialty. Specialties were compared using two-sided one sample t-tests and ANOVA, as appropriate.  

Results: We collected 112 patient education materials from 13 surgical specialties. Of these, 29 were pre-operative, 58 were post-operative and 25 were clinical in nature. The overall average FKGL for all the patient education materials was 8.08 (standard deviation [SD] 2.08), exceeding the NIH/AMA standards sixth grade level by an average of 2.08 grade levels (95% CI=7.69-8.47; P <0.0001). Among specialties, the highest mean FKGLs were Neurosurgery (mean=9.83, SD=3.29, CI=1.65-18.01) and Thoracic (mean=9.61, SD=0.75, CI=9.03-10.19) while the lowest were Plastic Surgery (mean=6.34, SD=1.54, CI=5.61-7.09) and Endocrine (mean=7.08, SD=1.62, CI= 5.92-8.24) (Table 1). Surgical specialties with the highest percentage of reading materials at or below a 6th grade level were Plastics (47.4%), ENT (25.0%), GI-General (23.1%), Endocrine (20.0%) and Transplant (12.5%). The other 8 specialties had no materials at or below a 6th grade level.

Conclusion: The readability of patient education material across surgical subspecialties at a single institution is poor and deviates significantly from AMA/NIH recommendations. No surgical specialties had a majority of their material at the recommended 6th grade level and all surgical specialties had an average FKGL above the 6th grade level. Targeting patient education material to reduce the FKGL may be an actionable improvement to impact health literacy and potentially health outcomes.

 

67.04 Impact of Preoperative and Postoperative Opioid Use on Surgical Readmissions

Posted on January 18, 2018

E. A. Dasinger1,2, L. A. Graham1,2, T. S. Wahl1,2, S. J. Baker1,2, M. T. Hawn3, T. Hernandez-Boussard3, K. Desai3, J. S. Richman1,2, K. M. Itani4, G. L. Telford5, S. J. Knight1,2, M. S. Morris1,2  1University Of Alabama At Birmingham,Birmingham, AL, USA 2Birmingham VA Medical Center,Birmingham, AL, USA 3VA Palo Alto Healthcare Systems,Palo Alto, CA, USA 4VA Boston Healthcare System,West Roxbury, MA, USA 5Clement J Zablocki Veterans Affairs Medical Center,Milwaukee, WI, USA

Introduction: The number of patients taking opioids has risen drastically over the last decade and recent literature suggests that preoperative opioid use is associated with higher readmission rates. Although opioids are widely used to manage acute postsurgical pain, some patients remain opioid dependent following surgery. This study examines the relationship between opioid use and surgical readmissions and evaluates the incidence of new persistent opioid use in a veteran population.

Methods:  We performed a national retrospective cohort study of general, orthopedic, and peripheral vascular inpatient surgeries occurring in the VA Healthcare System between October 2007 and September 2014. Pharmacy outpatient data within the VA Corporate Data Warehouse was used to calculate the proportion of days covered (PDC) for opioid medications in the six months prior to surgery and six months post-discharge. Patients were stratified into four groups defining preoperative opioid usage: no use, infrequent use (< 2 prescription fills or < 30 days of supply), frequent but not daily use (≥ 3 prescription fills with < 80% PDC), and daily use (≥ 3 prescription fills with ≥ 80% PDC). Our primary outcome of interest was unplanned 30 day readmission rates. Univariate and bivariate statistics along with adjusted logistic models were used to examine odds of pain-related readmission.

Results: A total of 237,441 patients were included in the analysis. In the six months prior to surgery, 59.8% showed no evidence of opioid use, 18.5% were considered infrequent users, 7.9% were frequent users, and 13.8% were considered daily opioid users. The adjusted odds of pain-related readmission within 30 days of discharge were higher for those with opioids on hand at admission and for the three groups with exposure to opioids within the six months prior to surgery as compared to the opioid naïve group: opioids on hand at admission (OR 1.17; 95% CI 1.05-1.31), infrequent (OR 1.12; 95% CI 1.02-1.23), frequent (OR 1.24; 95% CI 1.08-1.42), and daily (OR 1.40; 95% CI 1.23-1.59). Overall, patients who filled opioids at discharge had higher odds of pain related readmission within 30 days of discharge (adjusted OR 1.51; 95% CI 1.29-1.78). Of the previously opioid naïve patients, 6.8% became frequent users and 2.8% became daily opioid users at six months post-surgery. Of the previously infrequent opioid users, 19.4% became frequent users and 7.5% became daily opioid users at six months post-surgery. 

Conclusion: Preoperative and postoperative opioid use is associated with an increased risk for readmission. Decreasing the use of opioids before and after surgery may improve surgical quality and lead to better outcomes. Persistent opioid use following surgery is common and providers should minimize the amount of opioids prescribed and consider alternative pain management strategies to prevent patients from moving beyond acute opioid use.

67.05 Improved Peri-Operative Outcomes with Extended Lymph Node Dissection for Gastric Cancer in the U.S.

Posted on January 18, 2018

C. Granruth1, P. Friedmann1, P. Muscarella1, J. C. McAuliffe1, H. In1  1Montefiore Medical Center,Department Of Surgery,Bronx, NY, USA

Introduction:
Controversy remains regarding the extent of lymphadenectomy that should be performed at the time of gastrectomy for gastric adenocarcinoma. Although guidelines promote lymph node dissections of ≥15, extended lymph node dissection (ELND) has been reported to confer increased morbidity without oncologic benefit, contributing to poor uptake of this guideline. We utilized the National Cancer Data Base (NCDB) to examine peri-operative mortality and long-term mortality for gastrectomies with ELND compared to those without.

Methods:
Gastric adenocarcinoma patients diagnosed between 2004 and 2013 were identified. Analysis was limited to patients who were candidates for ELND, including ages of 18 – 74, stage II or III, and without any Charlson comorbidities. Demographis and outcomes were compared between patients who had ELND (≥16) to those who did not. Logistic regression, Kaplan-Meier and Cox regression analyses were performed using SAS 9.4 (Cary, NC).

Results:
Of 10,921 patients, 5,364 (49.12%) underwent ELND. They were more likely to be treated at academic/research institutions (48.64% vs. 37.92%), higher volume hospitals (25.82 vs. 17.01), and to have been transferred prior to treatment (55.59% vs. 49.90%). They were more likely to be stage III (64.60% vs. 53.14%), have tumor size >40mm (59.71% vs. 52.80%), and have positive regional lymph nodes (83.59% vs. 74.21%). Multivariate analyses showed that ELND was associated with improved 30-day mortality [aOR: 0.783 (95% CI: 0.607-1.009)], 90-day mortality [aOR: 0.694 (95% CI: 0.579-0.832)], and overall survival [aHR: 0.788 (95% CI 0.749-0.829)].

Conclusion:
We found improved peri-operative outcomes in those patients undergoing ELND. While these findings may reflect that ELND is more commonly performed in specialized centers, they suggest that ELND is safe, should be performed in appropriately selected patients. 
 

67.03 Redefining Surgical Quality Metrics: Optimal Length of Surveillance for Complications After Surgery

Posted on January 18, 2018

M. A. Chaudhary1, W. Jiang1, S. Lipsitz1, Z. Hashmi1, T. Koehlmoos2, P. Learn2, A. J. Schoenfeld1, A. H. Haider1  1Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 2Uniformed University Of Health Sciences,Bethesda, MD, USA

Introduction:

Thirty-day complications are reported by National Surgical Quality Improvement Program (NSQIP) and widely used in the surgical literature as a quality indicator for benchmarking surgical care. However, there is little evidence to suggest that the 30-day time point is the optimum length of surveillance to capture complications after surgery. The objective of this study was to determine the optimum surveillance period for complications in a national sample of high volume surgical patients.

Methods:

The TRICARE insurance database (2007-2014), with 9 million enrollees (military personnel and their dependents), was queried for adult (age 18-64 years) patients who underwent 1 of 11 high volume surgical procedures (including, general surgery, neurosurgery, orthopedic, cardiothoracic and urological procedures). Kaplan Meier (KM) curves were constructed to visualize the inflection point in the proportion of patients with a complication  (wound, infectious, neurological, cardiopulmonary, vascular and genitourinary complications) at each incremental follow-up day. Multiple linear spline regression modeling, based on observed survival at each incremental follow-up day, was performed and adjusted R-squared values calculated. Optimum length of surveillance was defined as the follow-up day for which the model had the highest R-squared value. Bootstrapping (non-parametric random resampling of the data) with 300 repetitions was performed to generate a 95% confidence interval around the optimal length of surveillance estimate.

Results:

Of the 100,098 patients included in the analysis, 21.8% had at least one complication within 90 days from the day of procedure. 49% of complications were captured within the first 15 days while 74% were captured in 30 days. Visual inspection of the KM curve (Figure) exhibited a demonstrable change in slope before the 20-day mark. In the spline model, day 15(C.I.: 14-15) had the highest R-squared value (0.98), indicating an inflection point.

Conclusion:

The data demonstrates that 75% of complications occur within 30 days. However, the majority of complications (nearly 2/3rd) actually occur within 15 days after surgery. Thus, a shorter follow up period for complications may be acceptable. 

 

67.01 Non-Invasive Neurally Adjusted Ventilator Assist after Congenital Diaphragmatic Hernia Repair

Posted on January 18, 2018

R. Amin1, M. Arca1  1Medical College of Wisconsin,Milwaukee, WI, USA

Background: Conventional modes of ventilation can result in patient-ventilator asynchrony, which may be overcome using neurally-adjusted ventilator assist (NAVA) methodology. The use of NAVA in congenital diaphragmatic hernia (CDH) patients is controversial, as the trigger for breaths is diaphragmatic muscle activity.  We report on our experience in using NAVA in CDH patients.

Methods: We performed an IRB-approved retrospective review of newborns with CDH from 1/1/2012-1/1/2017 at a Level I Children’s Surgery Center who underwent operative repair.  Data obtained include demographics, hernia defect, type of repair, pre and post-operative respiratory support, and outcomes.

Results: Thirty-seven patients underwent operative repair. Post-operatively, none required NAVA while on conventional mechanical ventilation (CMV), but 7 were placed on noninvasive-NAVA (NIV-NAVA) after extubation. Three patients were male. Three patients had right sided CDH. Average estimated postmenstrual age and weight at birth were 38 2/3 weeks [range 35 3/7-40/17] and 2.96 kg [2.21-3.5], and 40 2/3 [38 3/7-41 6/7] and 3.08kg [2.21-3.84] at repair.  The average initial arterial pCO2 was 72.2 mmHg.  High frequency oscillatory ventilation was used in 5 patients preoperatively; six were transitioned to CMV prior to repair.  Preoperatively, all required inhaled nitric oxide. Four required extracorporeal life support (ECLS) and one was repaired on ECLS.  All patients underwent open repair via abdominal approach, with patch repair in 5 infants. All were on CMV postoperatively.

Specified reasons for using NAVA post-extubation include increased work of breathing after extubation and previous failed extubation requiring reintubation. Five patients were extubated to NAVA directly. Average time on NAVA support was 9.4 days [5-21], with initial NAVA level of 3.1 [1-5], and NAVA level of 2 [0-3] at the end of support.

Four patients were weaned to room air [3-32 days] prior to discharge, and two were weaned to room air within a year.  Five patients went home on enteral feeds.  One patient had seizure activity, but none had intraventricular hemorrhage or periventricular leukomalacia. There was one hernia recurrence in the patient who was repaired on ECLS. There were no deaths.

Conclusion: This is the first report of NAVA being successfully utilized as an adjunct to wean infants from CMV after CDH repair, even in those who required a patch. 

 

67.02 Use of the Alvarado Score in Elderly Patients with Complicated and Uncomplicated Appendicitis

Posted on January 18, 2018

A. Deiters1, A. Drozd1, P. Parikh1, R. Markert1, J. K. Shim1  1Wright State University,Dayton, OH, USA

Introduction:   With increasing life expectancy, elderly patients experience a higher incidence of diseases previously associated with the younger population. With an incidence of acute appendicitis in this age group of approximately 9.3%, high rates of perforated and gangrenous appendicitis have been reported. The purpose of this study was to determine whether the Alvarado Score is beneficial in identifying complicated versus uncomplicated acute appendicitis in elderly patients. Early diagnosis of patients with complications from acute appendicitis would lead to early treatment.

Methods:   We conducted a retrospective review of patients 65 years and older who underwent an appendectomy for pathologically confirmed appendicitis. Patient data were collected from five local hospitals within one healthcare network. A review of 310 operative reports and patient charts from October 1, 2012 – December 31, 2016 yielded 216 patients who qualified for the study. Patients were grouped based on complicated (perforated or gangrenous or abscessed) versus uncomplicated appendicitis. An Alvarado Score is calculated from 8 sub-scores – signs, symptoms, and lab values (e.g., RLQ tenderness, leukocytosis >10,000). Eighty-six patients had complete data, and 130 patients had one or more missing sub-score. Multiple imputation was used to replace all missing sub-scores (12% of values).

Results:  The 110 of 216 patients (51%) with complicated appendicitis had a mean age of 72.9 years, while the 106 uncomplicated patients (49%) had a mean age of 73 (p=0.97), and the two groups did not differ significantly on mean duration of symptoms (complicated = 2.70 days vs. uncomplicated = 2.09 days; p=0.17). Among the 110 complicated patients 76% had perforated appendicitis, 38% were gangrenous, and 35% had an abscess.  

The mean Alvarado Score of the two groups did not differ (complicated = 6.86 vs. uncomplicated = 6.58, p=0.32). An Alvarado Score of 7 or higher indicates acute appendicitis. Within the complicated group, patients ≥76 years old were similar to those ≤75 years in proportion with an Alvarado Score ≥7  (≥76 years = 54% vs. ≤75 years = 53%, p=0.93).  However, within the uncomplicated group, younger patients were more likely than older patients to have an Alvarado Score ≥7  (≥76 years = 28% vs. ≤75 years = 54%, p=0.02). The complicated group was more likely to have postoperative complications (41% vs. 25%, p=0.012).  Mean hospital length of stay was greater in those with complicated appendicitis compared to uncomplicated (5.34 days vs. 3.12 days, p<0.001).

Conclusion:  We found that the Alvarado Score did not differentiate complicated from uncomplicated appendicitis in elderly patients. The scoring system also did not provide an accurate diagnosis of acute appendicitis in approximately half our patient population. Future studies should investigate why a high percentage of elderly patients present initially with complicated appendicitis. 

57.20 A Cadaver-Based Enteroatmospheric Fistula Model for Negative Pressure Therapy Training

Posted on January 18, 2018

A. Coleoglou Centeno1, C. B. Horn1, M. M. Frisella1, C. M. Donald1, G. V. Bochicchio1, S. R. Eaton1, J. P. Kirby1, L. J. Punch1  1Washington University,Department Of Surgery,St. Louis, MO, USA

Introduction:
Enteroatmospheric fistulas (EAFs) are associated with the need for complex wound care. Negative Pressure Therapy (NPT) is a helpful adjunct in management of complex wounds. The use of NPT in the management of an EAF allows for both enhanced wound care as well as control of fistula efflux, but is technically difficult to apply. As part of a Visiting Preceptorship in Acute Care Surgery, we developed a cadaver-based model for training of nurse practitioners (NPs) and physician assistants (PAs) in NPT application to EAFs.

Methods:
The training model was developed for use in a hands-on application of NPT on an EAF using a cadaver model.  The model was prepared by performing a midline laparotomy. Sigmoid colon was mobilized and ligated proximally. The distal bowel was cannulated with plastic tubing which was secured to the bowel and passed through the abdomen through a separate stab incision. This was connected to dilute solution of methylene blue mixed with saline. An additional resection of skin and fat was done to create a complex surrounding wound. We then performed a primary fascial closure and exteriorized the colon, maturing the edges of the bowel to the fascia thus simulating an EAF. Groups of two PAs or NPs along with course faculty applied the wound NPT to the EAF model. 

Results:
A cadaver based model for EAF was created and NPT was successfully applied by the course participants. All fistulas were successfully isolated with a barrier ring, sponge and ostomy bag (figure 1).

 

Figure 1. 1a. EAF model. Note exposed loop of sigmoid colon 1b. EAF model demonstrating methylene blue saline efflux. 1c. EAF model with NPT and ostomy appliance. Note cannula containing methylene blue tinted normal saline.

Conclusion:
We developed a cadaver-based EAF model for NPT training. This model could potentially impact practice by allowing all members of the surgical team to improve their application techniques. We acknowledge limitations to the model such as lack of pre- and post- course comparison and need for competency evaluation. Another limitation to the model could be its standardized implementation as a training system due to the costs and need for laboratory facilities. Future aims include further evaluation of the model’s impact on participant’s competence and confidence.

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