69.08 Appendectomy in Patients with HIV and AIDS: Not as Bad as We Once Thought

Posted on January 18, 2016

M. C. Smith1, P. J. Chung1, Y. C. Constable2, A. E. Alfonso1, G. Sugiyama1 1SUNY Downstate Medical Center,Department Of Surgery,Brooklyn, NY, USA 2SUNY Downstate College Of Medicine,Brooklyn, NY, USA

Introduction: Although the incidence of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) is decreasing, due to the effectiveness of antiretroviral therapy, the prevalence of HIV is increasing. As a result, patients are living longer and presenting with common surgical conditions such as acute appendicitis. Previous studies have examined single institution experiences, which have shown an increase in complications. We sought to investigate the effect of HIV and AIDS on postoperative outcomes in patients who undergo appendectomy.

Methods: We selected patients from the Nationwide Inpatient Sample between 2005 and 2012 who underwent either laparoscopic or open appendectomy for acute appendicitis. We excluded cases of interval appendectomy. We used ICD-9 codes to identify patients with HIV and AIDS, and to identify complications. Data on patient demographics, length of stay (LOS), total hospital charges, and mortality during admission were also extracted. Using multivariate logistic regression, we created statistical models that controlled for age, gender, race, insurance type, socioeconomic status, number of Elixhauser comorbidities, and presence of perforation.

Results: There were 821 patients with HIV, 422 patients with AIDS and 338,425 patients served as controls. On univariate analysis comparing patients with HIV to controls, mean LOS was higher (3.8 days vs 3.0 days, p<0.001) and mean total charge was higher ($33,350 vs $30,714, p<0.0001). Comparing patients with AIDS to controls, those with AIDS had higher mean LOS (5.0 days vs 3.0 days, p<0.001), higher mean total charge ($44,486 vs $30,704, p<0.0001), more mechanical complications (2.4% vs 0.6%, p<0.0001), and more postoperative complications (6.6% vs 3.1%, p<0.0001). Multivariate analysis showed that HIV status was not an independent risk factor for mortality or intraoperative and postoperative complications, but was associated with increased LOS (OR 1.12, 95% CI 1.08-1.17, p<0.0001). AIDS was an independent risk factor for postoperative infections (OR 2.10, 95% CI 1.37-3.21, p=0.0007), digestive complications (OR 1.57, 95% CI 1.01-2.43, p=0.046), increased LOS (OR 1.23, 95% CI 1.18-1.30, p<0.0001), and increased total charge (OR 1.18, 95% CI 1.11-1.26, p<0.0001).

Conclusion: In this large, retrospective analysis, we found that in patients with acute appendicitis who undergo appendectomy, HIV and AIDS were not observed to be independent risk factors for mortality. Though AIDS is an independent risk factor for an increased risk of postoperative infection and digestive complications, appendectomy is a safe procedure in this patient population. Further studies to investigate how to minimize these risks in the population with AIDS are warranted.

69.09 Unplanned Reoperations following Abdominal Surgery: Incidence and Failure-to-Rescue by Procedure

Posted on January 18, 2016

H. S. Kazaure1, S. A. Roman2, J. A. Sosa2 1Stanford University,General Surgery,Palo Alto, CA, USA 2Duke University Medical Center,Surgery,Durham, NC, USA

Introduction: Data on unplanned reoperation (UR) after complex abdominal surgery are limited. The incidence of UR in ≤30 postoperative days and its association with other adverse outcomes were analyzed.

Methods: Patients who underwent 9 groups of abdominal procedures captured in ACS-NSQIP (2012) were abstracted. URs and their association with subsequent complications and failure-to-rescue (FTR: case fatality after ≥1 complication) were analyzed using bivariate and multivariate methods.

Results:There were 71445 patients; 82.7% underwent non-emergent surgery. The UR rate was 7.0 % (median time to UR: 8 days); approximately 84.5%, 11.4% and 4.1% had 1, 2 and ≥3 URs, respectively. URs were more likely following esophageal operations (9.7%), proctectomies (6.7%), and small bowel resections (6.2%). Common indications for UR were bowel compromise, wound complications, and bleeding. Patients who underwent URs were more likely to experience subsequent complications (64.7% vs. 28.8%, p<0.001) and overall mortality (11.4% vs. 3.5%, p<0.001). FTR varied widely by procedure: it was highest for pancreas resections (20.7% vs. 3.7, p<0.001, for UR vs. no UR) and non-significant after exploratory laparotomies (17.6 vs. 21.5%, p=0.231 for UR vs. no UR). After multivariate adjustment, UR was associated incrementally with mortality (adjusted odds ratio: 2.2, 95% CI: 1.9 – 2.5 for 1 UR and 3.2, 95% CI: 2.5 – 4.1 for ≥2 URs).

Conclusion:1 in 14 patients undergoing complex abdominal surgery undergoes an UR in ≤30 postoperative days. These patients are more likely to experience subsequent complications and FTR. Our results suggest that UR may be an indicator for quality of care for certain non-emergent abdominal procedures.

69.05 Minimally Invasive Segmental Colectomy: Impact of Hospital Type on Short-Term and Oncologic Outcomes

Posted on January 18, 2016

U. P. Nag1, M. Adam1, C. T. Ong1, Z. Sun1, J. Kim1, J. Migaly1, C. Mantyh1 1Duke University Medical Center,Surgery,Durham, NC, USA

Introduction: While a minimally invasive approach is associated with improved short-term outcomes and equivalent oncologic outcomes, this may not be generalizable across hospital types. This study is designed to evaluate impact of hospital type on differences in short-term and oncologic outcomes between minimally invasive segmental colectomy (MIS) and open surgery.

Methods: Adult patients undergoing segmental colectomy for non-metastatic colon adenocarcinoma were identified from the 2010-2012 National Cancer Data Base. Descriptive statistics were used to characterize patterns of MIS (laparoscopic or robotic) vs. open colectomy by hospital type. Multivariable models were used to examine the effect of hospital type on short-term and oncologic outcomes from MIS vs. open surgery while adjusting for patient, clinical, and tumor characteristics.

Results: A total of 97,620 patients underwent segmental colectomy for cancer: 44,027 (45%) underwent MIS, and 53.593 (55%) underwent open surgery. Overall, 25% of cases were performed at academic, 60% comprehensive community, and 15% community centers. MIS was more often utilized at comprehensive community (61%) and academic centers (27%) than community centers (12%). Compared to open surgery, the MIS group was more likely to have a complete tumor resection, shorter length of stay, lower 30-day mortality, and better overall survival regardless of institution type (all p < 0.01). Length of stay was significantly shorter by 1 day in the MIS vs. open group across all hospital types (all p<0.01), without increased 30-day readmissions. MIS was significantly associated with lower 30-day mortality, which was similar across hospital types: academic [OR 0.51 (CI 0.41-0.64), p<0.01], comprehensive community [OR 0.56 (CI 0.49-0.63), p<0.01], and community [OR 0.45 (CI 0.34-0.61), p<0.01]. Overall survival benefit was also comparable throughout hospital types: academic [hazard ratio (HR) 0.71 (CI 0.69-0.76, p<0.01], comprehensive community [HR 0.73 (CI 0.69-0.78), p<0.01], and community [HR 0.72 (CI 0.63-0.810, p<0.01].

Conclusion: Minimally invasive segmental colectomy is associated with superior perioperative outcomes and lower 30-day mortality. Although hospital type may impact outcomes of other procedures, the benefits of minimally invasive techniques were observed across hospital types. Utilization of laparoscopy and robotic surgery may be variable across hospitals, but wider dissemination of minimally invasive techniques should be emphasized for colon cancer.

69.06 The Impact of Frailty on Outcomes Following Paraesophageal Hernia Repair Using NSQIP Data

Posted on January 18, 2016

M. Chimukangara1, M. J. Frelich1, M. Bosler1, L. E. Reinb2, A. Szabo2, J. C. Gould1 1Medical College Of Wisconsin,General Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,Biostatistics,Milwaukee, WI, USA

Introduction: Frailty is a standardized measure of physiologic reserve that has been used to predict morbidity and mortality following surgical procedures in the elderly. As a state of increased vulnerability to adverse outcomes, frailty is commonly associated with decreased reserves in multiple organ systems, such as declining cognition, physical ability, and health. We hypothesized that frailty, as assessed based on data derived from a large clinical database, would be associated with morbidity and mortality following paraesophageal hernia repair (PEH).

Methods: The National Surgical Quality Improvement Program (NSQIP) database was queried for ICD-9 and CPT codes associated with PEH repair. The NSQIP participant use files for the years 2011-2013 were utilized. Only subjects ≥ 60 years old were included. A previously described modified frailty index (mFI), based on 11 clinical variables available in the NSQIP dataset and derived from the model of cumulative deficits, was used to quantify frailty. Outcomes were 30-day mortality and the occurrence of post-operative 30-day complications. The Clavien-Dindo Classification system was used to characterize complication severity. Secondary outcomes were discharge destination and readmission. Multivariate logistic regression was used to determine the relationship between frailty, complications, and mortality.

Results: Of the 4434 PEH repairs performed in patients ≥ 60 years old in the study interval, 885 records were included in the final analysis (20%). Excluded patients were missing 1 or more variables in the 11-point mFI. The overall rate of complications that were Clavien-Dindo Grade ≥ 3 (Grade 3 = requiring endoscopic, radiographic, or surgical intervention) were 6.1%. Mortality was 0.9% (30-day). The overall readmission rate was 8.2% (30-day) and 10.9% of patients were discharged to a facility other than home. Relative to mFI scores of 0, 1, 2, and ≥3, the respective percentages for the four outcomes were as follows; Clavien-Dindo Grade ≥3 complication: 3.2%, 4.7%, 9.8%, and 23.3% (p <0.0001); mortality: 0.0%, 0.9%, 1.8%, and 2.3% (p 0.0974); discharge to facility other than home: 4.4%, 10.9%, 15.7%, and 31.7% (p <0.0001); and readmission: 8.9%, 6.8%, 8.5%, and 16.3% (p 0.1703). Grade ≥3 complications and discharge to a facility other than home were significantly correlated with mFI.

Conclusion: Frailty, as assessed by the mFI, is correlated with postoperative complications and discharge to a facility other than home following paraesophageal hernia repair. Due to many missing variables needed to calculate an 11-item mFI in the NSQIP dataset, significant portions of otherwise eligible patients were excluded from this analysis. The mFI may not be the ideal measure to assess frailty using the NSQIP dataset for this reason. Future investigation is needed to better quantify frailty based on the clinical variables contained in the NSQIP dataset.

69.07 Marginal Ulcer After Roux-en-Y Gastric Bypass: A Common Costly Problem

Posted on January 18, 2016

A. Furukawa1, D. T. Dempsey1, N. Williams1, C. Neylan1, K. Dumon1 1Hospital Of The University Of Pennsylvania,Department Of Surgery,Philadelphia, PA, USA

Introduction: Marginal ulcer (MU) is a known complication of Roux-en-Y gastric bypass (RYGBP) but few studies have looked at long-term incidence in this patient population. The purpose of this study is to better understand the prevalence, risk factors, complications, and cost of symptomatic MU in RYGBP patients in patients followed >2.5 years.

Methods: With IRB approval, all patients having RYGBP at our institution from 2003-2012 were reviewed. All patients who developed symptomatic marginal ulcers were analyzed (MU group=166). A randomly selected cohort of RYGBP patients without MU were selected and analyzed for comparison (non MU group=150) Charts were retrospectively reviewed for ulcer risk factors, ulcer complications, and charges (hospital and physician). Here, postoperative upper endoscopy (EGD) was used as a surrogate for utilization of healthcare resources. All statistical analysis including multivariate regression was performed Stata/IC 14.

Results: Over a 10 year span, there were 2,019 patients who underwent RYGBP. 166 developed MU (8% incidence of MU). Of those 166 patients, 135 (81%) were conservatively managed with medication and 31 (19%) needed ulcer operation. Of these 31 patients, 19 had emergent operations due to perforation and 12 had elective operations. Men were more likely to need emergency operation (p<0.05). On multivariate analysis, smoking and diabetes significantly increased the risk of MU (p<0.05), but hypertension, GERD, male gender, increased age, or increasing BMI did not. MU patients had a total of 437 EGDs after RYGBP, significantly more than patients without marginal ulcers who had a total of 41 (p<.001).

Conclusion: Symptomatic MU is common after RYGBP and leads to increased utilization of healthcare resources. Though smoking cessation is already recommended, increased MU incidence in smokers highlights the importance of adherence in RYGBP patients. To our knowledge, the relationship between MU and diabetes has not been looked at. Long term acid suppression after RYGBP should be considered, especially in men, diabetics, and in patients with smoking history.

69.03 Location of Ambulatory Laparoscopic Cholecystectomy in the Elderly Impacts Postoperative Acute Care

Posted on January 18, 2016

G. Molina1,2,3, B. Neville1, S. R. Lipsitz1, W. R. Berry1, A. B. Haynes1,2,3 1Ariadne Labs,Brigham And Women’s Hospital And The Harvard T.H. Chan School Of Public Health,Boston, MA, USA 2Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA 3Harvard Medical School,Boston, MA, USA

Introduction: Laparoscopic cholecystectomy is increasingly being performed in the ambulatory setting, including hospital and freestanding ambulatory surgery centers (ASCs). Previous research has demonstrated the safety of ambulatory laparoscopic cholecystectomy in the elderly. These studies, however, did not distinguish between hospital and freestanding ASCs.

Methods: We used logistic regression, clustering by facility to evaluate if ambulatory setting (hospital ASC versus freestanding ASC) was an independent predictor of acute care (ED visits or inpatient admissions) within 1 and 7 days after a laparoscopic cholecystectomy among patients 65 years or older in South Carolina. Due to low number of events, we used a machine learning technique (supervised principal components regression) to adjust for all available patient characteristics (gender, race, insurance, median household income, and preoperative Charlson comorbidity index score). This technique is an alternative to using all variables when adjusting by generating one covariate from a combination of the original variables. This new covariate retains much of the original information as possible in a single covariate. A sensitivity analysis evaluating ASCs that performed at least 25 laparoscopic cholecystectomies annually among all adult patients was also performed in order to evaluate if these findings would persist after taking annual volume into account.

Results: There were 6,299 elderly patients who underwent a same-day laparoscopic cholecystectomy in the ambulatory setting in South Carolina from 2006 to 2013. Of these, 5,819 (92.4%) patients underwent a laparoscopic cholecystectomy at 58 hospital ASCs compared to 480 (7.6%) patients who underwent this operation at 16 freestanding ASCs. Elderly patients who had laparoscopic cholecystectomy performed at a freestanding ASC had a higher odds of being admitted to the hospital within 1 day when compared to hospital ASCs (Adjusted Odds Ratio (OR)=10.4, 95% Confidence Interval (CI) 3.9–27.5) but not within 7 days (OR=1.9, 95% CI 0.8–4.2). There was no significant difference between hospital ASCs and freestanding ASCs when evaluating subsequent ED visits (within 1 or 7 days). The sensitivity analysis confirmed these results.

Conclusion: Elderly patients who had same-day laparoscopic cholecystectomy at freestanding ASCs in South Carolina were more likely to be subsequently admitted to the hospital within 1 day when compared to hospital ASCs. As more surgical procedures are performed in the ambulatory setting, preoperative screening is critical to identify the safest and most efficient ambulatory surgery setting. Further research is needed on how to minimize acute care need following laparoscopic cholecystectomy at freestanding ASCs among the elderly.

69.04 Do Hospital Factors Impact Readmissions After Colorectal Resections At Minority-Serving Hospitals?

Posted on January 18, 2016

E. M. Hechenbleikner1,2,3, C. Zheng1,2,3, S. P. Lawrence1,2,3, Y. K. Hong1,2,3, L. B. Johnson1,2,3, W. B. Al-Refaie1,2,3 1Georgetown University Medical Center,Washington, DC, USA 2Georgetown University Medical Center, MH-SORC,Washington, DC, USA 3Georgetown University Medical Center, MGUH,Washington, DC, USA

Introduction:

Minority-serving hospitals (MSH) reportedly have higher readmission rates after surgical procedures including colectomy; however, little is known about the contribution of hospital characteristics to the elevated risk of readmission. This study sought to explore the extent to which hospital factors drive readmissions after colorectal resections performed at MSH in the context of patient- and procedure-related factors.

Methods:

Over 168,500 patients who underwent colon or rectal resections in 374 California hospitals between 2004 and 2011 were analyzed, utilizing records from the State Inpatient Database and American Hospital Association Hospital Survey. Stepwise logistic models were built to determine the associations between MSH and 30-day, 90-day, and repeated readmissions, adjusting for patient, procedure, and hospital factors gradually. MSH were defined as hospitals with highest proportion (top decile) of Black and Hispanic patients.

Results:

Among all patients, 88.5% underwent colon resections, 85.8% had open procedures, and 17.7% ostomies. Overall 30-day, 90-day, and repeated readmission rates were 11.2%, 16.9%, and 2.9%, respectively. Odds for 30-day, 90-day and repeated readmissions after colorectal resections were 22%, 21% and 38% more likely at MSH vs. non-MSH, respectively (all p <0.01). Patient factors accounted for up to 74% percent of the observed increase in odds for readmission after colorectal resections at MSH; in contrast, hospital-level factors contributed only 20% after controlling for patient and procedure factors (Table 1).

Conclusion:

Patient-level factors appeared to dominate the increased readmission risk following colorectal resections performed at MSH while hospital factors were less contributory. These findings need to be further validated to shape quality improvement interventions to decrease readmissions.

68.19 Routine Chest Radiographs in the Post-Operative Management of Pectus Excavatum Bar Removal

Posted on January 18, 2016

A. S. Poola1, S. W. Sharp1, S. D. St. Peter1 1Children’s Mercy Hospital – University Of Missouri Kansas City,Pediatric Surgery,Kansas City, MO, USA

Introduction:
Since its description, the Nuss procedure has been implemented as an effective minimally invasive repair for children and adolescents with pectus excavatum. While there has been much published literature on pectus bar placement, there are a limited number of reports studying the corresponding bar removal procedure. Even less reported is the post-operative management following bar removal. Common practices have included obtaining a post-operative chest radiograph (CXR) despite the minimal risk of intra-thoracic complications associated with this procedure. The aim of this study is to review our experience with the bar removal procedure and with not obtaining routine CXRs following this operation.

Methods:
A single institution retrospective chart review was performed from 2000 to 2012. Patients aged 8-35 who underwent a pectus bar removal procedure were included. We assessed operative timing of bar placement and removal, length of procedure and post-operative radiograph findings, specifically looking at rate of pneumothoraces.

Results:
335 patients were identified in this study. Of these, 80 percent were male. The mean age of bar placement was 14 years with a standard deviation of 3 years while the mean age of bar removal was 16 years with a standard deviation of 3.5 years. The average time between bar placement and bar removal was 33 months (range: 11-110 months). Most of our patients had one bar placed at initial procedure while 8 percent had two bars placed during repair. Operative times varied but on average bars were removed in 30 minutes (range: 10-96 min). Intra-operatively, 8 percent of patients had ossification of their bars although there was no noticeable effect of this finding on operative time. Of our sample, 143 patients obtained a post-operative radiograph and of these 139 films revealed a pneumothorax. Only 1 patient obtained a chest tube for management of their post-operative pneumothorax. Only three patients were re-admitted and zero patients were hospitalized following their procedures.

Conclusion:
Despite the detection of early post-operative pneumothoraces following bar removal, we have seldom found the need to clinically intervene on these findings. This suggests that not obtaining routine imaging following bar removal may be a safe practice.

68.20 Weight regain following sleeve gastrectomy – a systematic review with narrative analysis

Posted on January 18, 2016

M. Lauti1, M. Kularatna2, A. G. Hill1, A. D. MacCormick1 1University Of Auckland,Auckland, -, New Zealand 2Middlemore Hospital, University Of Auckland,Department Of Surgery,Auckland, Auckland, New Zealand

Introduction:

Weight regain is a recognised problem after bariatric surgery and is associated with recurrence of obesity-related co-morbidities. Sleeve gastrectomy is one of the most commonly performed bariatric procedures but the definition, incidence and cause of this problem is poorly reported and poorly understood. We performed a systematic review to clarify these issues in patients following sleeve gastrectomy.

Methods:

A systematic review was performed using four electronic databases to locate articles reporting the definition, rate or cause of weight regain in patients at least two years from sleeve gastrectomy. Papers were excluded if the series was of non-primary sleeves, had follow-up outcomes of less than two years or were not reporting primary research.

Results:

After abstract screening, 66 full text papers were reviewed of which thirteen met the inclusion criteria. Five papers reported a definition, five papers reported a rate and nine papers proposed a cause for weight regain following sleeve gastrectomy.

Definitions for weight regain reported in the literature included a gain of 10kg from nadir weight or an increase in BMI of 5kg/m2. Rates of regain following sleeve gastrectomy ranged from 10.2% at two years to 75.6% at six years. Proposed causes for the regain included initial sleeve size, sleeve dilation, increased ghrelin levels, inadequate follow-up support and maladaptive lifestyle behaviours.

Conclusion:

Weight regain appears to be a common complication following sleeve gastrectomy that is variably defined, described and reported in the literature. We make a number of recommendations to improve the reporting of clinical series so this problem can be better understood.

69.02 Blunt Traumatic Aortic Injury in Adolescents: Do Open and Endovascular Modalities of Repair Compare?

Posted on January 18, 2016

A. Shah2, A. Ashfaq2, S. R. Money2, C. K. Zogg1, J. Fraser4, V. J. Davila2, J. M. Chang2, T. Oyetunji3, R. J. Fowl2, W. Stone2, A. B. Chapital2, A. H. Haider1 1Brigham And Women’s Hospital,Center For Surgery And Public Health, Harvard Medical School, Harvard T H Chan School Of Public Health,BOSTON, MA, USA 2Mayo Clinic In Arizona,Department Of Surgery,Phoenix, AZ, USA 3Children’s Mercy Hospital And Clinics,Department Of Surgery,Kansas City, MO, USA 4Phoenix Children’s Hospital,Department Of Surgery,Phoenix, AZ, USA

Introduction:
Despite their rarity in the pediatric population, traumatic aortic injuries can prove to be highly lethal. Endovascular aortic repair (EVAR) has been successfully employed in the management of adult blunt aortic trauma. However, its efficacy has not been elucidated in the pediatric population. The objective of this study was to gauge the burden of traumatic aortic injuries using a nationally representative sample and compare outcomes associated with reparative modalities in a nationally representative population of adolescent patients.

Methods:
Four years (2000/2003/2006/2009) of data from the Kids Inpatient Database were queried for adolescent (10-19y) patients with diagnoses of blunt traumatic injuries to the abdominal/thoracic aorta. Included patients were divided into those who underwent EVAR and open aortic repair (OAR). Differences in associated outcomes — mortality, morbidity (acute kidney injury, stroke, myocardial infarction, cardiac arrest, ischemic colitis, paraplegia), length of stay (LOS), and total hospital cost of care — were compared using multivariable logistic/linear (family gamma; link log) regression. Propensity-score quintiles were used to account for differences in patient-level factors; models were further risk-adjusted to account for potential confounding associated with hospital region, teaching status, and children’s-hospital status. They were weighted to provide national estimates and account for clustering of patients within hospitals.

Results:

A total of 161 records were identified, weighted to represent 244 admissions nationwide. Average age on presentation was 17.0 (±2.0y) with a male preponderance (75.6%). EVAR was attempted in 27.4% (n=52) of cases. Patients who underwent EVAR had higher median ISS compared to the OAR group (38 vs 33, p=0.002). Risk-adjusted odds of death among EVAR patients were significantly lower relative to patients managed using OAR (p=0.031). No differences were found for complications. Marginally significant differences were reported for both LOS and total cost of care (table). Relative to OAR patients, use of EVAR was associated with a risk-adjusted predicted mean difference of 2.6 additional days and a corresponding increase in cost of approximately $20,200.

Conclusion:
Despite higher ISS among adolescent patients undergoing EVAR procedures, risk-adjusted odds of death were significantly lower relative to OAR. Combined with a lack of variation in morbidity, the results suggest that EVAR is comparatively safe may even convey a survival advantage among adolescent patients. Ongoing research is needed to consider longer-term outcomes in a larger group of patients.

68.17 Pattern of Calcium and PTH Normalization at 12 Months Follow Up after Parathyroid Surgery

Posted on January 18, 2016

O. A. Lavryk1, A. E. Siperstein1 1Cleveland Clinic,Endocrine Surgery,Cleveland, OH, USA

Introduction: At 12 month after parathyroid surgery we expect cured patients to have same biochemical characteristics as healthy individuals. The aim of the current study was to compare patients’ characteristics at 12 months after neck exploration for primary sporadic hyperparathyroidism (1?HP) with the healthy controls.

Methods: 484 patients were analyzed, who underwent parathyroid neck surgery for 1?HP from 2000-2014. 74 healthy subjects were enrolled as a control group. Calcium (Ca) and parathyroid hormone (PTH) were collected before and after surgery. To assess the biochemical profile of patients on the graphical plots of Ca vs PTH were used to compare the 95 % confidence area of healthy patients to those after parathyroid surgery. Patients were supplemented with Ca and vitamin D postoperatively.

Results:Preoperatively patients with 1?HP had a Ca of 10.9 ± 0.5 (mean ± standard deviation (SD) mg/dL and PTH 124.4 ± 68.5 pg/dL vs controls of 9.2 ± 0.3 mg/dL and 34.4±13.4 pg/dL, respectively. On plots of Ca vs PTH, all 1?HP patients preoperatively had values outside the normal zone. Postoperatively at 12 months, 335 (69%) of patients returned within the normal zone. 13 (2.7%) had absolute elevation of Ca and PTH, showing continued disease. 2 (0.4%) patients had hypoparathyroidism, both after undergoing subtotal parathyroidectomy. 149 (27.9%) had Ca and PTH values outside the normal zone, but not falling into the above categories. There was no marked difference in patients with simple adenoma vs multiple gland disease.

Conclusion:At 12 moths follow up postoperatively, many patients with 1?HP fail to have their Ca and PTH fall within the 95% confidence zone for normal individuals. Thus, 5% are attributed to the confidence interval chosen. Although some may reflect the persistent disease, many patients have unclear an pattern,despite Ca and vitamin D supplementation. Longer follow-up might be needed for patients after parathyroid surgery to reestablish stabilization of biochemical profiles.

68.18 Regional Variations of In-Patient Costs after Pancreaticoduodenectomy

Posted on January 18, 2016

F. Ali1, A. Dua1, S. Desai2 1Medical College Of Wisconsin,General Surgery,Milwaukee, WI, USA 2Southern Illinois University,Vascular Surgery,Springfield, IL, USA

Introduction: This study aims to investigate regional variations of outcomes including length of hospital stay, mortality and in-patient costs associated with patients undergoing pancreaticoduodenectomy in the United States.

Methods: A retrospective analysis was completed using the Nationwide Inpatient Sample to select patients with pancreatic cancer that underwent pancreaticoduodenectomy between 2007 and 2011 in the United States. ICD-9 codes were used to identify disease and procedure. Demographics, inpatient mortality, length of hospital stay and in-patient costs across different regions of the United States were compared. A multinomial regression was completed to compare the outcomes amongst the various regions.

Results: A total of 27,267 pancreaticoduodenectomies for pancreatic cancer were performed in the United States during the five-year study period. There were no regional variations in demographics but in terms of comorbidities, COPD was significantly increased in the Midwest as compared to the Northeast (P<0.05), while renal failure was higher in the West compared to the Northeast (P<0.05). In terms of outcomes, length of stay was significantly higher in the South and West compared to the rest of the USA. The cost of care was also significantly higher in the west. Mortality rates were highest in the South (Table I).

Conclusion: Length of stay and mortality were highest in the South for patients undergoing Whipple procedures for pancreatic cancer whereas cost of care was highest in the West. There are no demographic variations within patient populations based on regions however patients in the West did have a higher incidence of renal failure which may contribute to the higher overall cost of in-patient care.

09.11 Age and Anti-Thyroid Drug Intolerance Predict Definitive Therapy in Pediatric Graves Disease

Posted on January 18, 2016

E. J. Graham1, J. Malinowski1, C. A. Dinauer1, E. R. Christison-Lagay1, C. E. Quinn1, T. Carling1, R. Udelsman1, G. G. Callender1 1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA

Introduction: Graves disease (GD) is an autoimmune disease of the thyroid with an incidence of 0.79 cases per 100,000 person-years in children aged 0-14 years. In the United States, the pediatric GD population has not been well characterized due to its low prevalence and lack of comprehensive follow up. The American Thyroid Association recommends anti-thyroid drugs (ATD) for primary treatment of GD in pediatric patients, but no clear recommendation exists for definitive treatment, i.e. radioactive iodine (RAI) or thyroidectomy. This study aimed to characterize demographics and predictors of treatment selection in pediatric patients with GD at a tertiary referral center.

Methods: Retrospective review was performed of all patients diagnosed with GD at age ≤18 years from 2000-2015 at a tertiary care center. Neonatal GD patients and patients whose primary follow up was not performed at our center were excluded. The effect of race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, other), insurance status (public, private, none), intolerance to ATD, presence of ophthalmopathy, age at diagnosis, and age at definitive treatment on election of definitive treatment and likelihood of remission was determined using ANOVA and logistic regression.

Results: Overall, 103 patients (81% female) were diagnosed with GD from 2000-2015 at median age 13 (range 2-18) years. Age at diagnosis did not differ between racial/ethnic groups or by insurance status. After primary ATD treatment, 11 (10.7%) patients entered remission at median 22 (range 3-126) months; 16 (15.5%) underwent RAI at median age 11 years; 34 (33.0%) underwent total thyroidectomy at median age 12 years; 45 (43.7%) continued ATD treatment only, with 23 (51.1%) of these continuing beyond 2 years. Type of treatment elected was independent of age at diagnosis, ophthalmopathy, insurance status and race/ethnicity. The likelihood of pursuing definitive treatment increased with age (OR: 2.6, p=0.01) and intolerance to ATD (OR: 174, p=0.01); patients with an earlier age at diagnosis trended toward greater likelihood of pursuing definitive treatment (OR: 1.8, p=0.06). Likelihood of remission was independent of all tested variables.

Conclusion:The management of pediatric GD is heterogeneous. Age at diagnosis and type of treatment elected were not impacted by socioeconomic status. Less than 50% of patients undergo definitive therapy (RAI or surgery) in spite of the low incidence of remission with ATD therapy alone. Increasing age and intolerance to ATD therapy increase the likelihood of pursuing definitive treatment. As pediatric GD is relatively rare, a prospective multicenter trial would be ideal to determine the optimal treatment algorithm for this patient population.

68.14 Bleeding Risk after Fine Needle Aspiration of Thyroid Nodules in Patients on Antithrombotic Therapy

Posted on January 18, 2016

R. M. Kholmatov1, T. A. Hassoon1, Z. Al-Qurayshi1, M. Anwar1, F. Murad1, H. Mahmood1, T. K. Thethi2, R. Aslam3, E. Kandil1 1Tulane University School Of Medicine,Surgery,New Orleans, LA, USA 2Tulane University School Of Medicine,Endocrinology,New Orleans, LA, USA 3Tulane University School Of Medicine,Otolaryngology,New Orleans, LA, USA

Introduction: Fine needle aspiration biopsy (FNAB) is relatively contraindicated in patients with suspicious thyroid nodules while on anticoagulant and antiplatelet agents. Our aim is to evaluate the bleeding risk associated with anticoagulation and antithrombotic therapy in patients presenting for FNAB of thyroid nodules.

Methods: After approval from institutional review board, we performed retrospective analysis of patients’ records who underwent FNAB of thyroid nodules by a single surgeon over past 5 years. 608 patients with a mean age of 53.12±14.08 years underwent FNAB of thyroid nodules. 140 (23 %) patients were on anticoagulants (warfarin, heparin, apixaban) or antiplatelet agents (aspirin, clopidogrel). We collected data on patients’ demographic and social history along with the postoperative diagnosis. Statistical analysis was performed using student's t test and Fisher’s exact test for the continuous and categorical variables respectively.

Results: Four out of 468 patients in the control group developed a small hematoma after FNAB, as compared to only one patient in the other group, who was taking warfarin and aspirin (OR 7.93; 95% CI 0.83-75.59, p=0.07). Patients with post FNAB hematomas were managed conservatively without a need for surgical intervention. There was no correlation between post FNAB hematoma and patients’ demographics, social history, ultrasonographic features, or postoperative diagnosis (p>0.05).

Conclusion: FNAB of thyroid nodules in patients who are undergoing anticoagulation is a safe and feasible approach without the need to discontinue anticoagulant therapy. However, further future prospective studies are warranted.

68.15 Comparing Blue Dye Alone with Combined Dye and Isotope in Breast Sentinel Lymph Node Biopsy

Posted on January 18, 2016

K. Tatsuda1, M. Nagahashi1, J. Tsuchida1, K. Moro1, T. Niwano1, C. Toshikawa1, M. Hasegawa1, Y. Koyama1, T. Kobayashi1, S. Kosugi2, H. Kameyama1, T. Wakai1 1Niigata University Graduate School Of Medical And Dental Sciences,Division Of Digestive And General Surgery,Niigata, NIIGATA, Japan 2Uonuma Kikan Hospital,Digestive And General Surgery,Minami-Uonuma City, NIIGATA, Japan

Introduction:

Blue dyes and radioisotope tracers have been used, either alone or in combination, to identify the sentinel lymph node (SLN). Previous studies indicate a superiority of combination of dye and isotope for SLN biopsy in breast cancer patients to a single method of blue dye in terms of lower non-identification and false-negative rates. With increasing experience, however, surgeons had become comfortable to use the single method of dye. The use of blue dye alone remains an attractive option because of its technical simplicity and because it does not require any additional equipment or procedures. In this study, we re-evaluate the practice of performing sentinel lymph node biopsy with blue die alone.

Methods:

A retrospective analysis was conducted of 114 consecutive patients with breast cancer at the authors’ institute between January 2014 and March 2015, when SLN biopsy was offered to all suitable patients with either a method with combined dye and isotope or dye alone. All procedures were done by experienced surgeons for SLN biopsy.

Results:

During the study period, 66 patients underwent SLN biopsy with combined dye and isotope, and 48 patients underwent that with dye alone. The SLN was identified in all patients in each group. There was no difference between SLN biopsy with combined dye and isotope and that with dye alone in terms of operation time, time for SLN procedure, and number of SLN (median; n = 2). A positive rate for SLN metastasis was 19.6% (13/66) for patients underwent SLN biopsy with combined dye and isotope, and 12.5% (6/48) 48 patients underwent that with dye alone; there was no difference between the groups (P = 0.446).

Conclusion:

Our results indicate that SLN with dye alone is feasible for patients with breast cancer with comparable outcome to the combined method. SLN with dye alone remains an option for experienced surgeons because of its technical simplicity and because it does not require any additional equipment or procedures.
This work was supported by the Japan Society for the Promotion of Science (JSPS) Grant-in-Aid for Scientific Research Grant Number 15H05676 and 15K15471 for M.N and 15H04927 for W.T. M.N. is supported by the Uehara Memorial Foundation, Nakayama Cancer Research Institute, Takeda Science Foundation, and Tsukada Memorial Foundation.

68.16 Predictors of Recurrence Following Open Inguinal Herniorrhaphy

Posted on January 18, 2016

P. M. Patel1, A. Mokdad1, A. Webb1,2, S. Huerta1,2 1University Of Texas Southwestern Medical Center,Dallas, TX, USA 2VA North Texas Health Care System,Surgery,Dallas, TX, USA

Introduction: Recurrence following open repair of inguinal hernias continues to be an important complication following repair. We hypothesize that there are factors that can determine recurrence such that these patients can undergo an alternative repair.

Methods: This a retrospective, single institution, single surgeon experience at the VA North Texas Health Care system between July 2005 to July 2015. All patients underwent the same standardized mesh repair. Using recurrence as the dependent variable, univariate analysis (UA) was performed using Fisher’s Exact Test for categorical and Student’s T-Test for continuous variables. Clinically relevant variables and variables with a p ≤ 0.2 were entered in a logistic regression model with recurrence as the dependent variable. Data are expressed as means ± SD and significance was established at a p ≤0.05 (two-sided).

Results: During the study period, 804 patients underwent open inguinal hernia repair (99.3 ± 0.3% male, 60.4 ± 12.4 years-old, BMI 26.7 ± 4.2 Kg/m2, 72.9% Caucasian, American Society of Anesthesiologists class average of 2.5, morbidity rate of 7.8 ± 0.9%) by the same surgeon. Sixteen recurrences were identified (2.0 %). Median follow up was 4.7 ± 2.7 years. Patients with recurrent hernia were less likely to have an indirect hernia (25.0 ±10.8% vs 54.3 ± 1.8%, p=0.02), and more likely to have a small bowel obstruction (6.3 ± 6.1 % vs 0.6 ± 0.3 %, p=0.01), a bowel resection (6.3 ± 6.1% vs 0.5 ± 0.3%, p <0.001), and a longer operative time (76.7 ± 28.7% vs 63.7 ± 22.1%, p=0.02). These patients were also more likely to be smokers (56.3 ± 12.4% vs 32.9 ± 1.7%, p=0.05). Multivariate analysis demonstrated that current smoking history (OR and 95% CI: 3.3; 1.2 – 9.3), OR time (1.1; .1.0 – 1.1), and repair of an indirect inguinal hernia (0.2; 0.04 – 0.5) were independent predictors of recurrence.

Conclusion: Patients with direct complex hernias are more likely to develop a recurrence. Current smokers should be told to stop smoking prior to repair.

68.11 Psychological factors as predictors of successful bariatric surgery

Posted on January 18, 2016

S. Sheikh1, T. Bell1, R. Grim1, P. Hartmann1, V. Ahuja1 1York Hospital,Surgery,York, PA, USA

Introduction: Obesity is commonly associated with a myriad of psychosocial conditions. However, the effects of these conditions in patients undergoing bariatric surgery is relatively understudied. The purpose of this study was to 1) identify psychosocial conditions in bariatric surgery patients, 2) assess changes in weight and psychosocial variables before and after bariatric surgery, and 3) identify psychosocial predictors of successful bariatric procedures at 5 years post-surgery.

Methods: Data of 93 patients undergoing Roux-en-Y gastric bypass surgery with age>18 years, BMI>40kg/m2, and/or had obesity related medical conditions were reviewed. Psychosocial variables were obtained from the Bariatric Surgery Screening Tool, Beck Depression Inventory II, Self-Report Family Inventory, and the Obesity Adjustment Survey (OAS). Factors analyzed included depression, obesity related quality of life (O-QoL), and family functioning. Descriptive statistics, paired-sample t-test and multiple regression were used. Successful bariatric surgery was defined as significant weight loss and few or no surgical complications.

Results: Results indicated that a high proportion (66.7%) of this sample had a behavioral health condition. Of note, 41.5% indicated some form of verbal/emotional abuse, and 20.7% indicate sexual abuse. On average, weight was about 76.09 pounds lower at six months, 94.75 lower at one year, and 84.53 at five years. Weight and measures of depression and obesity-related quality of life significantly improved at 5 years post-surgery. The regression model accounted for 13.9% of the variance; however, only one predictor variable (obesity-related quality of life) was found to be significant (p = 0.014). All other variables did not significantly contribute to predicting weight loss at five years after surgery. No psychosocial variable was predictive of complications.

Conclusion: Obese patients had a higher prevalence of behavioral health conditions such as depression when compared to the general population. However, this data did not reach statistical significance. Patients with a poor preoperative O-QoL were more likely to lose the maximum amount of weight after surgery. However, O-QoL, did not predict the risk of complications after bariatric surgery.

While all psychosocial factors should be considered, this study indicates that preoperative assessment of the O-QoL is important in identifying and optimizing the bariatric surgery candidates and therefore maximizing the success of the procedure.

68.12 Utilization of Intraoperative Cholangiography

Posted on January 18, 2016

M. C. Nally1, P. Patel1, J. Myers1, M. Luu1 1Rush University Medical Center,General Surgery,Chicago, IL, USA

Introduction: The utility of intraoperative cholangiography continues to be debated in the literature. Some surgeons perform routine cholangiography, while most use it selectively as an adjuvant tool in specific clinical situations. There is evidence to suggest that the use of cholangiography decreases the incidence of common bile duct injuries. It is also documented to cause increased operative times and cost, and, with the manipulation of the cystic duct during cholangiography, the procedure itself may actually lead to bile duct injury. Intraoperative cholangiography is also performed when there is a question of choledocholithiasis as it is diagnostic and can allow for therapeutic common bile duct exploration. Although with increasing availability of endoscopy, ERCP remains a pre and post operative option for management of choledocholithiasis.

Methods: A single institution retrospective chart review was performed to identify patients who underwent laparoscopic cholecystectomy completed between 2007 and 2013. Of those patients, the ones who underwent intraoperative cholangiogram were selected for further analysis. Specifically, hyperbilirubinemia, cholangiogram findings, attending surgeon, and need for common bile duct exploration were evaluated.

Results: Of the patients who underwent laparoscopic cholecystectomy (n=1590), 229 cholangiograms were performed (14.4%). Only 8.3% of the cholangiograms reported abnormal findings, which led to fifteen common bile duct explorations (6.6%). Two-thirds of these patients had elevated bilirubin, while the remaining one-third had normal liver enzymes. Twenty different attending surgeons performed intraoperative cholangiography over seven years. One attending performed 129 of these procedures (56%).

Conclusion: Intraoperative cholangiography continues to be used selectively and routinely depending on surgeon preference. When performed, the majority of cholangiograms do not show anatomic or pathologic abnormalities. And, even with the finding of choledocholithiasis on cholangiography, common bile duct exploration is, at times, deferred in favor of pursuing post operative endoscopic retrograde cholangiopancreatography. Overall, from this chart review, there does not appear to be specific indications or benefit of pursuing intraoperative cholangiography.

68.13 Frailty Predicts Postoperative Morbidity/Mortality after Colectomy for C-Difficile Colitis

Posted on January 18, 2016

R. Venkat1, E. Telemi1, O. Oleksandr1, V. Nfonsam1 1University Of Arizona,Surgery,Tucson, AZ, USA

Introduction: With increasing rates of antibiotic use in the aging population of the U.S., Clostridium difficile (C. difficile) infection of the colon is becoming more prevalent. We sought to evaluate the association between frailty and postoperative outcomes after colectomy for C. difficile colitis.

Methods: NSQIP cross-institutional database was used for this study. Data from 483 patients with a diagnosis of C. difficile colitis was used in the study. 73.71% underwent total (n = 356) and 26.29% partial (n = 127) colectomies. Modified frailty index (mFI) is a previously described and validated 11-variable frailty measure used with NSQIP to assess frailty. Outcome measures included serious morbidity, overall morbidity, Clavien IV (requiring ICU), and Clavien V (mortality) complications.

Results:Median age was 70 years, and BMI was 26.9Kg/m2. 44.4% of patients were males. 98.6% of patients were assigned ASA Class 3 or higher. The median mFI was 0.27 (0 – 0.63). As mFI increased from 0 (non-frail) to 0.36 and above, the overall morbidity and increased from 53.3% to 88.1% and serious morbidity increased from 43.3% to 76.1%, respectively. The Clavien IV complications rate increased from 30.0% to 73.9%. Mortality rate has increased from 6.7% to 46.3%. All results were statistically significant at p<0.01. On a multivariate analysis mFI was independent predictor of overall morbidity (AOR: 12.4, p<0.05) and mortality (AOR: 8.3, p<0.05).

Conclusion:Frailty is associated with increased risk of complications in C. difficile colitis patients undergoing colectomy. The mFI is an easy to use tool and can play an important role in the risk stratification of these patients, who generally have significant morbidity and mortality to begin with.

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

Posted on January 18, 2016

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

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

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

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

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

« Previous Page
Next Page »