68.09 Surgeon Perspectives on Inter-hospital Transfer for Gravely Ill Patients with Acute Surgical Problems

Posted on January 18, 2016

K. Kummerow Broman1,4, M. J. Ward2, B. K. Poulose1, M. L. Schwarze3 1Vanderbilt University Medical Center,General Surgery,Nashville, TN, USA 2Vanderbilt University Medical Center,Emergency Medicine,Nashville, TN, USA 3University Of Wisconsin,Vascular Surgery,Madison, WI, USA 4VA TN Valley Healthcare System,Geriatric Research And Education Clinical Center,Nashville, TN, USA

Introduction: Inter-hospital transfer is resource-intensive and can be burdensome for patients and families. Decisions regarding transfer can be particularly challenging for gravely ill surgical patients, for whom transfer may be arduous and of questionable clinical benefit.

Methods: We conducted semi-structured interviews with general surgeons who refer and accept transfer patients within a regional transfer network. Participants were identified using a combination of snowball sampling, where initial study subjects were asked to identify additional subjects, and purposive sampling where respondents were selected deliberately to increase variability. Surgeons were selected from three community hospitals that refer patients, three regional hospitals that both refer and accept, and one tertiary referral center that accepts transfer patients. We completed 15 audio-recorded interviews that included open-ended questions and three case-based vignettes. Each interview transcript was analyzed by at least two members of the research team using a deductive coding strategy. We used consensus coding to generate higher level analysis about the content regarding surgeon transfer decisions for gravely ill patients with acute surgical problems.

Results:Referring surgeons seek transfer when they identify discordance between patient needs and local resources. When patients are gravely ill, transfer decisions are influenced by clinical uncertainty and a duty to exhaustively pursue treatment options based on surgeon judgement or family request. Accepting surgeons at regional facilities consider local resources, patient ownership, and expected benefit in their decisions to accept patients. Tertiary facility surgeons report a policy to accept all transfer patients based on a perceived responsibility to the region and difficulty making treatment recommendations without in-person assessment, but they express concern that dying patients may be unnecessarily transferred without survival benefit or adequate discussion of local palliative options. Palliative care and expertise in end-of-life communication may be uniquely available in higher level centers, although respondents were conflicted about the appropriate allocation of limited resources, specifically bed availability, for dying transfer patients.

Conclusion:Current policies and practices may fail to identify dying patients who will not benefit from transfer. Remote consultation, cultural shifts in end-of-life communication, and access to palliative care at community hospitals could provide needed support to surgeons, patients, and families while allocating scare tertiary care beds more judiciously.

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

Posted on January 18, 2016

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

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

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

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

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

68.06 Bariatric Surgery and its Association With Improved Kidney Function Among African Americans

Posted on January 18, 2016

K. Chawla1, A. Vij1, S. Ajmeri1, A. L. Rodriguez1, G. Gilot1, F. De Souza3, G. Ortega3, C. O. Callender2, T. Fullum2 1Howard University,College Of Medicine,Washington, DC, USA 2Howard University College Of Medicine,Division Of Minimally Invasive And Bariatric Surgery, Department Of Surgery,Washington, DC, USA 3Howard University College Of Medicine,Outcomes Research Center, Department Of Surgery,Washington, DC, USA

Introduction: Obesity is associated with a number of comorbidities including chronic kidney disease (CKD). Bariatric surgery results in significant weight loss and post-operative improvements in estimated glomerular filtration rate (eGFR). There is a paucity of data on the effectiveness of bariatric surgery in improving eGFR among African American patients. We hypothesize that bariatric surgery is associated with improved post-operative kidney function among African Americans.

Methods: We conducted a retrospective analysis of patients who underwent bariatric surgery (roux-en-y gastric bypass and sleeve gastrectomy) between 2008 and 2013. We measured pre- and post-operative BMI and eGFR. Post-operative values were recorded 6 months following surgery. The eGFR was estimated by calculating creatinine clearance (CKD-EPI equation used), and a range of 90-125 ml/min/1.73m2 was considered normal. We categorized patients into three BMI categories – ‘35 ≥ BMI < 40′, ‘40 ≥ BMI < 50′ and ‘BMI ≥ 50′. We compared pre-operative eGFR to the post-operative values for patients with glomerular hyperfiltration (stage I CKD) and patients at CKD stages II-IV. We also analyzed the proportion of patients whose CKD condition improved to a less severe stage post-operatively.

Results: The results include 160 patients whose mean age at the time of surgery was 43.0 years. The overall mean eGFR was 104.6 ml/min/1.73m2 prior to surgery and rose to 110.0 post-operatively (p > 0.05). The mean BMI reduced from 49.1 kg/m2 pre-operatively to 38.3 kg/m2 post-operatively (p < 0.0001). Of the 160 patients, 28 had glomerular hyperfiltration (eGFR > 125) and 40 had stages II-IV CKD (eGFR 15-90) prior to surgery. The patients with stage I CKD had a mean pre-operative eGFR of 133.3, which reduced to 125.3 post-operatively (p = 0.0036). Among CKD stage I patients only those in the ‘40 ≥ BMI < 50′ BMI category encountered significant reduction in eGFR from 135.3 to 125 (p = 0.0258). Patients with stages II-IV CKD had a lower than normal mean pre-operative eGFR of 74.8, which rose to 82.6 post-operatively (p > 0.05). None of the BMI categories for patients with stages II-IV CKD showed significant improvement in kidney function. A stage I CKD resolution rate of 43.8% was seen following bariatric surgery, while 57.1% of patients at stages II-IV CKD improved to less severe stages following surgery.

Conclusion: African American patients experienced an improvement in their renal function following bariatric surgery. Further follow up is necessary to determine the effects of bariatric surgery on long-term renal function among African Americans.

68.07 Granulomatous Mastitis: Conservative vs. Surgical Treatment in a County Hospital

Posted on January 18, 2016

A. J. Green1,2, T. Rana2, P. Twomey1,2, R. Godfrey1,2 1University Of California – San Francisco,East Bay Surgery,San Francisco, CA, USA 2Highland General Hospital,Surgery Department,Oakland, CA, USA

Introduction:

Granulomatous mastitis is a chronic inflammatory disease of the breast that is considered idiopathic and has a debated etiology. The clinical presentation of the disease often mimics breast cancer. There is no consensus on the best treatment and methods range from observation and antibiotics to systemic steroids and mastectomy.

Our objective was to determine if conservative management of granulomatous mastitis without steroids and definitive surgery provides effective management for this disease.

Methods:

A retrospective review of institutional records of Highland Hospital in Oakland, California of all patients with a histopathologic diagnosis of granulomatous mastitis from June 2005 though July 2015. Demographic, clinical and outcomes data were analyzed using summary statistics.

We defined definitive surgery as mastectomy, lumpectomy or excisional biopsy.

Results:

A total of 46 women with granulomatous mastitis were identified. The mean age was 33.9 (range 24 – 55 years). 62.2% of women received conservative management with 85% resolution. This includes 22.2% who received only core needle biopsy or fine needle aspiration (88.9% resolution) and 40% who received incision and drainage (86.7% resolution). 35.6% received excisional biopsy. 68.8% of patients undergoing excisional biopsy also had a BIRADS 4 or higher reading on ultrasound or mammogram. 91.7% of patients with excisional biopsy had resolution of symptoms. A single patient (2.2%) received steroids after failed conservative management and continued to be symptomatic. Conservative management was successful in 87.5% of cases. The mean duration of follow up was 11.8 months (range 1 week to 45 months).

Significantly, 91.3% of patients with granulomatous mastitis were Hispanic. Approximately 30% of our hospital patients are Hispanic.

Conclusion:

Conservative management with interventions limited to aspiration, incision and drainage and antibiotics is frequently effective in the management of granulomatous mastitis. However, the radiologic and clinical presentation can mimic breast cancer, and excisional biopsy is often required to rule out a diagnosis of malignancy. Patients treated without steroids had recovery rates comparable to treatment with steroids reported in the literature.

68.02 Evaluating the Quality of Care Transitions Following Outpatient Surgery

Posted on January 18, 2016

M. McCabe1, R. W. Randle1, H. Chen1,2, C. J. Balentine1 1University Of Wisconsin,Department Of Surgery,Madison, WI, USA 2University Of Alabama,Department Of Surgery,Birmingham, Alabama, USA

Introduction: Improving the quality of care as patients transition from the hospital to home has been highlighted by the Institute of Medicine and the Centers for Medicare and Medicaid Services as a priority area for enhancing patient-centered care. The quality of care transitions has been assessed for complex inpatient medical and surgical patients but has never been evaluated for outpatient surgery. The purpose of this study was to use a validated transitions instrument to determine how well patients were being prepared for outpatient surgery at an academic hospital. We hypothesized that our extensive preoperative education and patient support services would result in excellent preparation for surgery and would be reflected by high scores on the instrument.

Methods: We administered the Care Transitions Measure (CTM), a validated assessment of care transition quality, to patients undergoing outpatient endocrine surgery. The survey measures patient comprehension of medications, treatment and discharge plans. Participants were surveyed at three time points: the pre-operative clinic visit, after surgery on the day of discharge, and at the post-operative clinic visit. The primary endpoint was CTM score at each time point. Secondary outcomes included postoperative complications.

Results: We approached 110 patients and 92 (84%) agreed to participate. Mean CTM scores for complex medical and surgical inpatients typically range from 65-70 on a 100 point scale, but our patients had considerably higher scores at all time points (Figure). After the initial clinic visit, mean CTM was 89 ± 2. After surgery, CTM scores remained high with a mean of 92 ± 1.7 on the day of surgery and 90 ± 2 at the postoperative visit, though none of the differences was statistically significant. These scores indicated that our patients had excellent comprehension of treatment plans, understood their medications, and felt that followup plans were adequately explained throughout their surgical experience. There was no significant difference in CTM scores between patients with and without postoperative complications.

Conclusions: Overall CTM scores in our population were extremely high following outpatient endocrine surgery. There are many mechanisms used at our institution to enhance patient understanding and care coordination including dedicated nursing staff, carefully constructed written educational material, easy access to surgeons by phone/e-mail and reinforcement of education in the clinic. Further work will explore which of these mechanisms is most responsible for our high quality care transitions.

68.03 Does Intraoperative Nerve Monitoring Reduce the Rate of Recurrent Laryngeal Nerve Injury?

Posted on January 18, 2016

B. C. Brajcich1, C. R. McHenry1,2 1Case Western Reserve University School Of Medicine,Cleveland, OH, USA 2MetroHealth Medical Center,Department Of Surgery,Cleveland, OH, USA

Introduction:

Damage to the recurrent laryngeal nerve during thyroidectomy can lead to vocal cord paralysis, resulting in hoarseness and respiratory distress. Prior studies have demonstrated mixed results regarding the role of intraoperative nerve monitoring (IONM) in preventing recurrent laryngeal nerve injury. The purpose of this study was to examine the effect of IONM on recurrent laryngeal nerve injury during thyroidectomy.

Methods:

A retrospective cohort study was performed on patients undergoing thyroidectomy performed by a single surgeon over a 6-year period beginning in 2009 (n=627). Routine intraoperative monitoring was implemented in 2012 and was used in a cohort of 315 consecutive patients. The recurrent laryngeal nerve was routinely identified and traced through its entire course in all patients and the IONM was used solely to confirm the functional integrity of the nerve throughout its dissection. The rate of recurrent laryngeal nerve injury was compared to a cohort of 312 consecutive patients who underwent thyroidectomy during the 3-year period immediately prior to implementation of IONM. Secondary analysis was performed to determine if there was a relationship between nerve injury and patient age, sex, substernal thyroid extension, central neck dissection, re-operative neck surgery, nodule size, thyroid gland weight, or pathology. Subgroup analysis was performed for patients with malignant pathology, substernal thyroid extension, re-operative neck surgery, and central neck dissection.

Results:

Of the 627 patients who underwent thyroidectomy, 7 (1.1 %) had a recurrent laryngeal nerve injury. There was no correlation between the use of the IONM and recurrent laryngeal nerve injury. Of the 531 nerves at risk in the cohort with IONM, 4 (0.75 %) were injured compared to 3 injuries (0.58 %) among the 517 nerves at risk in the cohort without IONM (p>0.05). No secondary measures demonstrated a statistically significant relationship with recurrent laryngeal nerve injury. Subgroup analysis did not show any relationship between IONM and nerve injury.

Conclusion:

IONM had no impact on the rate of recurrent laryngeal nerve injury during thyroidectomy. Further studies with larger sample sizes are necessary to confirm our findings, especially in specific high-risk subgroups.

68.04 Laparoscopic vs. Open Approach for Acute Abdomen in Pregnancy

Posted on January 18, 2016

A. Azim1, P. Rhee1, T. Orouji Jokar1, N. Kulvatunyou1, T. O’Keeffe1, A. Tang1, R. Latifi1, G. Vercruysse1, D. Green1, R. Friese1, B. Joseph1 1University Of Arizona,Trauma Surgery,Tucson, AZ, USA

Introduction:

Laparoscopic surgical technique is a standard of care for common surgical procedure such as appendectomy and cholecystectomy. Pregnant patients are a high-risk group for these surgeries and provide several technical difficulties. The aim of this study was to determine outcomes between open vs. laparoscopic surgical approaches in pregnant patients with acute cholecysitis and acute appendicitis. We hypothesized that laparoscopic procedure is a safe approach in pregnant patients with acute abdomen.

Methods:

We performed a four-year (2008-2011) retrospective analysis of national inpatient sample database. All pregnant patients who underwent operative procedure for the diagnosis of acute appendicitis and acute cholecystitis were included in the analysis. Patients with laparoscopic and open procedures were matched for age, type of admission, day of admission, location and teaching status of the hospital, severity of illness, and indication for procedure by using propensity score matching in 1:1 ratio. Matched samples were compared using t-test (parametric), chi-square, and Kruskall-Wallis (non-parametric) tests.

Results:

A total of 252 pregnant patients with the diagnosis of acute abdomen were identified. 213 required operative intervention. After propensity score matching 128 (64 laparoscopic: 64 open) were included in the analysis. Mean age of the population was 27 ± 6, 54% underwent appendectomy, and 46% underwent cholecystectomy. There was no difference in age (p=0.7), type of operation (p=0.3), day of admission (p=0.3), location (p=0.5) and teaching status of the hospital (p=0.8), severity of illness (p=0.7), and indication for procedure (p=0.9). Hospital length of stay (2.1± 1.9 vs. 3 ± 2, p=0.005) and total charges (22612 [12495-27786] vs. 29552 [16712- 34222], p=0.017) were significantly lower in laparoscopic group. There was no difference in complications (p=0.9). No fetal loss was seen in both groups. Table1 shows the comparison of the outcomes among the two groups.

Conclusion:

Minimally invasive approach to acute appendicitis and cholecystitis in pregnant patients is safe and cost effective. Avoidance of minimally invasive approach in pregnancy for fear of fetal complications is unwarranted.

67.19 Primary Anastomosis Versus Bowel Discontinuity in Damage Control Laparotomy

Posted on January 18, 2016

A. Hassan1, P. Rhee1, A. A. Haider1, N. Kulvatunyou1, T. O’Keeffe1, A. Tang1, R. Latifi1, G. Vercruysse1, D. Green1, F. Randall1, B. Joseph1 1The University Of Arizona,Trauma,TUCSON, ARIZONA, USA

Introduction:

The optimal management of bowel injury in the setting of damage control laparotomy (DCL) is not well defined. The aim of this study was to compare primary anastomosis (PA) versus bowel discontinuity (BD) in DCL at the first operation.

Methods:

An 8-year (2006-2013) retrospective analysis of all patients undergoing trauma laparotomy at our Level 1 trauma center was performed. We included patients with DCL requiring bowel resection. We divided the patients into two groups based on their treatment: PA and BD. Patients in BD group were re-anastomosed during the second operation. Outcome measures were mortality and complications. We compared the two groups for differences in demographics, injury parameters, lab data and outcomes.

Results:

A total of 162 patients had DCL during the study period of which 58 patients (36%) were included in our analysis. 32% (n=20) of the patients had a PA while the remaining 68% (n=38) patients had BD. Overall mortality rate was 34%. There was no difference in patient characteristics and intra-abdominal organ injuries between the two groups (Table 1). On multivariate analysis patients with BD had 4.6 times higher mortality rate compared to patients with PA (OR (95%CI) = 4.6 (1.08-25); p=0.04).

Conclusion:
Patients left in bowel discontinuity had 5 times higher risk of mortality compared to patient undergoing a primary anastomosis. Iatrogenic bowel obstruction after damage control laparotomy may have physiological effects contributing to adverse outcomes.

67.20 Endoscopic Ultrasound After Induction Chemoradiation Therapy Overstages Tumors for Esophageal Cancer

Posted on January 18, 2016

D. Giugliano1, F. Palazzo1, M. Pucci1, E. Rosato1, C. Lamb1, D. Levine1, A. Berger1 1Thomas Jefferson University,Philadelphia, PA, USA

Introduction: Endoscopic ultrasound (EUS) has been shown to be the most accurate method for staging patients with esophageal cancer. After neoadjuvant chemoradiation therapy (CRT), CT and PET scan are often used over EUS for re-staging due to post-treatment fibrosis and inflammation that may make EUS staging inaccurate. The aim of this study was to compare EUS staging and pathologic staging in patients who underwent induction therapy prior to esophagectomy.

Methods: We queried our IRB-approved prospective foregut database to identify a total of 26 patients from 2001 to 2015 who underwent post-induction EUS re-staging for locally advanced esophageal cancer. EUS post-induction stage was compared to pathologic stage. EUS nodal status was determined by nodal morphology and size and not by biopsy.

Results: The majority of patients (n=24, 92.3%) were diagnosed with adenocarcinoma. The average age was 58 years old (range: 41-77 years). Most patients (n=22 patients, 84.6%) were male. EUS over-staged tumors for the majority of patients (n=12, 46.2%). It correctly staged 26.9% (n=7) of patients and understaged 26.9% (n=7) of patients. Tumor size (T) was most often overestimated (n=13, 50.0%), as compared to being correctly estimated in 26.9% (n=7) of patients and underestimated in 23.1% (n=6) of patients. Finally, nodal status (N) was most often correct (n=15, 57.7%), and was underestimated in 26.9% (n=7) of patients and overestimated in 15.4% (n=4) of patients.

Conclusion: Post-neoadjuvant chemoradiation therapy re-staging using EUS most often overstages esophageal tumors. Tumor size is most often overestimated, while nodal status is most often correct. Subsequent therapy should not rely on post-neoadjuvant EUS stage.

68.01 Optimal surgical strategy for esophagogastric junction carcinoma.

Posted on January 18, 2016

M. Yura1, H. Takeuchi1, R. Nakamura1, T. Takahashi1, N. Wada1, H. Kawakubo1, Y. Kitagawa1 1Keio University, School Of Medicine,Department Of Surgery,Shinjuku-ku, TOKYO, Japan

Introduction: Incidence of esophagogastric junction carcinoma is increasing worldwide. However, surgical strategies for this cancer remain controversial. This study aimed to clarify the optimal surgical strategy for EGJ adenocarcinoma.

Methods: We retrospectively reviewed a data base of 87 consecutive patients with EGJ adenocarcinoma who underwent curative surgical resection at Keio University Hospital between January 2000 and December 2013. EGJ carcinoma defined as Siewert’s classification ?Siewert type I, N=11 (13%); Siewert type II, N=68 (78%); Siewert type III, N=8 (9%)?

Results: Of 87 patients, 33 (37%) were pT1 and 54 (63%) were pT2≤. Mediastinal lymph node (MLN) metastasis was observed in 9 patients. Patients with pT2≤ had a higher incidence of mediastinal lymph node MLN metastasis as compared with patients with pT1 (14.8% in pT2≤ and 3.0% in pT1). In the patients with pT1, lower MLN metastasis ?was identified with Siewert type I (1/6; 17%) and not identified with Siewert type II (0/25; 0%). Upper/middle MLN metastasis was observed in four cases with pT2≤?Siewert type I, N=3 (60%); Siewert type II, N=1 (12%); Siewert type III, N=0 (0%)?. Of all patients having pT2≤ carcinoma with the tumor center located below EGJ (N=36), no patients exhibited upper/middle MLN metastasis and one patient (2.7%) had lower MLN metastasis. In the patients with pT2≤ carcinoma that tumor center was located above EGJ (N=18), upper/middle MLN metastasis was observed in three patients (16.7%) and lower MLN metastasis was observed in five patients (27.8%). The transthoracic approach was used in all patients with Siewert type I and 12 patients (17.6%) with Siewert type II. The transabdominal approach was used in the patients with Siewert type II/III ?Siewert type II, N=56 (82%), Siewert type III, N=8 (100%)?.

Conclusion: In the patients with superficial Siewert type II carcinoma, necessity of mediastinal LN resection is very low. For those patients, laparoscopy-assisted proximal gastrectomy may be a minimally invasive surgical technique. MLN lymph node dissection through transthoracic approach seems unnecessary, particularly if the tumor center is located below EGJ.

67.17 Pre‐operative Selective Venous Sampling in Reoperative Parathyroid Surgery

Posted on January 18, 2016

S. Zaheer1, D. Graham1, L. Kuo1, H. Wachtel1, R. Roses1, G. Karakousis1, R. R. Kelz1, D. L. Fraker1 1Hospital Of The University Of Pennsylvania,Department Of Surgery,Philadelphia, PA, USA

INTRODUCTION
Reoperative parathyroid surgery (RPS) can be challenging, especially following bilateral neck dissection (BNE). Noninvasive imaging studies (NIIS) such as ultrasound, sestamibi scan, SPECT and magnetic resonance imaging are less sensitive in this setting. 4‐dimensional cat scan (4DCT), a relatively new imaging method, is superior to other NIIS in localizing parathyroid disease but is not widely available. In such scenarios, selective venous sampling (SVS) may be useful for operative planning. We present the results of SVS in a cohort of NIIS‐negative patients with persistent or recurrent disease.

Methods:
RPS patients enrolled in our institutional prospective endocrine surgery registry from 1997 to 2013 were identified for inclusion in the study. Patients with positive localization by NIIS were excluded from the study. Study patients underwent SVS followed by parathyroid exploration with intra-operative PTH monitoring. SVS results were classified as non-localized, lateralized (identification of the correct side of the abnormal gland) or localized (identification of the correct side and position of the abnormal gland) through an assessment of intra-operative findings and pathologic review. Descriptive statistics were performed. Test characteristics were calculated.

Results:
We identified 165 patients with recurrent/persistent disease necessitating surgical intervention. Of the surgical candidates, 19 patients had negative NIIS and were referred for SVS. The sensitivity of lateralization by SVS was 95% (18/19). The sensitivity of localization by SVS was 44.4% (8/18). The final diagnosis was adenoma in 15 patients, hyperplasia in 3 patients and parathyroid carcinoma in 1 patient. Immediate cure was achieved in 88.9% of patients. Long-term cure was achieved in 15/19 (78.9%) patients, among those who lateralized the cure rate was 14/18 (77.8%). Interestingly, cure was not achieved in 2/8 patients who were localized by SVS. One had parathyroid cancer metastatic to left lower neck and the other had multigland hyperplasia.

Conclusion:
SVS is a useful test for the preoperative localization of abnormal parathyroid glands when other NIIS fail. Despite SVS results, the long-term cure rate in this population remains substantially lower than that reported for initial surgical candidates. SVS is especially important in reoperative cases when 4‐ dimensional CT is not locally available.

67.18 Postoperative Outcomes in Patients Presented with Perforated Bowel: Early vs. Late Intervention

Posted on January 18, 2016

Z. Al-Qurayshi1, E. Kandil1 1Tulane University School Of Medicine,Surgery,New Orleans, LA, USA

Introduction: Time from hospital admission to surgery has been suggested to be a crucial risk factor. In this study, we aim to compare the outcomes of one day delayed surgeries to those done on the same day of admission in patients presented with perforated bowel.

Methods: Time from hospital admission to surgery has been suggested to be a crucial risk factor. In this study, we aim to compare the outcomes of one day delayed surgeries to those done on the same day of admission in patients presented with perforated bowel.

Results: 7,415 discharge records were included. 1,753 (23.5%) patients had delayed intervention, while (76.5%) patients had operation on the same admission date. Next day interventions were more likely to be associated with postoperative complications [OR: 1.24, 95%CI (1.08, 1.41), p=0.002]. However by considering complications types individually; pulmonary complications were higher for next day operations (p<0.01), while same day operation had higher risk of wound complications (p<0.01). Patients who had next day surgery were at risk of a hospital stay of more than 14 days (p<0.001). Hospital located in the Northern region of the United States were more likely to delay the intervention until the next day of admission compared to rest of United States( p<0.001). Additionally, women were at higher risk of next day operation compared to men (p=0.01). The average cost of health services for next day operation was significantly higher compared to same day operation ($33,146.00± 907.96 vs. $ 28,658.00± 414.33, p<0.001).

Conclusion: Delaying surgical intervention for patients presented with perforated bowels is associated with disadvantageous outcomes. Gender and geographical disparities associated with the time of intervention.

67.13 Frozen Section Analysis in the Post-Bethesda Era

Posted on January 18, 2016

T. M. Cotton1, X. Jing1, S. John1, R. Lirov1, B. Miller1, M. Cohen1, G. Paul1, D. Hughes1 1University Of Michigan,Ann Arbor, MI, USA

Introduction:
Limitations of intraoperative frozen section (FS) for indeterminate thyroid lesions are well-appreciated. Studies about FS utility have involved ‘follicular lesions’ (FL) and were before the Bethesda System for Reporting Thyroid Cytopathology (BSRTC) subcategorized indeterminate FNA results into follicular lesions of undetermined significance (FLUS) and suspicious for follicular neoplasm (SfFN). We hypothesize that FS will have less utility with FLUS lesions compared to SfFN due to improved cytological categorization in the post-Bethesda era.

Methods:
From 2008 to 2014, 479 patients underwent thyroid lobectomy. Pre-Bethesda (2008-2011) patients with an FNA diagnosis of FL and post-Bethesda (2011-2014) patients with an FNA diagnosis of FLUS or SfFN who underwent FS were identified. The study group was comprised of 135 patients (65 FL, 45 FLUS, and 25 SfFN). The sensitivity, specificity, PPV, and NPV of FS within these categories was compared to final histopathology.

Results:
In the FL group, 6/65 patients were found to have thyroid cancer within the sampled nodule on histopathology with FS having a sensitivity of 50%, specificity of 100%, PPV of 100%, and NPV of 95%. Three of the six cancer cases were identified on FS and changed the operation in 3/65 FL patients (4.6%). In the FLUS group, 5/45 patients were found to have thyroid cancer within the sampled nodule on histopathology with FS having a sensitivity of 20%, specificity of 100%, PPV of 100%, and NPV of 91%. One of the five cancer cases was identified on FS and changed the operation in 1/45 FLUS patients (2.2%). In the SfFN group, 4/25 patients were found to have thyroid cancer within the sampled nodule on histopathology with FS having a sensitivity of 50%, specificity of 100%, PPV of 100%, and NPV of 91%. Two of 4 cancer cases were identified on FS and changed the operation in 2/25 SfFN patients (8%). No patients were over-treated due to false positive FS and 3/70 patients (4.3%) avoided reoperation across post-Bethesda groups.

Conclusion:
FS had limited value before BSRTC, but is even less useful in FLUS patients in the post-Bethesda era. FS had a higher sensitivity in SfFN than FLUS patients and avoided reoperation in 8% of SfFN patients compared to 2.2% (FLUS) and 4.6% (FL).

67.14 Revisional Bariatric Surgery in African Americans: Short Term Outcomes

Posted on January 18, 2016

J. S. Kendall1, G. Ortega1,2, K. Williams1, K. Hughes1, E. E. Cornwell1, T. M. Fullum1, D. D. Tran1 1Howard University College Of Medicine,Washington, DC, USA 2Johns Hopkins University School Of Medicine,Baltimore, MD, USA

Introduction: African Americans have the highest incidence of obesity compared to other groups, and some have benefitted greatly from weight loss operations. Unfortunately there has also been an increase in the need for revisional surgeries due to unsatisfactory weight loss or weight regain. We report the short term outcomes of revisional bariatric surgeries in African Americans at a tertiary academic medical center.

Methods: We conducted a retrospective study of eligible subjects identified at Howard University Hospital. Patients included were those who underwent revisional bariatric surgery over a 5 year period from August 2008 to July 2013. Data on the patients’ demographics, body mass index (BMI), and comorbid conditions were recorded prior to the surgery and at 1, 6, and 12 months post-surgery.

Results: 364 patients underwent bariatric surgeries during the time frame of the study. 77 (21%) of the 364 were revisional bariatric surgeries. The original surgery was Roux En Y gastric bypass (RNY) in 74 (97%) patients, laparoscopic adjustable gastric banding (LGB) in 2 (3%) patients, and biliopancreatic diversion (BPD) in 1 (1%) patient. The mean pre-op BMI before the original procedure was 54.3 kg/m2, and the mean nadir bmi was 33.4 kg/m2. The mean revisional pre-op BMI was 42.1 kg/m2 and the mean BMI 12 months post-revision was 34.8 kg/m2. Average percent excess weight loss (%EWL) was 32.1% 12 months post-revisional surgery. Paired sample t-test comparing the means of the nadir BMI after the original surgery to the BMI 12 months post-revisional surgery showed no statistical difference (p>0.05). 7 (9%) patients developed post-operative complications. 2 (3%) patients showed post-operative bleeding but only one required a transfusion. 2 (3%) patients developed an incisional hernia through the revisional surgery incision, needing reparative surgery. 1 (1%) patient developed a small bowel obstruction. 1 (1%) patient developed a gastrojejunal stricture needing repair, and 1 (1%) patient developed sepsis from a staple line leak that was repaired. There were no mortalities.

Conclusion: Revision bariatric surgery produces similar results to the original procedure, and is feasible and safe for African Americans who have experienced weight regain or unsatisfactory weight loss after the original bariatric procedure.

67.15 Short Term Outcomes of Abdominal and Colorectal Surgery in Patients with Heart Transplant

Posted on January 18, 2016

A. Asban1, M. Traa1, N. Melnitchouk2 1Tufts Medical Center,Colorectal Surgery,Boston, MA, USA 2Brigham And Women’s Hospital,Boston, MA, USA

Introduction:
Due to the increase in the successful rate of heart transplant surgery as well as dramatic improvement of immunosuppression medications, the risk and complications of a abdominal and colorectal surgery were poorly described in literature.

Methods:
This is a single institution study of 32 heart transplant recipients who underwent abdominal, including colorectal, operations at Tufts Medical Center between 2003 and 2013. Medical records were reviewed for comorbidities, immunosuppression status, duration post-transplant, type of surgery, type of anesthesia, intraoperative complications, estimated blood loss, postoperative complications, length of stay, readmission and reason of readmission and 30-day mortality rate.

Results:

Over the 11-year study period, 32 patients with heart transplant at Tufts Medical Center underwent a total of 50 colorectal (20%) and other abdominal (80%) operations. Colorectal operations included left colectomy, exploratory laparotomy with lysis of adhesion, small bowel resection and examination under anesthesia and fulguration of anal condyloma. The most common procedure overall were incision hernia (40%) and diaphragmatic hernia (18%). 74% of the surgeries were elective and 26% emergencies. 94% of cases were performed under general anesthesia. The study population was 87.5 male and 12.5% female wit mean age of 55 years. In 50% of patients the indication for heart transplant was ischemic heart disease. 58% of patients had undergone abdominal surgery previously, 100% of patients were on immunosuppression, and 46% were on steroids. The median time elapsed since transplant was 765 days (range 1-3,563 days). Intraoperative complications were limited to bleeding (2%) and hypotension (2%). Postoperative complications included deep surgical site infection (4%) and superficial surgical site infection (2%), none of which happened in the colorectal surgery group. Of the bowel resection with anastomoses there were no anastomotic leaks reported. There were no major cardiac events noted in the perioperative period although sinus tachycardia was common intraoperatively. The mean length of stay was 4 days, with an 8% readmission rate for post operative surgical causes (including management of surgical site infection or pneumonia). Thirty-day mortality rate was 0%

Conclusion:
Our experience suggests that abdominal and colorectal surgery in heart transplant recipients is relatively safe. The incidence of surgical site infections was comparable to the general population, and there were no anastomotic leaks in our small sample despite immunosuppression. Surgeons should evaluate heart transplant patients for abdominal and colorectal surgery as they would any other patient presenting for emergency or elective care.

67.16 Racial Disparities in Presentation and Management in Hyperthyroidism Patients Prior to Surgery

Posted on January 18, 2016

J. Kim1, T. S. Wang1, K. M. Doffek1, A. A. Carr1, D. B. Evans1, T. W. Yen1 1Medical College Of Wisconsin,Surgical Oncology,Milwaukee, WI, USA

Introduction: Racial disparities in thyroid cancer are well-documented. However, there is a paucity of information on racial differences in the management of benign thyroid disorders. We sought to determine whether racial disparities exist in the etiology, presentation, and management of hyperthyroid patients prior to surgical intervention.

Methods: A retrospective chart review of a prospectively collected database was performed of hyperthyroid patients who underwent thyroidectomy at a single institution from 01/2009 to 02/2014. Data collected included patient demographics, etiology of hyperthyroidism, type and duration of hyperthyroid symptoms (unintentional weight loss, palpitations, heat intolerance, anxiety, emotional lability, tremor, muscle weakness and eye symptoms), thyroid hormone levels, and use of antithyroid medications and radioactive iodine prior to surgery. Racial differences for etiology, presentation, and pre-surgical management were examined by chi-square or Kruskal-Wallis test.

Results: Of the 191 patients, the majority (73%) were white; 18% (n=34) were black and 9% (n=17) other or unknown races. The most common etiologies of hyperthyroidism were Graves’ disease (51%), toxic multinodular goiter (34%), and toxic thyroid nodule (10%). There was no difference in the etiology of hyperthyroidism by race. At least one symptom was reported in 159 (83%) patients. By race, there was no difference in the presence of reporting at least one symptom, the presence of each of the eight symptoms, the maximum duration of symptoms, or the median duration of each symptom, except for heat intolerance. The median duration of heat intolerance was longer in the non-white patients (10 months in Blacks and 13 months in other races) compared to three months in white patients (p=0.03). The total number of symptoms per patient differed by race; non-white patients reported more symptoms than white patients (4-4.5 vs. 3; p=0.03). There was no difference in preoperative TSH or free T4 values by race. Prior to surgery, 135 (71%) patients received antithyroid medication; there was no difference in receipt or duration of medication by race. Only 14 (7%) patients received radioactive iodine treatment prior to surgery; there was no difference by race.

Conclusion: In this cohort of largely white patients, we found no racial differences in the etiology of hyperthyroidism, presence and duration of symptoms, biochemical level of disease, and preoperative management, except the findings that non-white patients reported longer duration of heat intolerance and presented with more symptoms than white patients. Prospective studies in larger, more racially diverse populations that include hyperthyroid patients who are managed either medically or surgically are needed.

67.11 Seasonal Variation in Acute Cholecystitis: A Fourier Transform Analysis.

Posted on January 18, 2016

Z. Fong1, D. B. López1, R. La Placa2, G. Jin1, K. D. Lillemoe1, D. C. Chang1 1Massachusetts General Hospital,Surgery,Boston, MA, USA 2Massachusetts Institute Of Technology,Department Of Physics,Cambridge, MA, USA

Introduction:
Seasonal variation has previously been demonstrated in multiple facets of surgery, such as acute vascular events and diverticulitis, as well as surgical outcomes. We investigated whether seasonal variation exists for acute cholecystitis.

Methods:
The National Inpatient Sample (NIS) database was queried for emergent admissions with a diagnosis of acute cholecystitis from 2003-2011, and aggregated into monthly averages. Fourier analysis of the monthly data was performed to detect periodic patterns in the data, a signal processing technique that is historically employed in areas of physics and engineering, and is a way of expressing a function (in this case, hospital admissions over time) as a sum of sinusoids. Comparison of sinusoid amplitudes (signal versus noise) allowed us to discern dominant cyclical patterns. Our findings were further confirmed with linear regression analysis.

Results:
There were 75,585 patients admitted emergently with a diagnosis of acute cholecystitis. Unadjusted analysis of the data demonstrated a trend towards increasing number of annual cholecystitis admissions. Fourier transform analysis detected a strong signal with cycle length of 12 months (coefficient ratios of 3.78 and 2.88 for unsmoothed and smoothed periodogram respectively). This annual cycle peaked in August (mean of 756.33 admissions), and was lowest in February (mean of 632.67 admissions). Linear regression confirmed that months July – October were associated with higher number of admissions, with the lowest coefficient in February (-50.89, p<0.001) and the highest coefficient in August (72.78, p<0.001) relative to January (figure).

Conclusion:
A seasonal pattern exists in the incidence of acute cholecystitis, with peaks in the Fall. The Fourier Transform technique was able to isolate unique pattern from fluctuating trends over time, and may have important clinical implications as it is extended into intraoperative and intensive care hemodynamic monitoring in the future.

67.12 Impact of BMI on Operating Room Times and its Financial Implications

Posted on January 18, 2016

H. Hanif1, F. Agullo1,2, T. Yeager1, G. Coleman1, I. Mallawaarachchi1, A. Nassiri1, V. Molinar1, A. Molinar2, A. Tyroch1, H. Palladino1,2 1Texas Tech University Health Sciences Center,Surgery And Biomedical Sciences,El Paso, TEXAS, USA 2Southwest Plastic Surgery,El Paso, TEXAS, USA

Introduction: Obesity has been the main focus of many public health efforts in the United States. It is a global epidemic with approximately 33% of adults being obese. Obesity both directly and indirectly leads to increases in health care expenditures and resources. Increased consumption of surgical services by obese patients compared to their non-obese counterparts for routine general surgery procedures has been analyzed. Our aim was to investigate the relationship between Body Mass Index (BMI) and the time required to complete standard tasks in the operating room during elective cholecystectomy and to identify the financial impact.

Methods: Our study investigated operative time differences in different BMI groups. Comparisons of continuous variables according to dichotomized BMI were done using a two group t-test or Wilcoxon rank-sum test, while one way analysis of variance or Kruskal Wallis test was used to compare continuous variables according to multi categorical BMI. Linear regression models were developed for all three outcome variables (operating room, anesthesia and surgery times) using multi-category BMI as the main exposure adjusted for age, gender, ethnicity, number of comorbidities, airway type and smoking history.

Results: We included 2068 patients in our study, 1037 patients with BMI<30 and 1025 patients with BMI≥30. The data was further classified according to the WHO obesity classification. The average operating room, anesthesia and surgery times (in minutes) for BMI<25 were 114.4, 124.6, 81.3 respectively and for BMI≥40 were 134.3, 140.5, 96.2. The times of all three outcome variables were significantly different between the two groups with P-values < 0.001. BMI, age, gender and ethnicity continued to be significant in all the final models. When age, gender and ethnicity were adjusted for in our final model, the coefficients for BMI≥40 category compared to BMI<25 category for operating room, anesthesia and surgery times were 22.0 (P-value<0.001), 18.2 (P-value<0.001) and 16.7 (P-value<0.001) respectively (Table 1).

Conclusion: As shown by our data there is significant increase in operative room, anesthesia and surgery times in patients with higher BMI which in turn leads to greater perioperative resource usage and increased hospital cost. We propose a change in CPT coding to compensate for the increased utilization of resources.

67.09 Crohns Disease: Comparing Outcomes Following Colorectal Surgery.

Posted on January 18, 2016

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

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

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

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

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

67.10 Outcomes Of Surgical Procedures In Patients Testing Positive For Cocaine On Urine Screening

Posted on January 18, 2016

U. Kannan2, M. M. John2, R. Gupta2, S. B. Remersu2, D. T. Farkas2 2Bronx- Lebanon Hospital Center,Surgery,Bronx, NY, USA

Introduction:
To review the outcomes following surgical procedures in patients testing positive for cocaine on preoperative urine toxicology screening

Methods:

The practice in our hospital is that patients with urine toxicology positive for cocaine are assessed clinically. If they are acutely toxic or they have a prolonged QTc interval on their electrocardiogram (EKG) the surgery is canceled unless it is an absolute emergency.The electronic medical records (EMR) were retrospectively reviewed for the years 2003-2014. Patients who underwent a surgical procedure whose urine toxicology screening was positive for cocaine were included. Only patients with a positive test on the same admission prior to the surgical procedure were included. Patients who did not receive general anesthesia were excluded. Patient demographics and the 30 day cardiovascular and neurological complications were collected and analyzed

Results:

There were 146 patients in total. After excluding the procedures without general anesthesia, there were 81 patients that were analyzed. There were 53 males and 28 females. The median age was 47 years (18-69 years). 21 procedures were elective and 60 were admitted through the emergency department. There were 54 general surgery cases, 8 orthopedic cases, 4 gynecologic, and 3 each of vascular, otolaryngology, dental, neurosurgical and urology cases.

Cardiovascular complications were noted in 4 patients (2 arrhythmias, non-ST elevated myocardial infarction (NSTEMI) and exacerbation of congestive heart failure) while neurological complications were seen in 2 patients (seizure and cerebrovascular accident). There was one mortality. The complications were reviewed and in most cases attributable to the illness and not cocaine (e.g. mortality after craniotomy for severe hemorrhagic stroke). The two arrhythmias (atrial fibrillation and supraventricular tachycardia) and the NSTEMI were the only ones possibly attributable to cocaine, and all three of these patients had other pre-existing cardiac comorbidities that could have contributed as well.

Conclusion:

A positive urine test for cocaine is not an absolute contraindication to surgery. In patients who are not acutely toxic and without a prolonged QTc interval, complications do not appear to significantly exceed that which would be expected in the population at large. The decision to proceed with surgery needs to be individualized to the patient and the indication for surgery.

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