67.06 Extreme Obesity Increases Surgical Site Infections But Not Major Complications After Renal Surgery

Posted on January 18, 2016

M. A. Mann1, M. Grimes1, M. L. Blute1, K. Zorn1, T. M. Downs1, S. L. Best1, F. Shi1, D. F. Jarrard1, S. Y. Nakada1, E. Abel1 1University Of Wisconsin,Urology,Madison, WI, USA

Introduction: Extreme or class 3 obesity (BMI ≥ 40) may be associated with increased morbidity following surgery. The objective of this study was to evaluate if patients with extreme obesity had worse perioperative outcomes following renal surgery.

Methods: Comprehensive medical records were reviewed for all patients treated with partial nephrectomy, radical nephrectomy or nephroureterectomy at our institution from 2000-2014. Complications occurring within 90 days were recorded and classified according to the Clavien-Dindo system. Univariable and multivariable models were used to evaluate the association of obesity with major complications (≥Clavien 3a), surgical site infections (SSI), blood transfusion (BT) rates and readmission rates.

Results: A total of 1109 patients were evaluated including 114 (10.3%) patients with BMI ≥40. Perioperative complications were identified in 279 (25.5%) patients including major complications in 80 (7.3%). Patients with BMI ≥40 were not at increased risk for major complications (p=0.2). Independent predictors of major complications included Charlson Comorbidity Index and surgical approach (open vs. minimally invasive).

A total of 217 (19.6%) patients received BT during the initial hospitalization following surgery. BMI ≥40 was not associated with increased risk of BT (p=0.9) SSI were observed in 60 (5.5%) patients. Patients with BMI ≥40 had an increased risk of SSI, OR 2.3 (95% CI 1.2-4.5).

A total of 59 patients (5.4%) were readmitted to the hospital with 30 days following surgery. BMI ≥40 was not associated with increased risk of readmission (p=0.4)

Conclusion: Extreme obesity is associated with increased risk of wound complications but not a higher risk of major complications, BT, or hospital readmission following renal surgery. When feasible, minimally invasive surgery may be associated with lower major complication rates.

67.07 Predicting Survival in the Separation of Conjoined Twins

Posted on January 18, 2016

D. K. Robie1, D. K. Robie1 1Mayo Clinic – Florida,Surgery,Jacksonville, FL, USA

Introduction:
The separation of conjoined twins requires thorough preoperative assessment, detailed operative planning, optimization of each twin’s medical status and multidisciplinary team preparation. Since each set of conjoined twins is unique and the condition is extremely rare, both surgeon and institutional experience will be limited. Our recent experience in separating omphalopagus conjoined twins highlighted the importance of these preparatory steps. The purpose of this review is to identify the key prognostic indicators that impact on survival.

Methods:
PUBMED was searched for publications on conjoined twin separations and operations performed between 1988 and 2015 were included in this review. Data gathered included type of conjoining; age at operation; whether emergent or elective separation; if emergent the primary indication for surgery; complexity of organ sharing; mortality and cause of death; survival. Significance of categorical variables on survival was determined using univariate analysis and the mean and median time to the separation operation determined.

Results:
There were 109 separations reviewed. Type of conjoining and % of total as follows: Omphalopagus (OP) 51 (47%), Thoracopagus (TP) 25 (23 %), Ischiopagus (IP) 22 (20%), Parapagus (PP) 5 (5%), Pygopagus (PGP) 4 (4%) and Craniopagus (CP) 2 (2%). Elective separation, survival and age at separation (range; median and mean in months (ms)): 29 OP sets (1 d to 12 ms, 1.25 ms, 3.6 ms) with 95% survival, ; 13 TP sets (1 m to 16ms, 4.5 ms, 6.3 ms) with 81% survival, 20 IP sets (1d to 26 ms, 10.5 ms, 12 ms) with 92.5% survival. Emergency separation and survival: 22 OP sets with 54% survival, 13 TP sets with 29% survival, 2 IP sets with 25% survival. Causes of death in total group(n): planned sacrifice 1, dependent parasite 2, severe congenital heart disease 13, pulmonary 7, sepsis 9, other 9 and unknown 7. Seven infants died intraoperatively and 7 died preoperatively. Indication for emergency separation and % survival; preop twin demise 7 sets (43%), clinical deterioration of one or both twins 16 (24%). 26 infants had severe congenital heart disease (5 with cardiac fusion) with 19 % survival. Predictors of adverse outcome; TP type, emergency separation, preoperative twin demise and presence of severe congenital heart disease.

Conclusion:

Survival following separation of conjoined twins is dependent on the type of conjoining, emergency versus elective separation, the presence of severe cardiac anomalies and the immediate condition of the infants prior to surgery. When time allows, efforts should be focused on maximizing the clinical condition of the infants prior to separation. It is important that the treatment team and the family are aware of the prognosis based on the unique aspects of the individual set of twins.

67.08 Total thyroidectomy does not affect bodyweight

Posted on January 18, 2016

J. C. Lee1,2, P. Chang1, R. Glick1, J. W. Serpell1,2, S. Grodski1 1Monash University,Endocrine Surgery Unit, The Alfred,Melbourne, VIC, Australia 2Monash University,Department Of Surgery,Melbourne, VIC, Australia

Introduction: Weight gain after thyroid surgery is a commonly encountered patient concern in clinical practice, but there is little published data on this topic. Therefore this study aimed to determine bodyweight (BW) change following total thyroidectomy (TTx), and comparing perceived to actual changes. Secondarily, the study also aimed to determine patient satisfaction regarding thyroxine dosing post-operatively.

Methods: Following institutional review board ethics approval, patients were recruited from the Monash University Endocrine Surgery Database between January 2013 and June 2014. All patients who underwent TTx at the Alfred Hospital were eligible. Pre-operative data were extracted from patient files (including BW, TSH, medications), while post-operative data were obtained by surveying the participants 6 to 18 months after surgery (including BW, medications, satisfaction scores). Clinically relevant change in BW was defined as 2 kg gain or loss. Data was analysed using standard statistical methods, including Student’s t-test, Chi-squared, and Fisher’s Exact tests as appropriate.

Results: A total of 107 patients satisfying the inclusion criteria were invited to participate, and were posted the questionnaire. A response was received from 79 patients (74%). The mean age of the respondents was 56 (range 15 – 84) years, with 3 times more females than males. The majority of participants had TTx for benign indications, and 19% had TTx for confirmed or suspected malignancy. Pre-operatively, 32 (42%) patients had a diagnosis of either toxic multinodular goiter or Graves’ disease, and 28 of them were on an anti-thyroid medication. Nearly half (34, 43%) of the participants had stable BW after TTx, while 24 (30%) gained an average of 6.8 kg (9% gain), and 21 (27%) lost an average of 7.8 kg (9.3% loss). There was poor concordance between perceived and actual BW gain or loss. Pre-operative thyrotoxicity did not appear to have any bearing on post-operative BW change. Anti-thyroid medications, gender and TSH levels were also not shown to be predictors of post-operative BW change. Taking their BW and thyroxine dosing into account, the majority of patients (81%) were satisfied with their post-operative management. There was no correlation between satisfaction scores and BW gain or loss.

Conclusion: Bodyweight change following TTx is unpredictable, and only less than one-third of patients experience weight gain. Pre-operative factors, including thyrotoxicosis, were not found to be predictors of post-operative BW change after thyroidectomy. Regardless of their BW status, the majority of patients were satisfied with their post-operative course after total thyroidectomy.

67.03 Parathyroidectomy or Cinacalcet Therapy for Secondary Hyperparathyroidism in End-stage Renal Disease

Posted on January 18, 2016

Q. TAO1, Z. Ji1, Z. Zhu1, R. Tang2, B. Liu2 1Affiliated Zhongda Hospital, Southeast University Medical School,General Surgery,Nanjing, JIANGSU, China 2Affiliated Zhongda Hospital, Southeast University Medical School,Nephrology,Nanjing, JIANGSU, China

Introduction: In this prospective cohort study, efficacy and safety of parathyroidectomy (PTX) were compared with that of cinacalcet-centred therapy (CCT) for the treatment of chronic kidney disease (CKD)-associated secondary hyperparathyroidism (SHPT) in end-stage renal disease (ESRD).

Methods: Adult patients with Stage 5 CKD between Feberary 2012 and December 2013 at our institution who met the indications for PTX, with an intact parathyroid hormone (iPTH) level ≥ 1000pg/ml associated with hypercalcemia and/or hyperphosphatemia for at least 50% of that period, were included. Baseline characteristics and iPTH, calcium, phosphorus and alkaline phosphatase (ALP) at baseline, 3 and 6 months were compared between the two groups (PTX versus CCT) using the χ2 and paired t-tests.

Results: Of the total population of 112 patients who satisfied KDOQI criteria for PTX, only 34 (30.4%) received PTX, the others received CCT. At baseline, PTX patients had higher iPTH (P=0.011) and ALP (P=0.027). Complete follow-up data at 3 months were available on 85 patients (PTX = 27; CCT =58). PTX had significantly reduction in iPTH (92 versus 56%) compared with CCT. A greater proportion of patients receiving PTX achieved target iPTH levels throughout the study compared with the patients receiving CCT (P=0.002 after 3 months; P=0.013 after 6 months). Changes from baseline in calcium and phosphate levels and proportion of patients achieving target values of bone markers were not significant for either intervention. Findings were consistent at 6 months.

Conclusion: PTX can reduce iPTH levels more than CCT in the patients who met indications for PTX. No significant difference in circulating bone markers reductions were found between these two groups.

67.04 Compliance with American Thyroid Association Guidelines for Total Thyroidectomy in Graves' Disease

Posted on January 18, 2016

S. T. Akram1, D. M. Elfenbein2, H. Chen3, D. F. Schneider1, R. S. Sippel1 1University Of Wisconsin School Of Medicine And Public Health,Department Of Surgery,Madison, WI, USA 2University Of California, Irvine School Of Medicine,Department Of Surgery,Irvine, CALIFORNIA, USA 3University Of Alabama – Birmingham School Of Medicine,Department Of Surgery,Birmingham, Alabama, USA

Introduction:
The American Thyroid Association (ATA) has issued specific pre-operative guidelines for patients undergoing thyroidectomy for treatment of their Graves’ disease. Our goal is to determine if compliance with ATA guidelines for thyroidectomy for Graves’ disease is associated with better outcomes.

Methods:
A retrospective review of a prospectively maintained database was performed to identify 228 patients with Graves’ Disease who underwent a total thyroidectomy between August 2007 and May 2015. Data was then extracted including patient demographics and clinical characteristics and treatment-related morbidity. Patients were considered to be in compliance with the ATA guidelines if they were treated pre-operatively with SSKI and were either rendered euthyroid with methimazole (T4<1.5 ng/dl) or if that was not feasible were treated with a β-Blocker. Analysis of these data was performed using Stata v11 statistical software.

Results:
The mean age of all patients in our study was 39 ± 1 years and 82% were female. The majority of patients were treated with methimazole (84%) and β-blockers (54%). All patients underwent a total thyroidectomy, and the mean OR time was 114 ± 3 minutes and mean estimated blood loss (EBL) was 45 ± 7 mL. About one third of patients (36%) had a complication following thyroidectomy. Transient hypocalcemia was the most common complication (27%). At the time of surgery, 52% of all patients were found to be in compliance with the ATA guidelines. Patients that were not prepped according to the ATA guidelines had more intraoperative tachycardia (episodes of heart rate exceeding 120) (0.3 vs. 4.6, p = 0.05), but thankfully had no difference in peak SBP (p = 0.64) or in number of episodes of SBP >180 (p=0.31). ATA prepped and non-prepped patients had similar EBL (45.9 vs. 47.3 mL, p = 0.93), mean OR time (113.1 vs. 117.4 minutes, p = 0.45), and length of stay (0.6 vs. 0.7 days, p = 0.46). ATA prepped and non-prepped patients had similar complication rates, including transient hypocalcemia (29.9% vs. 24.4%, p = 0.40), prolonged hypoparathyroidism (1.0% vs. 3.3%, p = 0.28), hoarse voice/temporary RLN palsy (2.2% vs. 3.1%, p = 0.37), prolonged RLN paralysis (3.1% vs. 2.2%, p = 0.70), hematoma formation (3.13% vs. 0%, p = 0.09), or returning to the OR (2% vs. 1.1%, p = 0.60).

Conclusion:
Our data suggests that compliance with ATA guidelines for thyroidectomy preparation is not a necessary prerequisite for a successful postoperative outcome. While preparation according to the guidelines decreased the frequency of intraoperative tachycardia, it did not impact intraoperative hypertension, OR time, blood loss, or post-operative complications. The use of SSKI and methimazole to prepare patients for thyroidectomy did not improve outcomes at a high volume center.

67.05 Early Laparoscopic Cholecystectomy for Acute Cholecystitis in the Elderly is Safe and Cost Effective

Posted on January 18, 2016

P. P. Patel1, J. M. Velasco1 1Northshore University Health System,Skokie, IL, USA

Introduction:
Early laparoscopic cholecystectomy (LC) for acute cholecystitis in the elderly has proven to be safe, however it has not been universally adopted. In spite of published guidelines, percutaneous cholecystostomy or delayed LC with antibiotic treatment has been increasingly utilized as the initial step in the management of these patients. In this era of fiscal scrutiny, specific cost benefits of early LC have not been well examined, particularly in the elderly. This study examines whether early LC in the elderly results in efficient and effective care when compared to alternative management approaches.

Methods:
A retrospective chart review of patients admitted to a four-hospital single university affiliated health system from January 1, 2009 to December 31, 2011 was completed. Patients older than 65 with histologically documented acute cholecystitis were selected. Eligible patients (237) were distributed into three groups based on initial treatment of cholecystitis: early LC within 7 days, delayed LC, or percutaneous cholecystostomy. Patient charges, including diagnostic tests, pharmacy and consultation fees, length of stay, and number of hospital admissions were compared between groups. Statistical analysis was completed by ANOVA allowing comparison of the means of the three patient groups.

Results:

Patients who underwent an early LC had an average LOS just over six days totalling appoximately $50,000 in charges, while those who had delayed cholecystectomies were admitted for two days longer with charges totalling approximately $70,000. The percutaneous group had stays significantly longer averaging two weeks with charges totalling over $100,000. Patients who underwent a delayed management strategy had a higher rate of recurrent events, requiring more interventions that resulted in a statistically significant cost increase.

Conclusion:

Early laparoscopic cholecystectomy completed within 7 days of presention is the most cost-effective treatment for acute cholecystitis in the elderly.

66.20 Comparing CT versus Diagnostic Laparoscopy in Suspected Anastomotic Leaks

Posted on January 18, 2016

J. K. Horwitz1, D. T. Huynh1, T. F. Barrett1, V. S. Tung1, C. M. Divino1 1Mount Sinai School Of Medicine,Department Of Surgery,New York, NY, USA

Introduction: An anastomotic leak (AL) is a serious complication of gastrointestinal surgery. Once identified, anastomotic leaks may be definitively managed with percutaneous drainage or re-exploration. The aim of our study is to compare CT imaging versus diagnostic laparoscopy (DL) as initial management strategies for evaluating patients with clinically suspected anastomotic leaks.

Methods: Patients who developed an AL at The Mount Sinai Hospital from 2003-2015 were identified retrospectively. Patients who were managed with an exploratory laparotomy without a prior CT or DL were excluded. The remaining patients were stratified into two groups based on the initial management of the suspected AL, CT versus DL. The sensitivities of the two diagnostics were compared as well as the outcomes, including: length of stay (LOS), SICU admission/LOS, 30-day mortality, requirement for a 2nd reoperation, and readmission. The groups were compared using the Fisher’s exact test and χ2 for categorical variables and the Mann-Whitney-Wilcoxon test for continuous variables.

Results: 184 patients who suffered ALs and met our inclusion criteria were identified. Within this group, 162 initially received a CT while 22 directly underwent a diagnostic laparoscopy. No differences were found between the groups’ age, sex, ASA, BMI, or comorbidities. The sensitivities of CT and DL were found to be 52.5% and 72.7%, respectively. No differences were found between the groups’ SICU admission rates, 30-day mortality, requirement for a 2nd reoperation, or readmission. A significant difference in LOS was observed between the two groups (p=0.007) with a median LOS of 18 days and 13 days for CT and DL, respectively. SICU LOS was also found to be significantly longer in the CT group (p=0.046) with a median SICU LOS of 6 and 3 days for CT and DL, respectively.

Conclusion: Suspected ALs must be approached with urgent and decisive action. Our data supports diagnostic laparoscopy as an effective and safe initial approach to clinically suspected anastomotic leaks, as demonstrated by a higher sensitivity and shorter LOS relative to CT imaging.

67.01 Size of recurrent laryngeal nerve affects vocal cord paralysis after thoracoscopic esophagectomy.

Posted on January 18, 2016

Y. Saito1, H. Takeuchi1, K. Fukuda1, R. Nakamura1, T. Takahashi1, N. Wada1, H. Kawakubo1, Y. Kitagawa1 1Keio University,Department Of Surgery,Shinjuku-ku, TOKYO, Japan

Introduction:
Recurrent laryngeal nerve paralysis is one of the most frequent and serious complications after esophageal cancer surgery. Recurrent laryngeal nerves are thin, about 1 to 2mm in size. In this study, we hypothesized that thin recurrent laryngeal nerve may affect postoperative vocal cord paralysis. We evaluated relations of left recurrent laryngeal nerve size and postoperative left vocal cord paralysis.

Methods:
This follow-back study included a total of 44 patients who underwent thoracoscopy assisted esophagectomy with lymphadenectomy along the recurrent laryngeal nerve from May 2012 to December 2013. When we exposed recurrent laryngeal nerves, we used single use scissor tips (Microline Surgical, Inc.). Diameter of the nerves were measured using the digital video recording of surgical procedures by the ratio between scissor and left recurrent laryngeal nerve. Median size of left recurrent laryngeal nerve for the 44 patients was 1.51mm. To evaluate relations of left recurrent laryngeal nerve size and postoperative vocal cord paralysis we compared patients with thin nerve and those with thick nerve. Twenty two patients had left recurrent laryngeal nerves under 1.5mm in size (thin group) and 22 patients had the nerves over 1.5mm (thick group). The average age was 63.2 years old (a range of 35-78), and 34 men and 10 females were included. For evaluation of vocal cord paralysis, a direct laryngoscopy and/or X-ray fluoroscopic test of swelling were performed after the operation.

Results:
There was not significant difference in the background factors, including age, sex, body-mass index, performance status, stage, histological type, or the location of tumor, in both groups. Operation time did not have the significant difference in both groups. The amounts of bleeding at thick group was significantly small. There was not the significant difference in metastasis of lymph nodes along left recurrent laryngeal nerve or the number of dissected lymph nodes along left recurrent laryngeal nerve in both groups. Incidence of postoperative left recurrent laryngeal nerve paralysis (Clavien-Dindo classification ≥ 1) was significantly higher (n=14, 63.6%vs n=5, 22.7%; p=0.006) in thin group.

Conclusion:
The recurrent laryngeal nerve paralysis was easy to be caused in the case that recurrent laryngeal nerve was thin.

67.02 The Perception of Diminished Surgical Outcomes Elderly Patients – Is it Really Age Related?

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: The general belief concerning elderly patients undergoing surgery is that they are at higher risk for post-operative complications than their younger counterparts. Few studies, however, differentiate age from the associated co-morbidities of aging. The aim of this study was to compare outcomes of patients undergoing colorectal resection stratified by age.

Methods: An extensive review for colorectal procedures performed from 2013 to 2015 at a single institution was conducted utilizing a NSQIP database. Patients who were ≤60 years old were compared to those who were ≥75 years old. Demographics, pre-operative co-morbidities, minor and major complications, and mortality were evaluated using standard statistical methods.

Results: Over the 2 years, 373 patients qualified for the study; 278 were ≤60 years, and 95 were ≥75 years. Mean age for the younger group was 47.8±9.7 vs 80.8±4.4 for the older group. BMI was 28.8±8.3 vs 25.6±4.5 (p=0.003), respectively. Both groups were similar in gender and race. The older patients tended to be more hypertensive (72.6% vs 33.8%; p<0.001) with higher rates of diabetes (22.1% vs 8.6%; p<0.001) and COPD (14.7% vs 1.8%). In the older group, 81.1% were ASA class 3-4 vs 45% in the younger group (p<0.001). The younger group had a higher rate of smokers (26.3% vs 7.4%; p<0.001). There was no difference in the percentage of laparoscopic cases; however, the older group underwent more right-sided colectomies (55.7% vs 31.2%; p<0.001) and more emergent cases (16.8% vs 8.6%; p=0.03). The older group required more post-operative transfusions (24.2% vs 13.7%; p=0.02), had a higher rate of 30 day mortality (6.3% vs 1.1%; p=0.01) and had a longer post-operative length of stay (11.7±8.4 days vs 9.5±9.6 days; p<0.001). However, after controlling for ASA class and emergent surgery status, multivariate analysis indicated that there were no significant differences between the older or younger groups in terms of post-op transfusions or LOS. Given the low incidence of deaths (N=9), MV analysis was not feasible for this outcome. There were no differences in post-operative surgical site infections, pneumonia, urinary tract infection, myocardial infarction, renal failure, DVT/PE, unplanned intubations, anastomotic leak, unplanned return to the OR and mortality after 30 days between older and younger patients.

Conclusion: Patients who were ≥75 years old had a higher prevalence of pre-operative co-morbidities and required more emergent operations. After controlling for ASA class and emergent status, there was no significant difference in outcomes between patients ≤60 years old or those ≥75 years old. The perception of increased risk of surgery associated with elderly patients appears to related to their pre-op comorbidities rather than their age.

66.18 Colectomy in Michigan: the Relationship Between Surgical Site and Urinary Tract Infection

Posted on January 18, 2016

J. E. Papin IV1,2, K. H. Sheetz1, D. A. Campbell1,2, M. J. Englesbe1,2 1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2Michigan Surgical Quality Collaborative,Ann Arbor, MI, USA

Introduction:
Following colectomy, the development of surgical site infections (SSI) and urinary tract infections (UTI) are common, morbid, and expensive. However, it is unclear to what extent associations between postoperative UTI and SSI affect patient outcomes. The purpose of this study was to determine whether post-operative UTI is an independent risk factor for subsequent SSI.

Methods:
Using data from the Michigan Surgical Quality Collaborative, we identified 30,727 patients undergoing colon resection within 73 hospitals between 2008 and 2015. We evaluated the independent effect of an initial postoperative UTI on the incidence of SSI using multivariate logistic regression adjusting for patient demographic, clinical, and case-specific Surgical Care Improvement Program (SCIP) process compliance.

Results:
In our study cohort, 1.2% of patients developed a postoperative UTI and 10.0% developed a postoperative SSI. Unadjusted rates of SSI were higher in patients with an initial post-operative UTI (22.7% v. 9.9% p<0.01). In multivariate models, post-operative UTI was an independent risk factor for the development of SSI (OR 3.35, 95% CI 2.50-4.48).

Conclusion:
Post-operative UTI is an independent risk factor for the development of SSI after colectomy. Though poorly characterized, quality improvement initiatives aiming to decrease the incidence of UTI may influence SSI rates following colectomy. These associations warrant further investigation and may allow for streamlining of practices designed to reduce postoperative infections.

66.19 Predicting Wound Complications with Preoperative CT Scans

Posted on January 18, 2016

R. J. Strobel1, C. S. Lee1, J. F. Friedman1, D. R. Grenda1, C. W. Inglis1, B. A. Derstine1, S. M. Bahroloomi1, A. M. Hammoud1, K. C. Leary1, A. R. Peltier1, S. C. Wang1, M. J. Englesbe1 1University Of Michigan,Department Of Surgery, Michigan Morphomic Analysis Group,Ann Arbor, MI, USA

Introduction: Wound complications – such as incisional hernia, ventral hernia, and wound dehiscence– are common following major abdominal surgery. Despite advances in surgical care, these complications remain prevalent. We hypothesized that analytic morphomics, a novel objective risk assessment tool, would explain the relationship between preoperative tissue composition and postoperative wound complications.

Methods: This is an observational study of 1,409 patients undergoing major abdominal surgery and who had a preoperative CT scan, all selected from the Michigan Surgical Quality Collaborative Database. The primary outcome is a composite of local wound complications, including incisional hernia, ventral hernia, wound dehiscence and major wound complications. Analytic morphomic measures of a single slice at the L4 vertebral level were investigated, along with variables related to patient demographics, medical history, admissions status, and comorbid disease. A p < 0.05 threshold in univariate analysis was employed for considering variables to be included in multivariable analysis.

Results: Wound complications occurred in 11.9% of patients. Analytic morphomic variables associated with wound complications are detailed in the figure. The final, single-slice model was assembled via backwards stepwise selection, and included 4 preoperative variables: subcutaneous fat area @ L4 (odds ratio [OR] = 1.67, 95% confidence interval [Cl] 1.03-2.78, P = 0.040), pack-years (OR = 1.18, 95% CI 0.99-1.38, P = 0.046), albumin (OR = 0.84, 95% CI 0.72-1.00, P = 0.044), and immunosuppressive therapy (OR = 1.97, 95% CI 1.15-3.26, P = 0.010).

Conclusion: Patients with a large subcutaneous fat area have a higher risk of wound complication. This may inform surgeon decision-making in the operating room.

66.15 Falls From Heights: Children Fare Better Than Adults

Posted on January 18, 2016

J. L. Carpenter1, T. L. Wiebe1, J. R. Rodriguez1, B. J. Naik1 1Texas Children’s Hospital,Division Of Pediatric Surgery, Department Of Surgery,Houston, TX, USA

Introduction: Falls are one of the leading mechanisms of injury in both children and adults. We hypothesize that children have better outcomes following falls than adults.

Methods: The 2007-2011 National Trauma Data Base (NTDB) was queried for ICD-9 code 882.0 (‘fall from height’). Patients were divided into three age groups (0-4 years, 5-14 and 15+) for comparison. Continuous outcomes were compared using ANOVA and categorical outcomes using chi-square test. Multivariate logistic regression using covariates of vital signs at presentation, Glasgow Coma Scale (GCS), Injury Severity Scale (ISS), and the need for an urgent operation was also performed to compare age groups.

Results: There were 44,416 patients identified; of these, 82% of patients were male and 15% were children <15 years of age. The mean age was 36.2 ± 20.1 years. ICU admission was required for 29% and urgent operation for 10%. Infants and toddlers had a higher rate of closed head injury than adults (5% versus 3%, p<0.001) and a concurrently higher ICU admission rate (45% versus 36%, p<0.001). The length of ICU stay (days), number of unplanned intubations, urgent operation rate, mortality, hospital length of stay (days), and ISS were all lower in children than adults (Table 1). Presenting GCS and ISS were significant predictors of ICU admission and mortality in both children and adults (p<0.001); however, vital signs on presentation were only predictive of these outcomes in the adult population (p=0.02).

Conclusion: Falls from heights are common in both children and adults. Based on our review of the NTDB, children incur less severe injuries and have better overall outcomes than adults yet have a higher rate of ICU admission. Abnormal vital signs at presentation may not be predictive of serious injury in children and may sometimes lead to over-triage for these patients.

66.16 Outcomes of Surgical Management of Acute Perforated Ulcer Disease in the NSQIP Database 2005 to 2013

Posted on January 18, 2016

J. Biggs1, S. Barnes1, S. Osterlind1, E. Dalton1, L. Hanley1, S. Ahmad1 1University Of Missouri,Surgery,Columbia, MO, USA

Introduction:
The management of peptic ulcer disease (PUD) has evolved from a primarily surgically managed disease to a medically managed one with advances in endoscopic therapies and treatment of H. pylori infection. While the incidence of hospital admissions for PUD may have changed over the decades, ulcer disease remains a significant cause for mortality, with perforation having a mortality of approximately 11-16%, and morbidity of approximately 30%. The incidence of acute perforation of PUD remains around 4-11 cases per 100,000/year and is the most common etiology for pneumoperitoneum identified on radiography. We utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database Participant User File (PUF) to study preoperative, demographic and postoperative variables that may be associated with morbidity and mortality after emergent surgical management of acute perforated PUD.

Methods:
The adult ACS-NSQIP database participant user files were queried from 2005 to 2013. Those cases performed emergently with a postoperative diagnosis of peptic ulcer disease were extracted. Using SPSS, correlations were then derived between patient factors, postoperative complications, and survival. P-values <0.01 were considered significant.

Results:
We extracted 5666 emergent cases with a postoperative diagnosis of perforated PUD. There were 723 deaths yielding a 30 day mortality rate of 12.8%. The mean age of the study population was 61. The most frequent postoperative complications were failure to wean from the ventilator within 48 hours (19.3%), need for blood transfusion (12.2%), septic shock (9.8%), and return to the operating room (9%). Non-survivors were more likely to be female, older, have a higher ASA classification, be functionally dependent and receive surgical treatment later within the hospital stay (Table 1). Females were more likely to be older, malnourished and receive transfusions despite a similar incidence of postoperative complications when compared to males. In a multinomial logistic regression model the patient factors with the highest risk for mortality were post-operative cardiac arrest (OR 13.7, 95% CI 7.4-25.3), septic shock (OR 4.1, 95% CI 2.9-5.7) and renal failure (OR 3.9, 95% CI 2.4-6.6).

Conclusion:
According to the NSQIP database, the mortality rate for emergent operations in perforated peptic ulcer disease was 12.8% which is consistent with prior studies. Older and female patients are at higher risk of death. This disease process appears to concentrate among older patients with a median population age of 61. Earlier diagnosis and surgical intervention improves survival. Poor nutritional status and certain post-operative complications may decrease the likelihood of survival.

66.17 Assessing the Critical Factors of SBAR as used in General Surgery Handoffs

Posted on January 18, 2016

H. J. Hawthorne1, T. N. Cohen1, W. D. Cammon1, J. Bingener2, S. Hallbeck1, J. Kang3, P. Santrach4, S. A. Elliott5, R. C. Blocker1 1Mayo Clinic,Center For The Science Of Health Care Delivery,Rochester, MN, USA 2Mayo Clinic,Department Of Surgery,Rochester, MN, USA 3Mayo Clinic,Office Of Leadership And Organization Development,Rochester, MN, USA 4Mayo Clinic,College Of Medicine,Rochester, MN, USA 5Mayo Clinic,Department Of Nursing,Rochester, MN, USA

Introduction: To improve a common source of communication breakdown in patient care, the Institute for Healthcare Improvement published a standardized handoff communication tool known as ‘SBAR’ (Situation (S), Background (B), Assessment (A) and Recommendation (R)). This study explored the use of SBAR for handoffs between surgical team members 6 years after implementation in a large tertiary care center.

Methods: Healthcare systems engineering researchers observed 23 operative procedures in June 2015. Case duration, presence and duration of handoffs, were recorded for the following participants – circulating registered nurses (RN), certified surgical technicians (CST), certified surgical assistants (CSA), and anesthesia providers including certified registered nurse anesthetist and anesthesiologists (CRNA/ANES). To evaluate the use of SBAR during handoffs, a binary approach to determine existence or nonexistence of each SBAR component (S, B, A, R) was applied and analyzed using nonparametric statistics.

Results: Of the 23 procedures (M = 219 min, SD = 92), 20 included at least one handoff during the operative procedure. Within these 20 cases, 127 handoffs were observed of which 119 could be assessed for SBAR use. CSAs performed fewer handoffs (10%) than CSTs (26%), anesthesia providers (30%) and RNs (34%) (p=0.0014). Of the 119 handoffs (M = 61sec, SD = 52), 90% included information about the patient’s situation, 58% discussed clinical background, 64% provided an assessment and 55% made a recommendation. SBAR components included in each handoff varied significantly by the role involved; specifically differences exist between CRNA/ANES and CSAs when evaluating use of ‘B’ (p=0.032), ‘A’ (p=0.048) and average number of SBAR factors included (p=0.043). When the core team member present at the start of the case handed off, information about the situation was included in 94%, background in 69%, assessment in 68% and recommendation in 68% of handoffs. The average number of SBAR factors used differed by who provided the handoff (original →relief, relief →original, relief →relief) (p=0 .0018), driven by the use of ‘B’.

Conclusion: This pilot study suggests that in a busy OR a handoff by a team member may occur every 35 minutes and adoption of the SBAR structure during surgical procedures differs by role and situation. Team members adjusted for prior knowledge (e.g. ‘B’) by the core team. The study was not scoped to investigate the effect of surgeon briefings on the differential use of SBAR or the effect of differential use of SBAR on the occurrence of non-routine events.

66.12 Utility of Post-Reduction Hospital Admission for Intussusception in Pediatric Population

Posted on January 18, 2016

Y. Puckett1, J. Greenspon1, C. Fitzpatrick1, D. Vane1, S. Bansal1, M. Rice1, K. Chatoorgoon1 1Saint Louis University School Of Medicine,Pediatric Surgery,St. Louis, MO, USA

Introduction: The standard practice in pediatric patients diagnosed with intussusception radiographically has been reduction via enema and admission for a period of nil per os and observation. However, little data exists that supports this practice. With the recent heavy emphasis on effective medical resource allocation, it is possible that this practice may be potentially eliminable. The objective of this study was to conduct a retrospective review for recurrence rates after enema reduction in children while in hospital, to examine the cost that is incurred by admission, and to examine whether post-reduction admission to hospital is necessary.

Methods: A retrospective chart review was performed on all patients aged 0-4 years old diagnosed with intussusception based on ICD-9 codes over the last twenty years at a single center pediatric hospital. Study included children 0-4 years of age who were treated for intussusception on first encounter with air contrast or barium enema that were subsequently admitted to the hospital for observation. Study excluded patients older than 4 years of age, those who were readmitted for recurrence after 48 hours, patients whose intussusception did not successfully reduce with enema on first try, and those who went to the operating room because of peritonitis on exam or perforation on enema. Early recurrence was defined as recurrence within 48 hours post-reduction.

Results: A total of 171 patients out of 272 met inclusion criteria. Out of 171 patients who were admitted to the hospital for observation post-reduction, only one experienced an early recurrence (0.6%). The median length of stay for all patients was 2 days with an interquartile range of 1-2. The average cost incurred per day for intussusception admission was determined to be $404.00 at our hospital.

Conclusion: Intussusception in a child that is successfully reduced via enema has a low rate of recurrence and is usually followed by prompt resolution of symptoms. An abbreviated period of observation in the emergency department post intussusception reduction may result in costs savings of approximately $808/patient.

66.13 International Trends in Incidence Rates of Thyroid Cancer from 1973-2007

Posted on January 18, 2016

B. C. James1, R. H. Grogan2, E. L. Kaplan2, P. Angelos2, B. Aschebrook-Kilfoy3 1Indiana University,Endocrine Surgery/Surgery/Indiana University,Indianapolis, INDIANA, USA 2University Of Chicago,Endocrine Surgery/Surgery/University Of Chicago,Chicago, IL, USA 3University Of Chicago,Department Of Public Health Sciences,Chicago, IL, USA

Introduction:
The incidence rate of thyroid cancer worldwide has been increasing at a dramatic rate. However, previous studies have shown that the rates in some countries appeared to be leveling off in recent years. We sought to evaluate recent trends in incidence rates and predict that these rates have continued to rise.

Methods:
Trends in the incidence rates of thyroid cancer were obtained from the WHO Cancer Incidence volumes 4-9, which contain incidence data reported by selected population-based cancer registries covering areas within Asia, Oceania, Africa, Europe, and the Americas between 1973 and 2007. Thyroid cancer classification was based on ICD-8, ICD-9, and ICD-10 for volumes 4,5-8,9-10, respectively. Percent change was calculated for each population to show the relative change in incidence rate by gender, histologic subtype, and mortality rate between 1973 and 2007.

Results:
Thyroid cancer rates increased from 1973 to 2007 for 18 of the 19 countries examined. The average increase in thyroid cancer incidence across populations was 88% in males and 108% in females. The largest increase was in New South Wales, Australia (266.67% in males and 365.22% in females). In contrast, thyroid cancer rates in Sweden decreased by 18% in males and 5% in females. Significant variation in incidence rates was present within every continent, and each country showed independent patterns of increase across continents. There was no correlation between underlying thyroid cancer incidence rates and the increase in incidence rate. A consistent ratio of three to one between females and males was observed in all populations at all time periods.

Conclusion:
This study has shown that there has been a global increase in thyroid cancer incidence rates between 1973 and 2007. Rates rose even in countries that are not technologically advanced, therefore we hypothesize that both environmental factor and detection bias are at play.

66.14 Preoperative Comorbidity Associated with Postoperative Complications Following Ventral Hernia Repair

Posted on January 18, 2016

R. Conway1, M. Zhao3, Y. Zeng2, J. Keith1 1University Of Iowa Hospitals & Clinics,Department Of General Surgery,Iowa City, IA, USA 2University Of Iowa,Department Of Biostatistics,Iowa City, IA, USA 3University Of Iowa,Carver College Of Medicine,Iowa City, IA, USA

Introduction: Ventral hernia-repair (VHR) is a common surgical procedure and often performed on patients with comorbid conditions such as chronic obstructive pulmonary disease (COPD), history of smoking, and previous surgical complications. Postoperative complications following VHR present patient morbidity and high cost to the medical system. Therefore, our aim was to determine if any correlation exists between preoperative co-morbid conditions and postoperative outcomes in patients undergoing VHR.

Methods: A retrospective chart review of 304 patients who underwent VHR at UIHC from 2010-2011 was performed. Multiple variables were investigated including the presence of ventral hernia recurrence, surgical site infection, readmission, and need for reoperation. A multivariable logistic regression model was developed to examine potential effects of independent variables on postoperative outcomes.

Results: A history of smoking (OR=1.03, p=0.004) and prior surgical site infection (OR=2.88, p=0.02) were associated with a significant increase in surgical site infection following VHR. Recurrence following VHR was significantly more likely in patients with a history of prior abdominal surgery (OR=1.31, p<0.001). A history of COPD increased the risk for second readmission following VHR (OR=11.9, p=0.02). Prior surgical site infection (OR=3.33, p=0.002) and history of COPD (OR=3.32, p=0.03) were associated with a significant increase in reoperation following VHR. (Table 1)

Conclusion: A preoperative diagnosis of COPD and a history of prior abdominal surgery, prior surgical site infection, and smoking all increase the risk for postoperative complications in patients who undergo VHR. More studies are needed to better understand the pathophysiology involved and how to reduce postoperative complications in VHR.

66.09 Pneumonia is Associated with a High Risk of Death Following Pancreaticoduodenectomy

Posted on January 18, 2016

R. T. Nagle1, H. Lavu1, E. L. Rosato1, C. J. Yeo1, J. M. Winter1 1Thomas Jefferson University,Department Of Surgery,Philadelphia, PA, USA

Introduction: Pancreatectomy is associated with a high complication rate of approximately 40%, and a mortality rate ranging from 1-10%. While many specific complications have been extensively studied, postoperative pneumonia has received relatively little attention.

Methods: We performed a single-institution, IRB-approved retrospective analysis of patients who underwent pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) from 2002 to 2014. Patient data were extracted from electronic medical records. Postoperative pneumonia was defined here as a radiographic finding of an infiltrate followed by antibiotic therapy. Pneumonia was further stratified by cause including ventilator-associated, aspiration, or community acquired. The incidence of post-pancreatectomy pneumonia, predictive factors, and its impact on post-operative outcomes were determined.

Results: 1526 patients underwent a pancreatectomy, including 1090 PDs (71%) and 436 DPs (29%). There were a total of 47 (4.3%) and 11 (2.5%) cases of pneumonia, respectively. The majority of the pneumonias were attributed to aspiration (87.2% and 81.8% in the two cohorts). Pneumonias were graded using the Clavien-Dindo classification, and were more frequently severe (grades 4 or 5) in the PD group (55.3% vs 9.1% with DP, p=0.006). In the PD group, univariate predictors of postoperative pneumonia included male gender (odds ratio (OR) 2.7, p=0.003), age (OR 1.03, p=0.041), COPD (OR 5.0, p<0.001), smoking history (OR 2.0, p=0.022), delayed gastric emptying (DGE, OR 10.3, p<0.001), and persistent oxygen requirement on post-op day 3 (OR 4.4, p<0.001). In a multivariate model, COPD (OR 3.2, p=0.036), DGE (OR 9.1, p<0.001), and persistent oxygen requirement on post-op day 3 (OR 3.2, p=0.005) remained significant predictors. Pneumonia rates in patients who experienced ISGPS grades B and C DGE were particularly high (51.8%) compared with grade A or no DGE (8.67%, p<0.001). In the PD group, postoperative pneumonia was associated with a prolonged length of stay (median 18 days, vs 7 days in the absence of pneumonia, p<0.001) and an extremely high 90-day mortality (38.9% vs. 3.9% in the absence of pneumonia, p<0.001). In a multivariate regression model of 90-day mortality after PD (Table 1), postoperative pneumonia was the most robust predictor of postoperative death (OR 24.1, p<0.001).

Conclusion: Pneumonia following PD is an uncommon but highly morbid event, with a substantially increased risk of death. Patients with pre-existing pulmonary disease are at increased risk, and severe DGE may lead to postoperative pneumonia due to an elevated aspiration risk. These data underscore the importance of cautious dietary progression and aspiration precautions in these individuals.?

66.10 Changing Risk Factors For Pediatric Cholecystectomy

Posted on January 18, 2016

Y. Puckett1, K. Chatoorgoon1, C. Fitzpatrick1, D. Vane1, J. Greenspon1 1Saint Louis University School Of Medicine,Pediatric Surgery,St. Louis, MO, USA

Introduction: Reports from other pediatric centers have defined obesity and Hispanic ethnicity as important risk factors for symptomatic cholelithiasis in children. We aimed to determine if other risk factors exist and if obesity and ethnicity are true risk factors versus symptoms of a more global etiology.

Methods: A retrospective review was performed on all children 0 to 19 years old who underwent a cholecystectomy from 1993-2014 in St. Louis, Missouri. Data was divided into 2 cohorts: Group I (1993-2003) and Group II (2004-2014). Age, gender, body mass index (BMI), weight group, race, ethnicity, indication for cholecystectomy, and type of gallstones were collected. Data was analyzed using Pearson’s-chi square test and and Fisher’s exact test for categorical variables and the Mann-Whitney U test for continuous variables.

Results: 452 patients underwent a cholecystectomy from 1993 to 2014. There were 171 patients in Group I and 281 patients in Group II. The rate of hemolytic disease requiring cholecystectomy was essentially unchanged (G1=70, G2=67) (p<.0001). Biliary dyskinesia was an indication only in the second group (G1=0,G2=28) (p<.0001). Cholecystectomy for non-hemolytic gallstones increased 82% (101-184) (p<.0001). Incidence of cholecystectomy remained stable in underweight children (G1=20, G2=21) (p<.003) however incidence of cholecystectomy in normal (G1=35, G2=53), overweight (G1=9, G2=24), obese (G1=23, G2=58) and severely overweight (G1=14, G2=28) children increased dramatically (p<.003). Mean BMI for the two groups increased slightly, (G1=23, G2=27.5) (p<.002), but essentially remained within the normal range.

Conclusion: At our institution, children undergoing cholecystectomy were found to have a normal BMI overall. However, the prevalence of overweight children undergoing cholecystectomies increased dramatically. In spite of significant increases in obesity in this population, the overall normal BMI of both groups suggests that diet rather than obesity may be the most significant etiology in the increased incidence of cholelithiasis in this pediatric population.

66.11 The i2b2 Cohort Discovery Tool Outperforms a Prospectively Maintained Internal Database

Posted on January 18, 2016

E. Toy1, C. Y. Peterson1, K. A. Ludwig1, T. J. Ridolfi1 1Medical College Of Wisconsin,Department Of Surgery – Division Of Colorectal Surgery,Milwaukee, WI, USA

Introduction: Designing high-quality clinical studies is often limited by poor understanding of study cohorts and populations, information that is difficult to obtain easily and efficiently, thus leading to poor recruitments and under-powered studies. The Informatics for Integrating Biology and the Bedside (i2b2) Cohort Discovery Tool provides an easy to use, self-service way for researchers to query an externally maintained database that draws information from the electronic medical record, stored in the i2b2 Clinical Translational Research Informatics Data Warehouse (CTRI-CDW). Search criteria can include nearly any piece of information in the medical record from demographics, diagnoses and procedure codes, laboratory test results, pharmacy orders and dispenses, as well as free text within clinical documents. In response to a query, the tool can return an approximate number of patients matching the search criteria without revealing identifying information. Searches can be stored online and de-identified information is released after IRB approval. Over eighty academic medical centers nationally have the i2b2 Cohort Discovery Tool integrated with the electronic medical record. The aim of the current project was to assess the performance of this tool when compared to a manually curated internal colorectal surgery database.

Methods: Both the manually curated internal database and the i2b2 Cohort Discovery Tool were queried by procedure name and/or corresponding for procedures occurring from February 2008 to April 2014 performed by a single surgeon. Procedures and CPT codes were grouped into three categories: 1. Low anterior resection ( CPT codes 44145, 44207, 44146, 44208), 2. Abdominal perineal resection (CPT codes 45110, 459395) and 3. Segmental colectomy (CPT codes 44140, 44141, 44143, 44144, 44160, 44204, 44206, 44205). Number of patients identified within each cohort were then compared.

Results: For low anterior resection, the internal database identified 83 patients while the i2b2 Cohort Discovery Tool identified 155. For abdominal perineal resections the internal database identified 28 patients while the i2b2 cohort Discovery Tool identified 97. For segmental colectomy, the internal database identified 176 patients while the i2b2 Cohort Discovery Tool identified 662 patients.

Conclusion: The i2b2 Cohort Discovery Tool outperformed the manually curated internal database on all queries, in part due to an early empahsis on neoplasms within the internally maintained database. The i2b2 Cohort Discovery tool has the potential to replace prospectively maintained departmental databases and has the potential to foster large multi-institutional studies as it is available in over eighty academic medical centers nationwide.

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