66.08 Do inter-hospital transfers for soft tissue infection improve care or outcomes?

Posted on January 18, 2016

J. C. Chen1, E. Finlayson2, K. F. Rhoads1 1Stanford University,Surgery,Palo Alto, CA, USA 2University Of California – San Francisco,Surgery,San Francisco, CA, USA

Introduction: Soft tissue infections (STI) are common and may require extensive surgical debridement and critical care management. Inter-hospital transfer may occur due to perceived need for higher level of care for these patients. In trauma, cardiology and stroke care, inter-hospital transfers have demonstrated benefit; however, the role of transfers in STI outcomes is unclear. The purpose of the current study is to determine whether transferring patients with STI is associated with differences in care or outcomes.

Methods: Patients with STI were identified by ICD9 codes in the 2011 California patient discharge database. Transfers between facilities were identified using a unique record linkage number for each patient. Retrospective analysis compared length of stay (LOS), rate of surgical intervention, ICU admission, sepsis and death between transferred and non-transferred patients.

Results: There were 39,820 patients identified with STI. Approximately 8% (3,311) were transferred from the original presenting facility and admitted to a different hospital. Patients who were transferred were younger than non-transferred patients (52.9 +/- 22.8 years vs. 55.2 +/- 20.9, p<0.0001). Patients with ‘other’ insurance, including Indian Health Service and Tri-Care military insurance, were transferred at the highest rates (13.4%). About 9% of patients with public insurance (Medicare and Medicaid) were transferred. The lowest transfer rate was for patients with no insurance (3.3%). There was a lower rate of surgical intervention among transferred patients (22.5%) versus non-transferred patients (26%; p<0.0001). Transferred patients had longer median LOS (4 vs. 3 days, p<0.0001), but there were no differences in ICU care (0.33% vs. 0.53%, p=0.13), sepsis (0.45% vs. 0.67%, p=0.14), or inpatient death (0.42% vs. 0.33%, p=0.35).

Conclusion: Inter-hospital transfers are expensive and in the management of STI they are not associated with any clinical advantage in care or mortality. Early initiation of antibiotics at the presenting hospital might achieve similar outcomes with lower resource utilization.

66.04 Frailty and Indication Alter Outcomes of Colorectal Surgery

Posted on January 18, 2016

E. A. Busch2, S. Koller2, M. M. Philp2, H. Ross2, H. A. Pitt1,2 1Temple University,Temple University Health System,Philadelpha, PA, USA 2Temple University,Temple University School Of Medicine,Philadelpha, PA, USA

Introduction: Frailty has been documented to adversely influence the outcomes of colorectal surgery. The potential role that the indication for surgery may have on morbidity and mortality has not been adequately studied. In addition, the interplay between frailty and indication has not been explored. Thus, the aim of this analysis was to define the influence that patient frailty and surgical indication have on the outcomes of colorectal surgery.

Methods: The American College of Surgeons- National Surgical Quality Improvement Program (ACS-NSQIP) Participant Use Files were queried for patients undergoing colorectal surgery in 2012 and 2013. Frailty was defined as five or more of eight preoperative variables including functional status, ASA 4 or 5, hypoalbuminemia, heart failure, COPD, diabetes mellitus, hypertension and male gender. Ten surgical indications included acute or chronic diverticulitis, bleeding, cancer without or with obstruction, IBD (Crohn’s or ulcerative colitis) enterocolitis, benign polyps or volvulus. Overall morbidity, serious morbidity and 30-day mortality were defined by ACS-NSQIP. Other known risk factors including age, BMI, race, emergent surgery and operative approach also were analyzed. Univariate analyses and multivariable logistic regression were performed in STATA 13.1.

Results:Of 29,219 patients undergoing colectomy, 2,077 (7.1%) were frail. The incidence of frailty varied from 1% for 1,994 Crohn’s patients to 38% among 138 patients with enterocolitis. Frailty increased mortality (p <0.05) for every indication except Crohn’s disease as well as serious morbidity (p<0.05) for all indicators except Crohn’s and benign polyps. The interplay between frailty and indication in the five groups with the worst mortality outcomes is presented in the Table.

In multivariable analyses both frailty (Odds Ratios 1.57-2.98) and surgical indication (Odds Ratios 1.11-1.47) remained independent predictors of overall morbidity, serious morbidity and mortality (all p<0.01).

Conclusion:The incidence of frailty varies dramatically among the multiple indications for colectomy. Both patient frailty and surgical indication influence the outcomes of colorectal surgery.

66.05 Predictors of Inguinodynia Following Open Inguinal Herniorrhaphy

Posted on January 18, 2016

P. M. Patel1, A. Mokdad1, T. Pham1,2, S. Huerta1,2 1University Of Texas Southwestern Medical Center,Dallas, TX, USA 2VA North Texas Health Care System,Surgery,Dallas, TX, USA

Introduction: Inguinodynia (pain ≥ 3 months following surgery) following open repair of inguinal hernias continues to be an important complication. We hypothesize that there are factors that can predict inguinodynia. This data could be used to identify techniques that aim at its prevention.

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

Results: During the study period, 804 patients underwent open inguinal hernia repair (99 ± 0.3 % male, 60.4 ± 12.4 years-old, BMI 26.7 ± 4.2 Kg/m2, 72.9% Caucasian, American Society of Anesthesiologists average 2.5, morbidity rate of 7.8 ± 0.9%) by the same surgeon. Fifteen patients experienced inguinodynia (1.9 %). Median follow up was 4.7 ± 2.7 years. Patients who experienced inguinodynia were more likely to have a bilateral hernia repair (26.7 ± 11.4% vs 8.1 ± 1.0%, p=0.01), repair of a recurrent hernia (26.7 ± 11.4% vs 7.0 ± 0.9%, p <0.001), and a simultaneous femoral hernia repair (13.3 ± 8.8% vs 1.0 ± 0.4%, p <0.001). Patients with inguinodynia were more likely to be younger (52.7 ± 10.1 years vs 60.5 ± 12.4 years, p=0.02), current smokers (73.3 ± 11.4% vs 32.6 ± 1.7%, p <0.001), have a positive cardiac health history (16.5 ± 1.3% vs 40.0 ± 12.6%, p=0.02), on anticoagulants (20.0 ± 10.3% vs 3.5 ± 0.7%, p <0.001), and have a post-operative complication (40.0 ± 12.6 % vs 7.2 ± 0.9%, p <0.001). Multivariate analysis identified a concurrent repair of a femoral hernia (OR and 95% CI: 12.2; 1.8-82.0) or recurrent hernia (4.6; 1.2-17.7), a current history of smoking (3.9; 1.1-14.1), younger age (6.4; 1.4-33.7) and post-operative complications (6.5; 2.0-21.4) as independent predictors of inguinodynia.

Conclusion: Younger patients and patients who have a bilateral, recurrent, or a concurrent repair of a femoral hernia as well as those who experience a morbidity are at risk of inguinodynia. Patients who smoke should be encouraged to quit prior to repair.

66.07 Impact of Resident Involvement in Whipple Procedures; An Analysis of 7,605 Cases.

Posted on January 18, 2016

K. L. Haines1, C. D. Goldman1, J. Franko1 1Mercy Medical Center,Surgery,Des Moines, IA, USA

Introduction: Recent decades have shown a substantial reduction in mortality and morbidity of Whipple procedures. Perioperative outcomes are thought to be volume-and surgeon-related. Therefore, using the NSQIP dataset, we examined effects of resident/trainee participation in Whipple procedures on mortality and morbidity.

Methods: The NSQIP database was queried for patients undergoing Whipple from 2008-2012. Data was categorized by resident participation (operation with resident versus attending only). Proportion of complications in each group was compared using chi-square test. Logistic regression model was built to analyze impact of multiple covariates on perioperative mortality within 30-days and first postoperative day. Data are presented as proportions and mean±SD.

Results: 12,104 Whipples were reported to NSQIP between 2008-2012. After excluding cases with missing data on resident participation, 7,605 were available for analysis. These cases were divided into two groups: attending alone (group A, n=1105) versus attending with resident (group B, n=6500). Patient comorbidities and demographics were the same between the groups. Operative time was increased with resident involvement (364±139 vs. 380±132 minutes, p<0.001). Length of stay was significantly decreased when residents were involved (13.7±15 vs. 12.7±12 days, p<0.0001). When comparing attending alone versus with resident, there was no significant difference in patient outcomes including incidence of renal failure (p<0.0001), septic shock (p<0.0001), reintubation (p<0.0001), death on operative day (p<0.0001), 30-day mortality (p<0.0001), and readmission rates (p<0.0001). Resident participation was not a significant 30-day mortality predictor in unadjusted (OR=0.73; CI 0.51-1.04, p=0.087) or risk-adjusted models (adjusted OR 0.79; CI 0.55-1.14, p=0.22).

Conclusion: Resident involvement did not influence mortality and morbidity rates of Whipple procedure in this study. Resident participation is associated with longer operative time, but also significantly shortened hospital stay. Reduction in length of stay for this complex operation may reflect that, contrary to oft-reported criticisms in the literature, present-day residents are, in fact, taking ‘ownership’ of the patients under their care.

66.01 Evaluation of POSSUM score for predicting morbidity after hepatectomy for hepatocellular carcinoma

Posted on January 18, 2016

K. Akahoshi1, T. Ochiai1, H. Ito1, S. Matsumura1, Y. Mitsunori1, A. Aihara1, D. Ban1, A. Kudo1, S. Tanaka1, M. Tanabe1 1Tokyo Medical And Dental University,Bunkyo-ku, Tokyo, Japan

Introduction: The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) scoring system is one of surgical risk scoring systems to predict postoperative morbidity and mortality, which was originally developed by Copeland in 1991 as a scoring system for surgical audit. The aim of this study was to analyze predictive value of POSSUM scoring system in patients undergoing surgical treatment for hepatocellular carcinoma (HCC).

Methods: All patients who underwent liver resection for HCC in our hospital between September 2010 and February 2012 were enrolled in this study. Various preoperative, intraoperative and postoperative patients’ data were collected retrospectively. POSSUM score was calculated, and estimated morbidity and mortality rates were compared with actual incidences of morbidity and mortality.

Results: A total of 100 patients, with 74 males and 26 females, were studied. The average age was 68.7 years old (range 52-84). Postoperative complications were seen in 31 of 100 patients (31%). There were 2 postoperative in-hospital deaths (2%). Bile leakage was the most common complication (9 cases). Univariate and multivariate analysis revealed that preoperative anemia (HR= 3.886; 95%CI: 1.499 – 10.073, p=0.005) and major hepatectomy (HR= 2.675; 95%CI: 1.064 – 6.729, p=0.037) were independent risk factors of postoperative complications. POSSUM scoring system predicted morbidity risk effectively. Correlation analysis demonstrated that observed morbidity rates were significantly correlated with estimated morbidity rates by POSSUM score (r=0.917). Estimated mortality rates were difficult to evaluate, due to the small number of postoperative in-hospital deaths.

Conclusion: POSSUM scoring system could effectively predict the risk of postoperative morbidity in patients underwent hepatectomy for HCC. POSSUM is expected to be a useful risk assessment system of liver surgery.

66.02 Is papillectomy for early ampullary carcinoma justified? – Analysis of 65 resected cases –

Posted on January 18, 2016

T. Ochiai1, T. Miura2, S. Tanaka1, S. Yamazaki2, A. Kudo1, N. Noguchi2, T. Irie2, D. Ban1, A. Aihara1, S. Matsumura1, Y. Mitsunori1, H. Ito1, K. Akahoshi1, M. Tanabe1 1Tokyo Medical And Dental University,Bunkyo-ku, Tokyo, Japan 2Ohta Nishinouchi General Hospital,Koriyama, FUKUSHIMA, Japan

Introduction:
Pancreatoduodenectomy was the standard treatment for ampullary carcinoma, regardless of staging, previously. With recent advances of diagnostic modalities, accuracy of preoperative staging of ampullary neoplasm has been improved, therefore, limited resection of early ampulla of Vater carcinoma has been performed such as; endoscopic papillectomy and transduodenal papillectomy. In this study, we studied consecutive 65 cases of pancreatectoduodenectomy and analyzed tumor staging and prognosis.

Methods:
From January 2000 to December 2014, consecutive 65 patients with carcinoma of the papilla of Vater underwent pancreatoduodenectomy (PD), pylorus preserving pancreatoduodenectomy (PPPD), substomach preserving pancreatoduodenectomy (SSPPD) or total pancreatecomy (TP) with dissection of regional lymph nodes in Tokyo Medical and Dental University Hospital (28 cases)and Ohta Nishinouchi General Hospital (37 cases). We retrospectively analyzed surgical procedures, macroscopic and microscopic curability, clinicopathologic variables and survival.

Results:
A total of 65 patients underwent PD, PPPD, SSPPD or TP, aged 44 to 88 years and consisted of 40 males and 25 females. The surgical procedure was PD in 28 case (43.1%), PPPD in 26 (40.0%), SSPPD in 10 (15.4%) and TP in 1 (1.5%). Patients were grouped according to UICC TNM-staging as stage IA (n=14, 21.5%), stage IB (n=12, 18.5%), stage IIA (n=10, 15.4%), stage IIB (n=22, 33.8%), stage III (n=4, 6.2%), or stage IV (n=3, 4.6%). The overall and disease-free 1-, 3-, 5-, 10- year survival rates were 91.4%, 70.9%, 50.9%, 48.1% and 81.5%, 59.7%, 48.7%, 42.9% respectively. In univariate analysis, age, the depth of tumor infiltration, lymph node involvement, differentiation, stage, curability and operative procedures were significantly different. In multivariate analysis, age (OR 1.08), lymph node metastases (OR 4.02), curability (OR 5.91) were significantly different in prognosis. Metastatic disease to regional lymph nodes was present in 41.5% patients. Moreover, 4 out of 11 (36.4%), with invasion to the sphincter of Oddi in pT1, revealed lymph node metastases.

Conclusion:
Although accuracy of preoperative staging of ampullary neoplasm has been improved, evaluation of minimal invasion of the Oddi’s sphincter is considered still difficult in general. As 36.4 % cases of invasion to the sphincter of Oddi in pT1 revealed lymph node involvement, pancreatoduodenectomy with lymphadenectomy should be required for cancer patients.

66.03 Predictors and Outcomes of Operations Performed on Young Adults at Free-Standing Children’s Hospitals

Posted on January 18, 2016

C. A. Gutierrez1, P. P. Chiu2, R. Dasgupta3, H. C. Jen4, D. H. Rothstein1,5 1State University Of New York At Buffalo,Department Of Surgery,Buffalo, NY, USA 2Hospital For Sick Children,Department Of Surgery,Toronto, Ontario, Canada 3Cincinnati Children’s Hospital Medical Center,Department Of Surgery,Cincinnati, OH, USA 4Tufts Medical Center,Floating Hospital For Children,Boston, MA, USA 5Women And Children’s Hospital Of Buffalo,Department Of Surgery,Buffalo, NY, USA

Introduction:
While free-standing children’s hospitals may provide superior care to young and specialized patients, it is not clear whether this salutary benefit extends to young adults treated at those same institutions. This study asks what patient and hospital factors influence the type of hospital providing surgical care to young adults, and what factors influence postoperative complications in this group.

Methods:
A retrospective cohort study was performed using the 2012 Kid’s Inpatient Database to quantify and qualify operations performed on patients aged 18-20 years. Obstetric operations were excluded. Patient variables included age, gender, race/ethnicity, payer status, type of operation performed and illness severity (as measured by the All Patient Refined-Diagnosis Related Groups severity score). Hospital variables included U.S. region, urban/rural location and specialty designation. Outcomes included operations performed at a free-standing children’s hospital and complications. Odds ratios (OR), along with 95% confidence intervals (C.I.), were calculated using multivariate logistic regression analysis to adjust for confounders.

Results:

Among patients aged 18-20, non-whites (OR = 0.83, 95% C.I. 0.77-0.89), those with private insurance (OR = 0.71, 95% C.I. 0.66-0.77), and those receiving care in rural areas (OR = 0.67, 95% C.I. 0.60-0.75) were less likely to undergo operations at free-standing children’s hospital than other hospitals. Patients undergoing elective operations (OR = 5.93, 95% C.I. 5.52-6.38), those living in the Midwest or West U.S. regions compared to the Northeast, and those with progressively higher APR-DRG severity scores were more likely to undergo operations at free-standing children’s hospitals.

Postoperative complications in this group of patients were more likely to occur when operations were performed at free-standing children’s hospitals (OR = 1.68, 95% C.I. 1.41-1.99), were elective (OR = 1.62, 95% C.I. 1.44-1.82), or involved non-white patients (OR = 1.12, 95% C.I. 1.00-1.26). Payer status, rural hospital location and U.S. region did not appear to influence complication likelihood. Higher APR-DRG severity scores were associated with progressively higher odds of incurring postoperative complications.

Conclusion:
Race/ethnicity, payer status, hospital location and APR-DRG severity scores may play a role in determining the type of hospital where young adult patients receive surgical care. Paradoxically, receiving care at a free-standing children’s hospital may confer a higher risk of postoperative complications in this specific group as compared to care at other types of hospitals. Further stratification of patients by type of operation required or region of country may help direct resource utilization and improve outcomes. More work is needed to determine optimal delivery of care for patients who are poised for transition between pediatric and adult surgical services.

65.20 Not All Massive Transfusions Are Created Equal: Characterizing Variable Transfusion Trajectories

Posted on January 18, 2016

E. W. Etchill1, M. C. Vespe2, A. Hassoune4, J. L. Correa Lopez3, M. R. Rosengart1, A. B. Peitzman1, M. D. Neal1 1University Of Pittsburgh School Of Medicine,Surgery,Pittsburgh, PA, USA 2Carnegie Mellon University,Statistics,Pittsburgh, PA, USA 3Universidad de Caldas,Surgery,Manizales, Caldas, Colombia 4American University Of Beirut,Surgery,Beirut, Beirut, Lebanon

Introduction: Massive transfusion is currently defined as the transfusion of at least 10 red blood cell (RBC) units in 24 hours. Unlike in trauma, the transfusion patterns for massively transfused nontrauma patients have not been explored. However, most institutions have recently implemented identical transfusion protocols for both trauma and nontrauma patients. We hypothesized that distinct subpopulations of massively hemorrhaging patients exist based on patterns of product transfusion.

Methods: We used cluster-based modeling to characterize transfusion patterns in massively transfused trauma and nontrauma patients. Massively transfused nontrauma patients from a single institution were identified and classified into the following groups: cardiovascular (CV), gastroenterology (GI), transplant, and spine surgery. We identified distinct trajectories for product delivery and compared the distribution of patients in each trajectory by transfusion indication.

Results: 363 patients were included for analysis, including 298 nontrauma patients. The median age was 54 years. GI surgery patients accounted for 34% of nontrauma patients, while CV patients comprised 23%. Transplants accounted for 32% and spine procedures 7%. Thirty day mortality among all patients who completed a 24 hour transfusion period was 27%. All patients received an average of 17 cumulative units of blood cells, 14 units plasma, and 14 units of platelets.

Three distinct trajectories were extracted (Figure 1). Most trauma (85%) and cardiovascular surgery (63%) patients fit into trajectory 1, while most GI (57%) and transplant patients (63%) comprise trajectory 3. Trajectory 2 primarily consists of a subset of GI (29%) and transplant (31%) patients. The difference in distribution of patients in each trajectory is statistically significant (p < 0.004). Three plasma and four platelet transfusion ratio trajectories were also extracted and exhibit similar variability.

Conclusion: We identified three patterns of product transfusion among all massively transfused patients. Trauma and cardiovascular patients are more likely to receive the majority of their blood products early, while GI and transplant patients receive products over a longer period of time. There is also a subset of GI and transplant patients that may not be adequately resuscitated during the initial attempts, ultimately leading to greater transfusion requirements. Future investigation into the impact of additional clinical characteristics on transfusion trajectories, as well as the effect of trajectories on patient outcomes, will allow us to more appropriately investigate and resuscitate this heterogeneous massive transfusion population.

65.21 Motorcycle Riders Versus Passengers: Who Suffers More?

Posted on January 18, 2016

T. Soleimani1, T. A. Evans1, S. I. Fernandez1, L. Spera1, R. Sood1, B. L. Zarzaur1, S. S. Tholpady1 1Indiana University School Of Medicine,Division Of Plastic Surgery,Indianapolis, IN, USA

Introduction

Numerous studies demonstrate the utility of safety equipment (helmets) in prevention of serious traumatic injury related to accidents involving motorcycles. Few studies have focused on whether the pattern of injury is different and if the protective benefit is the same in passengers when compared to riders. This study was designed to evaluate these differences in usage of helmets and subsequent patterns of injury between the riders and passengers of motorcycles.

Methods

Using 2007-2010 National Trauma Databank (NTDB), motorcycle trauma patients were identified by ICD-9 codes (Ecodes: E810-E819). The injured patients were divided into two groups: motorcycle riders or passengers (fourth digit 2 and 3 respectively). Demographics, helmet use, injury severity, and outcomes including mortality, major complications, and length of hospital stay (LOS) were compared and contrasted. Major complications were defined as acute renal failure, ARDS, cardiorespiratory arrest, coma, pneumonia, sepsis, cerebrovascular accident, and surgical site infection.

Results

A total of 79,818 riders and 5,896 passengers were identified. Riders were more likely to be older (mean: 40.4 vs. 38.8 years), male (91.9% vs. 17.1%), obese (2.4% vs. 1.9%), and non-white (17.8% vs. 13.6%). They were also more likely to be under influence of drugs (51.2% vs. 47.5%). They were significantly more likely to wear helmet (66.2% vs. 57.5%). For riders, older age, white race, and female gender were associated with higher rates of wearing helmet. For passengers, the rate of helmet use was not associated with age and had reverse association with white race and female gender.

The mean Glasgow coma scale (GCS) was similar between riders and passengers (mean: 13.2 vs. 13.1) however the Injury Severity Score (ISS) was slightly higher for the riders (mean: 12.9 vs. 13.7). The rate of major complications was significantly higher among the riders (8.1% vs 6.1%) even after adjusting for potential confounders. There were no significant differences in rates of mortality (4.6% vs 4.1%) and LOS between the riders and passengers. The unadjusted ICU admission rate was slightly higher for the riders (34.2% vs 32.7%). However, after adjusting for other potential confounders, the riders and passengers had no significant difference in rate of ICU admission.

Conclusions

This is one of the first studies to study demographics and outcomes of motorcycle passengers when compared to riders. There is a very small protective effect in being a passenger when major complications are considered, but mortality, LOS, and ICU admissions were all similar. Interestingly, while the outcomes are similar, the demographics of helmet use were different. Being young, white, and female all were associated with being an unhelmeted passenger; these trends should be prospectively followed and intervened upon as changes in this population’s behavior would yield significant life and quality of life dividends.

65.18 Relevance of Multidisciplinary Colorectal Tumor Board − A Prospective Study

Posted on January 18, 2016

A. Sasidharan1, K. Trencheva1, C. Merchant1, J. W. Milsom1, P. J. Shukla1 1Weill Cornell Medical College,Colorectal Surgery,New York, NEW YORK, USA

Introduction: In our Institutional Colorectal Multidisciplinary Team (MDT), selective referral of patients by treating physicians is made. The primary aims of this study were to evaluate the reasons for referral of patients with colorectal cancer to a multidisciplinary colorectal tumor board, and to evaluate whether the plan of care was changed as a result of tumor board review. The secondary aim was to compare the characteristics of patients who were referred to the MDT versus those who were not.

Methods: This was a prospective study involving subjects ≥ 18 years of age with colorectal cancer treated at our hospital from January to July 2015. Subjects who were referred to the MDT were compared to those who were not referred (but underwent surgical treatment). Demographics, preoperative and postoperative data, and surgical pathology results of the two groups were collected. Outcomes were analyzed at 1 and 3 months for both the referred (after discussion at MDT) and non-referred (after surgery) subjects. Univariate and multivariate logistic regression was performed to analyze the data.

Results: There were 106 subjects in the referred group and 35 in the non-referred group. The most common reasons for referral were: discuss management plan (89.6%), review radiology (70.7%), review pathology (53.7%) and discuss timing of surgery (1.8%). After discussion at MDT, plan of care changed in 32.1% (34/106) of the subjects. The revised plan was implemented in 67.6% (23/34) and was not implemented in 26.4 % (9/34) of the subjects. 2/34 are awaiting the commencement of treatment as recommended. The reasons for non-implementation were: patient’s choice, treating physician’s decision and age. The following variables were found to be significant in univariate analysis between the 2 groups, with p-value < 0.05: age, history of previous surgery, previous chemotherapy, previous abdominal surgery, tumor location and stage of cancer. Multivariate logistic regression with "referral to MDT’ being the outcome is reported in Table1.

Conclusions: The main reason for referral to MDT was to discuss management plan. Plan of care changed in nearly one third of the subjects as a result of MDT review. Tumor location and Stage of cancer are significant factors determining MDT referral.

65.19 TIMING OF VENOUS THROMBOEMBOLISM PROPHYLAXIS AFTER TRAUMATIC BRAIN INJURY: A SURVEY OF EAST MEMBERS

Posted on January 18, 2016

B. STROLLO1, G. Bennett1, M. Chopko1, W. A. Guo1 1State University Of New York At Buffalo,Surgery,Buffalo, NY, USA

Introduction: Patients with traumatic brain injury (TBI) are at a significant risk of developing venous thromboembolism (VTE). However, early pharmacologic prophylaxis risks progression of neurological site bleeding. Thus far, no national standard exists to guide for safely initiating pharmacologic prophylaxis of VTE after TBI. We designed this study to survey the EAST members on their practice patterns regarding timing of pharmacologic VTE prophylaxis after TBI.

Methods: Over 1 month, EAST members were emailed to participate in an online survey. Participants reported demographics, and responses to questions regarding VTE prophylaxis and timing of prophylaxis in 2 clinical scenarios of TBI.

Results:The response rate was 30.9%. The majority of the participants were from Level 1 trauma centers and academic teaching hospitals. Most respondents (75%) reported starting chemical VTE prophylaxis with a consensus between the neurosurgery and trauma/critical care services. While 76% of respondents reported experience of seeing pulmonary embolism without pharmacologic VTE prophylaxis, only 44% witnessed progression of TBI after chemical VTE prophylaxis. About half of surgeons surveyed considered their practice of VTE prophylaxis in TBI patients to be conservative. Almost 50% reported no standardized protocol in their institutions. While 1/3 of the members believed there are guidelines from EAST, another 1/3 were not aware of any guidelines available for VTE prophylaxis after TBI. Responses to questions regarding timing of pharmacologic VTE prophylaxis in a hypothetical patient are shown in Figure.

Conclusion:Currently there is a substantial variation in the practice patterns among EAST members regarding timing of pharmacologic VTE prophylaxis in TBI patients. This survey reinforces the need for prospective observational and randomized control trials to determine best practice of VTE prophylaxis in patients after TBI.

65.15 Limitations of the ACS NSQIP in Intracranial Aneurysm Management

Posted on January 18, 2016

H. Hong1, R. R. Kelz2, M. J. Smith1 1University Of Pennsylvania,Neurosurgery,Philadelphia, PA, USA 2University Of Pennsylvania,Surgery,Philadelphia, PA, USA

Introduction: Patients with intracranial aneurysm (ICA) may be suitable for either surgical or endovascular repair. The limited generalizability of existing studies comparing the two treatment modalities underlines the importance of using observational data to delineate optimal standards of practice. The multi-institutional American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) is considered the best available data source for surgical outcomes research, yet its utility in evaluating care for patients with ICA is unclear. This study assesses whether the current form of the NSQIP is sufficient for analyses on ICA-specific procedures.

Methods: A retrospective cohort study of patients undergoing surgical clipping (CPT codes 61697, 61698, 61700, 61702) or endovascular coiling (CPT 61624, 61635, 75894) of ICA was conducted using the ACS NSQIP participant use file 2006-2013. Prior to the analysis, a focus group of clinical experts was convened to identify significant preoperative and postoperative variables for ICA management. The availability of the data elements was tabulated. Univariate analysis using the chi-squared test was performed to compare patient, disease, and procedure characteristics. A multivariate logistic regression model was then developed to determine the factors associated with the primary outcome measure, 30-day combined death or stroke rate (30dDS).

Results: A total of 974 adult patients undergoing surgical clipping for ICA repair were identified for inclusion during the 8-year period. Zero entry of endovascular repair was found. A considerable number of potential risk factors (e.g. subarachnoid hemorrhage, ventriculostomy need, shunt need, family history of aneurysms, the Hunt and Hess grading, morphology, location, size, and number of aneurysms) and outcome measures (e.g. vasospasm, follow-up radiographic result, modified Rankin scale, Glascow outcome scale) were not available for analysis. For the clipping cohort, the overall 30dDS was 12.7% with 63 deaths and 80 strokes. In the multivariate model, only two variables—hypertension requiring antihypertensive medication and coma state prior to the operation—maintained significant association with higher risk of 30dDS (OR=2.4, 95% CI 1.2-5.1 and OR=6.8, 95% CI 2.2-22.8 respectively).

Conclusion: The study show that the current form of NSQIP is inadequate as data source for evaluating quality of ICA-related procedures. While a rudimentary outcomes study for surgical clipping of ICA is feasible, the database misses endovascularly treated patients and many variables of significant import to patients with ICA. To improve the utility of the database for this disease, the NSQIP might consider an ICA-specific pilot study including patients undergoing procedures outside of the operating room and making use of the expanded custom fields to capture the missing disease-specific risk factors and outcomes.

65.16 Readmission Rates Following Lower Extremity Bypass Vary Significantly Based on Surgical Indication

Posted on January 18, 2016

C. Jones1, A. Gullick1, D. I. Chu1, B. Pearce1, M. Morris1 1University Of Alabama – Birmingham,Department Of Surgery,Birmingham, AL, USA

Introduction:
Readmission rates following vascular surgery are among the highest within surgical specialties, and lower extremity bypass has the highest readmission rate of vascular surgery procedures. Understanding risk factors for and ultimately predicting readmission within this population could have significant clinical impact. We hypothesize that readmission rates following lower extremity bypass differ based on the indication for surgery.

Methods:
We queried the 2012-2013 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) procedure targeted vascular cohort to identify all patients who underwent lower extremity bypass. Patients were stratified by surgical indication: Aneurysm, Claudication, Critical limb ischemia rest pain, Critical limb ischemia tissue loss, or Other. Patients with a postoperative length of stay greater than 30 days or death within 30 days were excluded. Chi-square and Wilcoxon Rank Sums tests were used to determine the differences among categorical and continuous variables, respectively. The primary and secondary outcomes were unplanned readmissions and postoperative complications, respectively. Predictors of readmission were identified with logistic regression using a negative binomial model, and multivariable analysis was used to adjust the odds ratio of readmission for surgical indication.

Results:
Of the 4,676 lower extremity bypasses that were performed, 94.1% were elective and 5.1% were emergent. The cohort consisted of 65.2% males, 34.8% females, 72.2% whites, and 16.5% blacks. The overall 30-day readmission rate was 15.9%. Readmission rates varied significantly based on the indication for surgery. On unadjusted comparison, 20.2% of patients with tissue loss were readmitted compared to 16.8% with rest pain, 12.3% with aneurysms, and 9.8% with claudication (p<0.0001). Unadjusted postoperative cardiac and respiratory complications as well as major bypass reinterventions varied significantly based on surgical indication (Table). Significant adjusted odds ratios of readmission were 1.617 for tissue loss versus claudication (p=0.0003) and 1.533 for rest pain versus claudication (p=0.0013). Several odds ratios for readmission based on adjusted predictors of readmission were significant for surgical indications (Table).

Conclusion:
The risk for readmission after lower extremity bypass and postoperative complications vary significantly based on the surgical indication. All lower extremity bypasses are not performed for one diagnosis. If hospitals are to be penalized for high readmission rates, then the readmission rates following lower extremity bypass should be adjusted for surgical indication.

65.17 Effect of Cardiovascular Risk Factors on Microembolization Rates During Carotid Revascularization

Posted on January 18, 2016

C. E. Pina1, J. Li1, B. Rawal1, C. Giannarelli2, C. Faries1, V. Mani3, A. Vouyouka1, P. Krishnan2, R. Tadros1, J. Badimon2, Z. A. Fayad3, M. L. Marin1, J. Wiley2, P. L. Faries1 1Icahn School Of Medicine At Mount Sinai,Vascular Surgery,New York, NY, USA 2Icahn School Of Medicine At Mount Sinai,Cardiovascular Research Institute,New York, NY, USA 3Icahn School Of Medicine At Mount Sinai,Translational And Molecular Imaging Institute,New York, NY, USA

Introduction: Carotid revascularization poses inherent periprocedural risks to patients that must be weighed carefully against the benefits of preventing plaque embolism and stroke. Intracerebral microembolization of atherosclerotic plaque of the middle cerebral artery (MCA) is one of the major factors leading to increased cerebrovascular events and morbidity after minimally invasive and surgical carotid revascularization. Identification of specific demographic cardiovascular risk factors for increased microembolization can be useful in guiding decisions regarding choice and timing of procedure.

Methods: A total of 150 patients will be enrolled in this study. A preliminary analysis was done in 42 patients (male 74%; mean age 69.5) undergoing carotid endarterectomy (CEA, n=23) or carotid angioplasty and stenting (CAS, n=19). The ipsilateral MCA was intraoperatively monitored for microembolic signals (MES) using transcranial Doppler. Demographic analysis of 4 common cardiovascular risk factors (diabetes, hypertension, hyperlipidemia, smoking history) and presence of stroke symptoms was performed retrospectively.

Results: Results show a significant difference between patients with symptomatic stroke undergoing CAS and higher MES rates (63 + 31 vs. 30 + 10, p=0.004). We also found a non significant increase in average MES rates in CEA patients with diabetes (134 + 278 vs. 39 + 27), hypertension (83 + 202 vs. 63 + 80), hyperlipidemia (113 + 239 vs. 30 + 21), smoking history (111 + 230 vs. 24 + 14) or with stroke symptoms (151 + 306 vs. 42 + 45) compared to CEA patients negative for each risk factor or stroke, respectively.

Conclusion: Our preliminary data demonstrates statistically significant increased MES rates in symptomatic CAS patients compared to asymptomatic CAS patients. We did not see any significant increase in average MES during CAS for patients positive for diabetes, hypertension, hyperlipidemia, smoking history, and presence of stroke symptoms compared to patients negative for these risk factors. A positive trend towards higher MES rates in CEA patients with comorbidities compared to those without did not reach statistical significance probably due to lack of power. The study is ongoing and we are correlating this data with changes in neurocognitive status as detected by the Montreal Cognitive Assessment and the presence of micro-infarcts on cerebral DW-MRI.

65.12 How do Surgical Providers use Social Media? A Mixed-Methods Analysis using Twitter

Posted on January 18, 2016

N. Nagarajan1, B. J. Smart2, M. Dredze3, J. L. Lee5, J. Taylor1, J. A. Myers2, E. B. Schneider1, Z. D. Berger4, J. K. Canner1 1Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA 2Rush University Medical Center,Department of Surgery,Chicago, IL, USA 3Johns Hopkins University School Of Medicine,Department Of Computer Science,Baltimore, MD, USA 4Johns Hopkins University School Of Medicine,Department Of General Internal Medicine,Baltimore, MD, USA 5Johns Hopkins Bloomberg School Of Public Health,Baltimore, MD, USA

Introduction:
Providers, patients and advocates are increasing using social networking sites likes Twitter to disseminate information and to aid in healthcare decision-making. In surgery, despite anecdotes about enthusiastic adoption by providers, there is a lack of robust qualitative and quantitate data on the utilization of Twitter for professional use. Therefore, this study aims to identify surgical providers on Twitter and to analyze their usage patterns.

Methods:
Individual tweets on surgical topics were pulled from Twitter from March 27th to April 27th, 2015 using a comprehensive list of surgery-related hashtags. Following this, the unique profiles of users who generated these tweets were identified. Further, key word matching was used to isolate those who self-identified (in profile ID/screen name/biography) as being involved in a surgical field. The Twitter profiles of these selected ‘surgical providers’ were analyzed to extract information on pre-determined themes. Data was extracted on multiple qualitative and quantitative fields, including: sex, location, user-type, affiliation, surgical specialty, multimedia use, followers/following, number of tweets, list membership and time on twitter. Standard descriptive statistical analyses were used to summarize the findings.

Results:
A total of 17,783 surgery-related tweets were pulled in the study period from 7,713 unique users. Following this, 726 profiles (9.4%) were identified as ‘surgical providers’. The cohort had a heterogeneous mix of user-type (surgeons/students/physicians/researchers/institutions) with varied affiliations (academic/community/private/non-profit/government) and specialties (general surgery/breast surgery/plastic surgery/orthopedics/surgical oncology/surgical health systems). The median time on twitter for profiles in this cohort was 40.7 months and ranged from 3 months to 8.5 years. Overall, a majority of the users were from North America (58.3%), followed by Europe (21.2%) and Asia (12.0%). This cohort had cumulatively tweeted 1,814,017 times; the median number of tweets per user was 625, with users tweeting as few as 8 and as many as 112,648 times. The median number of followers for a profile (334 [range: 7-142,580]) was similar to the number that they themselves followed (323 [range: 3-66,731]). Users were also members of a number of lists (median 11 [range: 0-3,672]) that are created based on common interests and topics that they tweet on.

Conclusion:
Surgical providers on Twitter come from varied affiliations/specialties but are predominantly from developed countries in North America and Europe. Most profiles (71.1%) were created in the last 5 years, which may point to a growing understanding of the utility of this interface for building professional networks as well as for effective patient education. More in-depth content and network analyses are necessary to develop strategies for using social media to improve knowledge sharing, communication and collaboration between surgical providers, patients and patient advocates.

65.13 Patient perspectives about follow-up care and weight regain following sleeve gastrectomy

Posted on January 18, 2016

M. Lauti1, S. Stevenson1, A. G. Hill1, A. D. MacCormick1 1University Of Auckland,Department Of Surgery,Auckland, -, New Zealand

Introduction:

Weight regain following sleeve gastrectomy is an increasingly recognised and important problem. Despite this, it is poorly reported and understood. Similar to other centres, we have noticed an association between discharge from the bariatric service and the onset of weight regain. We aimed to elucidate this further from the patient perspective.

Methods:

Patients at least two years from sleeve gastrectomy, who had experienced weight regain, were invited to participate in a focus group discussion. Participants were asked to complete a demographic survey and discussions were audio-recorded. Transcripts underwent content analysis using an inductive approach.

Results:

Thirty-eight participants participated in one of seven focus group discussions. The majority of participants were female, European and satisfied with their surgery and follow-up care. Participants described positive and negative aspects of the surgery, their follow-up care and causes of weight regain. Important emergent themes included the desire for more support delivered within the overarching principles of providing individualised and specialised care by providers that maintain good rapport and assist in maintaining motivation. Furthermore, this follow-up support may be delivered in non-traditional ways rather than traditional face-to-face consultations.

Conclusion:

We conclude that individualised, innovative and sustainable care pathways are needed for our bariatric patients.

65.14 Post-Operative Costs to the Elderly Following Emergency Surgery; a Prospective Cost Analysis

Posted on January 18, 2016

G. J. Eamer1, L. M. Warkentin1, T. Churchill1, F. Clement2, R. G. Khadaroo1 1University Of Alberta,Department Of Surgery,Edmonton, AB – ALBERTA, Canada 2University Of Calgary,O’Brien Institute For Public Health,Calgary, AB, Canada

Introduction:
Aging populations and improved medical technology have led to increased surgical interventions in the elderly. North Americans aged 65 or older make up 15% of the population in 2015; this is projected to rise to 22% by 2050. Post-operative complications are associated with longer hospital stays, increased cost and lost independence. There is no data examining patients’ accrued personal expenses and lost working days following emergency surgery discharge. This study will estimate the financial and social costs incurred by elderly post-operative patients following acute abdominal surgery.

Methods:
A prospective cohort of 73 patients 65 or older was enrolled in a study of post-surgical interventions to improve outcomes. The patients underwent acute abdominal surgery at either of the two level 1 trauma centers in Alberta, Canada, and completed a 6-month follow-up. Exclusion criteria were elective or palliative surgery, trauma, previous admission, or dependence for 3 or more activities of daily living. A detailed chart review gathered clinical and biochemical data. A validated health resource utilization inventory (HRU) was performed at a 6-month follow-up, which included questions on employment and medical products use. Participants were compared between sites to ensure demographic homogeneity using Fischer’s exact tests or ANOVA. The cost of healthcare products used or purchased in the 6 months following discharge was estimated using government and commercial sources and our HRU. Multivariate linear regression assessed the association of age, preadmission care requirements, post-operative complications and readmission with post-discharge costs.

Results:
Mean age was 79.3 (SD 7.9). More than 98% were Caucasian (n=72); 68% were married; 67% were 3 or less on the Clinical Frailty Scale; and 77% were living independently without care. 62% were classified ASA 3 or 4 (n=45). Following discharge 35% required assistance with cleaning, 30% with shopping, 24% with laundry and meal preparation, 14% with finances and 8% lost employment hours. The mean health care expenditure was 797 Canadian dollars (SD $932, inter-quartiles $157, $1,142, max $4,547) in the 6 months following surgery. Post-discharge cost was associated with needing preadmission care (β 0.313, CI 350-2330, p = 0.009,) as was age (β 0.061, CI 3.7-9.6, p < 0.001). Increased discharge costs were also associated with postoperative complication ($617, β 0.356, CI $283-951, p < 0.001), as was being readmitted ($524, β 0.253, CI $44-1004, p = 0.03).

Conclusion:
Our data demonstrates the significant financial and social costs to patients upon discharge, with an estimated mean cost of $797 in the 6 months post-discharge. Complications pre- and post-discharge also increase out-of-pocket costs to the patient. Reducing complications will not only reduce costs during admission, but also reduce patients’ costs following discharge.

65.10 Central Pain Processing and Treatment Response in Anterior Cutaneous Nerve Entrapment Syndrome

Posted on January 18, 2016

D. Van Rijckevorsel1, O. Boelens2, R. Roumen3,6, O. Wilder-Smith4,5, H. Van Goor1 1Radboud University Medical Center,Department Of Surgery,Nijmegen, , Netherlands 2Maasziekenhuis Pantein,Department Of Surgery,Boxmeer, , Netherlands 3Máxima Medical Center,Department Of Surgery,Veldhoven, , Netherlands 4Radboud University Medical Center,Department Of Anesthesiology, Pain And Palliative Medicine,Nijmegen, , Netherlands 5Aalborg University,Center For Sensory-Motor Interaction,Aalborg, , Denmark

Introduction:

Anterior Cutaneous Nerve Entrapment Syndrome (ACNES) is a common cause of chronic abdominal pain, refractory to local treatment in about 25% of cases for yet unknown reasons. We aimed to assess central pain processing after ACNES treatment and possible relationships between central pain processing and treatment outcomes by performing Quantitative Sensory Testing (QST).

Methods:
50 patients treated for ACNES with locally oriented treatment were tested. They were allocated to a responsive or refractory group based on response to treatment. Patients showing an improvement of the Visual Analogue Scale (VAS) pain score combined with an absolute VAS of < 40 were scored as responsive.
Thresholds to pressure and electric skin stimulation were determined in the ACNES dermatomes and four control areas. Conditioned pain modulation (CPM) response to a cold pressor task was determined. Patients filled in three pain-related psychological questionnaires.

Results:
Patients refractory to treatment showed significantly lower pressure pain thresholds in multiple dermatomes. No differences were found between groups for electric thresholds or CPM response. Duration of complaints before diagnosis and treatment was significantly longer in the refractory compared to the responsive group, and scores on pain-related questionnaires were higher.

Conclusion:
ACNES patients refractory to treatment have more signs of sensitized central pain processing and a longer duration of complaints before diagnosis and treatment. It appears that the presence of sensitized central pain processing is associated with less effective locally-orientated treatment.

65.07 The Impact of Index Hospital Costs on Readmission Among Patients Undergoing Major Abdominal Surgery

Posted on January 18, 2016

A. Ejaz1, A. A. Gonzalez1, F. Gani2, T. M. Pawlik2 1University Of Illinois At Chicago,Surgery,Chicago, IL, USA 2Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA

Introduction:
Reducing postoperative readmissions have been identified as an opportunity for healthcare cost containment. We sought to identify the impact of index admission costs on readmission rates and quantify any potential variation in costs and readmission attributable to the patient, procedure, and provider.

Methods:
Patients who underwent a colorectal, pancreas, or liver resection between 2009 and 2013 were identified at a tertiary care hospital. Variations in the index hospital costs among providers were compared using coefficient of variation (CV).

Results:
Among 4,114 patients, the overall unadjusted 30-day readmission rate was 17.2% varying by procedure (colorectal: 18.6% vs. pancreas: 18.6% vs. liver: 10.1%, P<0.001). The mean cost of surgery during the index hospitalization was $33,809±34,663 and varied by procedure (colorectal: $32,957 vs. pancreas: $37,360 vs. liver: $27,476, P<0.001). Median index length of stay (LOS) was 7 days (IQR: 5, 11) and was higher among patients who were eventually readmitted (readmitted: 8 days [IQR 6, 13] vs. not readmitted: 7 days [IQR 5, 11], P<0.001). Patients readmitted had a higher incidence of index hospitalization perioperative morbidity (readmitted: 20.3% vs. not readmitted: 16.4%; P=0.007). On adjusted analysis, pancreas (OR 1.88) or colorectal (OR 1.94) resection and an observed: expected index LOS >1 (OR 1.44) were independently associated with a higher risk of readmission (all P<0.001). Total index hospitalization costs were higher among patients who were readmitted (readmitted: $36,607±26,718 vs. not readmitted: $33,229±36,069; P<0.001). Further, among patients without an index hospitalization complication, total costs remained higher among patients who were eventually readmitted (readmitted: $31,138±19,528 vs. not readmitted: $25,964±13,999; P<0.001). At the provider level, readmission rates varied among surgeons performing the same procedure (colorectal: 0%-33.3% vs. pancreas: 0%-37.5%vs. liver: 0%-25%). Similarly, substantial variation in index hospitalization costs was also observed among surgeons performing the same procedure for readmitted (Colorectal: 87.6% vs. Pancreas: 72.7% vs. Liver: 58.6%) and non-readmitted (Colorectal: 120.7%% vs. Pancreas: 103.4% vs. Liver: 69.9%) patients.

Conclusion:
30-day readmission rates among patients undergoing major abdominal surgery vary significantly. Higher index hospitalization costs did not translate in to lower readmission rate.

65.08 Does bariatric surgery alter breast cancer treatment?

Posted on January 18, 2016

A. Ardestani1, E. Pranckevicius1, M. Golshan1, A. Tavakkoli1, E. Sheu1 1Brigham And Women’s Hospital,Department Of Surgery/ General/GI Division,Boston, MA, USA

Introduction: Obesity is an established risk factor for breast cancer and is thought to adversely affect outcomes. The impact of significant and sustained weight loss as achieved by bariatric surgery on breast cancer is not well understood.

Methods: We performed an institutional retrospective review of patients who underwent bariatric surgery and were diagnosed with malignant breast disease from 1989–2014. We compared patient demographics, tumor characteristics, and surgical and adjuvant treatments in patients diagnosed with breast cancer before (‘BEFORE’ group) or after (‘AFTER’ group) undergoing bariatric surgery.

Results: We included 101 patients, 62 and 39 patients in the BEFORE and AFTER groups, respectively. Patients in the BEFORE group were younger and more obese (Table 1). No significant differences were observed in tumor pathology in the BEFORE and AFTER groups including tumor size, hormone receptor status or lymphovascular invasion. Surgical outcomes were also similar between the groups including the rates of axillary dissection, positive margin, and peri-operative complications. However, a higher proportion of patients in the BEFORE were treated with chemotherapy and radiation therapy (Table 1). Of note, hormonal therapy was similar between the groups (63% vs. 47%, P=0.14). There was also a trend for higher recurrence in the BEFORE group.

Conclusions: This study represents one of the largest studies of breast cancer outcomes in bariatric surgery patients. Despite significant weight loss, bariatric surgery has no impact on tumor stage at diagnosis or hormone receptor status. Bariatric surgery appears to decrease the need for re-excisions, chemotherapy, and radiation therapy without a negative impact on breast cancer recurrence.

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