62.07 Implementing a Resident Acute Care Surgery Service: Improving Resident Education and Patient Care

Posted on January 18, 2016

O. Kantor1, A. B. Schneider1, M. Rojnica1, A. J. Benjamin1, N. Schindler1,2, M. C. Posner1, J. B. Matthews1, K. K. Roggin1 1University Of Chicago,Department Of Surgery,Chicago, IL, USA 2Northshore University Health System,Department Of Surgery,Evanston, IL, USA

Introduction:
The American Board of Surgery recently changed the requirements for graduating surgery residents to a minimum of 25 cases as a teaching assistant (TA). To expand the resident education experience and allow for senior residents to be more autonomous in the management of patients both in the operating room and perioperatively, our program implemented a new Resident-run Acute Care Surgery (RACS) consult service. We hypothesized that creation of this service would increase TA cases and resident satisfaction, as well as be more efficient in evaluating consults.

Methods:
With the implementation of RACS, we switched from an attending-service based call model to a new admitting service that was mainly resident run with alternating attending supervision. Two residents (PGY4 or 5 and PGY2) staffed this service and all new surgical consults were directed to RACS. When appropriate based on resident experience and case complexity, the operative case was done as a TA case with the senior resident taking the junior resident through the case and the attending in the room. We collected information on TA case logs for senior residents pre (n=10) and post (n=11) implementation of the RACS service, independency data on the proportion of each case performed independently by residents, resident evaluations of general surgery services, and consult time (time from consultation to time patient seen) for the first 12 months of the service (June 2014-June 2015).

Results:
The number of total TA cases logged among graduating chief residents increased from a mean of 13.4 ± 13.0 (range 4-44) for pre-RACS residents to 30.8 ± 8.8 (range 27-36) for post-RACS residents (p<0.01). This increase was seen with a mean of one month spent on RACS for the post-RACS residents. Of 323 operative cases, the residents performed an average of 82% of the case independently. On resident service evaluations of RACS (n=27) compared to other general surgery services (n=127), there was a significant increase in the satisfaction with the variety of cases (mean 5.08 vs 4.52, p<0.01 on a 1-6 Likert scale) and complexity of cases (mean 5.35 vs 4.94, p<0.01). In addition, creation of a one-team consult service resulted in a more streamlined consult process, with average consult time of 22min for operative consults and 25min for non-operative consults.

Conclusion:
The implementation of a RACS service has increased resident autonomy, TA cases, and satisfaction with operative case variety, as well as increased the efficiency of surgical consultation at our institution.

62.08 Emerging Reimbursement Models in Surgical Practice: General Surgery Resident Perceptions

Posted on January 18, 2016

J. M. Linson1, J. W. Dennis1, E. Lerner1, M. Nussbaum1, J. Tepas1 1University Of Florida College Of Medicine,Surgery,JACKSONVILLE, FL, USA

Introduction:

The shift from Fee- For-Service (FFS) to value and quality based payment has stimulated multiple alternative payment models (APM) that include the Medicare ‘Shared Savings Program (SSP),’ ‘Pay for Performance (P4P),’ ‘Comprehensive Care Payments (CCP),’ and ‘Episode of Care/Bundled Payment (EOC/BP)’. The Department of Health and Human Services (HHS) has declared its goal to tie 30% of Medicare payments to alternative payment models by the end of 2016, and 50% by the end of 2018. Recently enacted legislation repealing the sustainable growth rate (SGR) intends to shift to >75% of reimbursement to APM. Little is currently known about the perception of this among General Surgery residents, who will inherit a system in flux upon completion of their training.

Methods:
An electronic survey was distributed to American General Surgery residents to assess their understanding and perception of these alternative models. Using Likert scale responses, surgical autonomy, patient satisfaction, coordination of care, control of costs, and surgical outcomes were evaluated with respect to these reimbursement models. Model types were compared by level of understanding and perception of impact on key areas of surgical practice.

Results:
255 surveys were distributed individually via program coordinators, and one link was distributed via the Association of Program Directors in Surgery list-serve, yielding a return of 183 responses. FFS and P4P were best known, with >75% of respondents reporting at least moderate familiarity. BP/EOC was at least moderately familiar to 62% of respondents. Conversely, 63.2% indicated limited familiarity with CAP. 60.2% were slightly or not at all familiar with CCP. 71% were either slightly or not at all familiar with SSP. Analysis of impact on surgical practice demonstrated consensus regarding anticipated effect on surgical autonomy and cost control (table). None of the models were seen as improving patient satisfaction. P4P was anticipated to improve outcome by 47.2% of respondents. A need for more education about the new healthcare reimbursement models was indicated by 95.1% of respondents.

Conclusion:

Most residents have limited familiarity with FFS, P4P and BP/EOC. Most also recognized the trade-off between surgical autonomy and cost control. Only FFS was perceived to have a positive effect on autonomy, while all alternative models had a perceived negative effect. Only P4P was perceived to have a positive impact on surgical outcomes by a majority of respondents. An overwhelming majority articulated need for more education in this area and a role in developing and evaluating these alternative models.

62.04 First-Case Delays: Curriculum-based Quality Improvement in Interdisciplinary Teams

Posted on January 18, 2016

A. Botty Van Den Bruele1, M. Main2, C. L. Leaphart1 1University Of Florida,Department Of Surgery,Jacksonville, FL, USA 2UFHealth Jacksonville,Perioperative Services,Jacksonville, FL, USA

Introduction: Quality Improvement (QI) education and Interdisciplinary teamwork for surgical residents are critical areas of program accreditation and practice management. Yet, surgical curriculum applying quality improvement methodology remains largely undefined. Our residency program incorporates a research-based curriculum for categorical interns with foundational instruction in QI methodology. To expand the curriculum and develop systems-based application of QI methodology, we hypothesized that selection of a clinical problem, first-case delays (FCD) in the OR, would provide QI instruction from an interdisciplinary perspective while addressing educational goals.

Methods: After instruction in fundamentals of research, IRB approval was obtained. Resident identification of FCD for the interdisciplinary study was guided by experienced faculty. Literature searches were used to develop data dictionaries of standardized reasons for case delay. The data dictionary was used for direct observation of patient and team-based readiness for in room start at 715 AM. Cases observed were General or Vascular Surgery cases in which residents were involved. Using QI methodology, Pareto analysis was performed to stratify reasons for delay and was compared to computer-recorded staff entries of reasons for delay. Analytical drill-down using Ishikawa diagrams further stratified contributing factors for case delays, providing additional opportunities to expand QI initiatives.

Results: A total of 27 first case starts were observed, of which 25 (92.6%) failed to start on time. Pareto analysis determined the most common reason for delay to be failure of OR room readiness (56%, n=14) followed by near equivalent delays for transport, patient availability, anesthesiology, or surgical reasons. By contrast, computer recorded entries listed surgical team readiness as the primary cause of delay indicating that efforts to address delays could be impaired if not targeted appropriately. Ishikawa diagrams (Figure) demonstrate the complexity of interdisciplinary team function required to prevent FCD while enhancing understanding of how to address delays.

Conclusion: Using clinical issues to apply QI methodology expands resident education in the science of quality improvement and interdisciplinary teamwork while broadening the resident’s understanding of the healthcare system. Ongoing collaboration of teams using QI methodology can be used to prevent first-case delays and improve teamwork in the OR.

62.05 Does Lung Implantation by a Resident Affect Short-Term Outcomes?

Posted on January 18, 2016

J. Price1, D. Williams1, R. Murthy1, J. Waters1, W. Ring1, M. E. Jessen1, M. Peltz1, M. Wait1 1University Of Texas Southwestern Medical Center,Cardiovascular And Thoracic Surgery,Dallas, TX, USA

Introduction: At training institutions, residents often assist with single or bilateral lung transplants. We sought to evaluate the short-term outcomes for these patients, comparing the results when implantation is performed by attending surgeons or when a resident is the implanting surgeon for one side if bilateral or for the entire single lung. We hypothesized that resident participation did not adversely affect outcomes after lung transplantation.

Methods: 243 lung transplant patients at a single center were reviewed. All patients underwent single (SLT) or bilateral lung transplant (BLT). The implanting surgeon and warm implantation time (WIT) were recorded for each side if bilateral or for the single lung, comparing Attending Only (AO) to Resident Participation (RP). We reviewed pre-, intra-, and post-operative variables. Groups were described by mean and standard deviation and compared by t-test, with p-value <0.05 considered significant.

Results: For BLT patients, age and lung allocation score (LAS) did not differ between the groups. While total WIT was significantly shorter in the AO group, cardiopulmonary bypass (CPB) rate, packed red blood cell (pRBC) requirement, duration of intubation, intensive care unit (ICU) stay, postoperative length of stay (LOS), primary graft dysfunction (PGD) grade, and 30-day mortality did not differ between the AO and RP groups. In SLT patients, the age again was similar, but the LAS was significantly higher in the RP group. However, WIT, CPB rate, pRBC requirement, duration of intubation, ICU stay, postoperative LOS, PGD grade, and 30-day mortality did not differ between the two groups. Table 1 summarizes this data.

Conclusion: Lung transplantation is a time-sensitive operation, and often residents are not allowed to perform the donor lung implantation due to this concern. These results show that residents, with proper attending supervision, can perform these difficult procedures with minimal increase in warm implantation time and no compromise in short-term outcomes for these complex patients.

62.06 Sharing Stress in Surgical Training?

Posted on January 18, 2016

S. Alken1, J. Luursema1, C. Fluit1, H. Van Goor1 1Radboud University Medical Center,Nijmegen, N/A, Netherlands

Introduction:

High levels of stress can cause cognitive overload, compromise technical and non-technical abilities of surgeons and can potentially compromise teaching climate and efficiency. This study aims to investigate how stress is perceived by trainees and faculty during a simulation team training, and how subjective stress is related to objective stress data.

Methods:

Data was collected during the Definitive Surgical Trauma Care (DSTC) course, a highly realistic hands-on trauma surgery team training performed on live porcine models. 7 surgical teams participated, each team existing of 1 faculty coaching 2 trainees.

Subjective stress was measured by the State Trait Anxiety Index (STAI; 6= lowest level of stress; 24= highest level of stress) and on a Visual Analogue Scale (VAS; 0= lowest level of stress; 100= highest level of stress). Objective stress was measured by saliva cortisol level, heart rate and heart rate variability. Saliva samples, STAI and VAS scores were collected 2 times at baseline and 4 times during the simulation training. Heart rate and heart rate variability was registered every 4 and 300 seconds respectively with the Health Patch™ (Vital Connect Inc, Campbell, USA) worn by all participants.

Results:

Trainees reported a significant increase of mean subjective stress during training compared to baseline (STAI: 12.44 vs. 9.65, +2.79, Wilcoxon SR Test, P = .005; VAS: 39.06 vs. 20.33, + 18.73, Wilcoxon SR Test, P= .007), whereas faculty did not (STAI: 9.87 vs. 9.21, +0.66, Wilcoxon SR Test, P = .180; VAS: 25.00 vs. 18.57, +6.43, Wilcoxon SR Test, P= .138).

Between the faculty and trainees within the same team, in-training VAS and STAI scores did not correlate (Pearson’s r ranging from -.580 to .765). Strong correlations were found between the in-training cortisol levels of faculty and trainees in 5 of 7 teams (Pearson’s r ranging from .929 to .979). Analysis of cortisol samples and Health Patch™ data is currently done.

Conclusion:

Perceived stress differed between faculty and trainees during a highly realistic damage control surgery team training, whereas objective stress as measured by cortisol did not. Possibly, stress remains unnoticed or neglected by faculty.

62.01 Post-80-hour Workweek Trends in General Surgery Resident Applications

Posted on January 18, 2016

J. A. Keeley1, C. DeVirgilio1, A. Moazzez1, S. Lee1, B. Jarmin2, A. L. Neville1 1Harbor-UCLA Medical Center,General Surgery,Torrance, CA, USA 2Gunderson Medical Foundation,General Surgery,La Crosse, WI, USA

Introduction: Over the past decade, it appears that the number of General Surgery residency applicants has increased. We hypothesized that implementation of the 80-hour workweek in 2003 may have influenced this trend. The purpose of this study was to evaluate national and local trends in applications to surgical residency after implementation of the 80-hour workweek.

Methods: NRMP Results and Data from the Main Residency Match between 1999 and 2014 were interrogated for the number of applicants, available general surgery positions, and ranks per available positions. Data from an academic program (California) and an independent program (Wisconsin) was also collected for available years, 2007 to 2014. Data was statistically analyzed using linear regression (SPSS V22).

Results: Nationally, the number of unfilled residency positions decreased from an average of 44.7 prior to 2003 to 4.1 after 2003, (p= 0.04). Since 2003, the percentage of total US applicants applying to surgery, the percentage of general surgery positions available, and the number of positions per US applicant have been stable (Figure 1). However, the number of ranks submitted per available position increased from 9.6 in 2004 to 11.0 in 2014 (p=0.007).

The number of applications submitted to the two individual programs increased over the last eight years, both in total number and in percentage of the US surgical applicants who applied to each program. Total US applicants (percentage of surgical applicants) increased from 237 (22.7%) and 72 (6.9%) to 377 (29.6%) and 187 (14.7%) respectively for the two programs studied.

Conclusion: Since the introduction of the 80-hour workweek in 2003, there has been an increase in the number of applications to individual programs and the number of ranks per position. This may reflect a perceived increase in the competitiveness of the specialty, particularly given the decreased number of unfilled positions since 2003. However, nationwide, the total number of applicants and number of positions available per applicant has remained stable. The increased number of applications to individual programs increases the difficulty of the interview selection process and suggests the need for a refined approach to selecting candidates.

62.02 An Exploration of Moonlighting Effects on Surgical Skill in Lab Residents

Posted on January 18, 2016

K. Law1, S. J. Gannon2,3, A. D. D’Angelo2, D. A. Wiegmann1, C. M. Pugh1,2 1University Of Wisconsin,Industrial And Systems Engineering,Madison, WI, USA 2University Of Wisconsin,Surgery,Madison, WI, USA 3University Of Wisconsin,Kinesiology,Madison, WI, USA

Introduction: Resident participation in dedicated research is a tradition in general surgery programs. To alleviate concerns regarding maintenance of clinical skill during the research years, some residents take extra call shifts or moonlight to offset potential skill reduction. Several research studies have characterized lab resident experiences during moonlighting. However, few have investigated how residents’ surgical performance is impacted by moonlighting. The aim of this paper was to determine if the effects of moonlighting can be objectively measured during assessments of surgical skill. Our hypothesis is that the quality and accuracy (errors) of resident performance in a simulated laparoscopic ventral hernia (LVH) would be positively correlated with moonlighting experience.

Methods: Thirty-eight surgical lab residents (PGY2-4; 54% female) had 15 minutes to complete two steps of a simulated LVH procedure including securing mesh anchoring sutures to the abdominal wall and affixing the mesh with a laparoscopic tacker. Residents identified how often they take clinical shifts in a pre-simulation general survey. Resident performance was determined by analyzing the hernia skins and errors made during the procedure. Post-simulation, hernia skins were graded on a 24-point scale for quality of repair. Procedural errors were identified using a checklist of previously identified common errors committed during the LVH procedure. Based on their moonlighting activity, residents were grouped into low or high moonlighting groups based on whether they reported one or fewer clinical shifts per month (n=22) or two or more shifts (n=16). A logistic regression analysis was used to predict frequency of moonlighting in lab residents using errors and final hernia grades as predictors.

Results: The logistic regression analysis using repair quality and error scores as predictors reliably distinguished between the two moonlighting groups (χ2 = 7.78, p=.02). The model explained 25.1% (Nagelkerke’s R2) of the between-group variance in predictor scores and correctly classified 73.7% of residents into their respective moonlighting group. Residents’ hernia quality repair scores (p=.021) made a significant contribution to the prediction. Errors did not. Residents in the high moonlighting group had better repair quality scores on average (M=16.5, SD=5.0) than the low moonlighting group (M=14.2, SD=5.2). There was no significant difference in the frequency of errors committed between the two groups (p =.61).

Conclusion: Residents who reported moonlighting had higher quality hernia repair scores compared to those who rarely if ever moonlighted. However there were no differences in the number of errors made between groups. These findings suggest that there is either a qualitative difference in the types of errors made by residents who moonlight or that they are better able to identify and manage errors when they occur, thereby not affecting repair quality.

62.03 Emotional Intelligence in Surgery: Relationship with Resident Performance and Job Satisfaction

Posted on January 18, 2016

R. H. Hollis1, L. M. Theiss1, M. S. Morris1, J. R. Porterfield1, J. M. Grams1, D. Chu1 1University Of Alabama At Birmingham,Dept Of Surgery,Birmingham, AL, USA

Introduction: Emotional intelligence (EI) has been associated with better performance and job satisfaction in several industries. The role of EI in the surgical profession is less clear particularly among surgical residents. Surgical resident performance is currently measured with ACGME competency based milestones and ABSITE scores. We hypothesized that higher EI would be associated with higher measures of resident performance and job satisfaction.

Methods: In 2015, a validated trait EI questionnaire (TEIQ) and job satisfaction survey were distributed to all general surgery residents at a single institution. These data were compared to resident performance which was defined by attending evaluations using the ACGME competency based milestones and standardized test scores (USMLE and ABSITE). Statistical comparison was made using Pearson correlation for continuous variables and ANOVA for categorical variables. The association between milestone scores and global trait EI was also evaluated using a general linear model to adjust for evaluation differences by post-graduate year (PGY).

Results: Overall survey response rate was 68.9%. Global EI did not significantly vary by resident age, gender, marital status, or PGY. Global EI was associated with scores on USMLE Step 2 (r=0.46; p=0.01) and Step 3 (r=0.54; p=0.01) but not ABSITE percentile scores (r=0.06, p=0.77). Clinical milestone scores significantly increased by PGY status (p<0.01), but were not associated with Global EI before or after adjustment for PGY (p>0.05). Global EI was associated with overall job satisfaction (r=0.37, p=0.04). Sub-analysis showed significant correlation between the EI domain of ‘well-being’ and a resident’s satisfaction with work supervision (r=0.47, p<0.01), work communication (r=0.38,p=0.03), and the nature of their work (r=0.45, p=0.01). Job satisfaction was not associated with ABSITE percentile scores.

Conclusion: Emotional intelligence was associated with job satisfaction measures and USMLE performance but not ACGME competency based milestones or ABSITE scores. EI may be an important factor for fulfillment in surgical training that is not currently captured with traditional in-training performance measures.

61.19 Esophageal Duplication Cysts And Closure Of The Muscle Layer

Posted on January 18, 2016

L. O. Benedict1, S. Bairdain2, J. K. Paulus4, C. Jackson1, C. Chen2, C. Kelleher3 1Tufts Medical Center,Pediatric Surgery,Boston, MA, USA 2Children’s Hospital Boston,Pediatric Surgery,Boston, MA, USA 3Massachusetts General Hospital,Pediatric Surgery,Boston, MA, USA 4Tufts Clinical And Translational Science Institute,Boston, MA, USA

Introduction: Foregut duplication cysts are rare congenital anomalies that require surgical intervention with approximately 10-15% of all gastrointestinal duplication cysts originating from the esophagus. Consensus is lacking among surgeons regarding closure of the esophageal muscle layer following resection of an esophageal duplication cyst and long-term outcomes are poorly documented. Therefore, we sought to determine whether closure of the esophageal muscle layer following resection influences short or long-term outcomes.

Methods: A retrospective cohort study performed at three institutions affiliated with childrens hospitals was performed. Patients undergoing resection of esophageal duplication cysts between 1990-2012 were classified according to whether the esophageal muscle layer was closed or left open. Demographic data, surgical technique, pre-operative symptoms and both short-term (< 30 days) and long-term (≥ 30 days) complication rates were abstracted from patient medical records.

Results: Twenty-five patients were identified with a median age of 15 years old (range: 2 months to 68 years old). Eleven patients had the esophageal muscle layer closed after surgical resection (44%). Of those 11 patients, one developed a short-term complication, dysphagia (9%, 95% CI: 2%, 38%). Only one patient returned to the operating room, after 30 days, for an upper endoscopy after developing symptoms of gastroesophageal reflux disease. Of the 14 patients who had their muscle layer left open, 3 patients (21%, 95% CI: 8%, 48%) developed short-term complications, 2 of whom required surgical intervention within 30 days. Furthermore, 2 additional patients required surgical intervention after 30 days for a long-term complication (diverticulum and cyst recurrence).

Conclusion: Surgical complications occurred more frequently in patients who had the muscle layer left open after resection of an esophageal duplication cyst. Additionally, the majority of patients requiring re-operation for both short-term and long-term complications occurred in this group. Though small, this study is the first to evaluate the complications after resecting esophageal duplication cysts. Our results suggest that closing the esophageal muscle layer following removal of an esophageal duplication cyst may be indicated to prevent both complications and the need for reoperations.

61.20 The Impact of Developing a Pectus Center for Chest Wall Deformities

Posted on January 18, 2016

K. W. Gonzalez1, B. G. Dalton1, E. M. Knott1, B. Kurtz1, A. S. Poola1, C. L. Snyder1, S. D. St. Peter1, G. W. Holcomb1 1Children’s Mercy Hospital- University Of Missouri Kansas City,Pediatric Surgery,Kansas City, MO, USA

Introduction: In July 2011, we established a dedicated center for patients with chest wall deformities to allow for more effective consultation and to initiate a bracing program for the carinatum patients. In this study, we evaluate the effect of this center on patient volume and management.

Methods: A retrospective review was conducted for 699 patients seen with congenital chest, rib and sternal anomalies between July 2009 – June 2013. Patient demographics, operative interventions, clinic and bracing visits were compared, based on the date of initial consultation, before the center opened (July 2009-June 2011, Group 1), versus after (July 2011-June 2013, Group 2). Comparative analysis was performed utilizing chi square and Mann-Whitney U test.

Results: Three hundred twenty new patients were in Group 1 and 379 in Group 2, for an 18.4% increase in patient volume. The number of excavatum patients increased from 172 (Group 1) to 189 (Group 2). The number of carinatum patients increased substantially from 125 (Group 1) to 165 (Group 2). The number of mixed defects and rib/sternal anomalies was similar between groups. The percentage of patients undergoing operative repair of carinatum/mixed defects dropped significantly from 15.1% (Group 1) to 1.1% (Group 2) (p < 0.01) whereas the percentage of patients undergoing nonoperative bracing for carinatum/mixed defects rose significantly from 20.1% (Group 1) to 62.2% (Group 2) (p < 0.01). Patients traveled between 3 and 1249 miles to visit the center for a single visit suggesting that although the majority of patients are regional, the catchment area has extended beyond adjacent states.

Conclusion: Initiating a dedicated pectus center increased patient volume and provided an effective transition to nonoperative bracing for patients with pectus carinatum. The concentrated focus of medical staff dedicated to chest wall deformities has allowed us to treat patients on a local and regional level.

61.15 Blunt Cardiac Injury: Improved Outcomes or Misdiagnosis?

Posted on January 18, 2016

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

Introduction:
Blunt cardiac injury (BCI) is uncommon. Its diagnosis, treatment and significance remain controversial. When diagnosed it is often treated with anti-arrhythmic drugs but there is little known regarding the outcome or effectiveness. The aim of this study was to assess the trend of reporting BCI using a national database.

Methods:
Retrospective 6-year (2007-2012) review of National Trauma Data Base (NTDB) of all chest trauma patients. Patients with ICD-9 Code of blunt cardiac injury (861.01) were identified. Outcome measures were mortality and admission characteristics. Regression and trend analyses were performed.

Results:

A total of 10,408 patients were included in our study. The rate of BCI was 7.45 per 10,000 patients (10,412/13,957,987) and has been decreasing over years, from 8.9 per 10,000 patients in 2007 to 6.3 per 10,000 patients in 2012 (p < 0.001). Mean age (45 ± 27 vs. 46 ± 28, p = 0.29) and male gender dominance (66.5% vs. 67.4%, p = 0.42), emergency department systolic blood pressure (117 ± 49 vs. 89 ± 39, p = 0.07), and emergency department heart rate (89 ± 39 vs. 91 ± 36, p = 0.12) did not change during the study period. 18 patients (0.2%) were diagnosed to have an associated cardiac arrhythmia. Mortality rate from cardiac contusion declined during the study period (20.7% vs. 13.8%, p < 0.0001). Mortality rate increased with increasing Chest AIS (Chest AIS-1: 4.9% vs. Chest AIS-5: 40%, p=0.001) however there were 420 patients who were diagnosed with BCI without a chest trauma (Chest AIS = 0).

Conclusion:
The incidence of blunt cardiac injury is uncommon and continues to decrease. The mortality rate has also decreased by a third. The true significance as well as relevance is yet unknown.

61.16 Intensive glycemic control reduces mortality and morbidity in cardiac surgery patients:Meta-analysis

Posted on January 18, 2016

K. P. Kulkarni3, R. S. Chamberlain1,2,3 1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2New Jersey Medical School,Surgery,Newark, NJ, USA 3St. George’s University School Of Medicine,St. George’s, St. George’s, Grenada

PURPOSE: Optimal glycemic control in cardiac surgery patients remains a laudable but confusing practice. Existing studies have primarily employed two maintenance strategies using either tight glycemic control (maintain <120 mg/dl) or liberal control (<200 mg/dl) with conflicting outcomes. Meta-analysis and meta-regression were performed to better delineate which approach (if any) is associated with reduced perioperative morbidity and/or mortality.

Methods: A comprehensive literature search of PubMed, Google Scholar and the Cochrane Central Registry of Controlled Trials was completed. Keywords searched were ‘insulin’,‘bypass’,’coronary’,’CABG’,’glucose’,’artery’,’intensive’,’cardiac’, and ‘surgery’. Eligible studies were randomized control trials (RCTs) utilizing two different glycemic control strategies with a mortality outcome. Primary outcomes were mortality, intensive care unit (ICU) length of stay (LOS), and hospital LOS.

Results: 14 studies were included in this study. Intensive glucose control significantly reduced mortality (relative risk (RR) = 0.742, 95% CI=0.566 to 0.973; p=0.031) and ICU LOS (Standardized difference of mean (SDM) = -0.352, 95% CI=-0.352 to -0.692; p=0.042) but did not influence overall hospital LOS (SDM= -0.255, 95% CI = -0.722 to 0.211; p=0.283). Significant secondary outcomes were overall infection (RR=0.444, 95% CI=0.322 to 0.611; p<0.001) and atrial fibrillation rates (RR=0.722, 95% CI=0.582 to 0.896; p=0.003). No difference in stroke (RR=2.279, 95% CI=0.525 to 9.885; p=0.271), deep sternal infection (RR=0.599, 95% CI=0.242 to 1.484; p=0.268), acute renal failure (RR=1.337, 95% CI=0.468 to 3.821; p=0.588), or prolonged intubation rates were observed (RR=0.990, 95% CI=0.661 to 1.483; p=0.962).

Conclusion: Optimal glycemic control is significantly linked to improved perioperative outcomes in cardiac surgery patients. Intensive glucose control (< 120 mg/dl) reduces mortality and ICU LOS in cardiac surgery patients, while also decreasing overall postoperative infection and atrial fibrillation rates compared to more liberal glycemic strategies. Additional adequately powered studies are needed to further investigate the nuances of optimal intensity and duration of glycemic control in this patient population.

61.17 Open Access Phone Triage for Veterans with Suspected Malignant Pleural Mesothelioma (MPM)

Posted on January 18, 2016

C. J. Siegert1,2, J. Lally1,4, M. Shoni1,2, P. M. Fisichella4, A. Lebenthal1,2,3 1VA Boston Healthcare System,Section Of General Thoracic Surgery,West Roxbury, MA, USA 2Brigham And Women’s Hospital,Division Of General Thoracic Surgery,Boston, MA, USA 3Brigham And Women’s Hospital,International Mesothelioma Program,Boston, MA, USA 4VA Boston Healthcare System,Department Of Surgery,West Roxbury, MA, USA

Introduction:
The Boston VA Healthcare System (VABHS) is one of a handful of VA hospitals throughout the country offering specialized care for MPM. Thus an increasing number of patients with suspected mesothelioma call to inquire about specialized, multi-modality care. Malignant Pleural Mesothelioma (MPM) is a rare disease affecting approximately 3000 Americans annually. A disproportionate amount of new patients are veterans, accounting for an estimated 1/3. The majority have distant history of asbestos exposure during military service. A latency period of decades is common, and the disease is difficult to diagnose. The treatment options include supportive care, chemotherapy and maximal cytoreductive surgery. Guidelines support multidisciplinary care, with evaluation by surgeons with expertise treating MPM.

Methods:
In 2011 we began to offer open access phone triage to Veterans with newly diagnosed MPM by a general thoracic surgeon and a member of the International Mesothelioma Program (IMP), VABHS. The patients were referred by primary care providers, oncologists, surgeons, veteran advocates or self-referred using online media. A total of 69 patients were triaged world-wide. Further documentation was requested and analyzed including records, diagnostics labs, radiology tests and pathology slides from an initial biopsy. Patients that were reasonable candidates for cytoreductive surgery were encouraged to travel to the WXVA for further assessment.

Results:
Out of 69 callers, 57 were Veterans, and we encouraged 46 to be seen by a surgeon with expertise in the field. 32 veterans were surgically staged at VABHS. 13 of these patients eventually underwent definitive surgery at VABHS, while 16 patients transferred their care to another hospital. 9 veterans opted out of surgery or had a contraindication to surgery. All service branches were represented for veterans with mesothelioma: Army (13), Navy (23), USMC (4), Coast Guard (2), Air Force (4) and unknown (11)

Conclusion:
Open access Phone triage for veterans with findings suspicious of MPM, by a surgeon with expertise in the treating MPM, provides guideline supported care for patients across the nation. Veterans who served in branches other than the Navy have significant representation.

61.18 Septal Myectomy is Safe and Effective at a Medium Volume Center

Posted on January 18, 2016

S. Mokashi1, I. Gosev1, S. McGurk1, M. Yammine1, K. Rajab1, P. S. Shekar1 1Brigham And Women’s Hospital,Cardiac Surgery,Boston, MA, USA

Introduction: Septal myectomy is the standard treatment for symptomatic hypertrophic obstructive cardiomyopathy (HOCM) refractory to medical therapy. To date, only outcomes from high volume centers have been reported. Herein we report mid-term results from a medium volume center.

Methods: A retrospective review of 47 patients undergoing septal myectomy for HOCM over a 10-year period was performed. Primary and secondary endpoints included: mortality, pacemaker placement, peak left ventricular outflow tract (LVOT) gradient and New York Heart Association (NYHA) class.

Results:The mean age was 57yrs ±12, and 47% (22) were women. Mean LVOT gradient was 79mmHg (±30), 39% (18) of patients had moderate or severe mitral regurgitation and 47% (22) were in NYHA class III/IV at baseline. Concomitant procedures included mitral valves (17), CABG (6), and aortas (3). Immediate postoperative LVOT gradient was 14mmHg±7 (p<0.001 vs. baseline). Operative mortality was 2% (1), and 15% (7) patients had new pacemaker placements. Median time to follow-up was 22 months, the mean LVOT gradient was 14mmHg±8 and 9% (4) patients were in NYHA class III/IV (both p ≤0.001 vs. baseline). Among 15 patients who were ≥3yrs from surgery (median 5.2 yrs.), LVOT gradient was 13mmHg±8 (p≤0.001 vs. baseline). There was one late death during the observation period, and one reoperative septal myectomy at 5yrs.

Conclusion: Our series shows a low operative mortality, sustained peak LVOT gradient reductions and improved symptomatology. The outcomes herein are comparable to previously published data from high volume centers. Therefore, septal myectomy at a medium volume center is safe and effective for HOCM.

61.13 Perioperative Outcomes Following Cardiovascular Surgery in Patients with 22q11.2 deletion

Posted on January 18, 2016

M. E. Mitchell1,2, D. Menhke2, P. Simpson2, M. Nugent2, A. Tomita-Mitchell2, N. Ghanayem1,2, S. Clarke1,2 1Children’s Hospital Of Wisconsin,Milwaukee, WI, USA 2Medical College Of Wisconsin,Milwaukee, WI, USA

Introduction:
22q11.2 is the most common deletion syndrome with an incidence of 1:4000. Up to 75% of patients with 22q11.2 deletion syndrome (22qDS) have congenital heart disease and need of congenital heart surgery. The known associated anomalies within the endocrine, neurologic, hematologic, and airway systems can have affects on their perioperative morbidity and mortality following cardiovascular surgery. Our study was to look at our single center institution perioperative morbidity in patients with 22qDS following cardiovascular surgery.

Methods:
This was a single center retrospective chart review of 99 patients that had cardiovascular surgery at Children's Hospital of Wisconsin between 2004-2011 and were in the Congenital Heart Disease Tissue Bank. Patients with 22qDS and matched controls, for age and type of surgery were identified. Data from the perioperative period was obtained and analysis was performed using classification trees.

Results:
Patients with 22qDS and a RACHS score < 2 had more cardiopulmonary bypass time > 150 min (p < 0.001). There was an increased risk of post-operative neurologic injury in patients with 22qDS that had a cardiopulmonary bypass time > 150 min (p<0.004). Cardiopulmonary bypass time was > 150 min in patients with 22qDS, higher RACHS scores, and no prenatal diagnosis (p<0.001). Patients with 22qDS had > 5 days of mechanical ventilation similar to patients with RACHS scores > 3 and cardiopulmonary bypass time > 150 min.

Conclusion:
This study shows there are increased post-operative morbidities in patients with 22qDS related to cardiopulmonary bypass, neurologic injury, and mechanical ventilation. Prenatal diagnosis also plays a role in length of cardiopulmonary bypass in patients with 22qDS. This suggests that further investigation with a larger cohort of patients with 22qDS is needed.

61.14 Role of the Surgical Robot in an Advanced Video-Assisted Thoracoscopic Program

Posted on January 18, 2016

M. Huang1, B. Zwierzchowski1, W. Wong1, T. Demmy1, E. Dexter1, M. Hennon1, A. Picone1, W. Tan1, S. Yendamuri1, C. Nwogu1 1Roswell Park Cancer Institute,Buffalo, NY, USA

Introduction: A steadily increasing proportion of thoracic procedures are being performed via minimally invasive techniques. The literature has demonstrated that video-assisted thoracoscopic surgery (VATS) techniques have improved patient recovery time with fewer postoperative complications, and sustained long-term survivorship data equivalent to open thoracotomy for early stage lung cancer. However, the additional benefit of robotic video-assisted thoracic surgery (RVATS) remains controversial. As a prelude to a prospective trial comparing RVATS with conventional VATS for lobectomy, we conducted a retrospective review of all RVATS cases at an academic, tertiary referral center with a focus on lobectomy cases.

Methods: A review was conducted of 101 consecutive patients undergoing robotic-assisted thoracoscopic surgery between August 2005 and May 2015. Outcomes data collected include operative time, blood loss, duration of hospital and postoperative ICU stay, chest tube duration, conversion rates, and perioperative morbidity and mortality. In addition, a subset cost analysis compared direct costs and medical supply expenses for 10 lobectomy cases, each performed by RVATS, VATS, and thoracotomy.

Results: In this initial case series of 41 cases of RVATS lobectomy, patients had a median hospital length of stay of 4 days, ICU length of stay of 0 days, chest tube duration of 2 days, and an average blood loss of 151 mL. One patient (2.4%) that was electively converted to thoracotomy for a large upper and middle lobe tumor, died from pneumonia and respiratory failure. There were 6 (14.6%) cases converted to open thoracotomy. Direct costs for lobectomies performed by VATS, RVATS and thoracotomy were $23,306, $25,510 and $35,195, respectively.

Conclusion: Progressive incorporation of the surgical robot in an already advanced thoracoscopic program is feasible. The immediate postoperative outcomes after RVATS lobectomy are similar to what has been reported from our institution and others for VATS lobectomy. RVATS was modestly more expensive than VATS, but both were significantly cheaper than thoracotomy. A prospective comparison of RVATS and VATS would provide greater understanding of the precise benefits or lack thereof of the Da Vinci surgical robotic system for minimally invasive lung resections.

61.10 Evaluation of Del Nido and Conventional Blood Cardioplegia in Adult Cardiac Operations

Posted on January 18, 2016

R. Ou1, A. Zhu1, A. Ashfaq1, S. Nguyen1, S. Riazati1, R. Satou1, R. J. Shemin1, P. Benharash1 1David Geffen School Of Medicine, University Of California At Los Angeles,Division Of Cardiac Surgery,Los Angeles, CA, USA

Introduction: The Buckberg blood cardioplegia has become the conventional solution for myocardial preservation during cadioplegic arrest. Recently, the del Nido cardioplegia solution has been utilized in pediatric cardiac operations and utilizes lidocaine rather than potassium to achieve diastolic arrest. Compared to conventional Buckberg cardioplegia it has the added benefit of only requiring one dose for up to 180 minutes of myocardial quiescence. By lowering cardioplegia volume, the del Nido method may reduce myocardial edema, hemodilution, arrhythmias and costs of care. In this study, we aimed to evaluate the safety and efficacy of del Nido cardioplegia in adult cardiac valvular operations.

Methods: The institutional Society of Thoracic Surgeons database was used to identify all adults undergoing aortic or mitral valve operations from January 2011 to May 2015. Patient demographics, operative characteristics and postoperative outcomes were gathered from the database as well as electronic medical records. Patients who received the del Nido solution (DN) were matched with those receiving conventional blood cardioplegia (CC) for procedure type as well as baseline characteristics such as age, gender, ejection fraction, diabetes, lung disease, among others. Statistical analysis was performed with STATA software (StataCorp, College Station) and P-values less than 0.05 were considered significant.

Results: During the study period, 54 patients met criteria and were included in the DN group while another 54 were assigned to the CC group after matching for baseline characteristics. The groups did not differ significantly in comorbid conditions as shown in Table 1. Compared to the CC group, DN patients exhibited a shorter crossclamp time (122 minutes vs 125 minutes, P= 0.87), higher in-hospital ICU length of stay (98 hours vs 96 hours, P= 0.59), mortality rate (9.3% vs 1.8%, P= 0.10), red cell transfusions (1.9 units vs 1.6 units, P=0.74) and readmission rates (13.2% vs 5.6%, P= 0.18). The fall in hematocrit immediately after the operation was similar between the DN (7.3%) and CC (7.9%) cohorts (P=0.63). Inotrope use between DN and CC measured by a Vasoactive Inotropic Score were also similar in the intraoperative period (7.3 vs 6.1, P=0.54) and postoperative period (2.4 vs 3.1, P=0.73).

Conclusion: Our data, although preliminary, suggests that the of del Nido cardioplegia solution was associated with a non-significant increase in mortality, readmission rate, ICU hours, and red cell transfusions. Given major differences in mechanism of action, the del Nido solution needs to be further evaluated in larger cohorts and include analysis of clinical as well echocardiographic outcomes.

61.11 Decreased Left Ventricular Function is Not a Contraindication to Transcatheter Aortic Valve Replacement

Posted on January 18, 2016

D. M. Strauss1, A. Das1, G. Savulionyte1, K. J. Oh1, N. L. Owen-Simon1, H. A. Cohen1, B. O’Murchu1, B. P. O’Neill1, G. Wheatley1 1Temple University,Philadelpha, PA, USA

Introduction: Transcatheter aortic valve replacement (TAVR) has been shown to have improved outcomes compared to surgical aortic valve replacement in high surgical risk patients with aortic stenosis. However, depressed left ventricular ejection fraction (LVEF) has been shown to be a relative contraindication to TAVR in these patients. The purpose of this study is to compare the outcomes of patients with decreased LVEF versus patients with normal LVEF.

Methods: A retrospective review of patients undergoing TAVR from December 2013 to June 2015 was performed. Institutional Review Board approval was obtained. Demographic information and outcome data were collected regarding LVEF, procedural success, and lengths of stay in the intensive care unit and hospital. Statistical analysis was performed using SPSS Statistics.

Results: Forty-two patients (5 Low LVEF, 37 High LVEF) underwent TAVR from December 2013 to June 2015. Average age for low LVEF patients was 70.6 years and 79.8 years for high LVEF patients (p=0.22). M:F ratio was 1:4 for low LVEF patients, and 12:25 for high LVEF patients (p=0.57). Average Society of Thoracic Surgeons (STS) score for low LVEF patients was 8.5, and 9.4 for high LVEF patients (p=0.32). [Figure 1] Four (80%) patients in the low LVEF group had a diagnosis of chronic obstructive pulmonary disease (COPD), and 19 (51.4%) patients in the high LVEF group had COPD (p=0.23). The Medtronic CoreValve was used in 3 patients with low preoperative LVEF and 12 patients with high LVEF (p=0.23), while the Edward SAPIEN prosthesis was implanted in 2 patients with low LVEF and 25 patients with high LVEF. Procedural success was 100% in both groups. Operative times averaged 125.4 (84-162) minutes in the low LVEF group and 124.0 (60-207) minutes in the high LVEF group (p=0.94). Four low LVEF patients (80%) were extubated in the operating room, while 29 (78.4%) high LVEF patients extubated in the operating room (p=0.94). Average intensive care unit stay (ICU) was 2.0 (1-3) days for low LVEF patients and 2.8 (0-12) days for high LVEF patients (p=0.14). Average hospital stay for low LVEF patients was 6.6 (3-9) days and 6.1 (2-28) days for high LVEF patients (p=0.75). 30-day mortality was 0 in low LVEF group and 5.4% (n=2) in the high LVEF group (p=0.059).

Conclusion: Patients with low LVEF undergoing TVR had comparable outcomes and length of hospital stay as compared to patients with high LVEF. As a result, low LVEF should not be used as an exclusion criteria for patient selection for TAVR. Additional studies are needed to evaluate long term outcomes and quality of life indicators.

61.12 Finite element analysis: Assessing the optimal patient-specific mitral valve repair.

Posted on January 18, 2016

A. E. Morgan1, L. Ge4, W. G. Morrel5, J. L. Pantoja5, E. A. Grossi3, M. B. Ratcliffe1,2 1University Of California – San Francisco,Surgery,San Francisco, CA, USA 2San Francisco VA Medical Center,Surgery,San Francisco, CA, USA 3New York University School Of Medicine,Cardiothoracic Surgery,New York, NY, USA 4University Of California – San Francisco,Bioengineering,San Francisco, CA, USA 5University Of California – San Francisco,School Of Medicine,San Francisco, CA, USA

Introduction: Mitral valve repair is superior to replacement in terms of long-term survival, but recurrent mitral regurgitation after repair for degenerative disease occurs at a rate of ~2.6% per year, with a 20% reoperation rate at 20 years. We hypothesize that durability of repair is related to geometry of initial repair, as well as stress distribution over the mitral valve and left ventricle. Previous studies demonstrate that repair by posterior leaflet resection increases stress across the posterior leaflet; we tested the hypothesis that repair by placement of prosthetic chordae tendinae resulted in reduced overall stress as compared to leaflet resection.

Methods: Magnetic resonance imaging and intra-operative 3D trans-esophageal echocardiography were performed before surgical repair of isolated P2 prolapse in a single patient. A finite element model of the left ventricle and mitral valve was created. Stress was examined in the preoperative state for the mitral valve and left ventricle, and for the following repairs: Triangular resection; Placement of one PTFE chord; Placement of two PTFE chords.

Results: The principal findings of this study are the following: 1) Placement of prosthetic chordae resulted in stable or decreased overall posterior leaflet stress for all phases of the cardiac cycle; 2) In contrast, triangular resection resulted in increased posterior leaflet stress, most prominently in diastole; 3) All repair techniques reduced stress on the anterior leaflet; 4) All repair techniques restored normal leaflet coaptation. An example of pre- and post-repair leaflet geometry is shown in the attached figure, for placement of two prosthetic chordae.

Conclusion: All repair techniques eliminated mitral regurgitation and restored normal leaflet coaptation. Finite element analysis revealed that mitral valve repair with prosthetic chordae restored normal leaflet geometry without creation of excessive stress on the valvular tissues, in contrast to leaflet resection, which significantly increased stress across the posterior leaflet. Future studies will examine this effect across a broad range of patients with the aim of developing a patient-specific tool for mitral valve repair preoperative planning and surgical education.

61.08 National Contemporary Outcomes of Open Throacoabdominal Aneurysm Repair in an Endovascular Era

Posted on January 18, 2016

T. Obeid1, K. Yin1, A. Kilic1, I. Arhuidese1, B. Nejim1, M. Malas1 1Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA

Introduction:
Open repair of thoracoabdominal aneurysm (TAA) and descending thoracic aneurysm (DTA) carries significant operative morbidity and mortality. Despite improved patient selection, evolving operative and anesthesia techniques, and better control of comorbid conditions, patient-level risk factors of open repair remain to be fully understood. We sought to evaluate risk factors affecting operative mortality of open TAA and DTA repair in a nationally validated multi-specialty dataset.

Methods:
We identified all TAA – including all Crawford extent types – and DTA cases in the National Surgical Quality Improvement Program (NSQIP) database between years 2005 to 2013. Operative mortality was defined as death within 30 days of surgery. A logistic regression model was constructed to evaluate the risk of patient’s age, gender, race, body mass index (BMI), comorbid conditions, functional status, American Society of Anesthesiologists (ASA) class, smoking status, alcohol intake, preoperative blood transfusion, rupture status, DTA vs combined Crawford extents, operating surgical specialty, preoperative hematocrit and creatinine levels.

Results:

A total of 1,048 patients had open TAA or DTA repair during the 9-year study period. Mean patient age was 67±12 years, BMI average was 27±6 and males comprised 60% of the dataset. Nearly 12.0 % of the patients presented with ruptured aneurysms. DTA comprised 10.6% of all aneurysms and concomitant dissection occurred in 12.7% of all cases.

Operative mortality was 14.0% (non-ruptured 11.4% vs. ruptured 34.2%, P<0.001) and the total proportion of patients with postoperative acute renal failure requiring dialysis was 12.6% (non-ruptured 11.8% vs ruptured 19.2%, P<0.001).

Each additional year in patient age or one unit increase in BMI increased the risk of death by 4% (OR 1.04, 95%CI 1.02-1.06, P<0.001, OR 1.04, 95%CI 1.00-1.08, P=0.03, respectively). Ruptured aneurysms had double the operative mortality risk (OR 2.26, 95%CI 1.26-4.03, P=0.010).

Being totally dependent had the highest effect on operative mortality, tripling the risk of death (OR 3.39, 95%CI 1.60-7.19, P<0.001), while preoperative chronic renal insufficiency added 26% mortality risk per 1 unit increase in creatinine level (OR 1.26, 95%CI 1.04-1.52, P=0.020).

Being a smoker and ASA class ≥4 versus ≤3 each increased the chances of death by 60% and 70%, respectively (both P < 0.05) (Table).

Conclusion:
Despite corseted efforts, open repair of thoracoabdominal aneurysm carries significant morbidity and mortality. Patient age and BMI equally affect the risk of operative mortality. Ruptured aneurysms and patients’ functional status have the highest effect on risk of operative death.

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