08.06 Do Clinical Pathways Actually Improve Outcomes for Pediatric Appendicitis?

Posted on January 18, 2016

L. R. Putnam1,2, T. G. Ostovar-Kermani1,2, K. T. Anderson1,2, D. H. Pham1,2, M. T. Austin1,2, A. L. Kawaguchi1,2, L. S. Kao3, K. P. Lally1,2, K. Tsao1,2 1University Of Texas Health Science Center At Houston,Pediatric Surgery,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Pediatric Surgery,Houston, TX, USA 3University Of Texas Health Science Center At Houston,General Surgery,Houston, TX, USA

Introduction: Standardized clinical care pathways for pediatric appendicitis are widely endorsed among children’s hospitals, yet their influence on patient outcomes is unknown. We aimed to determine the impact of a clinical care pathway for appendicitis, implemented at our children’s hospital in 2011, on length of stay, readmissions, and complications.

Methods: Pre-pathway data were compared to data from prospectively-monitored care pathways for all pediatric patients (<18 years) who underwent an appendectomy for acute appendicitis between June 2009 – December 2010 (pre-pathway) and January 2011 – May 2015 (pathway). Separate pathways were implemented for simple and complicated (gangrenous or perforated) appendicitis patients. Clinical outcomes including surgical site infections (SSI), initial and aggregate 30-day hospital length of stay (LOS), and readmissions within 30 postoperative days were recorded. Chi-squared, Student’s t-tests, Mann-Whitney U tests, and multivariate regression were performed; p-values <0.05 were considered significant.

Results: 2151 patients (pre-pathway: 582, pathway: 1569) underwent appendectomy for acute appendicitis from June 2009 – May 2015. Mean age of pre-pathway vs pathway patients was 9.9 ± 3.7 vs 10.4 ±3.8 (p=0.01). Gender, race/ethnicity, and insurance status were similar between groups (all p>0.05). Simple appendicitis pathway patients experienced decreased initial LOS (1.4 vs 0.9 days, p=0.03) and aggregate 30-day LOS with no difference in SSI, but increased readmissions (1.3% vs 3.4%, p<0.05). There were no significant differences in outcomes for complicated appendicitis pathway patients. On multivariate regression analysis of patients with simple appendicitis, the pathway predicted shorter LOS; younger age and public insurance predicted increased LOS and SSI (Table). For complicated appendicitis patients, laparoscopic appendectomy was associated with decreased LOS; there were no significant predictors of SSI or readmissions.

Conclusion:Clinical pathways do not appear to substantially improve outcomes in pediatric appendicitis. Within our institution, the clinical pathway for simple appendicitis patients was associated with decreased initial and aggregate 30-day LOS, but increased readmissions, whereas the complicated appendicitis pathway was not associated with any improvements. Further efforts should target decreasing readmissions for simple appendicitis patients and determining the impact of pathways on hospital resource utilization. Although there are many benefits to protocolized care, the true efficacy of increasing standardization may lie in process improvement and not directly related to patient outcomes.

08.17 Using Mixed Methods to Comprehensively Assess Processes of Surgical Care Delivery.

Posted on January 18, 2016

O. C. Nwanna-Nzewunwa1, M. Ajiko2, F. Kirya2, J. Epodoi2, F. Kabagenyi2, I. Feldhaus1, C. Juillard1, R. A. Dicker1 1University Of California – San Francisco,Center For Global Surgical Studies,San Francisco, CA, USA 2Soroti Regional Referral Hospital,Surgery,Soroti, SOROTI, Uganda

Introduction: Capacity assessment is an archetypal challenge in surgery. Existing assessment tools use the availability of surgical procedures and resources to identify availability of surgical care. Such methods may fail to capture important information relevant to decision-making and resource allocation among providers, policymakers, and international development partners. This study seeks the relevant information gaps in a tool currently used to assess surgical capacity and explores a mixed methods approach to generate a more complete assessment of hospital surgical capacity.

Methods: In June 2015, quantitative and qualitative research activities were conducted to assess emergency surgical care at a Ugandan Regional Referral Hospital. Infrastructure and human resources at a Regional Referral Hospital were assessed using the Surgeons OverSeas’ Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) tool, generating a standardized index and score. Thematic analysis was conducted on four semi-structured focus group discussions with 18 purposively sampled providers involved in the process of surgical care delivery. The process of emergency surgical care was directly observed using time-and-motion methodology over 53 consecutive days to produce a process map.

Results: The PIPES tool identified major deficiencies in workforce and infrastructure; but not the cumulative impact of these deficiencies (e.g. lack of physical space) on the timeliness and process of care. The PIPES tool (see table) lacked indices to capture the in-hospital delays; barriers to accessing available procedures; effect of poor remuneration of providers on their availability at work; upshot of the ‘no user fees policy’ on patient throughput and quality of care. These were revealed in focus group discussions, midnight census and process mapping which also provided sociocultural context and the inimical effect of well-intentioned policies on the process of care. The PIPES tool understated the surgical workforce because it did not include orthopedic officers in its personnel assessment; this may misdirect training and capacity building efforts to only physicians or surgeons. The tool did not show the serious impact of the few unavailable procedures on patient throughput and access to care and may misrepresent the availability of services.

Conclusion: There is a need to augment the information obtained from existing surgical care assessment tools. We recommend the use of direct observation of the process of care in combination with qualitative interviews that capture the providers' experience in order to have a robust assessment of the process of surgical care, especially in developing countries where the systems and processes are less well understood.

08.18 Do Minimum Volume Standards Improve Patient Outcomes with Organ Transplant?

Posted on January 18, 2016

L. H. Nicholas1, S. Stith2 1Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA 2University Of New Mexico,Albequerque, NM, USA

Introduction: A pervasive viewpoint in healthcare is that higher patient volume leads to better outcomes, implying that facility volume can be used to identify high-quality hospitals. Hundreds of studies documenting a positive correlation between hospital volume and patient outcomes (better outcomes at higher volume hospitals) have motivated the use of arbitrary minimum volume standards for elective surgical procedures. There is considerable variation across minimum volume standards used by the Centers for Medicare and Medicaid Services and commercial insurers when contracting with organ transplant centers. It is unknown whether some payers are relying on excessively high standards or whether payers are using thresholds that are too small.

Methods: We used data from the Scientific Registry of Transplant Recipients including all adult heart (54,874 patients in 191 transplant centers) and lung (25,128 patients in 103 transplant centers) transplants in the United States from October 1987 – December 2012 to assess whether transplant outcomes including 1-year mortality and 1-year graft failure vary across centers above and below the minimum volume standards. To account for potential confounding between unobserved patient characteristics and transplant center volume, we used an instrumental variables approach to predict volume of a patient's center with the volume of the center closest to a patient's home zip code.

Results: Minimum volume thresholds affect many transplant centers. Only 57% of kidney transplant centers, 71% of liver, 44% of heart, and 61% of lung transplant centers ever meet the highest minimum volume requirement during our study period. We failed to find a significant relationship between transplant center volume and patient outcomes for either patient or graft survival for any of the four organs studied.

Conclusion: Despite good intentions, minimum volume standards currently used by public and private payers are not identifying higher quality transplant centers and may create unnecessary barriers for patients who could be served by smaller, closer centers.

08.07 Is ‘Routine’ Trauma Underprioritized in Level 1 Trauma Centers?

Posted on January 18, 2016

D. Metcalfe1, O. A. Olufajo1, C. K. Zogg1, M. B. Harris2, J. D. Gates1, A. J. Rios Diaz1, A. H. Haider1, A. Salim1 1Harvard Medical School,Center For Surgery And Public Health,Boston, MA, USA 2Brigham & Women’s Hospital,Department Of Orthopedic Surgery,Boston, MA, USA

Introduction:

There is strong evidence to show that level 1 trauma centers (L1TCs) improve outcomes for severely injured patients. However, L1TCs typically host many complex services and manage a high volume of critically unwell patients. It is therefore possible that some clinical pathways will be disrupted in L1TCs and that vulnerable patient groups might compete ineffectively for resources with higher priority cases. There is emerging evidence that appendectomy for acute appendicitis is delayed in L1TCs with an associated increased rate of complications. Studies from the UK and the Netherlands have also reported that the care of older adults with hip fractures may be compromised in new trauma centres.

Our study sought to compare hip fracture outcomes between L1TCs and non-trauma hospitals (NTHs) to determine whether "routine" trauma is underprioritized in mature higher level trauma centers.

Methods:

Hip fracture cases were identified from the California State Inpatient Database (SID) 2007-2011. The California SID captures 98% of hospital admissions and a unique patient identifier permits admissions to be tracked across all hospitals in California. The inclusion criteria were age ≥65 and an operatively treated hip fracture. To minimize selection bias, patients were excluded if they had any other injuries or were transferred between hospitals. Outcomes were analyzed using multivariable logistic regression and generalized linear models for non-normally distributed data, adjusting for patient- (age, sex, race, payer status, Charlson Co-morbidity Index, weekend admission, admission source) and hospital-level (hospital bed size, teaching status) characteristics.

Results:

91,401 hip fracture admissions were identified, 6,468 (7.1%) of which were admitted to L1TCs and 61,896 (67.7%) to NTHs. The remaining patients (25.2%) were treated in lower level trauma centers.

The delay between admission and operation was longer in L1TCs (median 1 day; 90th percentile 3 days) than in NTHs (median 1 day; 90th percentile 2 days, Kruskall-Wallis p<0.001). Within a generalized linear model, operative delay was 0.29 (95% CI 0.08-0.51) days longer in L1TCs relative to NTHs. Length of stay was also prolonged in L1TCs by 0.85 days (95% CI 0.30-1.40). Both the odds of venous thromboembolism (OR 1.45, 95% CI 1.11-1.88) and unplanned 30-day readmission (OR 1.49, 95% CI 1.24-1.80) were higher in L1TCs. There were no mortality differences between L1TCs and NTHs.

Conclusion:

Operative treatment of hip fractures is delayed in L1TCs, which is associated with prolonged length of stay and increased risk of both venous thromboembolism and 30-day hospital readmission. Further work should aim to understand whether these findings can be explained by intense competition for resources (e.g. operating room time) and how clinical pathways for vulnerable populations can be optimized in L1TCs.

08.08 Characterizing Cancer-patient Sentiments Through Social Media: A Pattern-matched Twitter Analysis

Posted on January 18, 2016

W. Crannell1, E. Clark1, T. James1, C. Jones1, J. Moore1 1University Of Vermont College Of Medicine / Fletcher Allen Health Care,Surgery,Burlington, VT, USA

Introduction: Twitter is a well-known online micro-blogging social media device that currently has 302 million monthly active members. The service allows for the users to send small messages called ‘tweets,’ that are limited to 140 characters. With the increasing popularity of social media, such as Twitter, there has been wide recognition that meta-data are a very significant source of information. Increasingly, patients are utilizing Twitter as an outlet for their medical concerns, and thus we decided to test the twittersphere as a potential means by which to collect and analyze patients’ health sentiments in regards to cancer and surgical care.

Methods: A large sample of English tweets from March 2014 through December 2014 with imbedded location coordinates were obtained from the Twitter database. Using regular expression software pattern matching, the tweets were filtered by cancer diagnosis. For each cancer-specific tweetset, individual patients were extracted and the content of the tweet was categorized. The patients’ Twitter identification numbers were used to gather all tweets for each patient, and happiness values for patient tweets were calculated using a quantitative hedonometric analysis.

Results:The most frequently tweeted cancers were: breast (n=15421, 11% of total cancer tweets), lung (n=2928, 2.0%), prostate (n=1036, 0.7%) and colorectal (n=773, 0.5%). Patient tweets pertained to treatment course (n=73, 26%), diagnosis (n=65, 23%), and then surgery/biopsy (n=42, 15%). Computed happiness values for each cancer diagnosis revealed higher average happiness values for thyroid (h_avg =6.1625), breast (h_avg =6.1485) and lymphoma (h_avg =6.0977) cancers, and lower average happiness values for pancreatic (h_avg =5.8766), lung (h_avg =5.8733) and kidney (h_avg =5.8464) cancers. Data pertaining to cancer surgery tweets (n=1629, 1.1% of data set), show that patients (n=202) were more likely to express negative sentiments pre-operatively and more likely to express positive sentiments post-operatively.

Conclusion: The study confirms that patients are expressing themselves openly on social media about their illness and that unique cancer diagnoses are correlated with varying degrees of happiness. Twitter can be employed as a tool to identify patient needs and as a means to gauge the cancer patient experience. Tweets authored by patients are rich in content pertaining to active oncological and surgical treatment. These tweets differ in sentiment with respect to the patients’ operative date and tweets could thus allow for following patients through their treatment journey, potentially highlighting opportunities for improvement in surgical healthcare delivery. This is essential in order to maximize care and patient experience in an era in which patient satisfaction is increasingly being tied to reimbursement.

08.10 Surgeon-Patient Expectation Gap; Bigger Than We Thought?

Posted on January 18, 2016

R. N. Willis1, B. Edwards1, R. G. Sawyer1, M. D. Williams1 1University Of Virginia,Dept. Of Surgery,Charlottesville, VA, USA

Introduction:
Physicians and hospitals are frequently subject to performance measurements that are increasingly linked to reimbursement. Not least among these is Patient Satisfaction (PS). Previous reports have shown that PS is driven less by clinical outcome, and more by hospital and post-operative experiences of care. Ironically, research has shown that increased PS is correlated with better clinical outcomes and more appropriate use of the health care system. The aim of this study was to determine if the patient and surgeon expectations of recovery from surgery to are aligned.

Methods:
A 15-question Likert-style survey given to the patient and surgeon was deployed prospectively immediately following the conclusion of the pre-operative clinic visit. The survey encompassed multiple aspects of the patient’s recovery from perception of health and wellness to anticipated pain medication requirements, to length of expected recovery. All patients were 18 years of age or older.

Results:
Statistical analyses were conducted using Wilcoxon Signed Rank test and McNemar’s test as appropriate. The results were predominately non-parametric using a Likert Survey. Surgeons expected patients to feel more prepared for surgery (p=0.001), be more likely to walk the day after surgery (p=0.01) have better tolerance of surgery (p=0.03) and a more likely ultimate return to activities of daily living (p=0.002) than patients did. Whereas patients expected both more pain (p=0.006), less/ no need for narcotics (p=0.05) than surgeons.

Conclusion:
Our study demonstrates that in our sample population, surgeons and patients have significantly different expectations of important outcomes immediately after the conversation that should ideally set those targets. There is an opportunity to educate both patients and surgeons as to expectation and goal setting related to elective surgery.

08.11 Qualitative surgical research – why isn't it being published in surgical journals?

Posted on January 18, 2016

A. C. Robinson1, J. R. Appelson1, N. R. Changoor1, W. A. Davis1, A. H. Haider1, M. A. Morris1 1Brigham And Women’s Hospital, Harvard Schools Of Medicine And Public Health,Department Of Surgery,Boston, MA, USA

Introduction:

Recently, researchers have recognized the need for qualitative research in surgery, because it offers a toolset to understand lived experiences and the influence of social context in the healthcare setting. However, few studies have described the current state of qualitative surgical research. The present study is a comprehensive literature scope of qualitative surgical research to identify: (a) common approaches to qualitative surgical research; (b) gaps in the literature to inform future qualitative inquiry.

Methods:

We searched PubMed using ‘surgery’ and 7 qualitative methodology search terms (Grounded Theory, Constant Comparative, Phenomenology, Content Analysis, Discourse Analysis, Case study, Ethnography). Exclusion criteria included: mixed-methodology, literature/systematic reviews, non-surgical studies, and non-English language studies. Extracted data included: methodology (e.g. grounded theory, case study), methods (e.g. interviews, observations), surgical specialty (e.g. transplant, surgical oncology) and participant population (e.g. patient, family, provider). Four researchers extracted study information for relevant abstracts, and a fifth researcher independently reviewed 10% of abstracts to determine inter-rater reliability.

Results:

A total of 2,017 articles were reviewed. After removing duplicates, 39.4% articles were deemed relevant (N=795; κ = 0.74). The most common methodologies included: phenomenology (33.2%), grounded theory/constant comparative method (30.8%), and content analysis (24.7%). The most common approaches were interviews (82.8%) conducted with patients (62.3%). Sample sizes varied widely within methodologies (mean: 27, range: 1-797). The most common surgical specialties were transplant (14.8%) and surgical oncology (13.6%). Overall, 36.4% of studies were published in nursing journals, and 9% in surgical journals. Fewer than half of studies were published before 2011, thus over half have been published in just the last four years (52.3%).

Conclusions:

Our results suggest that qualitative surgical research is gaining in popularity despite the majority of relevant studies being published in non-surgical journals. Notably, nearly two-thirds of studies utilized only two of the seven methodological approaches (grounded theory and phenomenology). Further surgical qualitative research should take advantage of a greater variety of approaches to provide insight into rare phenomena and social context. For example, qualitative inquiry can inform complex issues, such as health disparities and training needs that are relevant to the increasingly diverse patient and healthcare professional populations.

08.12 When Low Risk Operations Fail: The Frequency & Predictors Of Unexpected Deaths In Surgical Patients

Posted on January 18, 2016

J. D. Bohnen1, N. F. Sangji1,2, E. P. Ramly3, H. M. Kaafarani1,2, K. D. Lillemoe1, D. C. Chang1,2 1Massachusetts General Hospital, Harvard Medical School,Department Of Surgery,Boston, MA, USA 2Codman Center For Clinical Effectiveness In Surgery,Massachusetts General Hospital,Boston, MA, USA 3Oregon Health And Science University,Department Of Surgery,Portland, OR, USA

Introduction:

Deaths among low-risk surgical patients represent an important quality improvement challenge and a potential malpractice risk. While there are many predictive models and calculators targeting overall mortality in surgical populations, a focused analysis of these ‘unexpected’ deaths may provide valuable information.

Methods:

The national ACS-NSQIP database from 2011-2012 was analyzed for all general and vascular surgery patients. NSQIP-calculated 30-day mortality risk was dichotomized at different levels, and the optimal cutoff point for ‘low’ vs. ‘high’ risk patients was established by the Youden Index, at which point the sum of sensitivity and specificity was maximized. Patients below the Youden-Index-derived mortality risk threshold were deemed low-risk (i.e. expected survivors); low risk patients who died within 30 days were considered ‘unexpected deaths’. Multivariable logistic regression models were constructed to identify perioperative predictors of unexpected deaths.

Results:

A total of 601,631 patients were analyzed. There were 8627 deaths overall (1.43%). The Youden-Index-derived cutoff point for ‘expected’ vs. ‘unexpected’ deaths occurred at a calculated pre-operative mortality risk of 1.4%. There were 994 deaths among low-risk patients (994/513702, or 0.19%), representing 11.5% (994/8627) of all deaths. In multivariable regression analyses, 19 unique variables were found to be independent predictors of unexpected deaths; the five strongest were: ASA 4 [OR=12.01, 95% CI: 5.09 – 28.33, p<0.001]; ascites [OR=2.74 (1.21 – 6.20), p=0.015]; history of CHF [OR=2.64 (1.58 – 4.39), p<0.001]; WBC > 25 [OR=3.32 (1.54-7.15), p=0.002]; preoperative weight loss [OR=2.69 (1.81 – 4.01), p<0.001].

Conclusion:

More than 11% of deaths in the surgical population occurred in low-risk patients and may be considered ‘unexpected’. The frequency and predictors of unexpected deaths provide new insights into the make-up of this unique patient group. These patients should be prioritized for directed quality improvement efforts.

08.13 Novel Approaches to Facilitate Statewide Surgical Quality Improvement: Development of the ISQIC

Posted on January 18, 2016

A. R. Dahlke1, A. Yang1, J. Johnson1, K. O’Leary3, L. Kreutzer1, P. R. Farrell1, J. Thomas1, R. Love1, A. Halverson1, M. Williams2, K. Y. Bilimoria1 1Northwestern University,Surgical Outcomes And Quality Improvement Center,Chicago, ILLINOIS, USA 2University Of Kentucky,Center For Health Services Research,Lexington, KENTUCKY, USA 3Northwestern University,Hospital Medicine,Chicago, IL, USA

Introduction: The Illinois Surgical Quality Improvement Collaborative (ISQIC) was developed to improve the quality of surgical care across the state. Our objectives were to (1) assess the needs, barriers and resource gaps to quality improvement in Illinois, (2) develop and implement novel approaches to facilitate Quality and Process Improvement (QI/PI), and (3) develop an extensive evaluation plan to examine the effectiveness of program implementation.

Methods: Fifty-three hospitals in Illinois were surveyed about their QI/PI needs and resources (Resource Survey), Board/leadership involvement in QI, safety culture (Safety Attitudes Questionnaire-SAQ), and the baseline knowledge of QI among individual clinicians and QI personnel (Quality Improvement- Knowledge Assessment Tool-QIKAT). In addition, hospital site visits were conducted for in-depth qualitative assessments of QI resources and barriers. A combination of novel and evidence-based approaches were developed and implemented across all 53 ISQIC hospitals. A mixed-methods approach was created to triangulate data from surveys, ethnographic observations, semi-structured interviews, focus groups, artifact analyses and process mapping to measure the effectiveness of each newly implemented approach to QI.

Results:From the Resource Survey, hospitals commonly listed issues with insufficient financial resources, implementation of QI projects, communication and buy-in from leadership, and engagement among physicians. Hospital site visits revealed that surgeons were unsure how to lead QI programs or act upon data, whereas hospital administrators were concerned about startup costs associated with QI programs. Approximately 85% of respondents (n=950) for the SAQ rated their hospital favorably for teamwork and safety climate, but reported less favorably for perceptions of management and employee engagement. The average baseline test score (n=150) for knowledge of QI approaches from the QI-KAT was 65%. To address the QI/PI needs, 21 novel approaches, grouped into 5 domains: guided implementation, education, comparative reports, networking, and funding, were implemented at each hospital (Table 1). Continuous evaluation using the tools developed to measure the effectiveness of each of the 21 individual approaches have allowed for iterative modification and improvement of approaches.

Conclusion:By evaluating hospitals’ needs, barriers, resources, and baseline QI/PI knowledge, we were able to design 21 approaches to facilitate rapid and effective QI in Illinois. Continuous evaluation and iterative improvement of the 21 approaches has allowed us to tailor these initiatives to local differences at individual hospitals.

08.14 Timing of Blood Cultures in the Evaluation of Postoperative Fever

Posted on January 18, 2016

L. R. Copeland-Halperin1, H. Prentice1, J. Dort1 1Inova Fairfax Hospital,Surgery,Falls Church, VA, USA

Introduction: Postoperative bacteremia is a common complication of surgery. Traditional teaching holds that fever beyond the fourth postoperative day (POD #4) warrants blood culture, yet supportive evidence is scant. We gathered data from patients with postoperative blood cultures to assess whether the POD on which a maximum temperature (Tmax) occurred predicted positive culture results.

Methods: We reviewed records at a large tertiary care hospital in Northern Virginia of all non-pregnant adult patients who had blood cultures drawn within the first 10 days after surgical procedures in 2013. Differences in culture yield in relation to the POD on which fever occurred were assessed using Fisher’s exact test.

Results: There were 5,418 blood cultures in 1,693 patients. Preliminary results based on 808 cultures from 306 patients (mean age 61.8 years, 51.9% women) identified 51 (6.3%) with organisms. Of these, 40 (4.9%) identified potential pathogens, while 11 were likely contaminants. The Tmax (mean 100.3°F, range 94.5°F-104.1°F) prompting the greatest number of blood cultures occurred on POD #1 (n=162; 20.3%), but only 1 culture on this day was actually positive (0.6%) (Figure 1). The Tmax most frequently associated with positive cultures (14.3%) occurred on POD #6. Most positive cultures (75.0%) were drawn when Tmax occurred on POD #4 or later (p <0.001).

Conclusion: The POD on which Tmax prompted blood cultures varied widely, and the overall yield of cultures was low. Pathogens were more often identified when Tmax occurred on POD #4 of later. Considering the yield and value of blood cultures, more judicious use of this resource could reduce the cost of postoperative care. Analysis of the complete dataset may identify other clinical predictors of pathogenic blood culture results and promote more efficient resource utilization.

08.15 Understanding Barriers to Efficiency in Robotic Surgery

Posted on January 18, 2016

B. T. Fry2, L. W. Hess3, M. Jain1, J. T. Anger1, R. Avenido1, B. Gewertz1, K. Catchpole1 1Cedars-Sinai Medical Center,Los Angeles, CA, USA 2University Of Michigan Medical School,Ann Arbor, MI, USA 3Pennsylvania State University,Eberly College Of Science,University Park, PA, USA

Introduction:

Robotic surgery offers advantages over conventional operative approaches but may also be associated with higher costs, additional risks, and new challenges. Surgical flow disruptions (FD) are defined as ‘deviations from the natural progression of an operation,’ and have been empirically associated with surgical errors, adverse events, and inefficiency. Understanding the etiology of FD in robotic surgery will help target training techniques and identify opportunities for improvement. This study explored the relationships between surgeon console time (SCT), the number and types of FD, resident involvement, and other contextual parameters.

Methods:

Thirty-two robotic surgery operations were observed over a six-week period at one 900-bed surgical center. Ten cases prior to this sampling were used to train two researchers and ensure high inter-rater reliability.

The researchers observed FD throughout the time the patient was in the operating room. Each FD was designated with the time and a descriptor, and was then classified into one of 11 different categories: communication, coordination, external interruptions, training, equipment, environment, patient factors, surgical decision making, instrument changes, psychomotor error, and robot console switch. SCT, resident involvement, robot model, and procedure type were also recorded.

Multi-variable statistics were used to evaluate the effects of these parameters on SCT and the number of FD.

Results:

Eight sacrocolpopexies, 21 prostatectomies, and 3 nephrectomies were observed. The mean number of FD was 48.2 (95% CI 38.6-54.8), and mean SCT was 163mins (95% CI 148-179). The Da Vinci S robot model was used in 14 cases, and the Si model was used in 18 cases. Nineteen cases involved residents, and 13 did not.

There was a mean of 60.8 FD (95% CI 47.8-73.8) in resident cases and 29.8 FD (95% CI 22.1-37.5) in non-resident cases. Resident cases demonstrated mostly training, equipment, and robot switch FD, whereas non-resident cases demonstrated mostly equipment, instrument change, and external interruption FD. A linear regression (r2=0.34) demonstrated that residents had a significant effect on number of FD (p<0.002), whereas robot model and procedure type demonstrated a non-significant effect.

The mean SCT with residents was 165.8mins (95% 149.7-181.9) and without residents was 160.2mins (95% CI 130.1-190.3). A linear regression model (r2=0.35) found resident involvement and robot model to be non-significant parameters, while procedure type (p<0.001) and total FD (p<0.034) significantly affected SCT.

Conclusion:

Resident involvement significantly increased the number of FD but did not affect SCT. This suggests that the FD encountered in resident training may not significantly affect operating time. Other FD, such as equipment issues or external interruptions, may be more impactful. Limiting these specific FD should be the focus of performance improvement efforts.

08.16 Since When Did Observation of Cancer Become Acceptable Treatment?

Posted on January 18, 2016

M. M. Dua1, T. B. Tran1, K. Hwa2, C. Cho-Phan3, G. A. Poultsides1, B. C. Visser1 1Stanford University,Surgery,Palo Alto, CA, USA 2VA Palo Alto Health Care System,Surgery,Palo Alto, CA, USA 3Stanford University,Medicine,Palo Alto, CA, USA

Introduction: Hepatobiliary malignancies are complex cases that require treatment through surgical, locoregional, and systemic therapies. Improved outcomes are observed when these cases are discussed among tumor boards and treated by multidisciplinary referral centers. We hypothesize there is significant delay in referral of many patients with primary hepatobiliary malignancies to tertiary multidisciplinary teams. The purpose of this study was to identify areas of mismanagement leading to delayed referral and treatment of hepatobiliary malignancies.

Methods: A retrospective review was performed of the patients referred to Liver Tumor Board from 2012-2014. Treatment recommendations were made by representatives from surgical oncology, hepato-pancreato-biliary (HPB) surgery, transplant surgery, interventional radiology, radiation oncology and medical oncology. Gross areas of mismanagement were defined as: 1) serial imaging of growing hepatobiliary tumors; 2) dismissal of imaging with overt tumors and negative biopsy; 3) failure to establish follow-up after identification of index tumor; and 4) failure to refer patients with resectable tumors. Referring institution characteristics were analyzed to determine risk factors for delayed referral.

Results: Of 208 patients, 80 (38%) were grossly mismanaged, most frequently because of definition 1 (49%) and definition 3 (26%). Risk factors for delayed referral included hospitals with less than 200 beds (OR-14.4, p<0.001), hospitals without any tumor board (OR-53, p<0.001), and hospitals without a surgeon specializing in oncology or HPB (OR-21.9, p<0.001). Cholangiocarcinoma was more frequently mismanaged than Hepatocellular carcinoma (OR-3 v 1.7).

Conclusion: The profound delay in referral of many patients with hepatobiliary malignancies compromises outcomes. Efforts to improve physician awareness and understanding of these tumors can facilitate expedited access to multidisciplinary care.

09.09 Sex Bias Exists in Human Clinical Surgical Research

Posted on January 18, 2016

N. A. Mansukhani1, D. Y. Yoon1, K. A. Teter1, V. C. Stubbs1, T. K. Woodruff2,3, M. R. Kibbe1,2 1Northwestern University,Surgery,Chicago, IL, USA 2Northwestern University,Women’s Health Research Institute,Chicago, IL, USA 3Northwestern University,Obstetrics And Gynecology,Chicago, IL, USA

Introduction: Sex is a highly conserved difference between members of the same species, but is a variable that is poorly controlled in clinical research. The objective of this study is to determine if sex bias exists in human clinical surgical research, and identify areas where the greatest and least sex biases exist. We hypothesize that males and females are not included in surgical clinical research in equal numbers, and that data are not reported or analyzed using sex as an independent variable.

Methods: All manuscripts published in Annals of Surgery, American Journal of Surgery, JAMA Surgery, Journal of Surgical Research, and Surgery in 2011 and 2012 were reviewed. Data abstracted included study type, location, number and sex of the subjects, the degree of sex matching, and inclusion of sex-based reporting, statistical analysis, and discussion of data.

Results: Of 2,347 articles reviewed, 1,668 included human subjects. Of these, an additional 365 were excluded on the basis of including animals or cells, studying a sex-specific disease, or not reporting the number of subjects included. Of the remaining 1,303 manuscripts, 17 (1%) were male-only studies, 41 (3%) were female-only studies, 1,020 (78%) included males and females, and 225 (17%) did not document the sex of the subjects studied. Using a liberal 90%, 80%, and 50% criteria for matching inclusion of both sexes, of the manuscripts that included both males and females only 118 (9%), 237 (18%), and 589 (45%) of studies matched the sex of the subjects included. For manuscripts that included both sexes, only 497 (49%) studies reported the data by sex, 432 (42%) analyzed the data by sex, and 299 (29%) included a discussion of sex-based results. Upon analysis of the different surgical specialties, a wide variation in sex-based inclusion, matching, and data reporting existed. Vascular surgery had the most male-only manuscripts (7%), breast surgery had the most female-only manuscripts (59%), surgical oncology included both sexes in the most manuscripts (91%), and breast surgery included both sexes in the least manuscripts (7%). Surgical education documented the sex of subjects in only 53% of publications, whereas thoracic surgery documented the sex of subjects in 95% of publications. Sex-based reporting of data was only performed in 28% of publications in American Journal of Surgery whereas it was performed in 45% of publications in JAMA Surgery.

Conclusion: Our data show that sex bias exists in human surgical clinical research. Few studies included men and women equally, less than one-third performed data analysis by sex, and there was wide variation in inclusion and matching of the sexes between the specialties and the journals reviewed. Because clinical research serves as the foundation for evidence-based medicine, it is imperative that this disparity be addressed because therapies and practice derived from such studies may be specific to only one sex.

77.16 The Impact of Early Recurrence on Quality of Life After Cytoreductive Surgery with HIPEC.

Posted on January 18, 2016

N. M. Hinkle1, V. Botta2, J. P. Sharpe1, P. V. Dickson1, J. Deneve1, G. M. Munene1 1Univeristy Of Tennessee Health Science Center,Surgery,Memphis, TN, USA 2Univeristy Of Tennessee Health Science Center,Medicine,Memphis, TN, USA

Introduction: Improved oncological outcomes following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) in highly selected patients have been well documented. The extensive nature of the procedure adversely affects quality of life (QoL). The aim of this study is to longitudinally evaluate QoL following CRS/HIPEC.

Methods: This is a retrospective review of a prospectively maintained database of patients with peritoneal malignancies undergoing CRS/HIPEC. Clinicopathological data, oncologic outcomes, and QoL were analyzed preoperatively and postoperatively at two weeks, one, three, six and twelve months. The FACT-C instrument was utilized to determine changes in QoL following CRS/HIPEC and the impact of early recurrence (<12months) on QoL.

Results:Thirty-six patients underwent CRS/HIPEC over 36 months. The median PCI score was 18 and the CC0/1 rate was 97.2%. Postoperative major morbidity was 16.7% with one perioperative death. Disease-free survival was 12.6 months in patients with high-grade tumors versus 31.0 months in those with low-grade tumors (p=0.03). QoL decreased postoperatively and improved to baseline in six months. Patients with early recurrence had a decrease in global QoL compared to preoperative QoL at 6 months (p<0.03) and 12 months (p<0.05). This correlation was not found in patients who had not recurred.

Conclusion:Patients who undergo CRS/HIPEC have a decrease in QoL that plateaus in 3-6 months. Early recurrence adversely impacts QoL at 6months and at 12month. This study emphasizes the importance of patient selection for CRS/HIPEC. The expected QoL trajectory in patients at risk for early recurrence must be carefully weighed against the potential oncological benefit of CRS/HIPEC.

77.17 Treatment of Non-Functional, Non-Ampullary Duodenal Neuroendocrine Tumors

Posted on January 18, 2016

T. J. Weatherall1, J. W. Denbo1, J. P. Sharpe1, M. Martin2, M. Ismail3, T. O’Brien6, K. Groshart4, R. Gupta5, S. W. Behrman1, J. L. Deneve1, G. Munene1, P. V. Dickson1 1The University Of Tennessee Health Science Center,Division Of Surgical Oncology,Memphis, TN, USA 2The University Of Tennessee Health Science Center,Division Of Hematology & Oncology,Memphis, TN, USA 3The University Of Tennessee Health Science Center,Division Of Gastroenterology & Hepatology,Memphis, TN, USA 4Trumbull Laboratories,Pathology Group Of The MidSouth,Memphis, TN, USA 5The University Of Tennessee Health Science Center,Division Of Pathology,Memphis, TN, USA 6Duckworth Pathology Group,Memphis, TN, USA

Introduction:
Duodenal neuroendocrine tumors(dNETs) are rare neoplasms and specific treatment recommendations are less clear than for other gastroenteropancreatic NETs. The purpose of the current study was to examine an institutional experience with well-differentiated, non-functional, non-ampullary dNETs and identify factors to help guide appropriate evaluation and management.

Methods:
We performed a retrospective review of patients with a diagnosis of dNET from 1993-2015, excluding those with hormonally functional or ampullary tumors. Clinical data was obtained from medical records and evaluated to identify predictors of regional lymph node(LN) metastases. Tumor grade was determined by Ki-67 index according to WHO definitions(G1≤2%; G2 3-20%). Regional lymph node dissection(RLND) was defined as an anatomic operation that included hepatoduodenal, peri-pancreatic, and hepatic arterial LNs.

Results:
During the study period, 36 patients were identified with a diagnosis of well-differentiated, non-functional, non-ampullary dNET. Resection was performed via surgery in 28 patients and endoscopy in 8. Operations included antrectomy(15), partial duodenectomy(6), transduodenal submucosal resection(4), and pancreaticoduodenectomy(3). Eight patients underwent formal RLND as part of their operation, yielding a median of 8(5-12) LNs vs 3(1-6) in those in whom LNs were sampled incidentally(p=0.003). Depth of tumor invasion was evaluable in 33 patients and involved the mucosa in 4(12%), submucosa in 22(67%), and muscularis propria in 7(21%). Ki-67 index was evaluable in 30 patients, revealing G1 tumors in 20(67%) and G2 in 10(33%). LNs were included in the specimen in 19/28(68%) with LN metastases identified in 5/19(26%). Of those with LN metastases, all had tumors ≤2cm and there was no significant difference in tumor size between LN+ and LN- patients(1.4cm vs 1.0cm, p=0.13). When compared to patients with no LN involvement, those with positive LNs were more likely to have muscularis propria invasion(80% vs 23%, p=0.04) and have undergone formal RLND(80% vs 31%, p=0.03). Among LN+ patients, 40% had G2 tumors vs 50% in LN- pts(p=0.99). Of LN+ patients, suspicious LNs were identified on preoperative CT in 40%. Preoperative EUS was not performed in any LN+ patients, however, when utilized was found to have 100% accuracy in predicting tumor depth of invasion. No patients were found to have distant metastases. At a mean follow up of 28 months, no patient developed recurrence or experienced disease-specific death.

Conclusion:
Non-functional, non-ampullary dNETs have a propensity to metastasize to regional LNs. Although preoperative CT and EUS may assist in treatment planning, tumor size and grade were not predictive of LN involvement. Therefore, performance of an anatomic RLND at the time of resection likely results in more accurate disease staging. Longer follow up is necessary to further evaluate the prognostic impact of LN+ disease and therapeutic benefit of RLND.

77.13 ‘Too Early?’: Timing of Live donor Liver Transplantation (LDLT)

Posted on January 18, 2016

E. A. Pomfret1, M. Akoad1, M. Simpson1, J. J. Pomposelli1 1Lahey Hospital And Medical Center,Transplantation And Hepatobiliary Diseases,Burlington, MA, USA

Introduction: Despite widespread success, there is still debate regarding the appropriate timing of LDLT. Patients with high MELD scores are often considered too sick for LDLT while those with low MELD scores may be considered ‘too early’. We compared characteristics of LDLT recipients with those patients without LDs who died on the waiting list during the same time period. The purpose of the study was to determine if patients with end-stage liver disease and availability of a LD are less likely to die on the waitlist.

Methods: Demographic and clinical data of patients who received LDLT (LD) or who died on the waitlist (DOW) between 2002 and 2013 were compared. Statistical analysis was performed sing SPSS; p values <0.05 were considered significant.

Results: 204 LDLT recipients and 198 patients who DOW were identified. Both groups were male predominant (72% LD vs. 62% DOW) and had similar MELD scores at evaluation (14.1+6.0 LD vs.15.7+6.5 DOW). Patients who died while waiting had lower platelet counts (105 vs. 149 LD, p=0.009) and albumin (2.6 vs. 3.2 LD, p=0.01) at evaluation and higher incidence of SBP (43.3% vs. 26.9% LD, p=0.001) than patients with LD. Their MELD at death was 24.9+12.9 vs. 14.8+6.0 at LDLT (p=0.001). Mean platelet count at death was 70.1 vs.136 at LDLT (p=0.002).

Additional comparisons are shown in Table 1.

Conclusion: Patient with an available LD are referred, listed and transplanted significantly earlier that those waiting for a deceased donor. Despite similar initial MELD scores, patients with LD were transplanted with improved nutritional status, less portal hypertension, fewer decompensating events such as spontaneous bacterial peritonitis (SBP) and were less likely to be temporarily inactivated. Availability of a LD affords the recipient with end-stage liver disease rapid referral, higher transplant rates, and less morbidity and mortality prior to transplant. Labeling candidates as ‘too early’ based on MELD score increases days inactivated and may result in worse outcomes.

77.14 Survival Benefit of Transplantation in Patients With Hepatocellular Carcinoma

Posted on January 18, 2016

L. Woolf1, R. S. Mangus1, A. J. Tector1, K. Ridlen1, M. Maluccio1 1Indiana University School Of Medicine,Surgery/Tranplant,Indianapolis, IN, USA

Introduction:
The absolute impact of given a given treatment for cancer is measured by how long a patient lives compared to their expected survival. For patients with hepatocellular carcinoma (HCC), life expectancy is often determined by the combination of liver related and tumor related variables. The Cancer of the Liver Italian Program Investigators (CLIP) score is one validated measure of survival in patients with HCC and has been used to assess disease free and overall survival in a large cohort of patients. The objective of this study was to evaluate the impact of transplantation on survival of HCC patients by comparing preoperative CLIP score estimates of life expectancy to post transplant survival.

Methods:
Records from a database of 1572 consecutive adult liver transplants performed at Indiana University between July 2001 and June 2015 were reviewed. Of these patients, 376 had HCC. CLIP scores were calculated for all patients, and patients were stratified by scores 0-1 (low risk), 2 (intermediate risk), and 3-4 (high risk). Life expectancy was estimated based on published survival rates for each CLIP score category. Post transplant survival was calculated using Kaplan-Meier methodology. The absolute survival benefit for each group was evaluated by comparing the average survival of all patients in each group compared to the estimated survival by CLIP score analysis.

Results:
The mean death-censored follow up for the entire population was 61 months from the date of transplant. The median survival has not yet been met. The mean actuarial survival was: 112 months, 108 months, and 77 months for CLIP 0-1, 2, and 3-4 respectively. This was compared to pre-transplant life expectancies of 38 months, 17 months, and 4 months, respectively. Therefore, for the three study groups, survival is increased by a minimum of 74, 91, and 73 months, respectively. 10 year survival is shown in the figure.

Conclusion:
Liver transplantation prolongs survival in the vast majority of patients with hepatocellular carcinoma compared to pre-transplant survival estimates. For the individual cancer patient with HCC, transplantation is the most promising treatment currently available.

77.15 Does Immunonutrition Improve Outcomes after Major Surgery?

Posted on January 18, 2016

K. N. Dautermann1, T. L. Schmotzer1, M. Henry1, A. I. Salem1, E. R. Winslow1, C. S. Cho1, S. M. Weber1 1University Of Wisconsin School Of Medicine And Public Health,Department Of Surgery,Madison, WI, USA

Introduction:

IMPACT® is an immunonutrition formula containing a unique blend of three synergistic immunonutrients of arginine, dietary nucleotides and omega-3 fatty acids. These factors are believed to play a major role in promoting T-lymphocyte growth and replication, modulating cytokines to produce less inflammatory and immunosuppressive mediators, and providing a source of purine and pyrimidine bases for DNA/RNA production. We sought to evaluate outcomes associated with utilizing enteral IMPACT® for patients undergoing pancreatectomies.

Methods:

Retrospectively collected data on pancreatectomy patients who received IMPACT® preoperatively for 5 days (3 cans/d) was analyzed and compared to pancreatectomy cases in our institutional NSQIP database who did not receive IMPACT®. Data collection included demographics, American Society of Anesthesiologists (ASA) status, rates of 30-day postoperative surgical site infection (SSI) and length of hospital stay (LOS). IMPACT® patients without NSQIP data had data on postoperative complications validated from chart reviews using NSQIP definitions. Outcomes were compared between groups.

Results:

A total of 26 patients who received IMPACT® were evaluated and compared to 348 patients who did not receive the formula. There was no difference in gender distribution (p=0.07), race (p=0.06), median age (0.06) or ASA status (p=0.8) between groups. On univariable analysis, there was no difference between rates of postoperative 30-day SSI in the IMPACT® group (0% vs 11%, p=0.09) or median LOS (7.5 (2-22) days vs 7 (2-57) days, p=0.2) (Table 1). A separate multivariable analysis adjusting for age and gender was performed and there was no association between IMPACT® and SSI (OR=0.15, p=0.19, CI=0.009-2.56) or LOS (p=0.08).

Conclusion:

There was no difference in 30-day postoperative surgical site infection or length of hospital stay between the groups. This is in contrast to previous reports describing decreased rates of postoperative surgical site infection and shorter LOS associated with the utilization of enteral immunonutrition formulas. Further evaluation with larger numbers of patients are required to better assess the role of enteric immunonutrition formulas in modifying short term postoperative surgical outcome after major surgeries.

77.10 Immunonutrition is associated with a decreased incidence of graft-versus-host disease:Meta-analysis

Posted on January 18, 2016

H. Kota3, 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

Introduction: Graft versus host disease (GVHD) is a serious complication of bone marrow transplantation requiring higher doses of glucocorticoids or immunosuppressive therapies, further straining transplant recipients. Immunonutrition, such as vitamins and amino acids, act to increase immunity, decrease inflammation, and decrease oxidative stress. This meta-analysis examines the impact of immunonutrition on the incidence of GVHD and post-operative infections among transplant recipients.

Methods: A comprehensive literature search for all published randomized control trials (RCTs) was conducted using Pubmed, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966-2015). Keywords in the search included all terms related to immunonutrition, such as ‘vitamin C’ or ‘ascorbic acid’ and ‘transplant.’ Outcomes analyzed included incidence of GVHD and infection.

Results: 8 RCTs involving 529 transplant recipients (261 receiving immunonutrition and 268 receiving standard nutrition) were analyzed. Immunonutrition reduced the incidence of GVHD by 17%; (RR = 0.832; 95% CI, 0.702-0.986; p=0.034). There was no significant difference in the incidence of infections with the use of immunonutrition (RR = 1.016, 95% CI, 0.819-1.261, p=0.885). Subgroup analysis by the type of immunonutrition, showed no difference in the incidence of GVHD or infections.

Conclusion: Immunonutrition reduces the risk of GVHD in transplant recipients possibly due to better nitrogen balance, immune support and free radical scavenging. Additional studies specifically evaluating the use of immunonutrition on infection incidence in bone marrow transplant recipients are required.

77.11 Readmission Following Liver Transplantation: An Unwanted Occurrence but an Opportunity to Act

Posted on January 18, 2016

M. S. Patel1, J. Mohebali1, J. Shah1, J. F. Markmann1, P. A. Vagefi1 1Massachusetts General Hospital,Division Of Transplant Surgery,Boston, MA, USA

Introduction:
Preventing hospital readmissions remains a priority for providing both quality and cost-effective care. Liver transplant (LT) patients are at high risk for readmission. We sought to identify predictors of readmission and to evaluate its impact on survival in a Region with prolonged waitlist times.

Methods:
A single center review of all consecutive adult, non-living donor LT’s at our center in Region 1 from 2005 to 2014 was performed, with linkage to the UNOS Standard Transplant Analysis and Research registry. Readmission was defined as hospitalization within 90 days of discharge. Logistic regression was used to identify independent predictors of readmission and Kaplan-Meier analysis was used to evaluate overall survival.

Results:
Over the 10-year study period, 325 patients underwent LT with an overall 90-day readmission rate of 46%. Upon multivariable analysis, independent predictors of readmission were age at transplant (OR 0.97[0.94-1] per year), male gender (OR 0.48[0.26-0.88]), hospital length of stay after LT (OR 1.03[1-1.05] per day), hepatitis C as a primary cause of liver failure (OR 2.33[1.40-3.86]), and death (OR 2.19[1.18-4.09]). On overall survival analysis, readmitted patients were noted to have a significantly lower survival compared to those who were not readmitted (p=0.008 on log-rank test, Figure 1) with five-year survival being 74% vs. 88%, respectively. Of those readmitted, only one patient (2.5%) died at the time of initial readmission.

Conclusion:
LT recipients are at substantial risk for readmission with nearly half of all patients re-presenting within 90 days of discharge. As readmission is associated with decreased long-term survival, an emphasis should be placed on optimizing those at increased risk prior to discharge. Furthermore, if readmission does occur, it appears to present an opportunity to intervene, as virtually no patients died during initial readmission.

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