90.14 Short-term Outcomes of Patients with Benign Colon Polyps Managed by Combined Endo-Laparoscopic Surgery (CELS)

Posted on January 26, 2017

M. Qi1, M. Kiely1, L. Chen1, J. Yoo1  1Tufts Medical Center,Colon And Rectal Surgery,Boston, MA, USA

Introduction: Despite advanced endoscopic techniques, some benign-appearing colon polyps are not removable endoscopically.  Surgical resection is typically recommended, even though the majority of these polyps do not contain cancer.  Combined Endo-Laparoscopic Surgery (CELS) is emerging as an alternative to bowel resection in this setting.  Simultaneous laparoscopy with CO2 colonoscopy may increase the chance of successful polyp removal without the need for a bowel resection.  However, short-term outcomes regarding this technique have not been widely reported.  Our goal was to review the CELS experience at our institution and evaluate short-term outcomes.

Methods: This is a single institution, retrospective analysis of all patients who underwent CELS from December 2014 to August 2016.  Patient demographics, operating room characteristics, pathology, and post-operative outcomes were analyzed on an intention to treat basis.

Results:We identified 11 patients with endoscopically unresectable polyps who underwent an attempted CELS procedure from December 2014 to July 2016.  Of these 11 patients, 10 (91%) had successful polyp removal using the CELS technique. One patient had a fixed polyp that required a laparoscopic right colectomy.  Her pathology was consistent with a tubular adenoma.

For all patients, the mean operating room time was 180 ± 58 min, and the median length of stay was 1 day (range 0-3 days).  Post-operative complications occurred in 1 patient, who developed a post-polypectomy bleed following resumption of anti-platelet therapy.  Of the 10 patients who had a successful CELS procedure, 9 of these polyps were ultimately benign (90%) and adenocarcinoma was present in one.  This patient underwent a laparoscopic right colectomy 12 days later.  The final pathology was consistent with a T1N0 cancer (0/20 lymph nodes). 

Conclusion:The endoscopic and surgical management of benign colon polyps continues to evolve.  CELS may be an alternative to bowel resection in select patients, and may be associated with improved patient outcomes and lower morbidity.  The inability to accurately determine the presence of cancer in these polyps is a limitation to this approach, and requires a thoughtful pre-operative discussion regarding the need for additional surgery following CELS. 
 

90.13 Outcomes of Inguinal Hernia Repair with Local Anesthesia vs General Anesthesia: Case Series

Posted on January 26, 2017

M. S. Sultany1, V. Jain1, J. Imran1, S. Huerta1,2  1University Of Texas Southwestern Medical Center,Department of Surgery,Dallas, TX, USA 2VA North Texas Health Care System,Department Of Surgery,Dallas, TX, USA

Introduction:

Inguinal hernia repair (IHR) is typically performed under general anesthesia (GA). However, in select patients who are high-risk for surgery under GA, repair under local anesthesia (LA) can be performed safely. There is a paucity of data comparing the outcomes of IHR with either LA or GA. The objective of this study is to compare operative time and postoperative outcomes of patients undergoing IHR with LA to those under GA.

Methods:

A retrospective review of patients undergoing IHR from 2005-2016 was performed. Patient cohorts were divided into those undergoing IHR with either LA or GA. Patient demographics, preoperative data, operative time and postoperative outcomes were analyzed using chi-square test for categorical data and Student’s t-test for continuous variables. 

 

Results:

A total of 931 patients were included in the study, of which 858 patients out of 931 (92 %) underwent IHR with GA and 73 patients (8 %) with LA. Patients undergoing IHR with LA had a higher mean age (68 years vs. 60 years). On univariate analysis, there were no differences in postoperative outcomes such as inguinodynia (1.8 % vs. 1.3 %, p = 0.78), recurrence rate (7.4 % vs. 9.5 %, p = 0.85) and hospital length of stay (0.373 vs. 0.057 days, p = 0.30) for those undergoing IHR with GA versus LA. In addition, there were no differences between groups with respect to the type of inguinal hernia (bilateral, unilateral or incarcerated), body mass index, American Society of Anesthesiologists (ASA) class or operative time.

Conclusion:

There is no difference in operative time, rate of inguinodynia, recurrence or hospital length of stay between patients undergoing IHR with either LA or GA. IHR with LA should be considered in select patients who are high-risk for surgery under GA. 

 

90.12 Optimizing Follow-up in Post-operative Parathyroidectomy Patients

Posted on January 26, 2017

S. R. Brown1, N. Bhutiani1, A. R. Quillo1  1University Of Louisville,Department Of Surgery, Division Of Surgical Oncology,Louisville, KY, USA

Introduction: Patients undergoing parathyroidectomy for primary hyperparathyroidism require long-term follow-up to adequately assess for cure of their disease.  For many of these patients, committing to repeated follow-up appointments, particularly 6 or 12 months after surgery, proves difficult.   The objectives of this study are to identify barriers to follow-up in patients undergoing parathyroidectomy for primary hyperparathyroidism, identify strategies to increase likelihood of follow-up, and sample patient interest in alternatives to traditional clinic visits. 

Methods: 98 patients undergoing parathyroidectomy between December 2012 and June 2015 who had both mailing address and working telephone number were identified.  These patients were sent a survey via mail regarding factors potentially influencing their ability to keep follow-up appointments and their attitudes towards alternative means of follow-up.  Survey results were tabulated and analyzed to identify factors affecting follow-up and potential alternatives.

Results: A total of 21 patients (21%) responded to the survey.  Patients lived an average of 22.6 miles from the surgery clinic offices in downtown Louisville (range 1 to 80 miles).  12 patients (57%) attended scheduled follow-up visits.  Of those patients that did not attend these visits, the majority (67%) cited being unaware of or forgetting their appointment as the reason for their absence.  Most patients stated that they still prefer a face-to-face visit with their surgeon for follow-up, though patients living greater than 35 miles from downtown Louisville and those with disabilities noted a preference for a telephone or videoconference based follow-up.

Conclusion: A number of patient-specific factors represent barriers to long-term surgical follow-up in patients undergoing parathyroidectomy for benign disease, including patient awareness, distance to tertiary referral center, and logistic considerations.  For patients with such considerations, maintaining close communication with patients’ endocrinologists and primary care providers represents a potentially effective strategy to ensure long-term cure of their hyperparathyroidism.        

 

90.11 Preoperative Esophageal Disease Increases Morbidity in Patients Undergoing Abdominal Surgery

Posted on January 26, 2017

A. Ramirez1, A. Tilak1, M. Sohn1, F. Turrentine1, R. S. Jones1  1University Of Virginia,School Of Medicine,Charlottesville, VA, USA 2University Of Virginia,School Of Medicine,Charlottesville, VA, USA

Introduction:  In North America the prevalence of gastroesophageal reflux disorder ranges from 18.1% to 27.8%. We measured the risks posed by preoperative esophageal disease to patients undergoing abdominal operations.

Methods:  2005-2014 ACS NSQIP data were merged with institutional Clinical Data Repository records to identify esophageal disease in surgical patients. Patients with gastro-esophageal reflux disorder, esophageal stricture, spasm, and diverticuli were categorized as having ‘mild-moderate’ disease while patients with achalasia, esophagitis, reflux esophagitis, esophageal ulcer, Barrett’s esophagus, and multiple diagnoses were categorized as having ‘severe’ disease. Thirty-day postoperative mortality and morbidity were modeled as a function of disease severity, adjusting for NSQIP risk of mortality or morbidity, demographic factors (age, sex, race/ethnicity), NSQIP targeted procedure groups, and open surgery indicator.

Results: Of 22,098 patients, 21.1% had preoperative esophageal disease (15.6% mild-moderate and 5.5% severe). Age, male sex, and African-American race were associated with postoperative morbidity in patients with esophageal disease (OR = 1.02, p < 0.001; OR = 1.41, p < 0.000; OR = 1.12, p < 0.032), respectively. Patients undergoing open procedures were more likely to have complications (OR = 2.55, p < 0.001). After adjustment, patients with preoperative mild-moderate and severe esophageal disease were 14% and 27% more likely to experience postoperative complications than patients without esophageal disease (p=0.034 and p=0.046), respectively. Esophageal disease was not associated with postoperative mortality.

Conclusion: Preoperative esophageal disease significantly increased the risk of postoperative complications. Surgeons should use increased caution with esophageal disease patients undergoing abdominal operations. 

 

90.10 Can clinical evaluation determine the need for pelvic x-ray in awake and stable blunt trauma patients?

Posted on January 26, 2017

M. Moosa1, I. Jangda1, H. Zafar1  1Aga Khan University Hospital Karachi,Department Of Surgery,Karachi, SINDH, Pakistan

Introduction:  Pelvic fractures is common and can be potentially life threatening.  The early diagnosis of pelvic fractures resulting from blunt abdominal trauma traditionally relies on the anterior-posterior pelvic radiograph although sometimes it may not give a definitive diagnosis of pelvic fractures. So reliability of pelvic x-ray has been questioned and ways of removing pelvic x-ray from the ATLS protocol are being observed on the basis of finding the reliability of clinical examination in finding out pelvic fractures in alert and awake, hemodynamically stable patient and also to avoid the unnecessary exposure of radiation and reduce the financial burden.

Methods:  This is a cross sectional study conducted in the department of surgery, Aga Khan University Hospital, Karachi. This study included patients with blunt trauma mainly the road traffic accident victims presenting the emergency department with GCS of 15, hemodynamically stable and alert and awake. Clinical examination of pelvis of these patients were done on three different examination maneuvers and assessment of pelvic made which was then compared to routine pelvic x-ray findings.

Results: 

Total of two twenty one (221) of blunt  trauma patients were reviewed having mechanism of injury being road traffic accident and history of fall. Of these 221 patients thirty two (32) were not entered in the study as they had GCS of < 15, fifteen patients were not included as they have abdominal tenderness, fourty one (41) patients had associated lower limb injuries. So the final of one thirty three (133) patients were included in our study. Of these 133 patients majority of patients were male around 91.7% and 8.9% were females. Mean age of patients included in this study 37 with standard deviation of +/- 14.2. Fourteen patients were positive for pelvic fracture on clinical examination and positive on PXR categorized as true positive (TP), fourteen patients were positive for pelvic fracture on clinical exam but negative on PXR and categorized as false positive (FP), two patients were negative for pelvic fracture on clinical exam but positive on PXR categorized as false negative (FN), one hundred and three patients were negative for pelvic fracture both on clinical exam and PXR and were labelled as true negative (TN).

Sensitivity, Specificity, Positive predictive value and Negative predictive value were calculated by using two X two table. Sensitivity of clinic examination was found to be 87.5%, Specificity 88.03%, Positive Predictive Value 50% and Negative predictive value 98.09%.

Conclusion: In relation to above mention findings new protocol can be advised for alert and awake patients and pelvic x-ray can be avoided helping in reducing the financial burden to patient, reducing emergency hassle and unnecessary radiation.  

90.09 Risk Factors Associated with Post Hemi – Closed Hemorrhoidectomy Secondary Hemorrhage

Posted on January 26, 2017

E. Inoue1,2, Y. Shimojima1, M. Matsushima1  1Matsushima Hospital,Coloproctology Center,Tobe Honcho, YOKOHAMA, Japan 2Yokohama City University Medical Center,Inflammatory Bowel Disease Center,Urafune, YOKOHAMA, Japan

Introduction:

Posthemorrhoidectomy secondary hemorrhage (PHSH) is a rare but serious complication after hemorrhoidectomy. The aim was to identify risk factors for this complication and that may provide information to improve outcome.

Methods:

We studied 1813 patients who underwent  hemi – closed hemorrhoidectomies in a single institution between January and December 2015. The hemi – closed hemorrhoidectomy is a most common procedure in  Japan. That is subsequently Millligan-Morgan procedure, close anal canal wound with a continuous suture to anal verge, it’ on this point that this procedure is different from Ferguson’s one. The hemi – closed hemorrhoidectomy is purported to be a less painful and reduce the wound infection rate. 50 patients were developed PHSH (PHSH group), whereas the remainder were classified to the non-PHSH group. The variables analyzed included age, gender, the required time for defecation, Goligher grade, anticoagulant agents, suture materials, operation time, intraoperative bleeding, and number of hemorrhoid excisions for each patient. The logistic regression model was used to assess the independent association of variables with PHSH.

Results:

Among the all patients, 50 developed PHSH (2.76%), and the mean period between operation and PHSH was 8.1 ± 4.8 days. Multivariate analysis revealed that patient’s gender, intraoperative bleeding, and number of hemorrhoid excisions for each patient were independently associated with risk of PHSH. Male patients were more likely than females to develop PHSH (relative risk, 2.04 ; 95 percent confidence interval, 1.10-3.81 ; P < 0.001). Intraoperative bleeding was 62.7±89.4 (ml) in the PHSH group, whereas that was 30.2±39.6 (ml) in the non-PHSH group (relative risk, 1.01 ; 95 percent confidence interval, 1.00-1.01 ; P < 0.001).Under two hemorrhoid excisions for each patient were lower than three and more hemorrhoid excisions to develop PHSH (relative risk, 0.40 ; 95 percent confidence interval, 0.22-0.73 ; P < 0.001).

Conclusion:

Our data suggest that the male patients, the amount of intraoperative bleeding, and more than three hemorrhoid excisions are highly correlated with this risk.

 

90.08 Spontaneous Enterocutaneous Fistula Closure Rates Improve with Standardization of Treatment.

Posted on January 26, 2017

S. Boateng1, N. Kugler1, C. Trevino1  1Medical College Of Wisconsin,Surgery – Division Of Trauma & Critical Care,Milwaukee, WI, USA

Introduction:  Enteric fistulae, an abnormal communication between the lumen of the gastrointestinal tract and the skin, are a devastating complication that can occur following abdominal surgery. Unfortunately, standardized care of these complex patients has not been implemented at the majority of tertiary hospitals. Thus we sought to evaluate the benefit of an evidence based clinical treatment protocol for enteric fistulae. We hypothesized that standardized treatment would increase spontaneous enteric fistulae closure rates and decrease hospital length of stay.

Methods:  We conducted a retrospective review of patients with an enterocutaneous fistula managed by the Division of Trauma and Acute Care Surgery at a tertiary academic medical center. Patients managed prior to implementation of a standardized treatment protocol were considered the control group for those patients managed post protocol implementation. A review of all eligible patient’s hospital and clinic medical records was performed to obtain data collection. The primary outcome of the trial was time to successful non-operative closure. Secondary outcomes included compliance with all elements of the treatment protocol and inpatient length of stay. Inpatient length of stay was determined from time of fistula identification to discharge, for those transferred to our facility length of stay is from time of admission to our facility to discharge.

Results: A total of 18 patients with enterocutaneous fistula managed by the multidisciplinary team were identified over 4 1/2 years with six control patients identified over the first half of this time period. The control group patients had a spontaneous closure rate of 16.7% with four of the remaining five undergoing operative closure, one patient was not offered operative intervention due to extensive medical co-morbidities. The mean length of stay within the control group was 37.5 days (Range 16-67 days). Twelve patients were managed utilizing the protocol with a spontaneous closure rate of 83% noted within this cohort, the remaining two patients within this cohort required operative closure. The mean length of stay post protocol implementation was 13.8 days (Range 4-28 days).

Conclusion: Implementation of a enterocutaneous fistula management protocol focusing on multidisciplinary management provides significant advantages for patients through improved spontaneous closure rates and decreased hospital length of stay.
 

90.07 Adaptation of a Transitional Care Protocol to Reduce Readmissions after Complex Abdominal Surgery

Posted on January 26, 2017

A. V. Fisher5, S. A. Campbell-Flohr5, L. Sell4, E. Osterhaus4, A. W. Acher5, K. Leahy-Gross4, M. Brenny-Fitzpatrick4, A. J. Kind6, P. Carayon7, D. E. Abbott5, E. R. Winslow5, C. C. Greenberg5, S. W. Weber5  4University Of Wisconsin Hospital And Clinics,Madison, WI, USA 5University Of Wisconsin,Department Of Surgery,Madison, WI, USA 6University Of Wisconsin,Department Of Medicine,Madison, WI, USA 7University Of Wisconsin,College Of Engineering,Madison, WI, USA

Introduction: Readmission is common after complex abdominal surgery, occurring in up to 30% of patients. While transitional care protocols are effective at decreasing readmission for medical patients, there is no evidence-based protocol for surgical patients.

Methods: The Coordinated Transitional Care Protocol (C-TraC), initially designed for medical patients, was used as the initial framework for the development of a surgery-specific protocol. Adaption was accomplished using a modified Replicating Effective Programs (REP) model developed by the Center for Disease Control. Hospital system characteristics, pre-existing resources and discharge processes, as well as clinical and social factors specific to surgical patients were first documented. Key-informant interviews were conducted with members of the medical C-TraC team, surgeons, nurses, and clinical team leaders in order to identify core elements of the pre-existing C-TraC protocol, align these elements within the health system and surgical context, and adapt the protocol with multi-disciplinary buy-in. Following this, specialized nurses were trained and the surgical C-Trac (sC-TraC) protocol was launched for high-risk surgical patients. Protocol refinement was accomplished by stakeholder meetings on a biweekly basis to perform rapid iterative adaptations.

Results: Pre-implementation planning through multi-disciplinary engagement allowed for integration with current systems, avoided duplication of processes, and defined goals for the protocol. Findings from key-informant interviews led to several unique elements that were incorporated into the sC-TraC protocol, including pre-discharge identification of red-flag symptoms, a standardized list of questions for follow-up phone calls to detect complications, and identification of unique outpatient resources to manage complications as an outpatient. These elements were intended to specifically address surgical issues such as nutrition, fever, ostomy output, dehydration, drain character, and wound appearance. The protocol maintained elements such as a pre-discharge meeting and inpatient integration by the transitional care nurse. After sC-TraC launch, the rapid iterative adaptation process led to changes in phone call timing, inclusion and exclusion criteria, and discharge instructions. The program was received well by patients with only 3 of 297 (1.0%) patients refusing enrollment, and 278 of 294 (95%) enrolled patients reaching full engagement with post-operative phone calls. Survey results from a random patient sample showed 100% overall satisfaction with the transitional program.

Conclusion: This transitional care protocol is the first to be specifically adapted to surgical patients, which occurred using a modified REP model and resulted in multi-disciplinary buy-in, low refusal rates, and high patient engagement and satisfaction. This adaptive process could be used to implement transitional care protocols at other program sites.

 

90.06 Prolonged Stay After Colectomy: Does Reason Differ Between a County and University Hospital?

Posted on January 26, 2017

D. F. Butler1, J. Anandam1, B. Williams1, S. C. Oltmann1  1University Of Texas Southwestern Medical Center,Colorectal Surgery,Dallas, TX, USA

Introduction:  

The National Surgical Quality Improvement Program (NSQIP) defines a prolonged length of stay (LOS) after colectomy as greater than 6 days, and uses this as a marker for quality of care. Causes for prolonged LOS can vary from medical to social, and understandably can be influenced by patient access to resources for post-hospital care. Protocol driven care may aid in overcoming those discrepancies. The aim of this study was to compare the rate of prolonged LOS after colectomy at a county hospital (CH) to a university hospital (UH), and evaluate the underlying factors contributing to the prolonged LOS. 

Methods:  
NSQIP participant user files from October 2014 to December 2016 from the CH and affiliated UH were utilized to identify all patients captured by respective institutional NSQIP, who underwent colectomy. During this time period, enhanced recovery pathways (ERP) were in place and operational at both institutions. Patients were flagged as prolonged LOS as defined by NSQIP. Charts were reviewed to determine the primary cause of increased LOS on post-operation day 6, and classified as ileus, leak or intra-abdominal abscess (IAA), surgical site infection (SSI), other infection, hemorrhage, medical complication or disposition planning.

Results:
The cohort included 239 patients, 57 from CH and 182 from UH.  There was no statistically significant difference between the number of patients with prolonged LOS between the university and county setting, 37% vs 33% (p=0.75).  The reasons for increased LOS were equivalent at both locations.  Notable differences were apparent in an increased number of Hispanic (30% vs 8%, p<0.001) and African American (42% vs 9%, p<0.001) patients at the county hospital.  Other demographic variables such as BMI, gender and age were similar.  Tobacco use was also increased at the community hospital (39% vs 13%, p<0.001).  All other NSQIP defined comorbidities were equivalent.  There was no difference in emergent case status.  An ERP was in place at both institutions, with usage of 55% at UH and 69% at CH (p=0.072).  Of those patients on an ERP, 3 total patients from UH (4.5%) and 6 total patients from CH (15%) had a prolonged LOS (p=0.003).

Conclusion:
Despite different practice environments, there were no statistically significant differences in the reasons for prolonged LOS between a large charity county hospital and a tertiary university hospital.  In this case the treating physicians practice at both locations and practice patterns can be somewhat standardized despite differences in available resources at the two locations.  This fact may account for the equivalence in both locations.  Additionally, both a large county hospital and a university hospital may be subject to a disproportionately higher volume of more complex patients based on their referral and transfer patterns accounting for increased LOS.  The difference in ERP usage between the two institutions is likely the result of a more inclusive program at the CH.
 

90.05 A Site-Specific Approach to Reducing ED Visits Following Bariatric Surgery

Posted on January 26, 2017

H. Abdel Khalik1, H. Stevens1, A. M. Carlin2, A. Stricklen1, R. Ross1, C. Pesta3, A. Ghaferi1  1University Of Michigan,General Surgery,Ann Arbor, MI, USA 2Wayne State University,Detroit, MI, USA 3McLaren Macomb Hospital,Mt. Clemens, MI, USA

Introduction:
Many emergency department (ED) visits following bariatric surgery do not result in readmission and may be preventable. Little research exists evaluating the efficacy of perioperative measures aimed at reducing ED visits in this population. Therefore, understanding the driving factors, such as patient and hospital characteristics, behind these preventable ED visits may be a fruitful approach to prevention. Furthermore, evaluating the efficacy of current perioperative measures may shed light on how to achieve meaningful reductions in ED visits.

Methods:
We studied 48,035 eligible patients who underwent bariatric surgery at across 37 Michigan Bariatric Surgical Collaborative (MBSC) sites between January 2012 and October 2015. Hospitals were ranked according to their risk-and reliability-adjusted ED visit rates. For hospitals in each ED visit rate tercile, several patient, surgery and hospital summary characteristics were compared. We then studied whether a hospital’s compliance with specific perioperative measures was significantly associated with reduced ED visit rates.

Results:
We found that only three of the 30 surgery, hospital, and patient summary characteristics studied were significant predictors of a hospital’s ED visit rate: rate of sleeve gastrectomies, rate of readmissions, and rate of VTE complications (p= 0.04, p=0.0065 and p=0.0047, respectively). Also, a hospital’s compliance with the perioperative measures evaluated was not a significant predictor of ED visit rates (p=.12).

Conclusion:
Current practices aimed at reducing ED visits appear to be ineffective. Due to heterogeneity in patient populations and local infrastructure, a more tailored approach to ED visit reduction may be more successful.
 

90.04 Weight-based Perioperative Antibiotics Dosing and Surgical Site Infection After Colectomy

Posted on January 26, 2017

J. J. Cedarbaum1, L. Ly1, R. Anand1, A. Hjelmaas1, Y. Chen1, S. Collins1, S. Regenbogen1  1University Of Michigan,University Of Michigan Health System,Ann Arbor, MI, USA

Introduction:
Obesity is a substantial risk factor for surgical site infections (SSIs). Antibiotic prophylaxis guidelines recommend weight-based dosing as one way to mitigate this risk. However, there is little clinical evidence to support this practice, and data on compliance is rarely collected in clinical registries. Using data from a population-based, statewide collaborative, we sought to evaluate the association between appropriate weight-based perioperative antibiotic dosing and the risk of SSI after colectomy.

Methods:
From a retrospective cohort from 73 hospitals in the Michigan Surgical Quality Collaborative (MSQC), we included all patients who underwent elective colectomy between 2012 and 2015. The primary outcome was the development of SSI within 30 days of surgery. SSI rates were compared between patients who did and did not receive compliant weight-based dosing.

Results:
Of the 4,801 patients included, 4,627 (96%) had appropriate weight-based dosing of perioperative antibiotics. Patients who received proper weight-based dosing had an overall SSI rate of 6.2% while those who did not receive weight-based dosing had an observed SSI rate of 9.8% (p=0.15). When evaluating only patients requiring dose-adjustment (those weighing in excess of 80kg, N=2,179), observed SSI rates were 6.9% with compliant weight-based dosing, versus 9.8% for non-compliant dosing (p=0.17). In post-hoc power analysis, there was only 30% power to detect this magnitude of difference in SSI rates for the >80kg subset.

Conclusion:
Weight-based dosing is already commonly used among MSQC hospitals. As a result of the small proportion of patients in the non-compliant dosing group, we did not detect a statistically significant reduction in the incidence of SSI among those with appropriate antibiotic dosing, although the relative risk of SSI was 30% less. As additional data on weight-based dosing compliance becomes available in MSQC we will return to this important question in order to make a more convincing determination as to the efficacy of this practice.
 

90.03 Severity of Diverticulitis in Patients with Polycystic Kidney Disease

Posted on January 26, 2017

M. Parker1, S. Kelley1, K. Mathis1  1Mayo Clinic,Surgery,Rochester, MN, USA

Introduction: Patients with polycystic kidney disease (PKD) who have had a kidney transplant have an increased risk of complicated diverticulitis compared to those who have had a transplant for other reasons. There is limited published literature regarding the risk of diverticulitis in patients with PKD who have not had a transplant.

Methods: We carried out a retrospective review of patients with PKD who were evaluated for diverticulitis in our system between January 2000 and June 2016. Patients were identified using ICD-9 and ICD-10 diagnosis codes. The electronic medical record was reviewed to obtain patient demographics, imaging, laboratory investigations, treatment course and outcomes. Patients without both documented polycystic kidney disease and diverticulitis in the electronic medical record were excluded. We compared patients who were status-post renal transplant at the time of diagnosis of diverticulitis, to patients with PKD and diverticulitis who did not have a renal transplant. Fisher’s exact test was used to compare categorical variables.

Results: Forty-one patients with PKD treated for diverticulitis were identified. Mean age was 60 (± 12), and 56% were female. Thirteen patients had undergone renal transplant. All transplanted patients had functioning allografts at the time of evaluation for diverticulitis (mean GFR 62). Mean GFR for non-transplant patients who were not on hemodialysis was 40. Three patients were on hemodialysis. Twenty-one percent of non-transplant patients had complicated diverticulitis, compared to 38% of transplanted patients (p=0.28). Fifty-four percent of patients in each group had recurrent diverticulitis either with a history of prior episodes reported by the patient, in health records from referring institutions, or with multiple episodes treated at our institution (p=1.0). There was one in-hospital death in each group. Thirty-two percent of non-transplant patients underwent operation, compared to 46% of transplanted patients (p=0.49). One patient in the non-transplant group underwent Hartmann procedure, and 8 underwent sigmoid resection with primary anastomosis without diversion. In the transplanted group, 2 patients underwent Hartmann procedure, one underwent sigmoid resection with diversion, and 3 underwent sigmoid resection with undiverted primary anastomosis.

Conclusion: In our group of patients, there is no statistically significant difference in rate of recurrent diverticulitis, complications from diverticulitis, or operative intervention in patients with PKD status-post renal transplant compared to those with PKD and no transplant.

 

90.02 Management of Complications by Acute Care Surgeons: Who Do We Fail to Rescue?

Posted on January 26, 2017

M. Dasari1, A. B. Peitzman1, J. W. Marsh1, D. Mohan1, M. R. Rosengart1, R. M. Forsythe1, J. L. Sperry1, M. E. Kutcher2  1University Of Pittsburgh Medical Center,Pittsburgh, PA, USA 2University Of Mississippi Medical Center,Jackson, MS, USA

Introduction:  'Surgical rescue' is defined as the surgical management of an acute complication of a surgical, interventional, or endoscopic procedure, and is a key pillar of Acute Care Surgery (ACS).  We compared complications, interventions, and outcomes between surgical patients who were successfully 'rescued' after a procedural complication and those who 'failed to rescue', defined by death in-hospital or within 30 days of discharge following a surgical complication.

Methods:  A prospective ACS database at an urban academic center was reviewed for acute surgical complications using an ICD-9 code-based screen, and linked with Social Security Death Index long-term mortality data.  Failure-to-rescue (FTR) was defined as in-hospital mortality or death within 30 days of discharge.

Results: Of 2,301 ACS patients screened from 1/2013 to 5/2014, 321 (14%) had an acute complication of a surgical (85%), endoscopic (8%), or interventional (7%) procedure; most commonly, wound complications (31%), uncontrolled sepsis (19%), and bowel obstruction (15%).  206 patients (63%) required operative intervention.  The most common rescue measures were bowel resection (22%), wound debridement (18%), and surgeon-guided resuscitation (17%).  Forty-four patients (14%) died in-hospital or within 30 days of discharge (FTR).  FTR patients were significantly older than rescued patients (55±15 vs. 67±14y, p<0.01), more commonly male (64% vs. 46%, p=0.03), and had more frequent pre-existing coronary disease (48% vs. 16%, p<0.01).  Lowest albumin and hemoglobin, as well as highest creatinine and lactate, were significantly higher in FTR patients (all p<0.01).  Bowel ischemia (20% vs. 12%, p<0.01) and perforation (18% vs. 6%, p<0.01) were more common complications in FTR patients, and more than twice as many FTR patients required bowel resection compared to successfully rescued patients (43% vs. 20%, p<0.01; Table 1).  The FTR rate was higher in consult and transfer patients (17%) compared to primary ACS service patients (8%; p=0.02).

Conclusion: Systematic study of failure to rescue in Acute Care Surgery identifies patients with significant comorbidities, critical physiological derangements, and frequent intestinal compromise; many are referred to an acute care surgeon specifically for rescue after a procedural complication.  Rapid assessment of frailty, appropriate goals-of-care discussion, and careful operative planning are critical in this high-risk population.

90.01 Survival Following Discharge to Post-Acute Care After Complex Surgery

Posted on January 26, 2017

J. T. Killian1, M. C. Mason2, P. J. Richardson3, P. Kougias2,3, F. Bakaeen4, A. D. Naik3,5, D. H. Berger2,3, C. Balentine1,6, D. A. Anaya7  1University Of Alabama at Birmingham,Department Of Surgery,Birmingham, Alabama, USA 2Baylor College Of Medicine,Michael E. DeBakey Department Of Surgery,Houston, TX, USA 3Houston Veterans Affairs Health Services Research And Development Center For Innovations In Quality, Effectiveness And Safety (IQUEST),Houston, TX, USA 4Cleveland Clinic,Department Of Thoracic And Cardiovascular Surgery,Cleveland, OH, USA 5Baylor College Of Medicine,Alkek Department Of Medicine,Houston, TX, USA 6University Of Alabama at Birmingham,Institute For Cancer Outcomes & Survivorship,Birmingham, Alabama, USA 7Moffitt Cancer Center And Research Institute,Department Of Gastrointestinal Oncology,Tampa, FL, USA

Introduction:  After complex surgery, patients are frequently discharged to post-acute care including skilled nursing facilities, inpatient rehabilitation, and long-term care. The purpose of this study was to describe survival after discharge to post-acute care in order to provide accurate information for informed consent and discussions with patients and their families prior to surgery.

 

Methods:  We retrospectively examined 60,666 patients within the Veterans Affairs system who had colorectal surgery, hepatectomy, pancreatectomy, coronary artery bypass grafting, abdominal aortic aneurysm repair, and peripheral vascular bypass from 2008-2011. Patients were classified by their discharge destination to home or to post-acute care (skilled nursing facilities, rehabilitation, or long-term care). We calculated five-year overall survival using the methods of Kaplan and Meier.

 

Results: A total of 4,744 (8%) patients were discharged to post-acute care. Of these, 2,180 (46%) patients were 70 years of age or older and 98% were men. Median follow-up was 3.3 years.  Overall survival at five years for all patients discharged to post-acute care was 50%.  Five-year overall survival for each procedure included: coronary artery bypass grafting (63%), open abdominal aortic aneurysm repair (50%), peripheral vascular bypass (44%), colorectal resection (41%), endovascular abdominal aortic aneurysm repair (40%), pancreatectomy (35%), and hepatectomy (22%). Survival for the total cohort and for each procedure was significantly worse for patients discharged to post-acute care compared to those discharged home (p<0.05). 

 

Conclusion: Discharge to post-acute care is associated with exceedingly poor survival following complex abdominal, cardiac, and vascular surgery.  For high risk patients, this information should be clearly communicated to patients and their families prior to consenting for surgery and during discharge planning.  Patients discharged to post-acute care also represent a highly vulnerable population that may benefit from preoperative and postoperative programs designed to enhance recovery from surgery. 

89.20 Does Sarcopenia Predict Worse Perioperative Outcomes for Ulcerative Colitis Patients?

Posted on January 26, 2017

C. Cadiz1, E. H. Wood1, M. Shah1, J. M. Eberhardt1, T. L. Saclarides1, D. Hayden1  1Loyola University Medical Center,Surgery,Maywood, ILLINOIS, USA

Introduction:
Sarcopenia has been associated with poor postoperative outcomes in cancer patients, and only recently has this been explored in patients with inflammatory bowel disease.  We aim to describe the influence of sarcopenia on perioperative and postoperative outcomes after colectomy for patients with ulcerative colitis.

Methods:
Skeletal muscle mass index was measured on perioperative CT scans (within 1 month of surgery) of patients undergoing colectomy for ulcerative colitis at a single tertiary care center, 2007-2015. Using Mimics® software (Belgium), skeletal muscle area including the paraspinal, psoas and rectus muscles, was measured three times at the L3 level and the mean along with the patient’s height was then used to calculate the lumbar skeletal muscle mass index (cm2/m2).  Sarcopenia was defined as 2 standard deviations below the index cutoff established in adult obese cancer patients: 38.5 in females, 52.4 in males (Lieffers 2012, Prado 2008).

Results:
36 UC patients had any type of colectomy with a CT scan performed within 1 month pre- or postoperatively. Mean age was 49.2 (17-84); 77.8% were male. Mean BMI was 26.8 (16.3-46.2). Overall prevalence of sarcopenia was 61.1%; 37.5% of females were sarcopenic at the time of surgery and 67.9% of males. Gender, race and surprisingly age were not associated with sarcopenia. Operative time was significantly associated with sarcopenia as was BMI. ICU admission trended toward significance (p=0.061). Overall postoperative complications were not associated with sarcopenia but UTIs were much more frequent (p=0.009). Readmissions, unexpected return to the operating room and mortalities were not associated with sarcopenia.   

Conclusion:

Sarcopenia  is extremely prevalent in patients with ulcerative colitis who require colectomy. Operative time, ICU admission and UTIs tend to be more longer and more frequent. Since the majority of patient did not undergo emergency colectomy, there may be time to optimize these patients with “pre-habilitation” if surgery is being considered in the near future.

 

89.19 Utilizing Game Theory to Model Patient Engagement in Self Care Following Surgery: A Pilot Study.

Posted on January 26, 2017

S. A. Castellanos1, G. Buentello1, J. W. Suliburk1  1Baylor College Of Medicine,Houston, TX, USA

Introduction:  Patient engagement is frequently discussed as a goal of patient education/discharge planning, yet remains hard to model and therefore challenging to optimize. Game theory is a field of study in which different models (games) analyze a player’s decision making process when his/her decision is contingent on what another player is going to do. This study seeks to develop a model to characterize patient decision making in engagement and then sought to correlate the model with qualitative analysis of semi-structured interview transcripts.

Methods:  Over a 6-month period, interviews were conducted within 6 weeks of discharge in patients undergoing thyroid, parathyroid or colorectal surgery. Interviews were recorded, transcribed, anonymized and then analyzed using Nvivo software platform. Blinded to transcript coding and results, a signaling game model was developed as follows: two players—Doctor (D) and Patient (P)—and two scenarios—one in which P is “engaged” [probability, α] and another in which P is “unengaged” [probability, (1-α)]. “Engaged” P’s represent patients who will call their doctor with problems at home post-hospitalization, and “unengaged” P’s are patients who will call no one or seek care elsewhere. Transcripts were reviewed for “Discharge Instructions,” “Discharge Process” and “Discharge Education” themes.

Results: As the model (game) evolves only P knows the starting state (engaged vs. unengaged).  The game is played anytime during P’s clinical care episode both pre- and post-operatively. P moves first by deciding to Ask (a) or Refrain (r) from questions. “Engaged” P’s prefer choosing a, but will choose r in certain situations, and the converse is true for “unengaged” P’s. In response to P’s behavior, D moves by deciding to Invest (i) resources in care for P or Maintain (m) the care at normal levels. If D chooses i, then P becomes “engaged” P. Otherwise, P will act according to baseline. Unless they believe P to be “unengaged”, D prefers choosing m over i. The optimal outcome for D and P results if P ends the game as “engaged”. Review of transcripts determined the levels of questioning exhibited by the patients only partly reflected activation towards proficiency in self-care. Across surgeries, there was poor demonstration that the clinical care team altered education efforts based on signaling from the patient.

Conclusion: A game theoretic “signaling model” is able to adequately characterize interactions between the care team and the patient. If the care team cannot perceive a patient’s engagement status via these signals, it must look for other ways to bring clarity into assessment of engagement.  Further work will be done to refine the model in order to optimize strategies to facilitate patient engagement.

89.18 Pre-operative Tylenol and Neurontin Reduces PACU Narcotic Requirements

Posted on January 26, 2017

T. Bernaiche1, G. Hafner1  1Inova Fairfax Hospital,Falls Church, VA, USA

Introduction:

Post-operative pain continues to be a significant problem, even after minimally invasive ambulatory procedures. Our study assesses if administering Neurontin and Tylenol prior to incision can decrease pain scores, PACU length of stay, and post-operative narcotic requirements after laparoscopic cholecystectomies and laparoscopic inguinal hernia repairs.

 

Methods:

Records of a single surgeon’s laparoscopic hernias and laparoscopic cholecystectomies from 2013-2014 were reviewed.  Differences between patients who received pre-operative Tylenol and Neurontin (PTN group) and those who did not (non-PTN group) were assessed using Student’s t test or Wilcoxon-Mann Whitney test and χ2 test or Fisher exact test.

 

Results:

173 patients were included in the study (76 laparoscopic cholecystectomy and 97 laparoscopic inguinal hernia repair).  There were 74 patients in the PTN group and 99 patients in the non-PTN group. Patients in the PTN group were less likely to receive post-operative narcotics (85.9% vs 97.3% [p=0.01]).  There was also a decrease in the median number of doses of post-operative narcotics received in the PTN group (2 (IQR 1-2) vs 2 (IQR 1-3) [p=0.029]).  There were no differences in pain scores between the two groups.  The PTN group had an increased PACU length of stay (179 min vs 142 min [p=0.005]).  The results remained unchanged after stratifying by surgery.

 

Conclusions:

Our study suggests that pre-operative Tylenol and Neurontin may play a role in decreasing post-operative narcotics use for laparoscopic hernia or laparoscopic cholecystectomy patients. Further investigation with prospective, randomized studies would clarify the utility of standardizing pre-operative Tylenol and Neurontin.

 

89.16 Is Colonoscopy Necessary Prior to Giving Neostigmine for Treatment of Colonic Pseudo-obstruction?

Posted on January 26, 2017

M. Nguyen1, D. Strosberg1, A. Brown1, E. Abel1, D. Eiferman1  1Ohio State University,Surgery,Columbus, OH, USA

Introduction:  

Surgical dogma dictates the necessity of ruling out distal mechanical colonic obstruction prior to using neostigmine to treat suspected colonic pseudo-obstruction (CPO) to avoid the risk for colonic perforation.  Gastroenterology guidelines recommend neostigmine as first line therapy for treatment of CPO.  Although colonoscopy provides excellent value as a diagnostic and therapeutic modality in CPO, urgent colonoscopy in the setting of an un-prepped and dilated colon also carries the risk of perforation.  This study examines if CPO can be safely treated with intravenous neostigmine without prior evaluation with colonoscopy to rule out distal obstruction and examines whether Computed Tomography (CT) scan can adequately assess the distal colon instead of endoscopy.

Methods:  

We retrospectively reviewed all patients who received neostigmine for CPO at a tertiary-care academic medical center between 2013 and 2016. Data regarding clinical characteristics including treatment pathways, imaging diagnostics, maximum colonic diameter, clinical response, complications, and need for surgical consultation and/or intervention were collected and analyzed using descriptive methods and student t-test.

Results: 

37 patients received neostigmine for the treatment of CPO. Average colonic diameter was 10.6cm prior to any intervention. 13/37 (35%) of patients were not evaluated for distal obstruction prior to neostigmine administration and 29.7% of patients were not evaluated by the surgical service during their hospitalization.  CT scan was used to assess for distal obstruction in 21/37 (56.8%) patients and colonoscopy was performed on only 8/37 (21.6%) patients. 76% of patients who received Neostigmine without prior colonoscopy to rule out distal obstruction resulted in improvement of symptoms. Two patients required surgical intervention due to complications unrelated to neostigmine administration.  One patient was diagnosed with distal obstruction from a colonic mass. No complications were reported due to neostigmine administration. Mean colonic diameter change was 4.0 cm with decompressive colonoscopy and 2.7 cm with neostigmine (p=0.28). 

Conclusion:

Our review suggests that neostigmine can be safely given for CPO without prior endoscopic evaluation nor surgical consultation to rule out distal mechanical obstruction, which challenges traditional surgical dogma.  In lieu of colonoscopy, CT scan can be safely utilized to rule out distal obstruction.  Administration of neostigmine without colonoscopy can minimize delay in treatment for CPO.

 

 

 

89.15 Endoscopic Retrograde Cholangiopancreatography Performed by Surgeons. A Single Center Experience.

Posted on January 26, 2017

M. Al-Mansour1, J. Hazey1  1Ohio State University,Surgery,Columbus, OH, USA

Introduction: ~~Endoscopic retrograde cholangiopancreatography (ERCP) is traditionally performed by gastroenterologists. We are reporting our institutional experience with a large number of cases performed by surgeons.

Methods: ~~We retrospectively reviewed the charts of 1399 patients who underwent 1810 ERCP procedures performed by surgeons between August 2003 and June 2016. The surgeons were trained in formal surgical endoscopy fellowships. Demographic, procedure-specific and outcome data were collected.

Results:~~The mean age was 52.8 years and 54.8 % of patients were female. A surgical endoscopy fellow was involved in 63.3% of the ERCP procedures. Successful cannulation of the common bile duct and/or pancreatic duct was achieved 91.2% of the time. The rate of major complications was 5%. The rates of post-ERCP pancreatitis, hemorrhage, cholangitis and perforation were 4.6%, 0.5%, 0.6% and 0.1% respectively. All-cause 30 day mortality was 0.5% and there were no ERCP-specific mortalities noted.

Conclusion:~~ERCP can be performed safely by fellowship trained surgical endoscopists with excellent success rates and low complication rates that are consistent with previously reported data.

 

89.14 Racial Disparities Among Patients Undergoing Pancreaticoduodenectomy: A Nationwide Analysis

Posted on January 26, 2017

K. L. Anderson, Jr.1, S. Thomas2,3, M. A. Adam4, R. P. Scheri4, M. T. Stang4, S. A. Roman4, J. A. Sosa3,4,5,6  1Duke University Medical Center,School Of Medicine,Durham, NC, USA 2Duke University Medical Center,Department Of Biostatistics,Durham, NC, USA 3Duke Cancer Institute,Durham, NC, USA 4Duke University Medical Center,Department Of Surgery,Durham, NC, USA 5Duke University Medical Center,Department Of Medicine,Durham, NC, USA 6Duke Clinical Research Instiute,Durham, NC, USA

Introduction:  Understanding and reducing racial disparities in health care is a high priority nationwide. Disparities in outcomes have been demonstrated for pancreatic cancer, but studies have been limited to single institution experiences or analyses focused only on White vs. Black patient groups. Our aim was to investigate how racial disparities have changed over the last two decades in the management of pancreatic cancer. 

Methods:  Adult patients undergoing pancreaticoduodenectomy for Stage I and II pancreatic adenocarcinoma were identified from the National Cancer Data Base, 1998-2011. Univariate analysis was used to compare demographic, treatment, and short-term outcomes. Multivariate regression and survival analyses were used to examine differences between races in access to high-volume (H-V) (≥11 cases/year) facilities and overall survival.

Results: Over the study period, 10520 patients underwent pancreaticoduodenectomy for adenocarcinoma at 1044 institutions, of which 8852 (84.1%) were White, 887 (8.4%) Black, 522 (5.0%) Hispanic, and 259 (2.5%) Asian. Compared to White (56.4%) patients, Black (63.1%), Hispanic (66.5%), and Asian (61.4%) patients were more likely to receive care at low-volume institutions. All other races experienced higher rates of 30-day readmission (Black: 9.6%, Hispanic: 10.7%, Asian: 11.2%) compared to Whites (8.0%, p=0.02), and longer length of hospital stay (Black and Hispanic median 10 days, Asian 11 days,) compared to White patients (9 days, p<0.001). Positive margin and 30-day mortality rates did not differ between races. After adjustment, Black [OR 0.74 (0.63-0.86), p<0.001] and Hispanic [OR 0.78 (0.64-0.95), p=0.01] patients had decreased odds of accessing a H-V facility compared to White patients. Over time, access to H-V facilities improved for Hispanic [p=0.03] and Asian [p=0.04] patients, while there was no significant change for Black patients [p=0.81] compared to Whites (Figure). In unadjusted analysis, there were no differences in overall survival based on race (p=0.47). After adjustment, Hispanic patients had decreased mortality compared to Whites  (HR=0.81, p=0.05), but no differences were seen for Black or Asian patients.

Conclusion:  Over time, access to H-V institutions improved for Asian and Hispanic patients compared to White patients, while the gap in access persisted for Black patients. Improving access to H-V institutions may provide improved outcomes for vulnerable minority patients. 
 

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