89.13 Factors Predispose Conversion: Laparoscopic to Open Cholecystectomy Mexican-American Population

Posted on January 26, 2017

F. A. Yamin1, L. Puckett1, A. Rios-Tovar2, B. R. Davis1  1Texas Tech University Health Sciences Center El Paso,Surgery,El Paso, TX, USA 2Methodist Hospital Dallas,Surgery,Dallas, TX, USA

Introduction:  Optimal management of cholecystitis and elective gallstone disease is laparoscopic cholecystectomy. Underserved patients on the US- Mexico border undergo more frequent rates of conversion from laparoscopic to open cholecystectomy. Diagnostic staging criteria for acute cholecystitis are described in the Tokyo Guidelines (2007). This study delineates criteria to predict conversion risk for a wide range of gallbladder disease presentations in the Mexican-American population with low access to surgical care on the US-Mexico border.

Methods:  This is a case-matched control study from University Medical Center of El Paso (July 2014- July 2015). Criteria include: demographics, ultrasound measurements, labs, and comorbidities. Multiple ranges are applied to individual variables and ranges were analyzed for statistical significance. Student’s t-test and Wilcoxon rank sum test assess the differences in risk factors for continuous variables. If they were categorical, the Fishers exact test, or chi-squared test was used to assess differences. The logistic regression model assessed likelihood of conversion. P values less than 5% were considered statistically significant. All analyses were performed using SAS V.9.4.

Results: Forty conversion to open and 275 laparoscopic cases were analyzed (male 79, female 208). Ethnicity included Hispanics (235) and Non-Hispanics (52). Elective surgery (132) and cholecystitis (155) were grouped. In an unadjusted model: WBC, total bilirubin, gender, ethnicity and gallbladder dimensions (wall thickness, length, and width) are significant risk factors for conversion. In the adjusted model, only white blood cell count, gender and ethnicity were significant. Odds of conversion in Hispanics are 10 times higher compared to Non – Hispanics. Odds of conversion for males are 3 times more likely. Odds of conversion are 7% more likely for each unit change in WBC. Conversions had an average WBC of 14,000 (max. 18,000, SD 4,000); total bilirubin average of 1.2 (max. 1.53, SD .28); gallbladder wall thickness average 3.30 cm ( SD 1.51), gallbladder length average  9.51 cm (max. 22.1, SD 4.36); and gallbladder width average is 3.79 cm (max. of 5.6, SD 1.31cm). Hospital length of stay and complications to include partial cholecystectomy and bile leak increased parallel with conversion rates. 

Conclusion: Determination of preoperative factors that predispose to conversion from laparoscopic to open cholecystectomy allow for adjunctive treatment measures to include cholecystostomy and delayed operative intervention to reduce complications. Application of specific ranges smaller than the standard deviation would improve reliability of these predictors and demonstrate limitations of this study. This study expands known criteria for severity grading specific to the underserved population on the US-Mexico border. Further investigation creates improved power to predict the best course in complicated gallstone disease in the Mexican-American population with low access to expedient surgical care. 

 

89.12 Temporal Trends in the Management of Small Bowel Obstruction

Posted on January 26, 2017

M. Khalil1, T. Orouji Jokar1, H. Nerkar1  1New York Medical College,General Surgery,Brooklyn, NY, USA 2New York Medical College,General Surgery,Brooklyn, NY, USA

Introduction: Over the past few years the mangaement of small bowel obstruction (SBO) has been transitioned from operative to non-operative management. Furthermore, with increasing expertise in the laparoscopy, an increased use has been observed in emergent cases. The aim of this study was to assess the temporal trends in the management of SBO and outcomes differences of open versus laparascopic adhesiolysis. 

Methods: We performed a five year (2008-2012) retrospective analysis of national inpatient sample. We identified patient with SBO using ICD-9 diagnosis codes for small bowel obstructin with concomitant codes for intra-abdominal or peritoneal lysis of adhesions, gangrenous or obstructed hernia, or small bowel malignancy. Open adhesiolysis was identified using procedure code 54.59 and laparoscopic adhesioslysis was identified using 54.51 and 54.21. Our outcomes were trends in operative versus non-operative management of SBO and differences in outcomes between open versus laparosopic adhesiolysis. 

Results: A total of 503974 patients with SBO were identified, mean age of population was 48 (27) years, and 58% were female. There was no significant increase in total number of SBO over the years (p=0.68). The rate of operative intervention gone down significantly from 21% to 19% over the years (p<0.001). The total hospital charges and length of stay (LOS) was significantly lower in non-operative management (p<0.001 for both inferences). On comparison between open and laparoscopic adhesiolysis, the rate of open adhesiolysis decreased from 81% to 76% (p<0.001). The total LOS (p<0.001) and hospital charges (p<0.001) were significantly lower in laparoscopic group.

Conclusion: The non-operative management appears to be the favored treatment strategy in the management of SBO. However, in the sub-group of patient who require surgery, there has been an increasing role of laparoscopy. Further studies are warranted to better define these outcomes differences. 

 

89.11 Modified dome down laparoscopic cholecystectomy using only three trocars in the left abdomen

Posted on January 26, 2017

H. Bonatti1, N. Kubicki2, S. Kavic2  1Shore Regional,Surgical Care,Easton, MD, USA 2Medical Center,General Surgery,Baltimore, MD, USA

Introduction: The majority of surgeons use four ports for laparoscopic cholecystectomy (LC). We propose a three port technique with access from the left upper quadrant (LUQ).

Methods: Ninety-one LCs performed from 6/2013 – 12/2016, were analyzed. Trocars are placed in the LUQ (5mm), umbilicus (5 or 10-12mm), and between the two (5mm). The third troacar was replaced by a Teleflex minigrasper in 29 cases. After the gallbladder (GB) serosa is incised on both sides, a window is created behind the GB midportion and widened towards fundus and infundibulum. Cystic artery and duct are dissected out obtaining the critical view and after the last fundus adhesion is cut, they are secured with clips or endoloop.

Results: Median age of 60 women and 31 men was 57.2 (range 16.5-89.6 ) years. LC was done for acute cholecystitis (n=12), chronic cholecystitis (n=70), other (n=9). In 79 cases (87%), the procedure could be completed with three instruments, in five cases an additional instrument was inserted for second procedures (paraesophageal hernia repair, cystgastrostomy, appendectomy, extensive lysis of adhesions (n=2)). In seven cases an additional 5mm port was placed for GB retraction; a Keith needle was used for GB suspension in four patients. Ten cases were done with two five mm ports and a minigrasper and in 53 cases the modified dome down technique was completed (remaining cases were done in traditional dome down technique). There were no vascular or bile duct injuries in this series. 39% of cases were done as outpatient procedures, 35% of patients required 23hours observation and 26% were hospitalized.

Conclusion: Three instrument modified dome down technique with trocar placement in LUQ is feasible and safe in easy and difficult cases.

 

89.10 Quadrant Localization Of Parathyroid Adenoma; Performance Of 4D-MRI Neck Parathyroid Protocol

Posted on January 26, 2017

K. O. Memeh1, J. Palacios1, M. Guerrero1  1Banner- University Of Arizona Medical Center,Surgery,Tucson, AZ, USA

Introduction:

Accurate pre-operative image localization is useful in selecting minimally invasive parathyroidectomy in patients with primary hyperparathyroidism (PHPT). Sestamibi scan, ultrasound, compted tomography and conventional magnetic resonance imaging (MRI) has varying accuracy in localizing parathyroid adenoma. Our group has shown that 4D MRI is more accurate than conventional imaign in identifying single adenomas. In this study, we set out to determine if 4D-MRI is able to accuratley localize the quadrant (superior or inferior) of the adenoma.

Methods:

We analysed and matched the result of MRI parathyroid protocol of all patients who underwent parathyroidectomy for PHPT at the University Of Arizona Medical Center between Feb 2015 and May 2016 with the intra-operative findings. All resections were confirmed successful with adequate decrease in intraoperative PTH as defined by the Miami criteria.

Results:

A total of 26 patients with PHPT underwent pre-operative localization with 4D-MRI neck. 14 patients had single adenoma and 12 patients had multi- gland disease. MRI accurately distinguished single from multigland disease in 85% of cases.  MRI accurately identifed single adenomas in 100% of patients. MRI was further able to identify the correct quadrant in all patients with single adenoma. However, MRI was only accurate 67% of the time in identifying multi-gland disease, but accurately idenified all (3) double adenoma’s.

Conclusion:
4D MRI accurately identified single and double adenomas in their respective quadrants. However, accuracy in multigland hyperplasia was lower. This study shows that 4D MRI is a usefule imaging modality in single and double gland disease.
 

89.09 NaMELD and Peri-operative Outcomes in Emergency Surgery

Posted on January 26, 2017

E. L. Godfrey2, M. L. Kueht1, A. Rana1, S. Awad3,4  1Baylor College Of Medicine,Department Of Surgery, Division Of Abdominal Transplantation And Hepatobiliary Surgery,Houston, TX, USA 2Rice University,Department Of Bioengineering,Houston, TX, USA 3Baylor College Of Medicine,Department Of Surgery,Houston, TX, USA 4Michael E. DeBakey Veterans Affairs Medical Center,Department Of Surgery/Critical Care,Houston, TX, USA

Introduction:  Recently, the Sodium-Model for End-Stage Liver Disease (NaMELD) score has been shown to be a superior measure of liver disease severity in transplantation, but has not yet been applied extensively in non-transplant surgery.  We aimed to analyze NaMELD scores and outcomes of cirrhotic patients that underwent emergency surgery with the hypothesis that there would be a discrete NaMELD score threshold at which outcomes would be significantly worse.

Methods:  We conducted a retrospective chart review of all patients with cirrhosis who underwent emergency surgery at our institution between January 2001 and April 2013.  Univariate and multivariate regression was used to identify predictors of peri-operative outcomes: 30-day mortality, peri-operative morbidity, and disposition at time of discharge (home or need for transitional care). NaMELD scores were analyzed at 1-unit increments to determine risk thresholds.

Results: 85 patients with cirrhosis underwent emergency surgery. Univariate threshold analysis identified NaMELD risk cutoffs of 19, 17, and 12 for predictors of 30-day mortality (OR=3.44), peri-operative morbidity (OR 3.08), and discharge to home (inverse relationship, OR=0.31), respectively.  Multivariate analysis revealed independent predictors of intraoperative complications to be congestive heart failure (OR=11.65) and serum creatinine (OR=2.25). Independent predictors of morbidity and discharge to home were estimated blood loss in surgery (OR=1.01) and the presence of a post-operative complication (OR=0.21), respectively. When patients were grouped by NaMELD score, most complication types occur more frequently in higher scored groups.

Conclusion: Although emergency surgery in patients with cirrhosis can be life-saving, knowledge of the significant peri-operative risks should drive the discussion with the patient and family.  While further study is needed to develop a definitive threshold of NaMELD scores to predict negative outcomes of surgery in cirrhotics, this analysis shows an NaMELD of 17 is associated with increased peri-operative complications, 19 with higher 30-day mortality, and 12 with increased need for transitional care after discharge.

 

89.08 Preoperative platelet-to-albumin ratio predicts outcome of patients with bile duct carcinoma

Posted on January 26, 2017

N. SAITO1, Y. Shirai1, T. Horiuchi1, H. Sugano1, R. Iwase1, K. Haruki1, Y. Fujiwara1, K. Furukawa1, H. Shiba1, T. Uwagawa1, T. Ohashi2, K. Yanaga1  1The Jikei University School of Medicine,Department of Surgery,Minato-ku, TOKYO, Japan 2The Jikei University School of Medicine,Division Of Gene Therapy, Research Center For Medical Sciences,Minato-ku, TOKYO, Japan

Introduction:  Several studies on bile duct carcinoma have investigated systematic inflammation-based preoperative prognostic indicators such as platelets, albmin and inflammatory mediators. Since inflammation is associated with prognosis, we hypothesized that the Platelet-to-Albmin Ratio (PAR), a novel inflammation-based prognostic score, is associated with long-term survival in patients with bile duct carcinoma after hepatic or pancreatic resection. The aim of this study is to evaluate a prognostic value of preoperative PAR in bile duct carcinoma.?

Methods:  A total of 59 patients who underwent pancreatic resection for bile duct carcinoma were studied. The patients were divided into two groups as PAR ≥ 72.6 x 103 or < 72.6 x 103 on the basis of ROC curve analysis (2-year survival, AUC=0.709 ± 0.08, p=0.002). Survival data were analyzed using the Log-rank test for univariate analysis. Multivariate analysis was performed by Cox proportional regression model with backward elimination stepwise approach.

Results: The PAR was a significant prognostic index on univariate analysis for DFS and OS. The PAR also retained its significance on multivariate analysis for DFS (HR 4.422, 95%CI 1.168 – 16.732, p=0.029) and for OS (HR 6.232, 95%CI 1.283-30.279, p=0.023). On multivariate analysis, in addition, tumor differentiation (HR 2.711, 95%CI 1.279 – 5.747, p=0.009) was an independent risk factor for DFS. For OS, along with PAR, tumor differentiation (HR 3.238, 95%CI 1.349 – 7.771, p=0.009), intraoperative blood loss (HR 1.001, 95%CI 1.000 – 1.002, p=0.036) and serum CEA (HR 6.051, 95%CI 1.484 – 24.669, p=0.041) were independent risk factors by multivariate analysis.

Conclusion: The preoperative PAR is a novel and significant independent prognostic index for DFS and OS in patients with bile duct carcinoma after pancreatic resection.

 

89.07 Incidental Carcinoma in Multinodular Goiter is Associated with Lower Rates of Recurrence

Posted on January 26, 2017

N. Zern1, A. Glover3, A. Aniss2, M. Sywak2, L. Delbridge2, S. Sidhu2  1University Of Washington,Department Of General Surgery,Seattle, WA, USA 2University Of Sydney,Endocrine Surgical Unit,Sydney, NSW, Australia 3Memorial Sloan-Kettering Cancer Center,New York, NY, USA

Introduction: Incidental malignancy after thyroidectomy for multinodular goiter is not rare. This study examines clinical outcomes of patients with incidental carcinoma after thyroidectomy for benign disease. 

Methods: A retrospective review of our thyroid cancer database was performed for years 2000-2015. Patients were analyzed who underwent total thyroidectomy for benign multinodular goiter. Patients were included for analysis as cases without suspected malignancy if preoperative fine needle aspiration was benign, non-diagnostic or not performed, and if final pathology showed an incidental differentiated thyroid carcinoma > 1 cm. Micro-carcinomas were excluded from this study.  These cases were matched to thyroidectomy patients with suspected malignancy based on gender, age and size of tumor. Primary outcome measure was recurrence defined by need for further surgery. 

Results: 71 patients underwent thyroidectomy for benign goiter with incidental carcinoma >1 cm. 72% were female with average age of 54 years at operation. The predominant histology was papillary carcinoma (77%). 27/71 patients (38%) underwent nodal resection. 10/27 (37%) had positive nodal metastases.   Matched controls with preoperatively suspected malignancy (n=137) showed similar histology, however 53/96 (55%) patients who underwent nodal resection had nodal metastases. Follow up was similar between groups (25 vs. 31 months, p=0.1) as was total dose of radioactive iodine therapy (5.6 vs. 5.4 GBq, p=0.8). Significantly more patients required an operation for recurrence in the control group, 11.7% vs. 2.8% (p=.04). 

Conclusion: Incidental thyroid carcinoma in benign multinodular goiter has low rates of recurrence. Standard investigations in these patients failed to yield a diagnosis of cancer preoperatively, likely due to the favorable features of these tumors. The absence of aggressive pathology leads to a better outcome following surgical resection.

 

89.06 "Second-Look” Laparotomy: Warranted, or Contributor to Excessive Open Abdomens?

Posted on January 26, 2017

N. Z. Hansraj1, A. Pasley1,2, D. G. Harris1, J. J. Diaz1,2, B. Bruns1,2  1University Of Maryland,Acute Care Surgery,Baltimore, MD, USA 2University Of Maryland,Trauma,Baltimore, MD, USA

Introduction:  Previous work from our institution illustrates a 28% rate of open abdomen (OA) utilization for emergency general surgery (EGS) patients undergoing laparotomy, with 27% of those left open to facilitate “second-look” (SL). With varying reports on the utility of SL laparotomy, the purpose of the current study is to determine whether EGS OA patients managed with SL laparotomy required additional bowel resection. We hypothesize that many of these SL patients could be managed with single-stage operative therapy and thus decrease the number of OA patients.

Methods:  This is a retrospective review of prospectively collected data from Jun 2013-Jun 2014, evaluating EGS patients managed with an OA who required bowel resection in either index or SL laparotomy. Demographics, co-morbidities, and clinical variables were collected. Indication for resection at SL, complications, and mortality rates were recorded. Charlson co-morbidity index (CCI) was calculated. Fischer exact t-test was used for statistical analysis. 

Results: 96 patients were managed with OA of which 59 (61%) of those underwent bowel resection and 50 (86%) were left in discontinuity. The mean age of the patients undergoing bowel resection was 62y, with 31 males. Comorbidities included prior MI in 10, DM in 22, CKD in 12, and PVD in 26 patients, with mean CCI of 3. The mean time to SL laparotomy was 25-hours. In the 59 patients with OA and bowel resection, 18 (30%) required resection at SL. Of those 18 patients, 60% (11) had questionable areas while 39% (7) had normal appearing bowel at the end of the index operation. Of those 18 requiring resection at SL, 14 had resection at index operation and only 4 did not. At SL laparotomy, 47% (28/59) of the cohort had fascia closed. Further evaluation of causation for resection at SL laparotomy included: evolution of existing ischemia in 6, new onset ischemia in 5, staple line revision in 4, and “other” causes in 3. Preoperative shock at pre-index operation was a predictor of need for further resection. Leaks, dehiscence, and surgical site infections were higher in the SL no resection group, though not statistically significant. The mean length of stay was 32.8 days, with 23 ICU days, and 19 Ventilator days, with no difference between the groups. The Mortality rate in the SL resection group was 50% (9/18) versus 39% (16/41) in the SL no resection group.

Conclusion: As nearly one-third of patients undergoing SL laparotomy required additional resection, with 39% of those having normal appearing bowel at index operation, SL laparotomy appears to be a justifiable indication for EGS OA techniques. 

89.05 Is Screening for Hypercalcemia worthwhile? An Analysis of 1,302,802 Patients

Posted on January 26, 2017

S. J. Baker1, C. Baletine1, R. Xie1, H. Edenfield1, H. Chen1  1University Of Alabama,Surgery,Birmingham, AL, USA

Introduction:  Laboratory screening and identification of pathology at earlier stages can prevent disease progression, reduce surgical risks, and potentially improve overall outcome. Despite the potential benefits of early screening, the effectiveness is dependent upon the disease incidence and the availability of the test.   Lack of access to care restricts early screening in certain socially disadvantaged populations. This study examined disparities in routine serum calcium screening and the incidence of hypercalcemia within a health system where racial minority groups are adequately represented.   

Methods:  :  All patients at a large academic health center with several hospitals and outpatient clinics during 2011-2015 were included.  Demographic and laboratory data in the Electronic Medical Record (EMR) systems were analyzed to assess the calcium screening rates and incidence of hypercalcemia by age, gender, race, and insurance type. One way frequency, chi-square test of independence and multivariable analyses were conducted. 

Results: In this 5 year period, 1,302,802 patients were evaluated, including 379,021 African Americans (28%), 20,398 Hispanics (2%), 13,022 Asians (1%), 762,915 Caucasians (59%), and 127,446 other ethnicities (10%). Of these patients, 577,994 (48%) had at least one serum calcium level recorded.  Older age, male, black, and covered by Medicare are significantly associated with higher calcium screening rates. The screening rate in patients older than 65 was 57% versus 45% ( in their counterpart. Males had higher screening rate than female (51% vs. 46%).  African Americans were more likely to have a serum calcium level drawn (52%) versus Caucasians (48%), Asians (44%), and Hispanics (35%;).  In addition, patients with Medicare were most likely to have calcium level screening (56%), followed by private insurance (48%), Medicaid (34%), and uninsured (20%).  The overall incidence of hypercalcemia was 2.2%, ranging from 0.9% in Asian males to 2.8% in African American females (see Table).

Conclusion: Significant disparities in laboratory testing exist within a large population cohort. Despite this, the incidence of hypercalcemia is relative low, suggesting that routine screening of any group of patients is likely not cost effective.

 

89.04 Characterizing Early Postoperative Hospital Readmissions Following Bariatric Surgery

Posted on January 26, 2017

K. Levene1, M. Bai2, A. Suzo1, R. Dettorre1, B. Needleman1, S. Noria1  1Ohio State University,Division Of General And Gastrointestinal Surgery,Columbus, OH, USA 2Ohio State University,College Of Medicine,Columbus, OH, USA

Introduction:  Readmission rates are a performance metric in the Pay for Performance model, implemented by the Centers for Medicare and Medicaid Services, which have an effect on hospital reimbursement and hospital ranking. Hospital readmissions, during the early postoperative period after bariatric surgery, range from 5% – 20%, and are predominantly related to poor pain control, nausea, vomiting, dehydration and wound infections. Based on this, we sought to characterize factors related to readmission at our institution to identify actionable targets to reduce rates.

Methods:  A retrospective review was conducted on patients who underwent primary Roux-en-y gastric bypass (RYGB) and sleeve gastrectomy (SG) at The Ohio State University from July 2014 to February 2016.  We included all patients treated according to our standard Care Coaching model throughout their index admission and subsequently readmitted prior to their first postoperative clinic visit.  Variables reviewed included age, gender, ethnicity, co-morbidities, BMI, hospital length of stay, days to readmission, cause for readmission, number of readmissions, postoperative BMI, and insurance status.

Results: From July 2014 to February 2016, 477 patients underwent primary RNYGB or SG. Of these patients, 32 (6.7%) were readmitted (53% RYGB, 47% SG). Within the readmitted cohort, 84% were female, and 78% were Caucasian. Average age and BMI was 41.7 years, and 47.47 kg/m2, respectively. The average length of stay for the index admission was 2.9 ± 1.1 days. The time to readmission was 6.56 ± 4.8 days. Of note, 41% of readmitted patients were covered by Medicaid/Medicare, while 59% had commercial insurance. No self-pay patients were readmitted. Interestingly, breakdown of insurance coverage for patients who undergo surgery demonstrated 14.5% Medicare/Medicaid, 83.2% commercial insurance and 2.3% self-pay. Primary complications leading to readmissions included, nausea/vomiting/dehydration (28%), pain (22%), and surgical site infection (19%).  Nine percent of readmitted patients were readmitted a second time.

Conclusion: At our institution, rates for primary RYGB and SG fall within the national average. However, despite the implementation of the OSU Care Coaching model, our standardized post-operative care pathway, the readmission rate for Medicare/Medicaid beneficiaries is high given they comprise only 14.5% of the total number of patients having surgery. Therefore, future endeavors will include a more in-depth analysis of our Medicare/Medicaid beneficiaries to assess the gaps in care which, in turn, will be integrated into a program of individualized pre- and post-operative preparation with clear recovery expectations. Ultimately, integration of a care-navigator for Medicare/Medicaid beneficiaries may help overcome obstacles to recovery and decrease readmission rates in this patient population.

 

89.03 Outcomes of Surgical Repair for Perforated Peptic Ulcer Disease among the Elderly: A NSQIP Analysis

Posted on January 26, 2017

V. T. Daniel1, J. T. Wiseman1, J. Flahive1, H. P. Santry1  1University Of Massachusetts Medical School,Department Of Surgery,Worcester, MA, USA

Introduction: The management of perforated peptic ulcer disease (PUD) has drastically evolved over the last fifty years due to the advances in medical treatment. Despite medical management resulting in fewer elective surgical repairs, the number of emergent surgical repairs have risen. Furthermore, as the elderly population increases, the demographics of patients requiring emergency general surgery has shifted to an older cohort. Although hospitalizations for PUD are now among older adults compared to younger adults twenty years prior, contemporary national data evaluating operative outcomes for open surgical repair for perforated PUD among the elderly are lacking.  

 

Methods: With use of the National Surgical Quality Improvement Program (2007-2012), patients 65 years and older who underwent open surgical repair for perforated PUD were evaluated. The primary outcome was 30-day mortality. Secondary outcomes were 30-day postoperative complications. Univariate and multivariable regression analyses were performed.

 

Results: Overall, 1422 patients 65 years and older underwent open surgical repair for perforated PUD. At the time of the operation, 19.3% were current or recent tobacco users and 9.2% required steroid use. Mean (± Standard Deviation) total hospital length of stay was 14 days (± 16). The most common postoperative complications were pneumonia (11.4%), septic shock (11%), and superficial site infection (5.1%) The overall 30-day mortality rate was 18.1%. After adjustment for other factors, 30-day mortality was significantly associated with postoperative pneumonia (odds ratio [OR], 2.71; 95% confidence interval [CI], 1.48-4.98; P =.001), higher American Society of Anesthesiologists classification (OR, 2.59; 95% CI, 1.67-4.02; P <.0001), postoperative ventilator dependence (OR, 4.89; 95% CI, 2.91-8.14; P <.0001), and postoperative septic shock (OR, 5.07; 95% CI, 2.85-9.03; P < .0001).

 

Conclusions: At U.S. hospitals, open surgical repair for perforated PUD among the elderly is associated with significant 30-day morbidity and mortality rates. As the U.S. population ages, preoperative risk stratification strategies should focus more on the age of the patient given the high mortality rates among the elderly. 

 

89.02 Can Local Anesthetics Decrease the Use of Postoperative Narcotics in Outpatient Hernioplasty?

Posted on January 26, 2017

T. DiNitto1, D. Hill1, K. Khariton1, M. Castellano1  1Staten Island University Hospital,Northwell Health,Staten Island, NY, USA

Introduction:

Prescription narcotic misuse is an epidemic in the United States. This study set out to examine whether liposomal bupivacaine (Exparel), 0.25% bupivacaine (Marcaine), or 1% lidocaine with epinephrine mixed with 0.25% bupivacaine would decrease the postoperative use of narcotics in ambulatory hernioplasty.

Methods:

A single surgeon performed 427 consecutive tension-free plug and patch mesh hernia repairs under local anesthesia with IV sedation from April 1, 2015 to December 31, 2015. Hernia repairs included inguinal, ventral, incisional, and umbilical. In 9.3% of cases two hernias were repaired during the same procedure. Every patient was seen between six and eleven days post hernioplasty and a standardized pain questionnaire was completed regarding subjective pain, prescription “painkiller”, and over the counter pain medication use in both quantity and duration. The primary endpoint was percentage of patients not requiring narcotics for pain control.

Results:

The Exparel group (147) and the Marcaine group (144) had similar results at 59% and 55% of patients who were able to avoid postoperative narcotics completely. The commonly used lidocaine with epinephrine/Marcaine mixture had only 39% success rate, significantly lower than the other groups.  Included in the study were patients that had two simultaneous hernia repairs where the exparel group only had 5.4% with 14% in the Marcaine.

Conclusion:

Our study demonstrates Exparel and Marcaine performed similarly reducing the need of postoperative narcotic use in outpatient hernia surgery by over 50%.  Both were a considerably better option than the Lidocaine/Marcaine mixture. The average cost difference between Exparel and Marcaine is exponential, with a difference of over 200 dollars per patient. Marcaine provides a significant cost benefit while achieving similar if not better postoperative pain relief and reduces postoperative narcotic use. Because of the similar outcome in pain control as well as the cost benefit, Marcaine has become the standard of care in our hernia center.  

89.01 Where You Live Matters: Regional Differences in Outcomes After Percutaneous Cholecystostomy

Posted on January 26, 2017

A. E. Hozain1,2, P. J. Chung1,2, M. C. Smith1,2, V. Roudnitsky2, A. E. Alfonso1, G. Sugiyama1  1State University Of New York Downstate Medical Center,Department Of Surgery,Brooklyn, NY, USA 2Kings County Hospital Center,Department Of Surgery,Brooklyn, NY, USA

Introduction:
With over 200,000 cases per year, acute cholecystitis is one of the most frequent causes for admission to hospitals and management by general surgeons. Percutaneous cholecystostomy is an increasingly used treatment for patients diagnosed with acute cholecystitis, who are otherwise too ill to undergo cholecystectomy. Given these patients’ significant comorbidities, a retrospective analysis to determine predictors of mortality was performed using the Nationwide Inpatient Sample (NIS).

Methods:
The Nationwide Inpatient Sample (NIS) from 2005 – 2012 was sampled. Inclusion criteria included patients with a diagnosis of acute cholecystitis by ICD 9 code (574.0, 574.00, 574.01, 575.0, 575.12) who underwent percutaneous cholecystostomy (51.01). We excluded patients with a diagnosis of acalculous cholecystitis (575.10), patients age < 18 years, and cases where gender, race, weekend admission, and month of admission data were missing. For each case, we computed the Elixhauser-Van Walraven score for comorbidity status. Multiple imputation was performed for missing data. We then performed multivariable logistic regression analysis with inpatient mortality as the primary outcome variable. Age, gender, race, insurance status, income status, hospital size, hospital type, geographical region, weekend admission, month of admission, and Elixhauser-Van Walraven score were used as risk variables.?

Results:
8,299 patients were included in this study. 785 (9.46%) patients died during the hospital admission. After adjusting for the risk variables, predictors for inpatient mortality included age (OR 1.16 [1.00 – 1.34 95% CI], p = 0.0492), receiving care in an urban non-teaching hospital (OR 1.27 [1.08 – 1.50 95% CI], p = 0.0169), female gender (OR 1.30 [1.12 – 1.52 95% CI], p = 0.0006), and the Elixhauser-Van Walraven score (OR 2.13 [1.93 – 2.36 95% CI], p < 0.0001). There was a decreased risk of death for patients receiving care in the Midwest (OR 0.74 [0.59 – 0.94 95% CI], p = 0.0357) and West (0.78 [0.63 – 0.98 95% CI], p = 0.0357) compared to the Northeast.

Conclusion:

Adjusting for multiple variables, receiving treatment within the Midwest and Western regions of the United States was independently associated with a decreased risk of mortality in patients undergoing percutaneous cholecystostomy. Risk factors associated with increased mortality include age, female gender, Elixhauser-Van Walraven comorbidity score and urban, non-teaching hospitals. To improve outcomes nationally, models looking at practice differences between regions may further elucidate significant differences in quality or process of care.  

88.20 Depression Increases Amputation and Mortality Risk in Patients with Peripheral Arterial Disease

Posted on January 26, 2017

S. Lee1, A. Khakharia1, Z. O. Binney1, G. Zahner2, M. S. Grenon2, S. Arya1,3  1Emory University School Of Medicine,Vascular Surgery,Atlanta, GA, USA 2University Of California – San Francisco,Vascular Surgery,San Francisco, CA, USA 3Atlanta VA Medical Center,Surgery Service,Decatur, GA, USA

Introduction: As a multi-system illness, peripheral arterial disease (PAD) affects many areas of patients’ lives, including their mental health. Recent studies have associated depression with increased risk of PAD. The link between PAD outcomes and depression has however yet to be fully defined. In this study, we examined the effects of comorbid depression on amputation rate and mortality in the Veteran Affairs (VA) population.

Methods: Patients with PAD in the VA database were identified (2003-2014) using a validated algorithm. The diagnosis of depression was defined using 2 outpatient diagnosis codes for depression within 14 months or one inpatient primary diagnosis code of depression (ICD-9 codes 296.2, 296.3, 300.4 and 311). Outcomes were amputation risk and overall mortality at 1, 3, and 5 years. Kaplan-Meier analysis was used to assess time to amputation. A Cox proportional hazards model was used to assess the effect of depression on amputation and mortality adjust for covariates, including age, gender, race, social economic status, comorbidities, cholesterol levels, creatinine, and medications.

Results: In 208,194 patients with PAD, depression was present in 15.2% of the cohort, with occurrence of 14,981 major amputations and 99,870 deaths [Median follow up 5.2 yrs]. Bivariate comparisons showed increased risk of amputation at 1, 3 and 5 years for patients with depression (4.6% vs 3%, 7.3% vs 5.1% and 10.3% vs 7.3% respectively; p<0.0001 for each group). Mortality was also similarly higher in patients with depression at each time point (7.2% vs 6.2%, 22.4% vs 20.0% and 38.3% vs 33.5% respectively; p<0.0001 for each group). On Kaplan-Meier analysis, patients with depression had more amputations earlier in the disease course than patients without depression [Figure 1] but did not have an increased risk of mortality after accounting for censoring [Figure 2]. In the Cox model, depression was associated with a 16% higher amputation risk as compared to patients with no underlying depression [HR 1.16; 95% CI (1.11, 1.22)].  Depression was also associated with increase in overall mortality of 17% [HR 1.17; 95% CI (1.14, 1.19).

Conclusion:PAD patients with depression have a significantly higher risk of amputation and mortality than patients without depression. These results suggest that concomitant depression in PAD contributes to morbidity and mortality of these patients and could possibly be a target for intervention.

 

88.19 Feasibility of an Image-Based Mobile Health Protocol for Postoperative Wound Monitoring

Posted on January 26, 2017

R. Gunter1, S. Fernandes-Taylor1, S. Rahman1, L. Awoyinka1, K. Bennett1, C. Greenberg1, K. C. Kent2  1University Of Wisconsin,Wisconsin Institute Of Surgical Outcomes Research,Madison, WI, USA 2University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction:
Surgical site infection is the most common nosocomial infection and a leading cause of unplanned hospital readmission among surgical patients. Many of these infections develop in the critical interval between hospital discharge and routine follow-up. If diagnosed at an early stage, SSI can often be treated in the outpatient setting. However, patients rarely recognize early stage wound infections causing them to present with an advanced infection requiring rehospitalization or operative reintervention. An intervention to prevent these catastrophic consequences would represent a substantial improvement in patient care. To address this, we developed and pilot tested a mobile health application (app) and protocol of remote wound monitoring using smartphones for vascular surgery patients at a large tertiary care academic institution.

Methods:
We are currently recruiting 40 patients following vascular surgery. Eligible patients are 18 years of age or older with an incision at least 3 cm in length. Patients participate in a training session to learn to use the iPhone and the wound monitoring app. Following hospital discharge, patients send digital images of their wound and responses to a short survey daily for two weeks. Experienced healthcare providers on the vascular surgery service review these submissions daily and contact patients for any concerning findings. We will present final results, if accepted.

Results:
Since June 2016, 89 patients have been screened, 41 of whom were eligible for participation. Twenty-eight have consented to participate and been enrolled (68% consent rate). Fifty-four percent of participants were novice smartphone users. Participants completed training in an average 16.5 minutes, with an average system usability score of 85.2 (scale 0-100). Fifty-five percent of participants submitted data every day, with an average of 1 day missed per participant. A provider reviewed submissions an average of 9.4 (range 0.1-51.6) hours after submission. Review took an average 2.3 (range 1-33) minutes per patient, with an average total 7.9 (range 1-39) minutes per day. Three participants were readmitted, two of whom fell on amputation stumps. Two early wound infections were detected using submitted images and treated on an outpatient basis; no wound infections developed undetected in monitored sites. Patient satisfaction has been universally high upon completion.

Conclusion:
Vascular surgery patients and their caregivers are willing to participate in a mobile health program aimed at remote monitoring of postoperative recovery, and they are able to complete the program with a high level of fidelity and satisfaction. Such a program is easily integrated into existing service lines and does not add a significant clinical burden. Preliminary results indicate the ability to detect and intervene on wound complications at earlier stages and prevent hospital readmission and potentially catastrophic wound complications.

88.17 Examining the Impact of Hospital Transfer in Patients with Isolated Lower Extremity Vascular Trauma

Posted on January 26, 2017

C. McDaniel1, N. Samra1, B. Hu2, W. Zhang1, T. Tan1  1Louisiana State University Health Sciences Center, Shreveport,Vascular And Endovascular Surgery,Shreveport, LA, USA 2Cleveland Clinic,Cleveland, OHIO, USA

Introduction:
Care of patients with vascular trauma often poses complex challenges that prompt transfer to higher-level trauma centers. We seek to investigate the impact of hospital transfer on the outcomes of patients with isolated lower extremity vascular injuries.

Methods:
A retrospective review of the National Trauma Data Bank (2007-2014) was performed to identify patients with isolated lower extremity vascular injury. Bivariate analysis was used to compare patient characteristics and outcomes between those transferred into level I centers and patients treated at non-level I trauma centers. Multivariable logistic regression was used to examine association between hospital transfer and outcomes, as well as factors associated with fasciotomy.

Results:
Among 2,698 with lower extremity vascular trauma included in the study, 35% (956) were transfer to level I trauma centers and 65% (1,742) were treated in non-level I centers. Overall amputation rate was 12% and fasciotomy rate was 35%, and were similar between two cohorts (Table 1). Although there were no significant impact on mortality or amputation rates, hospital transfer was associated with increased risk of fasciotomy (OR 1.3, 95% CI 1.1-1.6, p=.002) in patients with lower extremity vascular injuries. Other factors associated with fasciotomy were open surgery (OR 1.8, 95% CI 1.4-2.2,p<.001), venous (OR 1.5, 95% CI 1.1-2.0,P=.02) and nerve injury (OR 2.7, 95% CI 2.2-3.2,p<.001).

Conclusions:
Hospital transfer was associated with increased risk of fasciotomy that might be secondary to potential delay in care in patients with lower extremity vascular injuries.

 

88.16 Brachial Vein Arteriovenous Graft: Approach From Small Outflow Vein To A Large Diameter Vein

Posted on January 26, 2017

P. Sanchez1, J. C. Duque1, g. klimovich2, H. Labove4, L. Martinez2, R. Vazquez-padron2, L. Salman3, M. Tabbara2  1University Of Miami,Medicine,Miami, FL, USA 2University Of Miami,Surgery,Miami, FL, USA 3University Of Miami,Interventional Nephrology,Miami, FL, USA 4University Of Miami,Miller School Of Medicine,Miami, FL, USA

Introduction:

Arteriovenous Grafts are created in the arm when there are no adequate veins for a fistula. The outflow vein is usually the axillary vein in order to match the outflow to a 6-8mm graft. Our technique involves using a 3.5-4 mm brachial vein and create a preliminary mid arm brachial artery to brachial vein arteriovenous fistula. This is followed with a graft extension involving ligation of the fistula and using the dilated, mature vein as the outflow in an end-to-end anastomosis.  

Methods:
The study included 92 patients who underwent a Brachial- Brachial Arteriovenous Graft creation at the University of Miami or Jackson Memorial Hospital from 2008 to 2015. The effects of primary graft survival were determined using multivariate logistic regressions and Cox proportional hazard models adjusted for clinical and demographic covariates (age, gender, ethnicity, hypertension, diabetes, antiplatelet agents, statins, prior catheter use, history of previous AVF and graft size). 

Results:

Neither primary nor secondary graft survival was significantly correlated with clinical and demographic covariates.  Primary failure at one year (365 days) was 55.4% (51 patients) with a mean survival of 283 (±128) days. The most common intravascular intervention in primary graft survival was balloon angioplasty in 32 (64.0%), followed by thrombectomy 11 (22.0%) and finally surgical revision 7 (14.0%).     

Conclusion:

Our results suggest that the technique of a brachial vein fistula, followed by graft extension can result in a durable access and preserves the axillary vein for future grafts.

 

88.15 Assessment of Ventricular Mass Changes after Arteriovenous Fistula Banding in Hemodialysis Patients

Posted on January 26, 2017

J. C. Duque1, C. Cortesi1, A. Dejman3, L. martinez2, r. vazquez-padron2, L. salman4, m. tabbara2  1University Of Miami,Medicine,Miami, FL, USA 2University Of Miami,surgery,Miami, FL, USA 3University Of Miami,Nephrology,Miami, FL, USA 4University Of Miami,Interventional Nephrology,Miami, FL, USA

Introduction:

Cardiac remodeling and left ventricular hypertrophy are relatively common complications seen in patients with advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD) ranging from 32 to 75% and 27 to 58%, respectively. Arteriovenous fistula (AVF) for hemodialysis has been traditionally implicated as one of the main factors related to cardiovascular stress and subsequent remodeling. 

Methods:

We retrospectively reviewed AVF banding procedures performed at University of Miami Hospital /Jackson Memorial Health System between Jan 1st 2009 and Dec 31st 2014. Demographic data, patient´s comorbidities, AVF type and 2D-Echocardiogram done before and after banding with a minimum interval of 6 months from the procedure were analyzed. 

Results:
From at total of 74 patients who underwent AVF banding, 24 had 2D-Echocardiogram performed before and after the banding; 33 patients had a 2D-Echocardiogram done before and 38 had it after the procedure. The interval time between the 2 sonograms was 1108.9 (±628) days, 651.8 (±484) days before and 457.0 (±365) days after the surgical banding. The mean age at the time of the procedure was 55 (±12); hypertension was present in 95.8% of the patients, coronary artery disease 41.6% and diabetes mellitus 62.5%. Brachio-basilic AVF was the most common vascular access in 62.55% of the patients, followed by brachio-cephalic in 29.1% and radio-cephalic in 8.3% of the patients. Left ventricular mass calculated by (LVmass(ASE): 0.8 (1.04 ([LVIDD + PWTD + IVSTD] 3 – [LVIDD] 3 ))+ 0,6 g) was 202.8 (±78) before the surgical banding and 216.8 (±82) after the banding with a p value: 0.5591. (Normal LV mass 90 – 117).

Conclusion:

We found statistical significance supporting that patients with ESRD who underwent AVF surgical banding have minimal changes or left ventricular mass restitution after the procedure and likely the hypertrophic changes are related to non-surgical factors.

88.13 Human Immunodeficiency Virus effect on Hemodialysis Arteriovenous Fistulas Remodeling Outcomes

Posted on January 26, 2017

A. Dejman1, J. C. Duque2, L. Martinez3, L. Salman4, R. Vazquez-Padron3, M. Tabbara3  1University Of Miami,Nephrology,Miami, FL, USA 2University Of Miami,Medicine,Miami, FL, USA 3University Of Miami,Suergery,Miami, FL, USA 4University Of Miami,Interventional Nephrology,Miami, FL, USA

Introduction:
Arteriovenous fistulas (AVF) for hemodialysis in ESRD patients is the preferred vascular access type and it currently remains to be one of the areas under profound research given the high rates of failure, complications and cost burden for the health system. Multiple advances in vascular diseases in HIV patients independent to hemodialysis accesses have been reported. One remarkable connotation is the role of the HIV virus and the direct effect in the vessel wall, in which some authors have shown that these patients have a higher incidence of cardiovascular illnesses with elevated morbidity and mortality and poor vascular outcomes. Unfortunately, the impact of the Human Immunodeficiency Virus (HIV) in the AVF remodeling and outcomes is not well known.

Methods:
This retrospective study assessed the impact of HIV infection on one-stage and two-stage hemodialysis AVF outcomes. The study included 494 patients but only 42 patients were HIV positive. All of them underwent an AVF creation at the University of Miami/Jackson Memorial Hospital from 2008 to 2014. The effects of HIV on primary failure were determined using multivariate logistic regressions and Cox proportional hazard models adjusted for 10 clinical and demographic covariates.

Results:

Primary failure was not correlated with clinical including medications and demographic covariates, but population was relatively younger than controls. Patients with diagnosis of HIV had a positive correlation with AVF primary failure (p=0.004) no mater the anastomosis type. Patients with HIV and history of previous AVF had association with primary failure (p=0.002). Moreover different access such as Tunneled dialysis catheters showed correlation with primary failure (p=0.012)  A T-cell subset including  (CD3, CD4, or CD8)  did not show any association with primary failure. 

Conclusion:

Our results suggest that HIV immunosuppression may play a role in AVF outcomes specially primary failure. HIV infection relates to increased rate of AVF primary failure, but this is not explained by the T-cell subset counts and  there should be a different immunological relationship between AVF failure and vascular remodeling.

 

88.12 The Role of Inferior Vena Cava (IVC) Filters in Robotic Gastric Bypass Procedures

Posted on January 26, 2017

N. J. Gargiulo1, N. Cayne2, E. Lipsitz3, G. Landis4, F. J. Veith2  1Cinch Valley Medical Center,Vasclar Surgery,Richlands, VIRGINIA, USA 2New York University School Of Medicine,New York, NY, USA 3Albert Einstein College Of Medicine,Bronx, NY, USA 4North Shore University And Long Island Jewish Medical Center,Manhasset, NY, USA

Introduction:  It has been previously suggested that inferior vena cava (IVC) filter placement at the time of open gastric bypass in patients with a body mass index (BMI) > 55 kg/m2 reduces both the pulmonary embolism rate and perioperative mortality.  This has not been observed in patients undergoing laparoscopic gastric bypass.  Little is known regarding the necessity of IVC filter placement in patients undergoing robotic gastric bypass surgery.

Methods:  Over a 3 year period, 51 morbid obese patients have undergone robotic gastric bypass procedures, and 37 (72.5%) had a BMI > 55 kg/m2.  All 51 patients had routine preoperative subcutaneous lovenox injections and systemic compression devices prior to the administration of general anesthesia.  Robotic gastric bypass was completed utilizing the da Vinci system.
 

Results: Fifty of 51 (98%) patients remained free of thrombo-embolic phenomena over the 3 year period (range 6 months-3 years) following successful robotic gastric bypass with the da Vinci system.  One patient (2%) with a BMI > 55 kg/m2 developed a pulmonary embolism (PE) 1 month post procedure.  She was treated  successfully with intravenous heparin and had complete resolution of the PE.  She was incidentally diagnosed with a Factor V Leiden deficiency and placed on long-term oral anticoagulation.
 

Conclusion: It appears that IVC filter placement at the time of robotic gastric bypass is not required even in patients with a BMI > 55 kg/m2.  A note of caution should be exerted in those obese patients who have a hypercoagulable disorder.  An aggressive posture should be advocated in this small sub-group of morbid obese patients which may consist of immediate anticoagulation (when it is deemed safe) following their procedures.  

 

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