50.18 Management of Rib Fracture Patients: Does Obesity Matter?

Posted on January 18, 2018

A. Lichter1, F. Speranza1, W. Rebekah1, P. Parikh1, R. Markert1, G. Semon1  1Wright State University,Dayton, OH, USA

Introduction: Obesity has been on the rise in recent decades and has created a significant burden on health care. Obesity plays significant role in presentation and management of trauma patients, including management of pneumonia in polytrauma patients. However, role of obesity has not been evaluated for chest trauma patients with rib fractures.  This study, aims to determine its impact and management of patients who sustain rib fractures as a result of a traumatic incident.

Methods: This study was approved by Wright State University’s IRB.  All adult trauma patients who sustained blunt chest wall trauma causing rib fractures and were presented at our Level 1 Trauma Center from 2013-2014. were included in the study. All the patients who survived less than 48 hours, had penetrating injuries to the chest, or had a concomitant head injury were excluded.  Obesity was defined as a body mass index (BMI) of ≥30.  Both obese and non-obese groups were compared using Pearson Chi-Square test for categorical variables and Man-Whitney U Test for continuous variables. We compared both these groups after adjusting for Injury Severity Score (ISS) using logistics regression when the assumptions for this test are met.  

Results:  213 patients met the inclusion criteria with an average 3.6 ribs fracture. Consistent with the national average, 64 (30.6%) were obese. Both obese and non-obese groups of patients did not differ in age (61.6 vs. 59.9, p=0.89).  Obese patients had higher ISS (17.0 vs 13.9, p=0.05), and significantly higher ventilator days (2.1 vs. 1.2, p=0.003), ICU Length of Stay (LOS) (3.3 vs. 1.9, p=0.004), and total hospital LOS (9.6 vs. 6.0, p=0.019) than non-obese group, however, the mortality was not significantly different (p=0.37).  Since ISS was higher in obese group, we controlled for ISS and determined that the obese patients were more likely to require mechanical ventilation both before and after controlling for ISS (34.4% vs. 16.1%, p=0.003).

Conclusion:  Rib fractures remain an important focus in obese patients admitted to trauma centers since they are at increased risk for requiring mechanical ventilation and has worse outcomes, although overall mortality is not affected. Rib fracture protocols that focus on increased pain control, aggressive pulmonary toilet regimens and possible early surgical intervention need to be further investigated specifically in obese patients to decrease the associated morbidity and improve outcomes.

50.19 Predictors of 30 Day Readmission Following Percutaneous Cholecystostomy

Posted on January 18, 2018

M. Fleming1, Y. Zhang2,3, F. Liu2,4, J. Luo2, K. Y. Pei1  1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA 2Yale University School Of Medicine,Section Of Surgical Outcomes And Epidemiology, Department Of Surgery,New Haven, CT, USA 3Yale School Of Public Health,Department Of Environmental Health Services,New Haven, CT, USA 4Beijing 302 Hospital,Beijing, FENGTAI QU, China

Introduction:
High risk patients undergoing cholecystectomy may experience increased morbidity and mortality. Consequently, percutaneous cholecystostomy (PC) has been utilized as a treatment option for acute cholecystitis in this cohort of patients.  Little is known about incidence of and predictive risk factors for readmission following PC; therefore, we sought to determine predictors of readmission after PC.

Methods:
Patients who had PC from 2013-2014 were identified from the National Readmission Database (NRD) by the Healthcare Cost and Utilization Project (HCUP). A 30-day readmission was defined as a subsequent admission within 30 days following the first admission discharge date. Multivariate logistic regression models using stepwise selection were employed to select significant predictive variables. 

Results:
A total of 3,368 patients were identified with 698 (20.7%) readmissions during the study period. Severity of illness directly correlated with readmission risk at 30 days (moderate loss of function OR 1.60 95% CI 1.11 – 2.30, major loss of function OR 1.76 CI 1.23 – 2.52, extreme loss of function OR 2.37 CI 1.62 – 3.46). Additionally, alcohol use (OR 1.45 CI 1.02 – 2.07), congestive heart failure (CHF, OR 1.26 CI 1.01 – 1.57), depression (CI 1.42 OR 1.08 – 1.86), metastatic cancer (OR 1.56 CI 1.05 – 2.30) and peripheral vascular disease (OR 0.73 CI 0.54 – 0.99) were closely correlated with risk for readmission at 30 days. Uncomplicated diabetes (P = 0.05), hypertension (P = 0.93), obesity (P = 0.61), and renal failure (P = 0.47) were not correlated with risk for readmission.

Conclusion:
Percutaneous cholecystostomy has become a crucial tool for the acute care of high risk patients with cholecystitis. However, a significant proportion of patients are readmitted within 30 days following discharge. These patients may benefit from increase care coordination services starting at their index admission and increased communication with the clinical team once the patient is discharged.  Additional studies are needed to determine optimal timing to interval cholecystectomy.

50.15 Robotic Inguinal Hernia Repair: An Academic Medical Centers Experience with First 200 Cases

Posted on January 18, 2018

V. Tam1, J. Borrebach2, S. Dunn2, J. Bellon2, H. Zeh1, M. E. Hogg1  1University Of Pittsburgh Medical Center,Division Of Surgical Oncology,Pittsburgh, PA, USA 2University Of Pittsburgh Medical Center,Wolff Center At UPMC,Pittsburgh, PA, USA

Introduction:
Over the past 5 years, robotic surgery has acquired an increasing share of general surgery cases. Robotic inguinal hernia repair has been shown to be safe and feasible by single surgeons in small case series, but no studies have assessed the safety and efficacy of robotic inguinal hernia repairs by multiple surgeons across multiple centers. We aimed to evaluate the outcomes of the early experience of over 200 consecutive robotic inguinal hernia repairs performed in an academic multi-hospital system.

Methods:
Consecutive robotic inguinal hernia repairs performed between 12/2015 and 3/2017 were analyzed. Retrospective chart review was performed to collect information pertaining to pre-operative patient characteristics and post-operative outcomes. Hospital records were queried for intra-operative information and readmission records. Descriptive statistics were performed to analyze the cohort.

Results:
Over 15 months, 210 robotic inguinal hernia repairs were performed across 7 hospitals by 16 surgeons. The mean patient age was 57.6 (SD 14.1) years, 91.9% were male, and the mean BMI was 26.8 (SD 4.4). Bilateral hernia repairs were performed on 72 (34.3%) patients. Incarceration was present in 13 (6.3%) patients, 29 (14.3%) had a reoperation for a recurrent hernia, and 46 (23.1%) had a history of any previous abdominal surgery. The mean operative time was 102.3 (SD 38.6) minutes and a resident or fellow trainee was present in the operating room for 87 (41.4%) cases. The only two intra-operative complications reported were a sigmoid serosal tear and one case of excessive blood loss. There were no conversions to open or reoperations. Follow-up was available for 145 (69.0%) patients at a mean length of 17.6 (SD 5.9) days. Minor post-operative complications occurred in 33 (15.7%) patients, including 10 (4.8%) with urinary retention and 9 (4.3%) with scrotal swelling. Of 11 (5.2%) patients who visited the emergency room visit for a procedure-related complication within 10 days after discharge, no patients required readmission. 

Conclusion:
In the largest case series of robotic inguinal hernia repairs to date, early experience in an academic multi-hospital system with resident and fellow trainees produced safe outcomes including no open conversions, reoperations, or readmissions. Rates of minor complications were comparable to those reported for laparoscopic and open surgical approaches. 
 

50.16 Automating Post-Operative Care through Patient-Centered Short Message Service (SMS)

Posted on January 18, 2018

S. C. McGriff1, D. Kumar1, P. R. Moolchandani1, M. K. Hoffman2, M. A. Davis2, J. W. Suliburk2  1Baylor College Of Medicine,Houston, TX, USA 2Baylor College Of Medicine,Michael E. DeBakey Department Of Surgery,Houston, TX, USA

Introduction:  Studies have found that in-person postoperative care for low risk operations is both costly for patients and system and not always necessary. Using text messages could be an inexpensive, patient-centered, and safe method to screen patients for complications. We conducted a study to determine the feasibility of using an automated text message system as a screening tool for need for in-person postoperative follow-up.

Methods:  Patients who underwent a laparoscopic operation for non-complicated appendicitis or cholecystitis were recruited and enrolled into the study on day of discharge. The study population was polled to determine preferences for frequency and time of text messaging. Subjects received text messages tailored for patient-centered screening of warning signs of post-operative complication. If screened positive, the participant’s physician was notified. Participants were asked patient satisfaction questions.

Results: During a 5-month period, 44 patients were screened, 39 patients were enrolled: 24 following cholecystectomy operations and 15 following appendectomy operations; 18 received text messages in English and 21 received text messages in Spanish. 2 participants were readmitted with a complication and both were successfully identified by the automated system. 15% of participants elected to cancel their follow-up appointment. 74% of participants with scheduled follow-up appointments attended their appointment. Participant response rate to text messages for the first 10 days following discharge is summarized in Table 1. Of the participants completing the study, 96% indicated they would use the automated text messages again.

Conclusion: This pilot study has shown that an automated text message system as a screening tool for post-op complication is feasible and safe in a safety-net population. Our system was able to capture progression of relevant symptoms of participants and notify the participant’s physician when warning signs were detected. Furthermore, participants would use the text message system again. Given inconsistent response data, there is opportunity for improvement in patient engagement with the communication system. A larger implementation is warranted to demonstrate clinical utility and cost effectiveness.

 

50.13 The Early Impact of Medicaid Expansion on Insurance Coverage for General Surgery

Posted on January 18, 2018

A. S. Chiu1, R. A. Jean1, J. Ross2, K. Y. Pei1  1Yale University School Of Medicine,Surgery,New Haven, CT, USA 2Yale University School Of Medicine,Internal Medicine,New Haven, CT, USA

Introduction:
In 2014, the expansion of Medicaid under the Affordable Care Act allowed states to extend Medicaid benefits to adults with incomes less than 138% of the federal poverty level. Although the Supreme Court ruled that states could opt out of Medicaid expansion, 26 states and the District of Columbia expanded Medicaid eligibility in 2014, with five more states subsequently doing the same. Medicaid expansion has contributed to a decrease in the number of uninsured patients and an increase in the utilization of primary care services; however, it remains unclear whether this has translated into increased insurance coverage for surgical patients.  

Methods:
The National Inpatient Sample (NIS) is the largest all-payer, nationally representative database in the United States. Discharges for the 10 most burdensome emergency general surgery operations (defined as a combination of frequency, cost, and morbidity), were identified in the NIS between 2010-2014. Weighted averages were used to produce nationally-representative estimates. The primary outcome studied was the distribution of insurance type for surgical patients before and after Medicaid expansion in 2014.

Results:
After Medicaid expansion, the proportion of operative admissions covered under Medicaid rose from 15.5% to 18.5% (p<.001), or by approximately 20%. Over the same time, the proportion of uninsured surgical patients decreased from 8.9% to 6.6% (p<.001). In total this translated into an increase of 32,185 general surgery patients who were covered under Medicaid, and 34,305 fewer uninsured general surgery patients. The percentage of privately insured patients decreased from 40.9% in 2010 to 36.2% in 2014 (p<.001), while the percent of Medicare patients rose from 30.4% to 35.4% (p<.001) over the same period. 

Conclusion:
In the first year of Medicaid expansion alone, data from a nationally representative sample shows that the number of general surgery patients covered by Medicaid increased by more than 30,000, while the number of uninsured general surgery patients fell by nearly 35,000. The proportion of private insurance has also gone down over this period, with a reciprocal rise in Medicare coverage, likely explained by demographic shifts towards an aging population. Continued study is needed to evaluate the ongoing impact Medicaid expansion is having on coverage for surgical patients.
 

50.14 POSTOPERATIVE RESPIRATORY FAILURE: Safer Surgery IMPROVES OUTCOMES

Posted on January 18, 2018

A. L. Lubitz1, J. A. Shinefeld1, T. A. Santora1, A. Pathak1, E. E. Craig1, A. J. Goldberg1, H. A. Pitt1  1Temple University,Philadelpha, PA, USA

Introduction: Postoperative respiratory failure is an uncommon, but deadly and costly complication. Approximately 30% of patients who suffer this complication die, and the excess cost is estimated to be $50,000.00 per patient. The aim of this analysis is to document that a multidisciplinary Safer Surgery approach can reduce the incidence of postoperative respiratory failure.

Methods: Postoperative respiratory failure was monitored in both the Vizient (University HealthSystem Consortium) and the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) databases. In Vizient the Patient Safety Indicator (PSI)-11 documents the observed (O) rate per 1,000 cases, the expected (E) rate per 1,000 cases, and the O/E ratio for postoperative respiratory failure. PSI-11 data were monitored from Fiscal Years (FY) 2014-2017. In the ACS-NSQIP database both unplanned intubation and ventilation greater than 48 hours are reported as odds ratios and deciles. Data in the 10th decile are classified as “Need Improvement” while 2nd to 9th decile outcomes are “As Expected.” Safer Surgery is a multidisciplinary initiative whose aim is to optimize the preoperative, intraoperative and postoperative phases of care. Patient education and preparation are key elements in this program, as are surgeon, anesthesiologist and nursing interventions. The RECOVER mnemonic was developed to emphasize: R-review materials, E-expand your lungs, C-cough and deep breath, O-oral care, V-vary activity, E-eat safely and R-rest with the head of the bed up. Educational materials are distributed to patients in surgery clinics, Preanesthesia Testing (PAT) and via the patient portal of our electronic medical record system. Multimedia educational materials were produced for patients, residents and nursing staff.

Results:Patient Safety Indicator (PSI)-11 O/E Ratio decreased from 1.36 in FY 14, to 0.77 in FY 15, to 0.48 in FY 16 to 0.43 in FY 17 (Table 1). The Observed PSI-11 mortality was 30% in the first 18 months of the analysis and decreased to 15% in the most recent 18 months. These improvements represent a savings of 11 lives and $1.5 million dollars. Both the ACS-NSQIP unplanned intubation and ventilator greater than 48 hours needed improvement in FY 15 (Table 1). Both of these metrics have improved to “As Expected” in FY 16 (Table 1).

Conclusion:A multidisciplinary Safer Surgery program improved postoperative respiratory failure outcomes at an academic medical center. A bundle of preoperative, intraoperative and postoperative best practices resulted in improved respiratory outcomes.

 

50.12 Preoperative Antibiotic Timing and Postoperative Duration in Ruptured Appendicitis

Posted on January 18, 2018

R. Amin1, S. Walker1, K. Somers1, M. Arca1  1Medical College Of Wisconsin,Milwaukee, WI, USA

Background: Our practice for ruptured appendicitis has evolved from administering intravenous (IV) and oral antibiotics for a predetermined number of days postoperatively, to only giving inpatient IV antibiotics until the following criteria is met: afebrile for 24 hours, tolerating oral diet, and pain control without IV medications. We aimed to determine whether the timing of preoperative antibiotics relative to incision, and duration of immediate postoperative antibiotics impact the development of surgical site infection (SSI).

Methods: We performed an IRB-approved single institution retrospective review of all patients with ruptured appendicitis based on a prospectively collected registry from January 1, 2013 until October 31, 2016. Univariate and multivariate analyses were performed with CI >95%.

Results: There were 406 patients; 62% were male. Median age was 10.3 years (IQR, 7.3, 13.2). The majority of our patients had an American Society of Anesthesiologists (ASA) classification of 1 or 2 (78.5%), while 21% were ASA 3, and 0.5% classified as ASA 4.  Laparoscopic surgery was performed in 89.9% of cases, 5.7% of these cases were converted to open, and 4.4% were performed in an open fashion. Sixty-three patients (15.5%) developed SSI: 5 (1.2%) superficial, 2 (0.5%) deep, and 54 (13.3%) organ space. There were two wound dehiscence’s. There was no statistically significant difference in sex, age at operation, or ASA in terms of SSI development.

Pre-operative antibiotics: All patients received IV antibiotics at time of diagnosis, leading to an average interval of 96+90 minutes between preoperative antibiotic administration and incision. When comparing patients who received preoperative antibiotics <60 minutes or >60 minutes before incision, we found no statistical significance in SSI development (p=0.64).

Post-operative antibiotics: We grouped patients using the number of antibiotic days they received immediately following surgery. There was no difference in SSI based upon timing of the immediate postoperative antibiotic dose (p=0.707). Predictably, patients with SSI had longer median antibiotic treatment (9 days [IQR 5,13]) than those without (5 days [IQR 3,6], p<0.001).

Antibiotics and complications: Patients that developed SSI were grouped by the total number of postoperative antibiotic days received. The distribution was as follows: 1 day (n=10, 3 SSI), 2 days (n=31, 1 SSI), 3 days (n=62, 6 SSI), 4 days (n=76, 3 SSI), 5 days (n=74, 3 SSI) and >5 days (n=153, 47 SSI).

For each additional hour of case length, the odds of complication roughly double (OR= 2.08 [95% CI 1.27, 3.39], p=0.0034

Conclusion: Timing of preoperative antibiotics relative to incision did not affect SSI rates. Duration of immediate postoperative antibiotics does not affect SSI development, provided clinical criteria are used to guide antibiotic management.  Longer operative time is associated with higher complications.

50.10 Can the Laparoscopic Approach Be Employed in Octogenarians with SBO?

Posted on January 18, 2018

E. H. Chang1, P. Chung3, M. J. Lee1, M. Smith5, K. Barrera1, V. Roudnitsky2, A. Alfonso4, G. Sugiyama4  1State University Of New York Downstate Medical Center,General Surgery,Brooklyn, NY, USA 2Kings County Hospital Center,Division Of Trauma And Acute Care Surgery,Brooklyn, NY, USA 3Coney Island Hospital,Department Of General Surgery,Brooklyn, NY, USA 4Hofstra Northwell School Of Medicine,Department Of Surgery,Hempstead, NY, USA 5Vanderbilt University Medical Center,Department Of Trauma Surgery,Nashville, TN, USA

Introduction: The number of octogenarians is projected to increase four-fold by the year 2050. Laparoscopic surgery (LAP) has been associated with decreased length of stay and pain, however the open approach is often employed for small bowel obstruction (SBO). Our aim was to compare laparoscopic surgery (LAP) in the octogenarian population in patients presenting with SBO from adhesive disease with the traditional open exploratory approach. 

Methods:

An observational study utilizing ACS NSQIP from 2006-2014 was performed. Patients ≥80 years of age, who underwent emergency surgery within one day of admission with a postoperative diagnosis of intestinal/peritoneal adhesion with obstruction (ICD9 560.81) were included in the study. Risk variables of interest included: age, sex, race, BMI, preoperative sepsis, ASA classification, length of stay (LOS), postoperative mortality, and postoperative pneumonia. Univariable analysis was performed using Student’s t-test and Wilcoxon Rank Sum Test for continuous variables while Fisher’s Exact Test and Chi-square Test for categorical variables. Multivariable analysis was performed using Logistic Regression. 

Results:

A total of 103 LAP and 692 open cases were identified. There were no significant differences in age (p=0.1518), sex (p=0.7994), BMI (p=0.1151), or race (p=0.3722) between the groups. However, the open group tended to have higher ASA class (p=0.0225) and incidence of preoperative sepsis (p=0.01597). Unadjusted outcomes showed longer LOS in open vs LAP (median 4.0 vs 8.0 days, p<0.0001), higher incidence of postoperative mortality in open vs LAP (p=0.0071), and higher incidence of postoperative pneumonia in open vs LAP (p=0.0032). Logistic regression with postoperative mortality and pneumonia ad dependent variables were performed adjusting for preoperative risk variables and LAP vs Open. Age (OR 1.11, 95%CI 1.01-1.22, p=0.0311) and preoperative sepsis (OR 3.77, 95%CI 1.06-12.02, p=0.0287) were associated with mortality. Male sex (OR 2.68, 95%CI 1.58-4.60, p=0.0003) and open procedure (OR 5.03, 95%CI 1.50-31.34, p=0.0282) were associated with postoperative pneumonia. 

Conclusion:

We compared outcomes after LAP vs open adhesiolysis for adhesive SBO in the octogenarian population. Adjusting for multiple preoperative variables and LAP vs open approach, we found that age and presence of preoperative sepsis, but not procedure type, was associated with mortality. Therefore, octogenarians who present with SBO due to adhesive disease may benefit from an initial laparoscopic approach. Further prospective studies are warranted.
 

50.11 Gastrografin Challenge Protocol Decreases Length of Stay in Patients with Small Bowel Obstruction

Posted on January 18, 2018

W. Huett1, N. J. Bruce1, W. C. Beck1, M. K. Kimbrough1, J. Jensen1, M. Sutherland1, R. Robertson1, K. W. Sexton1  1University Of Arkansas For Medical Science,Little Rock, AR, USA

Introduction:  The gastrografin challenge (GGC) is a diagnostic tool used to predict the need for surgery in patients with small bowel obstruction (SBO) due to adhesive disease.  The GGC was recently implemented into the management of SBO protocol for surgical services at our institution in the 3rd quarter of 2015. We hypothesized that the length of hospital stay would subsequently decrease for patients receiving our updated protocol utilizing the GGC.

Methods:  In this retrospective analysis of prospectively collected data, the length of stay for patients admitted to surgery services for SBO before and after implementation of the GGC protocol were measured. The GGC clinical protocol could be found on the division website and was implemented using morning report. If contrast reached the colon at 24 hours, nasogastric tube was removed and diet advanced.  If contrast failed to reach the colon at the 24 hour film, operative therapy was recommended. As an additional, temporal control, patients admitted to the medicine service with SBO before and after the surgical services implemented the GGC protocol were examined as well.

Results: A total of 1,468 patients admitted to the surgical services were included in our analysis, as well as 1,026 patients admitted to the medicine service. Implementation of the GGC protocol in the management of adhesive small bowel disease on surgical services reduced the average length of stay by 2 days (7.3± 11.5 days, n=993; vs 5.3 ±  9.6, n=475, p=0.0002).  There were 993 patients in the control group, and 475 patients in the intervention arm.  There was no difference in mean length of stay for patients admitted to the medicine service with SBO in the time before and after implementation of GGC protocol by surgical services (6.3 ±  11.7 days, n=649 control; 7.0 ±  11.8 days, n=377, p=0.8).  In the patients admitted to the surgical services before the protocol, 24% underwent an operation compared to 5% after implementation of the protocol (p<0.0001).

Conclusion: Use of the GGC in the initial, protocol-driven management of adhesive SBO decreases length of stay likely due to a decreased need for operative intervention. 

 

50.07 Neutrophil Lymphocyte Ratio (NLR) Predicts Hospital Length Of Stay In Acute Appendicitis

Posted on January 18, 2018

E. B. Rodas1,2, M. Guillén2, E. Granda2, F. Martínez2, E. B. Rodas1,2  1Virginia Commonwealth University,Acute Care Surgical Services/ Surgery,Richmond, VA, USA 2Universidad Del Azuay,Cuenca, AZUAY, Ecuador

Introduction:
Neutrophil to lymphocyte ratio (NLR) has demonstrated to be a marker of inflammatory response in many conditions including acute appendicitis. We hypothesize that admission NLR could predict hospital length of stay (HLOS) in acute appendicitis.

Methods:
A retrospective cohort study was conducted during 2013 in a tertiary hospital and included all patients admitted through the emergency department with the diagnosis of acute appendicitis treated surgically. A database utilizing SPSS-V19 was created. To evaluate sensitivity of the test we constructed ROC curves; association between variables and risk was evaluated with chi-square and odds ratio.

Results:
During the 12-month period 338 patients were admitted with acute appendicitis. There were 203 (60.05%) male and 135 (39.94%) female patients. Mean age 34.67 ± 11.65 years. When chi-square was applied to increased NLR and HLOS a value of 21.36 (p <0,05), odds ratio 3.019 (CI 1.874-4.864). Also chi-square was applied to NLR and ICU admission, a value of 3.64 (p <0.05) and an odds ratio of 6,18 (CI 0.736 – 51.931). Moreover, the NLR for the different phases of appendicitis was: inflammatory phase (n=87), 7.98 (± 10.40), suppurative (n=142) 11.27 (± 23.54), gangrenous (n=67) 8.15 (± 4.78) and perforated (n=42) 18.44 (± 23.78).

Conclusion:
In acute appendicitis, a higher NLR is associated with an increased in HLOS. The utilization of this simple parameter could potentially be used to allocate resources at the time of admission. Furthermore, NLR trended upward as the disease severity progresses. Additional studies are warranted to validate these findings.
 

50.08 Risk Factors of Mortality in Patients with Necrotizing Soft Tissue Infections in Rwanda

Posted on January 18, 2018

M. CHRISTOPHE1, J. Rickard2,4, F. Charles1,3, N. Faustin1,2  1University Of Rwanda,College Of Medicine And Health Sciences,Kigali, KIGALI, Rwanda 2University Teaching Hospital Of Kigali,Surgery,Kigali, , Rwanda 3Rwanda Military Hospital,Plastic And Reconstructive Surgery,Kigali, KIGALI, Rwanda 4University Of Minnesota,Surgery And Critical Care,Minneapolis, MN, USA

Introduction: Necrotizing soft tissue infections (NSTI) is an emergency surgical condition with severe physiologic and metabolic derangement that predisposes the patient to increased mortality and morbidity worldwide, particularly in developing countries if not diagnosed and treated early.

Methods: This prospective observational cohort study includes all patients aged12 and above who presented at Department of Surgery, University Teaching Hospital of Kigali from April 2016 to January 2017 with NSTI. We describe epidemiology, operative management, and outcomes of care. We evaluated the risk factors for mortality using bivariate and multivariate logistic regression.

Results:We identified 175 patients with confirmed diagnosis of NSTI. The majority of patients (53%) were male and the mean age was 44 years. The median duration of symptoms was 8 days (Interquartile range (IQR): 5-14) .The overall mortality was 26%. The median length of hospital stay was 23days (IQR: 8-41). Multivariate regression analysis revealed four independent predictors of mortality: presence of shock at admission (odds ratio (OR) 14.15, 95% confidence interval (CI):0.96-208.01, P=0.05), chronic kidney disease (OR 8.92, 95% CI:1.55-51.29, P=0.01) infection located to the trunk (OR: 5.60 , 95% CI:0.99-31.62, P=0.05), and presence of skin gangrene (OR 4.04, 95% CI: 1.18-13.76, P=0.02).

Conclusion:NSTI mortality is high. Patients present in late stage, which carries increased mortality and morbidity. It is imperative that increased efforts need to be done in regards to early consultation, diagnosis and surgical management to prevent bad outcomes

 

50.09 Incidence and Histopathologic Variations in Appendiceal Neoplasm Presenting as Acute Appendicitis

Posted on January 18, 2018

R. F. Brown1, K. Cools1, M. Shah1, W. Stepp1, T. Reid1, A. Charles1  1University Of North Carolina At Chapel Hill,Chapel Hill, NC, USA

Introduction: Patients with a primary appendiceal neoplasm (PAN) often present with variable symptoms, including those of acute appendicitis (AA).  However, with the incidence of PAN increasing nearly two-fold over the past ten years, it is vital to evaluate the effect this has on patients who present with AA, but ultimately have PAN.  The purpose of this study is to identify variations in PAN incidentally diagnosed after treatment for AA.

Methods:  A retrospective review of a pathology database was performed identifying all patients who underwent surgical management of AA between January 2000 and December 2015. Pathology reports were reviewed and patients with PAN were identified. Pearson chi-squared test was performed to compare the difference in incidence of PAN after treatment for AA.

Results: Of the 4336 patients surgically treated for AA between 2000-2015, 1.2% (n=51) had PAM.  Between 2000-2005, incidence of PAN in those presenting with AA was 0.5% compared to 1.3% between 2006-2010 and 1.6% between 2011-2015 (p<0.001 for all).  Table 1 demonstrates patient demographic and histopathological variation over these time periods.  This indicates an increase in the proportion of carcinoid, adenocarcinomas, mixed adenoneuroendocrine carcinomas, and other malignant tumors over time.

Conclusions: Our data suggest that the incidence of PAN presenting as AA is significantly increasing over time.  Additionally, there appears to be a shift in the pathologic variation of PAM, with a decrease in mucinous cystadenomas and an increase in adenocarcinoma and mixed adenoneuroendocrine carcinomas. These findings suggest that acute care surgeons must be increasingly aware that every appendectomy is potentially an oncologic procedure.

50.05 Perioperative Factors Influencing Urinary Retention After Laparoscopic Inguinal Hernia Repair

Posted on January 18, 2018

D. F. Roadman1, M. Helm1, M. Goldblatt1, A. Kastenmeier1, T. Kindel1, J. Gould1, R. Higgins1  1Medical College Of Wisconsin,Milwaukee, WI, USA

Introduction:  Post-operative urinary retention (POUR) after laparoscopic inguinal hernia repair has an incidence of 2-30%. POUR can lead to urinary tract infections, longer lengths of stay, and decreased patient satisfaction. The primary objective of this study was to determine the incidence of and perioperative factors contributing to POUR at our institution in patients who underwent a laparoscopic total extraperitoneal (TEP) inguinal hernia repair. 

Methods:  A retrospective chart review was performed of patients who underwent a laparoscopic TEP inguinal hernia repair at our institution from 2009 to 2016. POUR was defined as patients who required indwelling or straight urinary catheterization postoperatively due to an inability to void spontaneously. Univariate analyses were performed on perioperative variables and their correlation with POUR. 

Results: In total, 578 laparoscopic TEP inguinal hernia repair patients were included in the study: 277 (48%) indirect, 144 (25%) direct, 6 (1%) femoral, and 151 (26%) combination of direct, indirect and/or femoral hernias. Of these, 292 (51%) were bilateral and 286 (49%) were unilateral. Overall, 64 (11.1%) of the 578 patients developed POUR, requiring urinary catherization post-operatively. POUR was significantly associated with benign prostatic hyperplasia (BPH), age 60 years or older, urinary tract infection (UTI) within 30 days, and lower body mass index (BMI) (Table 1). Additional pre-operative, intra-operative, and post-operative variables that were not statistically significant determinants of POUR are also listed in Table 1.

Conclusion: Patients greater than 60 years old, with BPH, and a lower BMI were more likely to develop POUR after laparoscopic TEP inguinal hernia repair. Additionally, these patients were also more likely to develop a UTI within 30 days. Identifying patients at higher risk for the development of POUR can help with patient education and expectations. Additionally, future quality initiatives can be explored to minimize the incidence of POUR in high risk patient populations.

 

50.06 Outcomes of Acute Appendicitis in Veteran Patients

Posted on January 18, 2018

O. Renteria1, S. Huerta1,2  1University Of Texas Southwestern Medical Center,Surgery,Dallas, TX, USA 2VA North Texas Health Care System,Surgery,Dallas, TX, USA

Introduction: Some studies indicate that non-complicated acute appendicitis might be treated exclusively with antibiotics instead of an appendectomy.  We hypothesize that conservative treatment might not be appropriate for veteran patients.    

Methods: This a retrospective, single institution analysis at the VA North Texas Health Care system between 7/05 to 6/17 for all patients who underwent an appendectomy (n=345).  Patients who had an appendectomy for cancer, or incidentally for other reasons were excluded (n=35) as were patients with interval appendectomies (n=16) as well as patients with perforated appendicitis (n=14).  Using postoperative complications as a dependent variable, univariate analysis was performed using Fisher’s Exact Test for categorical and Student’s T-Test for continuous variables.  Significant variables were included in a multiple logistic regression model with postoperative complications as the dependent variable. Data are expressed as means ± SD and significance was established at a p≤0.05 (two-sided).

Results: Of patients who underwent an appendectomy for acute appendicitis (n=280; male=90%; age=46.0±15.7 y.o.; BMI=31.2±18.3 Kg/m2), seven had a malignancy in the specimen (2.5%), one had endometriosis and five had been previously treated conservatively.  Without major complications, minor complications occurred in 20 patients (7.1%) and 30-day mortality was zero. LOS was 3.7±4.3 days. On presentation, 91% of patients had a CT scan and 92% underwent a laparoscopic appendectomy.  Conversion rate was 5%.  Age (57.4±13.1 vs. 45.4±15.6 y.o); blood loss (75.6±95.1 vs. 18.4±27.7 cc); ASA (2.6±0.9 vs. 2.2±0.8); tachycardia on initial presentation (95.2±20.6 vs.  85.8±17.1 bpm); and leukocytosis (16.1±4.8 vs. 13.2±4.4 cc/U) [all p’s <0.05] were associated with complications.  Patients with a gangrenous appendix and history of cardiovascular disease were also more likely to have complications.  Blood loss (OR=1.1; 95% CI 1.0 to 1.1) and a history of cardiovascular disease (OR=4.8; 95% CI 1.2 to 19.9) were independent predictors of complications.

Conclusion:  In Veteran patients, the low rate of complications, the risk of harboring malignancy and failure to conservative management argue against managing acute appendicitis with antibiotics compared to an appendectomy.

50.03 Do Ventriculoperitoneal Shunts Increase Complications after Laparoscopic Gastrostomy in Children?

Posted on January 18, 2018

E. Rosenfeld, MD1, K. Mazzolini, BS1, A. S. DeMello1, A. Karediya1, Y. Yu1, J. G. Nuchtern1, S. R. Shah1  1Baylor College Of Medicine & Texas Children’s Hospital,DeBakey Department Of Surgery,Houston, TX, USA

Introduction: In patients requiring gastrostomies, ventriculoperitoneal (VP) shunts are a frequently encountered comorbidity. The objective of this study is to evaluate the postoperative management of children with VP shunts that undergo laparoscopic gastrostomy placement, and determine their incidence of complications. We hypothesized that the presence of a VP shunt wound not increase the rate of immediate complications in children undergoing laparoscopic gastrostomy placement.  

 

Methods: Children 18-years-old or younger who underwent laparoscopic gastrostomy placement at a freestanding academic children's hospital between 1/1/2014 and 9/30/2016 were reviewed. Data collected included demographics, postoperative feeding regimen, and clinical outcomes (including complications within 90 days of gastrostomy placement). We compared patients based on their presence of a VP shunt prior to laparoscopic gastrostomy. Statistical analysis was performed using Chi-square, Fisher's exact and Wilcoxon Rank-Sum tests.

 

Results: We reviewed the medical records of 270 children that underwent laparoscopic gastrostomy placement by 15 pediatric surgeons. Of these, 9% (25) had a previously placed VP shunt. In comparing patients with a VP shunt to those without a VP shunt there was no significant difference in median age (4 vs 3 years, p=0.92), gender (48% vs 51% males, p=0.80), body mass index (15 vs 16, p=0.69), or preoperative diet (48% vs 47% nasogastric tube dependent, p=0.60). In addition, there was no significant difference in intraoperative or postoperative management in those with or without a VP shunt: procedure time (43 vs 42 minutes, p=0.37), type of gastrostomy placed (96% vs 97% MIC-KEY button, p=0.37), postoperative gastrostomy contrast study (9% vs 7%, p=0.68), day of initiation of postoperative feeds (84% vs 73% on postoperative day #1, p=0.70), method of initiation of feeds (60% vs 55% continuous, p=0.25), and type of initial feeds (83% vs 71% Pedialyte, p=0.24).  Similarly, there was no significant difference in clinical outcomes between the two cohorts, including hospital length of stay, return to the emergency department, or postoperative complications within 90 days (Table 1). 

 

Conclusion: Children with ventriculoperitoneal shunts do not have a higher rate of immediate complications after laparoscopic gastrostomy placement, and may be managed similar to other children in the postoperative period.    

50.04 Robotic Port Site Hernias After General and Oncologic Surgical Procedures

Posted on January 18, 2018

R. Diez-Barroso1, C. H. Palacio1, J. A. Martinez1, A. Artinyan1, K. Makris1,2, D. S. Lee1,2, N. N. Massarweh1,2, C. Chai1,2, S. Awad1,2, H. S. Tran Cao1,2  1Baylor College Of Medicine,Houston, TX, USA 2Michael E. DeBakey Veterans Affairs Medical Center,Houston, TX, USA

Introduction:
Robotic surgery has evolved as a platform for various general and oncologic surgical procedures.  With increasing use of this technology, whether 8-mm ports should be closed comes into question.  We sought to characterize the incidence of port site hernias (PSH) and outcomes of patients who underwent general and oncologic robotic-assisted surgical procedures.

Methods:
A retrospective chart review of a single institutional database identified patients who underwent robotic-assisted general and oncologic surgeries from July 2010 to December 2016.  For each patient, the number, location, and size of all robotic ports were collected.  PSH was detected either clinically or radiographically, in which case it was defined as a disruption of the fascia with eventration of fat or bowel at a site of prior port placement on imaging.

Results:

178 patients underwent robotic general and oncologic surgical procedures, with 725 total ports, including 433 8-mm working ports, 72 12-mm working ports, 178 camera ports, and 42 assistant ports.  94% of the patients were male, the mean age was 63±12, BMI was 29±7 kg/m^2, and median ASA score was 3.

Types of cases included rectal (38.2%), colon (20.2%), hepatopancreatobiliary (14.0%), inguinal hernia (12.4%), and other hernias (14.6%).  8-mm robotic port sites were not closed, whereas all larger port sites were.

At a median follow-up – defined by date of most recent surgery clinic visit or most recent abdominal cross-sectional imaging study available – of 193 days, there were 3 PSH through 8-mm port sites (1.7% of patients and 0.7% of 8-mm port sites).  2 of the 3 required emergent reoperation for small bowel incarceration, and both were through lateral-most port sites, above the iliac crest.  BMIs of these two patients were 33 and 34, and operative times for their index operation were 598 minutes and 366 minutes.  The third 8-mm PSH contained fat and was through a port site at the linea semilunaris.

Conclusion:
PSH through 8-mm robotic ports occur infrequently, but can cause significant morbidity.  Closure of 8-mm port sites might be considered at sites of relative fixation where abdominal wall layers have limited ability to slide over one another, and in the setting of long operative times, significant torque at the port site, and patient factors such as obesity.

50.02 BMI as an Independent Risk Factor for Complications after Laparoscopic Ventral Hernia Repair

Posted on January 18, 2018

L. Owei1, R. Swendiman1, S. Torres Landa1, D. Dempsey1, K. Dumon1  1Hospital Of The University Of Pennsylvania,Gastrointestinal Surgery,Philadelphia, PA, USA

Introduction:
A body mass index (BMI) greater than 30kg/m2 is a known independent risk factor for surgical and medical complications following open ventral hernia repair (VHR). This study aims to examine the relationship between BMI and laparoscopic VHR.

Methods:
Data was obtained from the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2015. Patients were stratified into 7 BMI classes, as well as by hernia type (reducible vs. strangulated) and time of repair (initial vs. recurrent). Univariate analyses, namely the Chi-square test for categorical variables and ANOVA or Kruskal-Wallis for continuous variables, were employed to examine the association between BMI class and patient characteristics, comorbidities, recurrent hernia repair, strangulated hernias, and risk of perioperative complication. Logistic regression was used to assess the risk of complication by BMI class with adjustment for potential confounders.

Results:
Of the 57,957 patients who underwent laparoscopic VHR between 2005 and 2015, 61.4% were obese. Patients were stratified into 7 body mass index (BMI) classes: underweight (BMI < 18.5 kg/m2), normal weight (BMI 18.5 – 24.9), overweight (25 – 29.9), obese (30 – 34.5), severely obese (35 – 39.9), morbidly obese (40 – 49.9), and super obese (BMI ≥ 50). When stratified by BMI class, we found significant differences in age, gender, race, comorbidities, and pre-operative characteristics. The overall complication rate was 4.0%, ranging from a low of 3.0% for normal BMI patients, to 6.9% for patients with a BMI ≥ 50 kg/m2. Recurrent repair and strangulated hernias both demonstrated higher complication rates. All complications (surgical and medical) were significantly associated with BMI class (p < 0.0001). This association remained even after adjusting for age, sex, race, comorbidities, recurrent repair, and strangulated hernias. Patients with a BMI ≥ 40 kg/m2 were found to be significantly more likely to have a complication compared to patients with BMIs ≤ 25kg/m2 (Table 1). This risk of complications further increased with increasing BMI class.

Conclusion:
Obesity, especially those in a higher BMI class, is an independent risk factor for surgical and medical complications after laparoscopic VHR. Patients with BMIs ≥ 40kg/m2 are at 1.3 times greater risk for complications. While this group is different from the patients undergoing open VHR, the higher threshold at which BMI becomes a significant risk factor in laparoscopic VHR suggests that a laparoscopic approach should be considered for patients with BMIs ≥ 30kg/m2 to reduce their risk of post-operative complications.
 

5.20 Impact of Margins on Re-excision Rates for Breast-Conserving Surgery

Posted on January 18, 2018

K. Shuman1, E. Malone2, J. Richman2, C. Parker2  1University Of Alabama at Birmingham,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,Department Of Surgery,Birmingham, Alabama, USA

Introduction:  Approximately 60-75% of breast cancer patients will choose to undergo a lumpectomy. Ideally, an adequate surgical margin is achieved during the initial operation. The definition of an adequate margin has long been debated, which has contributed to the variability in re-excision rates currently ranging from 20-60%. However, in 2014, a new consensus statement was released by the Society of Surgical Oncology (SSO) and the American Society for Radiation Oncology (ASTRO) which defined a negative margin as “no ink on tumor” for stage I and II invasive breast cancers. This retrospective review aims to analyze the impact of the “no ink on tumor” guideline on re-excision rates for patients who have undergone breast conserving surgery at a single institution. We hypothesized that acceptance of this new standardized definition would result in fewer re-excision lumpectomies for patients with stage I and II invasive breast cancers. 

Methods:  We identified all women (≥ 18 years) with a preoperative breast cancer diagnosis who underwent a lumpectomy at a single institution in 2013, the year before the SSO-ASTRO Consensus Statement, and 2015, the year after release.  A re-excision was any procedure documented as an excisional biopsy, biopsy with or without needle localization, or lumpectomy in the medical record of a patient who previously underwent a lumpectomy procedure. Race, age, anesthesia type, and re-excision status were compared. Chi-square tests and t-tests were used to test for bivariate associations between categorical and continuous variables and the year.

Results: Of the 232 malignant lumpectomy cases in 2013, 71 were re-excision surgeries (31%) compared to 64 (24%) of the 268 malignant lumpectomy cases in 2015 (p=0.09). There were no significant differences by age, race, or anesthesia type (all p>0.05).

Conclusion: The release of the SSO-ASTRO consensus statement of “no ink on tumor” has the potential to reduce the amount of additional, unnecessary surgeries for close margins. Reducing re-excision surgeries could improve patient satisfaction and outcomes as these operations pose additional stress on the patient physically, mentally, and economically as well as delay adjuvant therapies. While our data did not reach statistical significance, it suggests a reduction in the number of re-excision surgeries from the year 2013 to 2015, consistent with the expected results of the SSO-ASTRO consensus statement. A larger study will be needed to provide more conclusive evidence.

50.01 Impact of Acute Care Surgery Service on Diverticulitis Patients Managed with Operative Intervention

Posted on January 18, 2018

M. N. Khan1, M. Hamidi1, A. Jain1, E. Zakaria1, N. Kulvatunyou1, T. O’Keeffe1, A. Tang1, L. Gries1, B. Joseph1  1University Of Arizona,Tucson, AZ, USA

Introduction:
Trauma services are increasingly providing emergency surgery (ES) care by developing “acute care surgery service (ACS)” which is a combination of trauma surgery, broad-based ES, and surgical critical care. ACS implementation has been shown to provide timely care with improved patients outcomes. The aim of our study was to evaluate the impact of ACS on outcomes in patients who underwent ES for acute diverticulitis

Methods:
We reviewed all patients who were admitted with the diagnosis of acute diverticulitis from 2009-2014. Patients who underwent ES (within 24 hours of hospital admission) were included while those who were admitted during ACS implementation year (2011) were excluded. Patients were divided into two groups: (Pre-ACS [2009-2010] and Post-ACS [2012-2014] and were matched in a 1:2 ratio using propensity score matching for demographics, comorbidities and admission vitals and labs. Outcome measures were time to evaluation by the surgeon, time to operating room (OR) from emergency department (ED), hospital length of stay (LOS), complications, mortality and adjusted hospital charges.

Results:
A total of 1216 patients were analyzed. 284 patients underwent operative intervention within 24 hours of admission, of which 207 patients (Pre-ACS, 69; Post-ACS, 138) were matched. Patients in ACS group had lower median time to evaluation by the surgeon (150 minutes vs 313 minutes, p<0.001), less median time to OR from ED (8.3 hours vs 12.4 hours, p<0.001), less median hospital LOS (6.3 days vs 8.1 days, p=0.02) and a less median hospital charges ($52,252 vs $59,543, p<0.001) as compared to the pre-ACS group. However, there was no difference in complications rate (35% vs 37%, p=0.12) and mortality rate (5% vs 6.6%, p=0.18) between the two cohorts.

Conclusion:
Acute care surgery model implementation at our institution lead to earlier time to evaluation by surgeon, less time to OR from ED, a shorter length of hospital stay, and reduction in hospital charges. Acute care surgery model results in better patient outcomes and improved utilization of hospital resources in patients undergoing operative intervention for acute diverticulitis.
 

5.18 The Impact of Pre-Operative Breast MRI on Surgical Wait Times in a Public Hospital Setting

Posted on January 18, 2018

E. Warnack1, S. Dhage1, K. P. Joseph1  1New York University School Of Medicine,Surgery,New York, NY, USA

Introduction:
Use of MRI for pre-operative evaluation of newly diagnosed breast cancer has become more common, despite questionable impact on survival outcomes. We sought to examine whether or not MRI led to further delay in definitive surgery at this public hospital, and to determine how often and in what manner pre-operative breast MRI changed surgical management. We also sought to examine characteristics of patients who received preoperative MRI.

Methods:
Our breast clinic database was used to identify patients who received surgery between January and December 2015. From this group, patients who received preoperative MRI  were identified. Characteristics of patients, including ethnicity, age, tumor stage, and type of surgery, were collected for both groups. Mean time to surgery, from biopsy definitive operation, was calculated for both groups. Patients who received neoadjuvant chemotherapy were excluded. Of those who received MRI, data on whether MRI changed surgical management was abstracted.

Results:
A total of 101 patients received breast surgery at our institution over a one-year period, and 27 patients received MRI for preoperative planning purposes. There were no significant differences in the MRI and no MRI group in terms of ethnicity (p 0.227.) There were significant differences in the two groups for age, (p .002) stage (p .049,) and type of surgery received (p .005). Patients with stage 2A cancer were 5.1 times more likely (p.026) to receive MRI, and patients with stage 2B cancer were 7 times more likely (p .021) to receive MRI, compared to patients with stage 0 disease. Patients who underwent MRI were less likely to receive lumpectomy or re-excision (OR .212, p .002,) compared to mastectomy. The group of patients who did not undergo MRI experienced slightly longer mean time to surgery (38.75 days compared to 37.4 days in MRI group.)  Of those who received MRI, most (22, 81.4%) had abnormal results, and 13 (48.1%) underwent biopsy as a result of MRI. MRI changed management in nine patients (33.3%,) in most cases by converting a planned lumpectomy to mastectomy. 

Conclusion:

Interestingly, there was no significant difference in time to surgery between the MRI and no MRI group, suggesting that MRI did not cause substantial delay in management. Patients were more likely to receive MRI if they had advanced stages of cancer, and those that received MRI were more likely to receive mastectomy compared to lumpectomy. Considering the high rate of change in surgical management for those who received MRI, and the equivalent time to surgery in this group, it may be inferred that MRI is a helpful imaging study in select patients with breast cancer. Further studies are needed to explore long-term outcomes of those who received MRI. 

 

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