51.19 Utility of 3D Laparoscopy in Spleen Conserved Surgery in Traumatic Spleen Rupture

Posted on January 31, 2019

Y. He1, G. Chen1, G. Li1, L. Zou1  1Guangdong hospital of TCM,Zhuhai Campus,GUANGZHOU, GUANGDONG, China

Introduction: To analyze the feasibility and safety of utilizing 3D laparoscopy in spleen repair surgery in acute grade ? /?? traumatic spleen rupture. 

Methods: Retrospective analyze 6 patients with acute impatent abdominal trauma which confirmed grade ?/? traumatic spleen rupture by 3D laparoscopy exploration, and treated with laparoscopic spleen repairment by suture in our center from January 2017 to June2018. We analyzed the parameters of perioperative period and summarized the operative experience.

Results: One patient composed with liver rupture while another with jejunum rupture. All repairments of spleen and other organ by suture under 3D laparoscopy were successfully completed without conversion to splenectomy or open surgery. No patient suffered from postoperative intrabdominal bleeding or need secondary abdominal exploration. The average time for spleen repairment is 24±13min, average amount of abdominal drainage in the first 24hours after surgery is 55±33ml, and average postoperative hospitalization days are 6±2.5 day.

Conclusion: 3D laparoscopy providing more magnified view and guarantee more accurative manipulation which make spleen repairment by suture feasible and safe in a less invasive way for grade ?/? traumatic spleen rupture. Also, any other composing intrabdominal organ impairment is feasible to detect and manipulate with 3D laparoscopy.

51.18 Acute Necrotizing Pancreatitis: Has Conservative Management Replaced Surgery?

Posted on January 31, 2019

F. Mannan1, R. C. Gill1, A. R. Alvi1  1The Aga Khan University Hospital Karachi,General Surgery,Karachi, SINDH, Pakistan

Introduction:
The main purpose of this study was to review the trends in management of patients presenting with acute necrotizing pancreatitis (ANP) over the last seven years and its effect on morbidity and mortality.

Methods:

A retrospective cohort study was conducted on all patients presenting with the diagnosis of acute necrotizing pancreatitis presenting to the Aga Khan University Hospital in between the year 2008 to 2015. The study population was broadly categorized in to two groups based on the way these were managed. The first group consisted of patient who underwent surgery for acute necrotizing pancreatitis while the second group was composed of those who were conservatively managed.  Patient outcomes were assessed in terms of hospital stay, complication rates and in-hospital mortality. Data was analysed using SPSS version 20. Comparison of outcomes between two groups was done using chi-square test, Fischer exact test or t-test wherever applicable. A p-value of less than 0.05 was considered statistically significant.

Results:

A total of n=110 patients were included in the study with 68% (n=75) males and 32% (n=35) females. Nasojejunal route was found to be the most commonly utilized route of feeding in these patients consisting of around 49% (n=54) patients with forty percent (n=44) tolerating direct oral diet. The outcomes in both these groups in terms of hospital stay, complication rate, and in hospital mortality were not found to be statistically significant. The conservative group however was significant in terms of cost-effectiveness which was shown by a p value of (0.035). The management of this clinically important disease over the years showed an increased trend towards conservative approach in our institute.

Conclusion:

Our study further substantiates the recent global trend of conservative approach towards managing patients with acute necrotizing pancreatitis as reflected in the recent available literature. Though both our study groups were comparable in terms of hospital stay, complications and mortality but conservative measures were seen to be more cost effective in the long term.

 

51.17 Application of intraoperative ultrasound in complicated laparoscopic cholecystectomy

Posted on January 31, 2019

L. Guowei1, Z. Liaonan1, H. Yaobin1, C. Guobin1, L. Guowei1  1Guangdong hospital of TCM, Zhuhai Campus,Guangzhou, GUANGDONG, China

Introduction: To measure the biliary tract relationship of gallbladder triangle in complicated laparoscopic cholecystectomy, avoiding right hepatic pedicle and common bile duct injury.

Methods: We analyzed 21 patients with different cholecystitis received laparoscopic cholecystectomy between Jun. 2018 and Jul. 2018 in our center. Intraoperative ultrasound was performed on gangrenous cholecystitis, atrophic cholecystitis, and porcelain gallbladder. The shortest distance between the gallbladder bed and the right hepatic pedicle was recorded, and the complications were recorded.

Results:14 cases of all?gangrenous cholecystitis, the average distance was 0.543±0.062cm, 5 cases of all, the average distance of atrophic cholecystitis was 0.372±0.033cm, 2 cases of porcelain gallbladder, the average distance was 0.34±0.02cm, and the average distance of 21 cases was 0.483± 0.094 cm, no postoperative jaundice and postoperative biliary fistula in all cases.

Conclusion: Intraoperative ultrasound for complex laparoscopic cholecystectomy can avoid the right hepatic pedicle injury and increase the safety of cholecystectomy. It may reduce the risk of postoperative complications.

 

51.15 Post-Operative Biliary Type Symptoms after Cholecystectomy. A Real Entity or just Nuisance Value?

Posted on January 31, 2019

E. Krombholz1, L. G. Collins1, W. Joyce1,2  1Galway Clinic,Surgery,Galway, Ireland 2Royal College of Surgeons,Dublin, Ireland

Introduction:
Right upper quadrant pain (RUQ) can persist after successful laparoscopic cholecystectomy (LC). This can cause patient distress and significant diagnostic and therapeutic challenges.

Methods:
A retrospective review of 210 consecutive patients undergoing cholecystectomy by a single surgeon was completed. Demographics, indication for procedure, type of procedure, final diagnosis and further treatment were reviewed. The presence and etiology of persistent RUQ post-operative pain was evaluated in this patient group.

Results:
The data of 210 patients was assessed. Conversion to open surgery was 4.4% (n=9). Planned open surgery was 1.9% (n=4). There were no postoperative deaths or major complications. 8.37% (n=17) of patients reported persistent RUQ pain post-operatively. Within this patient subgroup, 13 patients underwent LC and 4 patients underwent open surgery. The primary causes of persistent post-operative pain in this patient subgroup were musculoskeletal (53% ,n=9), neuropathic (12%, n=2), common bile duct stone (6%, n=1), and no cause found (12%, n=2).

Conclusion:
This study demonstrated that post-cholecystectomy pain syndrome is a real entity affecting 8% of this study cohort. The primary cause of post-operative pain was found to be musculoskeletal in origin. However for one patient in this cohort, the primary cause of pain was a common bile duct stone. Therefore, it is essential that post cholecystectomy patients with persistent RUQ pain are fully investigated to ensure that biliary pathology is not missed.
 

51.14 Perioperative Management and Outcomes Following Cesarean Section in Rural Rwanda

Posted on January 31, 2019

C. Mazimpaka1, E. Uwitonze1, T. Cherian2, B. Hedt-Gauthier2, R. Riviello2,3, S. Hakizimana1,5, Z. El-Khatib4, G. Magdalena2, K. Sonderman3, C. Habiyakare5, F. Kateera1, T. Nkurunziza1  1Partners In Health,Kigali, KIGALI, Rwanda 2Harvard School Of Medicine,Global Health And Social Medicine,Brookline, MA, USA 3Brigham And Women’s Hospital,Boston, MA, USA 4Karolinska Institutet,Public Health Sciences,Stockholm, STOCKHOLM, Sweden 5Ministry of Health,KIGALI, KIGALI CITY, Rwanda

Introduction: Cesarean sections (c-sections) are essential in reducing maternal and neonatal deaths. There is a paucity of research regarding c-section care and outcomes in rural African settings. This study aimed to describe the characteristics of women receiving c-sections at Kirehe District Hospital (KDH) in rural Rwanda, the clinical care provided to them, and the maternal and neonatal outcomes

Methods: This cross-sectional study included all adult women who are residents of Kirehe District and received c-sections at KDH during April 1-September 30, 2017. Demographic and clinical characteristics of these women were extracted from the mother study dataset, and newborn outcomes data were retrospectively extracted from medical charts. Descriptive analyses were performed and frequency and percentages were reported

Results: Of the 621 women included in the study, most were 25-34 years old (45.7%; n=284), married (42.2%; n=262), had only primary education (67.5%; n=419), and were farmers (75.7%; n=470). Burundian refugees from Mahama Refugee Camp comprised 13% (n=86) of the study population. The most common indication for c-section was a previous c-section (31.9%, n=198), followed by acute fetal distress (30.8%, n=191). About 68% spent 3 days or less at the hospital post-surgery and over 95% did not have any postoperative complications prior to discharge. Approximately 10% of neonates were admitted to the neonatal unit, with the most common reason being neonatal infection (59.6%, n=31)

Conclusion: Our findings shed light on c-section deliveries at a rural district hospital in sub-Saharan Africa. KDH represents a typical rural health facility serving residents with low economic and education level. Unique to KDH catchment population is refugees from Mahama Refugee Camp. Previous c-section as the primary indication for c-section will result in high future demand for this surgery. This highlights the need to explore appropriateness and uptake of Vaginal Birth After Cesarean in rural district hospitals.

 

51.13 Effect of ASA Class 3 & 4 in Elective Inguinal Hernia Repair and Surgical Site Infections

Posted on January 31, 2019

B. A. Farber1,2, D. H. Midura1,2, P. Sreeramoju1,2  1Albert Einstein College Of Medicine,Surgery,Bronx, NY, USA 2Montefiore Medical Center,Surgery,Bronx, NEW YORK, USA

Introduction: Inguinal hernia repair is one of the most common general surgical procedures performed worldwide. The American Society of Anesthesiologists (ASA) physical status classification system is widely used as a system to predict perioperative risk, with ASA class 3 and 4 being high risk for elective surgery. We hypothesized that elective hernia repairs on patients with ASA Class 3 and 4 would have no increased risk of surgical site infections or perioperative morbidity or mortality.

Methods: We performed a retrospective review of National Surgical Quality Improvement Program (NSQIP) data generated from our institution. Data of patients older than 18 years of age undergoing elective inguinal hernia repair between January 2014 and December 2017 was reviewed. Patients were stratified based on American Society of Anesthesiologists (ASA) physical status classification system. Categorical variables were assessed using Fishers exact test.

Results:Two hundred fourteen patients were identified during our study period. Median age was 61 years (Range = 19-94 years) and 91% (n=195) were male. One hundred fifty one patients (71%) were ASA 1-2, and 63 patients (29%) were ASA 3-4. Surgical site infections were not found to be significantly increased when stratifying based on ASA classification 1-2 vs 3-4 (p=0.29). There were no mortalities during our study period.

Conclusion:Elective inguinal hernia repairs are safe, and higher ASA class patients do not experience higher rates of morbidity or mortality. 

 

51.12 Inguinal Hernia Repair Outcomes and Morbidity: Local vs General Anesthesia, A Retrospective Review

Posted on January 31, 2019

J. Favela1, T. Phung2, M. Argo1, S. Huerta1,2  1University Of Texas Southwestern Medical Center,Dallas, TX, USA 2VA North Texas Health Care System,Dallas, TX, USA

Introduction:
Open inguinal hernia repair is one of the most common procedures done around the world and in the United States. While using general anesthesia has been the norm for many years, new anesthetic modalities such as local and regional anesthesia are gaining popularity. This is a retrospective chart review assessing the differences in morbidity as well as operative and perioperative time between local and general anesthesia in open inguinal hernia repairs (OIHR) all performed by a single surgeon at a single Veteran’s Hospital. We hypothesize the use of general anesthesia concurs no benefit when compared to local anesthesia when it comes to overall patient morbidity.

Methods:
A comprehensive chart review of all 1146 patients who underwent an OIHR performed by a single surgeon was completed. Parameters recorded included patient demographics (BMI, age), patient comorbidities, operative times (preoperative holding time, surgical time, operating room time, and Post Anesthesia Care Unit (PACU) time), and postoperative surveillance including (inguinodynia, recurrence, and morbidity). Patient morbidity was subdivided into distinct categories including: wound hematoma, infection, urinary retention, pain, and other. A Chi-Square analysis was completed to assess the difference between inguinodynia, recurrence, and morbidity in the two anesthesia groups. A paired two sample t-test was used assess the difference in operative and perioperative time.

Results:
Based on the analysis we conducted, there is no significant difference in recurrence (p = 0.297), inguinodynia (p = 0.467), or morbidity (p = 0.128) between local and general anesthesia. Within the morbidity group, only wound hematoma was significantly decreased in the local anesthetic group (p = 0.003). A significant decrease in the preoperative and postoperative time was observed when local anesthesia was utilized in place of general anesthesia. On average pre-operative holding times decreased by 16 minutes (p = 0.001). Postoperative (or PACU) time decreased by 37 minutes (p < 0.0001). Operative time decreased by an average of 8 minutes, but this was not statistically significant (p = 0.46).

Conclusion:
While this data set is limited to the experience of a single surgeon at a single hospital, there is sufficient evidence to suggest local anesthesia reduces preoperative and postoperative time and resources. Furthermore, local anesthesia does not appear to be inferior with regards to patient outcomes including: inguinodynia, recurrence, and other complications.
 

51.11 Acute Care General Surgery at a Free-Standing Cancer Center. Are There Any Benefits?

Posted on January 31, 2019

C. R. Ledet1, D. A. Santos1, A. R. Limmer1, H. M. Gibson1, B. D. Badgwell1  1University Of Texas MD Anderson Cancer Center,Surgical Oncology,Houston, TX, USA

Introduction:
Cancer is the second leading cause of death in the United States. Recently, cancer patients have benefited from advancements in both diagnostic tools and therapies, which often extend both disease-free and overall survival.  As a result, a number of cancer patients are living longer with solid and hematologic malignancies.  Cancer patients frequently require general surgical consultation for conditions that arise during their treatment, or as a consequence of therapy.  In addition, general surgeons are frequently consulted for long-term complications of oncologic surgery.  However, acute care general surgery services are infrequently described in cancer centers that are not affiliated with a general hospital.  The purpose of this study was to determine the clinical presentation and management associated with cancer patients requiring acute care general surgery consultation at a free-standing cancer center.

Methods:
We performed a retrospective review of the general surgery consult database at our free-standing cancer center from 10/2015-8/2017.  All patients included in the database are patients that have a suspicion of cancer, actively being treated for malignancy or in long-term surveillance. Clinical, demographic, and treatment variables were extracted for patients undergoing general surgical consultation.  The wait time for outpatient vascular access placement was recorded to evaluate a change during the study period.

Results:
In 2015, the acute care general surgery service was initiated at our institution.  There was a 60% increase in general surgical consults during the study period (212 vs. 542 consults). Over 95% of the general surgical cases were elective outpatient surgeries, while only 2-4% of cases were emergent.  In 2017, almost 50% of the elective cases were comprised of vascular access placement for chemotherapy. With the addition of acute care surgeons, the average wait time for vascular access decreased by more than 50%, median wait time in 2015, 2.2 days ( 1.9-4.3 days) vs. 0.96 days (0.56-2.33 days) in 2017.  Open and minimally invasive inguinal, umbilical, parastomal and ventral hernias constituted 21% of the surgical practice followed by cholecystectomy (with/ without intraoperative cholangiogram) which comprised 10% of cases.  Other common indications for consultation that were less than 10% of the practice included excisional lymph node biopsies for disease diagnosis, splenectomy, skin and soft tissue excisions and feeding tube access. 

Conclusion:
 Acute care general surgeons play a unique role at dedicated cancer centers by providing surgical expertise for cancer patients during their diagnosis, treatment, and survivorship period.  This study demonstrates the service viability and increased efficiency of general surgeon integration into a free-standing cancer center.      

 

51.10 Perianal Abscess: When Should Surgeons Get Involved?

Posted on January 31, 2019

S. Shraga1, O. Zayko1,2, B. Silverstein1, A. Gruessner1, T. Schwartz1  1Kings County Hospital Center, Brooklyn, NY, USA 2SUNY Downstate, General Surgery, Brooklyn, NY, USA

Introduction:

Perianal abscess is a common presenting complaint in the Emergency Department. Incision and drainage(I&D) is the standard of care for this disease. Despite adequate drainage there is a high recurrence and complication rate. In our busy inner city hospital, emergency physicians(ED) as well as general surgeons(GS) perform bedside I&D of perianal abscesses. Our aim is to analyze differences in patient demographics, management and outcomes based on type of provider performing I&D. 

Methods:

 A retrospective review of electronic medical records(EMR) of patients with bedside drainage of perianal abscess over a five year period(2010-2016). EMR’s were reviewed to evaluate differences in patient demographics and outcomes for those with drainage done by ED versus GS. Statistical analysis was done using chi-square and Fisher’s exact tests. Multivariate analysis was used to build predictive models.

Results:

Of 220 patients with perianal abscess 120 were drained at bedside; 97 were drained by GS and 23 drained by ED. Patients drained by ED were younger(p=0.02) and with less systemic signs of infection such as fever(p=0.01). The ED were more likely to use packing(p=0.01) and intravenous antibiotics(p=0.09). ED drainage had increased risk for thirty day complication(OR=10.1)  and thirty day readmission(OR=5.1) using a model that adjusts for patient factors.

Conclusion:

While patients with perianal abscess treated by surgery tend to be sicker; they are less likely to have post procedure complications and readmission.

 

51.09 Mortality of Non-trauma Emergency Laparotomy in an Acute Care Surgery Center.

Posted on January 31, 2019

A. D. Shahait1, A. D. Hollenbeck1, D. Kristl1, H. Dolman1, J. D. Tyburski1, G. Mostafa1  1Wayne State University,General Surgery,Detroit, MI, USA

Introduction:  Emergency laparotomy (ER) is a common operation that deals with a wide range of pathologies. Preoperative optimization is often lacking due to the urgent nature of the disease process. Multiple studies have shown a mortality rate of 14% in ER compared to 1.5-9.8% in elective operations. In this study, we review the outcome of ER at our academic acute care surgery center.

Methods:  A retrospective analysis of all adult patients who underwent non-trauma ER, between January 2008 to December 2013 was conducted. Data included; demographics, clinical features, preoperative laboratory, comorbidities, time to surgery, ICU admission, and 30 & 90 days mortality.     

Results: A total of 234 patients [123 male (52.6%), 111 female (47.4%)] were included. ER was performed within 4 hours (immediate) of presentation in (93) 39.7% ,within 4-12 hours (early) in (53) 25.4%, and within 12-24 hours (late) in (63) 30.1% of patients. Overall mortality was (16) 6.8%, and (15) 6.4% at 30 and 90 days, respectively. Both 30-day and 90-day mortality were significantly higher with chronic obstructive pulmonary disease (p=0.014), blood transfusion (p <0.001), ICU admission (p<0.001), Ventilator days > 4 (p=0.013), hyperlipidemia (p=0.014), heart rate > 90 beat/minute (p=0.003), temperature >38 C or <35 C (p=0.013) and Systolic blood pressure < 90 mmHg (p<0.001). The timing of surgery, gender, age >75 years, ethnicity, cardiovascular diseases, smoking, and body mass index had no impact on mortality.

Conclusion:  ER can be performed with lower mortality than previously reported. Specific predictors of mortality are identified that could improve optimization and be used for risk assessment.

51.08 Evolution of a Scale Based Pay Plan for an Academic General Surgery Division

Posted on January 31, 2019

E. W. Nelson1, M. C. Mone1, C. Ward1, S. R. Finlayson1  1University Of Utah,General Surgery/Surgery,Salt Lake City, UT, USA

Introduction: In response to internal and external pressures to be sustainable, equitable, and transparent, faculty pay models in academic surgery have been evolving.  This review examines the transition from a purely incentive based model to a scale based pay plan and the effects on clinical productivity as measured by relative value units (RVUs) as well as possible impact on recruitment, attrition, compensation, and sustainability.

Methods:  Over a three year transition period (7/2015-6/2018) an academic division of general surgery converted from a purely incentive based pay model to a scale based model.   Beginning on July 1, 2015, faculty salaries of 18 academic general surgeons were renegotiated and fixed at or near the average of the previous four fiscal years, July 2011 – June 2014.  Two full time VA faculty and three faculty with administrative positions were not included.  Over the next 18 months, a graduated scale based on rank and years in rank was developed using 50th % AAMC salary guidelines with refinements for subspecialties based on national standards including AMGA, SVC, and MGMA.  When the scale was implemented on Jan 1, 2017, all faculty salaries above scale were frozen at that level and salaries below scale were adjusted half way to scale with eventual adjustment to full scale pending financial sustainability for the entire group. For comparison, incentive based years included fiscal years 2011 to 2015 and pay scale years were fiscal years 2016-2018. When calculating RVU averages per year, years worked by surgeons included partial years based on date of hire and separation.

Results: On January 1, 2017, when compared to the salary scale, twelve faculty (6 males and 6 females) had previous salaries that were below scale and had annualized adjustments half way to scale.  Overall, adjustments averaged $15,345 with a maximum of $60,000.  Additional salary adjustments for males averaged $11,403 and $19,087 for females.  Between fiscal year 2011 and fiscal year 2018 the division grew by 160%, from 10 (8 males and 2 females) to 26 (16 males and 10 females).  New faculty salaries were determined on scale based on previous academic rank and years in rank.  Over the same period, 5/30 faculty left the division only one of whom had been placed on the salary scale; two recruited to other academic programs, two into private practice, and one transferred to another division. Based on the growth in faculty size, total divisional RVU’s grew from 65,063 in 2011 to 164,096 in 2018.  However, when comparing incentive based years to pay scale years, per faculty average RVU’s/year decreased by 5.5% (7347 vs 6943).

Conclusion: Transition from an incentive based salary plan to a scale based model has had only modest effect on surgeon yearly RVU productivity and faculty attrition.  While the transition to full scale of all faculty awaits financial sustainability, exceptional diverse growth through recruitment has been maintained.

 

51.07 Psoas Muscle Area Predicts Acute Respiratory Distress Syndrome in Acute Pancreatitis

Posted on January 31, 2019

P. Kandagatla1, A. Hodari Gupta1, D. Abbass1, C. Fisher1, B. Knisely2, R. Cho2, N. Schmoekel1, J. Stassinopoulos1  1Henry Ford Health System/Wayne State University,Department Of Surgery,Detroit, MI, USA 2Henry Ford Health System/Wayne State University,Department Of Radiology,Detroit, MI, USA

Introduction:

            Acute Respiratory Distress Syndrome (ARDS) is a serious complication of acute pancreatitis. However, limited literature exists pertaining to patient characteristics that can help predict the development of ARDS among patients with acute pancreatitis. Sarcopenia, based on psoas muscle area on imaging, has been predictive of outcomes after surgery. We hypothesized that sarcopenia would correlate with the development of ARDS in patients admitted for acute pancreatitis.

Methods:

            We performed a retrospective study of patients that were admitted to the ICU for acute pancreatitis at our institution. Patients that did not have a CT of their abdomen were excluded from the study. Patient characteristics including demographics, medical history, BMI, labs at admission, and functional status were collected. An average psoas muscle area for each patient was calculated at the level of L3 and standardized to their height. Sarcopenia was determined by gender-based cutoffs of the psoas areas. We then performed both univariate and multivariate analysis to determine significant covariates in the development of ARDS.

Results:

            We included 218 patients in the study. Of these patients, 32 (14.7%) developed ARDS. In univariate analysis, there was no significant difference in the proportion of patients with ARDS that were sarcopenic (50.0% vs 35.7%, p = 0.12). The mean age was significantly higher in those that developed ARDS (58.0 vs 47.3, p<0.01). There was no difference in gender (59.4% male vs 55.9%, p = 0.72), mean BMI (30.1 vs 29.1, p = 0.52), mean albumin (2.71 vs 2.85, p = 0.48), and mean serum creatinine (2.01 vs 1.52, p = 0.14). Patients with ARDS had a higher proportion of biliary etiology (38.7% vs 14.9%, p < 0.01, history of coronary artery disease (21.9% vs 11.4%, p = 0.01) and COPD (25.0% vs 10.3%, p = 0.02). Patients that developed ARDS also had a lower proportion of functionally independent patients (54.2% vs 80.9%, p<0.01). In multivariate analysis, the only significant predictors for ARDS were the presence of sarcopenia (OR = 5.15, 95% CI: 1.23-21.49) and a history of COPD (OR = 6.60, 95% CI: 1.46-29.96).

Conclusion:

            In our single institute retrospective study, we have found a significant relationship between the presence of sarcopenia based on psoas muscle area and the development of ARDS. Further research on utilizing this simple measurement to risk-stratify patients with acute pancreatitis is warranted.

51.06 Development of an Automated Digital Surgical Safety Checklist to Reduce Surgical Errors

Posted on January 31, 2019

J. Langell1,2,3, J. Ferraro1, M. Young1, C. Mi1, Y. Deng1, C. Swensen1, J. Langell1,2,3  1University Of Utah,Center for Medical Innovation,Salt Lake City, UT, USA 2University Of Utah,Department Of Surgery,Salt Lake City, UT, USA 3VA Salt Lake City Health Care System,Center of Innovation,Salt Lake City, UT, USA

Introduction:

Preventable surgical errors occur in 3-16% of surgeries worldwide and account for >1 million deaths per year. These include wrong site surgeries, wrong procedure, wrong patient, incorrect implant and other so called “never events”. The use of surgical safety checklists (SSC) as a tool to improve surgical communication and planning have been shown to be effective in reducing preventable surgical errors in numerous research studies. Outside of monitored research studies, the effectiveness of SSC drops substantially due to provider complacency and poor compliance.  

Methods:  

We conducted a literature review on surgical safety checklist efficacy and compliance issues and performed observational checklist usability studies and stakeholder review sessions. Output from these reviews and studies were used as design inputs for the development of an automated, digital surgical safety application.  Iterative usability testing and human factors design analysis were then performed on the completed product with input from multiple surgeons, anesthesiologist, nurses and surgical technicians. 

Results: 

A literature review on surgical checklists noted concerns with team engagement, checklist compliancy, lack of participation, failure to complete the entire checklist and lack of accountability and ownership. Our internal analysis demonstrated similar findings, in addition we found that many checklist items were filled out in advance, especially the post-procedure portions. Stakeholder analysis highlighted a need for 1) automation of patient identification, critical characteristics, procedure performed and operative location verification 2) a need to increase team engagement and accountability 3) prevention of user complacency and compliance errors. Data acquired through these studies were used as design inputs to produce a fully functional automated, digital surgical safety checklist application. The final product provided a user-centered design with automated patient identity feature via scannable QR code technology, provided mistake proof checklist question progression and completion, increased team engagement through large monitor projection, and increased accountability through signature capture and electronic medical record documentation. A final usability analysis of the application received uniformly positive feedback for adoption and use by all clinical team members.

Conclusion:

Current paper-based surgical safety checklists suffer from use complacency, poor compliance, low provider engagement and lack of accountability.  Automated digital surgical safety checklist may provide a solution to overcome these barriers and improve the impact of surgical checklists in reducing surgical errors due to poor communication and planning.  

51.05 Local vs. Other Forms of Anethesia for Open Inguinal Hernia Repair: A Meta-Analysis of RCTs

Posted on January 31, 2019

M. B. Argo1, J. G. Favela1, S. Huerta1  1University Of Texas Southwestern Medical Center,General Surgery,Dallas, TX, USA

Introduction: There continues to be variation in the choice of anesthetic technique for open inguinal hernia repair (OIHR) worldwide, which seems to be guided by patient’s satisfaction and surgeon’s preference. The factors determining the use of local anesthetic (LA) compared to spinal (SA) and general (GA) anesthesia remains equivocal as previous data has compared either SA or GA [all others (AO)] to LA. We hypothesize that outcomes and operative room times are superior with LA compared to AO for the repair of OIHR. The present study is an analysis of all randomized controlled trials (RCTs) in patients undergoing OIHR comparing LA to AO.

Methods:  PubMed, MEDLINE, Ovid syntax from 1949 to Jan 2018 , the Cochrane Library, Google, ang Google Scholar were reviewed by two independent reviewers following PRISMA guidelines. We identified 73 potential manuscripts, following exclusion of papers that were not OIHR, did not include anesthesia type, and non-randomized trials, 16 RCT’s were available for inclusion. The parameters evaluated were short-term complications (urinary retention, wound infections, and hematomas), patient satisfaction, length of hospital stay (LOS), total surgical time, total operating room time, and postoperative pain. Review Manager 5.3 was used to test for overall effect between the included studies. 

Results: The use of local anesthesia was favored in the majority of analyses. Overall complication rate favored LA (p=0.12), but only urinary retention was significantly decreased in LA (p=0.002). Both wound infection (p=0.12) and hematoma (p= 0.67) favored OA. Patient satisfaction favored the use of LA (p=0.10). Total surgical time was increased in LA versus OA (p = 0.86; 95% CI [-7.2,8.6]), but the overall operating room time was significantly decreased when LA was used (p<0.001; 95% CI [-18.4,-7.1]). Seven of the ten studies that recorded LOS reported a significant decrease when LA was used.  

Conclusion: This meta-analysis demonstrates that LA is a well-tolerated anesthetic approach for OIHR.  OR times and urinary retentions are significantly improved with LA vs.AO.  LA improves the economic burden by decreasing operating room time and decreasing overall intraoperative and early postoperative costs, which is significant for a procedure performed so frequently.   

 

51.04 Factors Associated with Complications in Medical and Surgical Management of Diverticulitis

Posted on January 31, 2019

S. Wei1, K. M. Mueck1, A. A. Radwan1, C. Wan1, C. E. Wade1, T. C. Ko1, S. G. Millas1, L. S. Kao1  1McGovern Medical School at UTHealth,Acute Care Surgery,Houston, TX, USA

Introduction:  Complications during hospitalization for diverticulitis are difficult to classify using traditional tools such as the Clavien-Dindo system, since only 10% of patients require surgical intervention during the same admission. The Adapted Clavien-Dindo in Trauma (ACDiT) grading system is advantageous over the traditional Clavien-Dindo score because it is applicable to emergent surgeries and to patients managed non-operatively.  We have shown that ACDiT is applicable to acute diverticulitis patients, and we aimed to identify factors associated with ACDiT ≥ grade 2 complications in acute diverticulitis patients managed medically or surgically. ACDiT score of 2 means the complication required pharmacologic treatment (not including antiemetics, antipyretics, analgesics, diuretics, and electrolytes) or unexpected blood transfusions, but did not require unplanned procedures or intensive care unit admission.

Methods:  We performed a retrospective cohort study of patients hospitalized for acute diverticulitis admitted to surgery between 2011 – 2016 at a safety-net hospital. Baseline demographics and hospitalization data were collected. ACDiT scores were assigned; scores range from 0 to 5b, with 0 indicating no deviation from treatment plan and 5b indicating death despite active treatment. Univariate analysis was performed. Inverse probability weighted (IPW) propensity scores were assigned for surgical management, and IPW regression analysis was used to determine factors associated with ACDiT ≥ grade 2.

Results: Of 260 patients, 177 (68%) were managed medically. There were no differences in age, sex, race, Charleston Co-morbidity Index (CCI), or intraabdominal drain placement based on management strategy. On multivariable analysis, percutaneous drainage was associated with higher odds of ACDiT ≥ grade 2 with medical and surgical management. Higher CCI increased the odds of ACDiT ≥ grade 2 with medical management, while open surgery increased the odds of ACDiT ≥ grade 2 with surgical management. On IPW propensity score analysis, Hinchey 3, percutaneous drainage, and surgical management had 11-, 9-, and 3-times higher odds of having a complication of ACDiT ≥ grade 2 (Table).

Conclusion: The ACDiT score can be used to grade complications in acute diverticulitis patients managed medically or surgically, and to identify factors contributing to worse outcomes regardless of management strategy. Factors associated with ACDiT ≥ grade 2 include Hinchey 3, percutaneous drainage, and surgical management. ACDiT should be considered as a tool that can be used to benchmark outcomes for acute diverticulitis and to compare the effectiveness of strategies addressing risk factors for complications.

51.03 Comparison of Robotic Versus Laparoscopic and Open Repair for Inguinal Hernias

Posted on January 31, 2019

D. T. Lammers1, J. P. Kuckelman1, J. Bingham1  1Madigan Army Medical Center,Department Of General Surgery,Tacoma, WA, USA

Introduction:
Inguinal hernia repair is one of the most common surgical procedures performed worldwide. The development of the robotic assisted inguinal hernia repair theoretically allows for optical and technical advantages over laparoscopic surgery with improved post-operative pain and recovery over open methods. These theories are yet to be clearly described with a paucity of data comparing robotic inguinal hernia repairs to other commonly performed methods. We characterize our experience with robotic assisted inguinal hernia repair compared to open and laparoscopic approaches.

Methods:
Retrospective review using a prospectively collected data base of all inguinal hernia repairs over 7 years at a single institution. Data was grouped to compare between robotic, laparoscopic and open cases. Comparisons were made for all perioperative data, including patient demographics, intra and post-operative outcomes. Statistical significance was set at a p value of 0.05 comparing mean using ANOVA and Chi-square analysis.

Results:
A total of 277 matched cases met inclusion criteria and were compared. There were no statistical differences in age, gender, or preoperative comorbidities between groups. BMI was significantly higher in the robotic group when compared to laparoscopic and open inguinal hernia repairs at 31 vs 26 and 27, respectively (p=0.001). Operative times were found to be significantly longer with robotic cases at an average of 146 minutes vs 75 minutes in the open group and 86 minutes with laparoscopic cases (p=<0.001). Greater than 30 day follow up was accomplished in 95% of patients. Readmission within 30 days occurred more frequently with the open group (2.4%) when compared to both laparoscopic (1.2%) and robotic (0%) groups (p=0.03). There were no differences seen between groups with regards to post-operative complications including surgical site infections, return to the operating room, length of stay, thromboembolic events, and death (Figure 1).

Conclusion:
Robotic inguinal hernia repair was preferentially performed in larger patients with significantly better or equivalent outcomes when compared to laparoscopic or open inguinal hernia repairs, although associated with longer operative times. Robotic repairs are a viable and safe option for inguinal hernias.
 

51.02 Analysis of the Pediatric Appendicitis Score as a Clinical Adjunct

Posted on January 31, 2019

J. Stevens4, N. Vaughan3, L. Burkhalter2, G. Wools2, A. Alder1,2  1University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA 2Children’s Medical Center,Department Of Pediatric Surgery,Dallas, Tx, USA 3Baylor Scott and White Medical Center,Department Of Surgery,Dallas, TEXAS, USA 4University Of Texas Southwestern Medical Center,Medical School,Dallas, TX, USA

Introduction:  Acute appendicitis is the most common cause for urgent surgical intervention in children. Accurate and timely diagnosis of pediatric appendicitis is thought to minimize complications. The pediatric appendicitis score (PAS) was developed by Samuel in 2002 and has been refined to help guide decision-making for diagnosing appendicitis with a goal to limit unnecessary imaging or procedures and to lower hospital costs. PAS is the core of a practice guideline that was implemented at our institution in September 2012 with intent to minimize unnecessary imaging and lower negative appendectomy rates. The purpose of this study was to evaluate the integration of the PAS into our appendicitis pathway to determine appropriateness of utilization.

Methods:  This is a retrospective review of all patients at an urban, referral children’s hospital whose evaluation for appendicitis included a PAS from July 2017 to December 2017. Data analyzed included imaging rates, appendectomy rates and pathology reports.

Results: 1741 patients were evaluated with 503 undergoing appendectomy. 423(24.3%) patients had a complete PAS with the remaining missing portions of the PAS, most commonly lab results. 1501(92%) patients had an ultrasound and 339(20.8%) had a CT with 66(4%) having imaging done before the PAS was filled out. 109 patients had conclusive imaging from an outside hospital and were excluded from these results. Overall compliance with the PAS protocol was 11.3% with 96.6% of patients with a completed PAS >7 having imaging. 

Conclusion: The PAS has not become a valuable tool as part of our appendicitis pathway to reduce over-imaging of children and lower negative appendectomy rates. Compliance with the guideline (PAS >7) would have resulted in a reduction of ultrasound and CT utilization of 243(16.2%) and 78(23%), respectively. In contrast, compliance would have doubled the negative appendectomy rate from 4 to 8%. Often, imaging is ordered prior to completion of the PAS. The default approach to any patient with possible appendicitis appears to be an ultrasound first and possibly a CT if it is still inconclusive. The PAS has not proven to be an important component of an acute appendicitis practice guideline at a busy tertiary children’s facility with a high volume of patients with appendicitis. A practice guideline that reflects our current practice potentially would save time, money and prevent patients from unnecessary radiation exposure from CT scans.

 

51.01 The Feasibility of Extracorporeal Membrane Oxygenation (ECMO) in Burn and Inhalation Injury Patients

Posted on January 31, 2019

T. D. Reid1, Y. Mikhaylov-Schrank1, C. Gaber1, P. D. Strassle1, R. Maine1, S. M. Higginson1, A. G. Charles1, C. Beckman1, B. A. Cairns1, L. Raff1  1University Of North Carolina At Chapel Hill,Chapel Hill, NC, USA

Introduction:
Burn inhalation patients are at risk for Acute Respiratory Distress Syndrome (ARDS) given pulmonary damage, systemic cytokine release, and large volume fluid resuscitation. As many as 86% of mechanically ventilated burn patients suffer from ARDS. Extracorporeal Membrane Oxygenation (ECMO) is a useful adjunct in patients with severe ARDS after failure of maximal ventilatory therapy. However, few studies have looked at the utility of ECMO following burn inhalation injury. We hypothesized that the use of ECMO in burn and inhalation injury patients is both safe and effective.

Methods:
This is a retrospective review of prospectively collected ECMO program data at the University of North Carolina. Patients included in the study were All adult and pediatric patients with burns and/or inhalation injury with ARDS that underwent Veno-venous (VV) or Veno-arterial (VA) ECMO cannulation between November 2008 and October 2017. Baseline characteristic information was collected. Primary outcomes included mortality on ECMO and 30-day mortality. Secondary outcomes included critical care and ECMO related complications. Frequencies and percentages were presented for categorical data and medians and interquartile ranges were presented for continuous data.

Results:
Of the 21 patients in this study, 16 (76%) were male. Six (29%) patients had burns only, 3 (14%) had inhalation injury only, and 12 (57%) had both burns and inhalation injury. Median percent burn was 28% of total body surface area. Patients had a median age of 48 years (IQR 26-55) with a range of 2 to 72 years. Median hours on ECMO was 116 hours and 90% percent of cannulations were VV. Substance abuse was common in this population at 33%. Eight (38%) patients required hemodialysis, which was performed via the ECMO circuit, and 12 (57%) patients were placed on a lasix infusion. Tracheostomy was performed in 18 (86%) patients. One (5%) patient died while on ECMO from cardiac causes. Total 30 day mortality was 19% (n=4) and 90-day mortality was 24% (n=5). These additional deaths were sepsis-related. Eight (38%) patients had ECMO-related complication; 3 (14%) had minor bleeding, 3 (14%) had bleeding requiring transfusion of more than 2 units, 1 (5%) had a deep venous thrombosis at the cannula site, 1(5%) had a malpositioned cannula, and 1(5%) had an arrhythmia. Only two of the patients who died had a complication related to ECMO. Both patients had bleeding requiring transfusion, however both patients died of sepsis unrelated to the bleeding. 

Conclusion:
In this study, 30-day survival was 81%, and 90-day survival was 76%. While 38% of patients had complications, the majority were minor and did not lead to morbidity or mortality. These numbers are comparable to the current literature on ECMO unrelated to burns, that demonstrate a survival of approximately 60-75%. ECMO in burn and inhalation injury patients appears to be safe and effective. Larger trials are needed to examine the use of ECMO in this population.
 

50.20 The Prognostic Value of CT Angiography in Endoscopic Intervention of Acute Lower GI Bleeds

Posted on January 31, 2019

A. Zhong1, C. Divino1  1Mount Sinai School Of Medicine,General Surgery,New York, NY, USA

Introduction:
Diagnostic modalities for lower gastrointestinal bleeds (LGIB) include endoscopy, mesenteric angiography, capsule endoscopy, nuclear RBC scans, and most recently CT angiography (CTA). The advantages of CTA include a sensitivity and specificity of 98.4% and 93.3%, visualization of the entire abdomen, and expediency. There are no clear guidelines to help providers decide on which diagnostic or interventional modality is optimal for their patient with a LGIB, often leading to confusion and unnecessary invasive workup. We propose that CTA’s can safely be used as an initial diagnostic modality in guiding intervention, specifically endoscopy, in acute LGIB’s.

Methods:
A single-institution retrospective chart review was performed of a cohort of patients who had procedure codes for endoscopy, abdominal CT angiography, and an ICD code for lower GI bleed over a period of 18 years (2000-2018).

Results:
185 patients were identified into the cohort. 51 of those patients had a CTA to diagnose an acute LGIB. A total of 69 CTA’s were performed in those 51 patients. 27/69 CTA’s had a subsequent endoscopic intervention. 22/27 CTA’s were negative for intraluminal contrast extravasation on arterial or venous phase, and 5 were positive. 17/22 (77.3%) negative CTA’s had subsequent diagnostically negative endoscopic procedures. 18/22 (81.8%) negative CTA’s had subsequent endoscopic procedures that resulted in unsuccessful intervention. Out of the 69 CTA’s, only 2 resulted in an AKI in dialysis dependent ESRD patients. No patients required surgical intervention. There were no mortalities.

Conclusion:
CTA should be the universal initial diagnostic modality in a patient with an acute LGIB when they present to an inpatient setting. It is fast, safe, and effective in identifying bleeds and potential sources. CTA’s can result within hours of presentation, have a better adverse event profile than other modalities, and have the highest sensitivity and specificity of all modalities. CTA’s have been shown to predict mesenteric angiographical diagnosis and intervention. A negative CTA is predictive of a negative endoscopic intervention, signifying that not all LIGB’s require additional attempts at diagnosis or intervention. A negative CTA can predict that a patient with a LGIB can be safely observed with transfusions as necessary. The results of the CTA should be used to guide clinical decision making in order avoid unnecessary work up, waste of healthcare resources, and potential risk from additional procedures.
 

50.19 Comparative Analysis of Long-term Outcomes of Open, Laparoscopic, and Robotic Inguinal Hernia Repair

Posted on January 31, 2019

C. Timmerman1, H. Zhu1, T. Pham1, S. Kukreja1, S. Huerta1  1University Of Texas Southwestern Medical Center,Dallas, TX, USA

Introduction:  Many techniques are currently available for the repair of inguinal hernias. As inguinal hernias are one of the most common operations performed by general surgeons, any aspect associated with outcomes and cost should be analyzed. We hypothesized that open inguinal hernia repair (OHR) is associated with superior outcomes and less operative time compared to laparoscopic (LHR) and robotic (RHR) repair.

Methods:  This is a single institution retrospective review of patients undergoing open (n=1100), laparoscopic (n=128) and robotic (n=71) inguinal hernia repair at the VA North Texas Health Care system between 7/05 and 6/17. Univariate analysis was performed using Fisher’s Exact Test for categorical and Student’s T-Test for continuous variables. We excluded 61 patients with both bilateral and recurrent hernia. For the remaining 1238 patients (964 unilateral, 165 bilateral, and 109 recurrent) variables with a univariable p≤0.15 were entered in a backward selection algorithm to yield the parsimonious multivariable regression model. Multivariable logistic regression analyses (MVA) were used to assess the association between treatment and overall complication rate, adjusting for hernia type (unilateral, bilateral, and recurrent). Data are expressed as means ± SD and significance was established at a p≤0.05 (two-sided).

Results: All patients were men and slightly overweight. Compared to the OHR, the LHR patients were three years older. Complex hernias were substantially more common in the LHR and RHR compared to the OHR cohort. All patients had similar comorbidities except for a history of cardiac disease which was more common in patients with OHR compared to both LHR and RHR (all p’s <0.05). Univariate analysis showed that: OR time [65.5±26.1 vs. 78.4±27.1 vs. 117.5±61.8 (both p’s<0.001)]; inguinodynia [1.5% vs. 26.6% vs. 28.2% (both p’s < 0.001)]; and overall complications [11.2% vs. 34.4% vs. 38% (both p’s < 0.001)] were fewer for OHR compared to both LHR and RHR. Recurrence for OHR was similar to LHR, but less than RHR [1.7% vs. 3.9 vs. 5.6% (p=0.1 OHR vs. LHR; p=0.04 OHR vs. LHR)]. Adjusting for hernia type, RHR was significantly associated with a longer OR time compared with OHR (p<0.001), while LHR is significantly associated with a shorter OR time compared with OHR (p<0.001). MVA also showed that LHR or RHR surgery has a significantly higher overall complication risk compared to OHR.

Conclusion: For unilateral hernia repair, the open approach remains the gold standard operation. LHR and RHR are associated with a higher rate of overall complications. Randomized controlled trials are needed to more conclusively demonstrate the best approach to IHR.

 

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