50.18 Increasing Use of Thyroidectomy as Definitive Treatment for Hyperthyroidism

Posted on January 31, 2019

A. Asban1, A. Anue1, H. Chen1  1University Of Alabama at Birmingham,Department Of Surgery,Birmingham, Alabama, USA

Introduction:
Thyroidectomy is a definitive treatment for hyperthyroidism. The initial discussion to undergo thyroidectomy is usually carried out between a patient and a primary care physician or an endocrinologist. At our institution, it is unknown how often patients with hyperthyroidism are referred for thyroidectomy and what are the common reasons for referral. Therefore, the purpose of this study is to examine the trend of thyroidectomy over a 6-year period and to identify reasons for referral. 

Methods:
We identified 237 patients with hyperthyroidism underwent thyroidectomy from January 2016 to December 2016. To examine the trend of thyroidectomy over the study period, patients were divided into six groups according to the year of thyroidectomy, group 1 to group 6, from 2011 to 2016, respectively. For each group, patients’ charts were reviewed for the reasons why patient was referred for thyroidectomy (primary outcome), time from diagnosis and/or start of antithyroid drugs (ATDs) to thyroidectomy, as well as the trend and total number of thyroidectomies each surgeon did during the study period (secondary outcomes). Differences in primary and secondary outcomes between groups were examined.

Results:
The mean age was 44 ± 15 years, 73% were women, and 54% were Caucasian. Majority of patients presented with palpitation 65%, weight loss 50% and heat intolerance 44%. The median preoperative TSH was 0.008 mU/L. A significant increase in the rate of thyroidectomy over the study period was observed where 31 patients underwent thyroidectomy in 2011 compared to 61 patients in 2016. Among the total cohort, the most common reasons patients were referred for thyroidectomy were resistance or intolerance to ATDs followed by patient’s preference and presentation with obstructive symptoms with no statistically significant difference between groups. The median time from diagnosis to surgery was 8 months (0 to 204 months) and 7 months from initiation of ATDs to thyroidectomy with no significant difference between groups.  A total of 13 surgeons operated in during the study period with no noticeable change in volume over time.  

Conclusion:
 An increase of thyroidectomy rate was observed at our institution over the last 6 years. Patients mostly referred due to resistance or intolerance to antithyroid medications, patients’ preference of surgery and presentation with obstructive symptoms. ?
 

50.17 Totally Extraperitoneal Approach for Complex Abdominal Wall Reconstruction

Posted on January 31, 2019

S. J. Kumar1, Z. D. Warriner1, Y. W. Chang1, M. A. Plymale1, D. L. Davenport1, A. Wade1, R. W. Edmunds1, J. S. Roth1  1University Of Kentucky,General Surgery,Lexington, KY, USA

Introduction: We describe five years’ experience of totally extraperitoneal approach (TEP) with component separation for complex ventral hernia repair (VHR). Complex ventral and incisional hernia management with abdominal wall reconstruction (AWR) has typically involved obligatory peritoneal entry for adhesiolysis, with subsequent risk of enterotomy. We have previously demonstrated that totally extraperitoneal (TEP) approach to AWR is feasible and results in shorter operative times with similar complication rates.  Our objective is to review continued experience with TEP hernia repair at our institution, specifically addressing technique, decision-making, and outcomes.

Methods: A retrospective review of TEP cases performed over five years.  TEP involves hernia sac identification and preservation. Hernia sac is dissected circumferentially until edges of intact anterior fascia identified. Posterior component separation performed as required for fascial closure. Hernia sac is then imbricated within the preperitoneal space or posterior rectus sheath in the midline. Mesh is placed as retromuscular sublay and linea alba restored ventral to mesh.

Results: Between January 2012 and December 2016, we used this technique for 166 cases. Four cases required intraperitoneal entry to explant densely adhered mesh. 86.1% of cases had ≤ 1 prior repair and 89.2% ASA wound class 1. Median defect size 135cm2 and mostly Rives-Stoppa or transversus abdominis release performed for component separation. Median operative time was 175 minutes, blood loss 100ml, and incidence of enterotomy was 0%. Median length of stay (4 days) and time to return of bowel function (4 days) were favorable.  Overall wound complication rate was 27.1%, specifically 9% required seroma drainage and 3% (five patients) required re-operation for various wound or mesh complications. As of April 2018, 4 (four) patients returned back to our institution for SBO, all of which resolved with conservative management.

Conclusions: Totally extraperitoneal hernia repair can be performed safely, with a low risk of enterotomy and post operative small bowel obstruction in selected patients. The TEP approach allows for hernia repair with avoidance of both peritoneal entry and adhesiolysis.  Future studies are required to validate these results.

 

50.16 The Microbiome of Gastrointestinal Perforations: Does it Matter?

Posted on January 31, 2019

V. T. Daniel1, D. V. Ward2, C. I. Kiefe3, B. A. McCormick2, H. P. Santry4
 1University Of Massachusetts Medical School,Department Of Surgery,,Worcester, MA, USA 2University of Massachusetts Medical School,Center For Microbiome Research,Worcester, MA, USA 3University Of Massachusetts Medical School,Department of Quantitative Health Sciences,,Worcester, MA, USA 4The Ohio State University Wexner Medical Center,Department Of Surgery,Columbus, OHIO, USA

Introduction: Although many pro-inflammatory conditions have been shown to have decreased microbiome diversity (alpha) as well as dysbiosis, little is known about the gut microbiome of patients with gastrointestinal perforations with inflammatory etiologies. In addition, it is unclear whether gut dysbiosis plays a role in the development of poor outcomes of surgical patients. Therefore, the objective of our study was to prospectively evaluate outcomes of patients with gastrointestinal perforations who underwent surgical intervention, to characterize the microbiome of these patients, and to assess the alpha diversity of these patients who develop poor outcomes.

Methods: Patients with stomach, small intestine, and large intestine perforations who underwent surgical intervention at a single institution were included in this prospective, translational study. 16srRNA gene sequences extracted from swabs at the perforation site were analyzed and then the reads were clustered and classified to microbial genome using QIIME. Specific taxonomic abundances were assessed. Analysis of composition of microbiomes (ANCOM) was used to assess differences of alpha diversity within groups. Outcomes assessed were 30-day mortality, 30-day postoperative sepsis, and all-cause 30-day readmission rate.

Results: Interim analysis demonstrated overall 28 subjects with stomach (18%), small intestine (36%), and large intestine (46%) perforations underwent surgical intervention. The majority were males (68%) with a mean age of 66 years (SD 16 years) who were not smokers (71%) nor used steroids (86%).  The 30-day mortality rate was 14% and postoperative sepsis rate was 50%. 30-day readmission rate was 11%. Bacteroidetes dominated the gut microbiome of patients with gastrointestinal perforations. Although not significant, microbiome alpha diversity was lower for the following groups: those who died within 30 days postoperatively compared to those who did not (p=0.59), those with postoperative sepsis compared to those without (p=0.76), and those who were readmitted within 30 days compared to those who were not (p=-.67).

Conclusion: In our small sample size, we did not find any significant differences in microbiome alpha diversity among patients with gastrointestinal perforations who had poor postoperative outcomes; however these preliminary data demonstrate high mortality among those with gastrointestinal perforations and suggest possible similarities between gut microbiome of patients with gastrointestinal perforations. Further research is needed to better characterize the microbiome of a larger sample of patients with gastrointestinal perforations compared to controls, and furthermore, those with gastrointestinal perforations who develop poor outcomes.

 

50.15 Outcomes of Ventral Hernia Repair in the Obese and Morbidly Obese: a Single Institution NSQIP Review

Posted on January 31, 2019

F. Gleason1, K. Feng1, S. Baker1, P. Washburn1, C. Perkins1, J. Richman1, M. Morris1, A. Parmar1  1University Of Alabama at Birmingham,Birmingham, Alabama, USA

Introduction:

Post-operative outcomes of ventral hernia repairs (VHR) in obese and morbidly obese patients are poorly defined. To identify the association between obesity and postoperative outcomes, we reviewed our experience in this patient population. We hypothesized that postoperative morbidity and readmission would increase with increasing body mass index (BMI). 

Methods:
We identified all patients undergoing elective VHR at our institution from 2012 to 2017 who were included in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). Hernia specific characteristics were abstracted through chart review and patients with missing information were excluded. Hernia width was classified using European Hernia Society width classification:  W1 (<4cm), W2 (4-10cm), and W3 (>10cm).  Patients were stratified by BMI category based on the World Health Organization definitions of obesity: preobese (25-29.9), obese class I (30-34.9), obese class II (35-39.9), and obese class III (≥40). Surgical site occurrence (SSO) was defined as any surgical site infection or wound disruption. Descriptive statistics were calculated, and factors associated with SSO and readmissions in a bivariate analysis were included in a logistic regression model.

Results:
A total of 334 patients underwent elective VHR and had complete data on hernia characteristics.  The mean age was 58.1 (+ 13.0), 57% (n=190) were female, 80.2% (n=268) were ASA class III, and 14.7% (n=49) were active smokers.  Average BMI was 31.4 (range 17.8-55.5) and the majority of patients had a BMI<30 (47.9%), followed by 27.3% with a BMI 30-35, 13.8% BMI 35-40, and 11.1% with a BMI >40. Average hernia length was 8.6cm (0.4-45cm) and hernia widths were W1 (n=115, 34.4%), W2 (n=148, 44.3%), and W3 (n=71, 21.3%), and were similarly distributed across BMI categories. Operative approach included open (70.0%), laparoscopic (24.6%) and robotic (5.4%). Mesh was used in 62% of cases (71.4% intraperitoneal underlay, 5.5% preperitoneal underlay, 15.9% onlay, 0.3% unknown). The remaining repairs were component separation (27.0%) and primary suture repair (10.8%). Postoperative SSO occurred in 5.7% (n=19) of the cases, and the 30 day readmission rate was 7.2%. There was a trend towards increasing SSO by BMI groups and unplanned readmission, although these were not statistically significant. In a logistic regression model adjusting for hernia width, duration of operation, and patient smoking history, increasing BMI was only weakly associated with increased SSO (OR 1.081, CI 1.02-1.15) and unplanned readmission (OR 1.06, CI 1.01-1.12).

Conclusion:
We demonstrated that acceptable immediate post-surgical outcomes for elective ventral hernia repair are possible in a select population of older, obese patients with large hernia defects. While increasing BMI was associated with increased SSO and readmissions, these effects were relatively small.

50.14 The Utilitarian Gastrojejunostomy: Evaluation of Indications and Techniques on Surgical Outcomes

Posted on January 31, 2019

B. A. Potz1, C. C. Ciambella1, V. L. Garcia1, K. P. Charpentier1, W. G. Cioffi1, T. J. Miner1  1Rhode Island Hospital,Surgical Oncology,Providence, RI, USA

Introduction:  A gastrojejunostomy (GJ) is commonly created to manage a broad range of general surgical problems.  Understanding the differences in groups of patients undergoing this procedure may allow improved patient selection and perioperative management.

Methods:  10 year retrospective review of a prospective surgical database. 386 consecutive adult patients were evaluated for operative indications, gastric outlet obstruction (GOO) scores, technical details, perioperative management, surgical outcomes, NGT tube utilization.  Surgical intent to identify palliative operations was determined by previously established criteria. 

Results: 295(76%) of the 386 GJ were performed as part of a cancer operation.    301 (77%) of the GJ were associated with partial gastrectomy (PG) included with the surgical procedure.  Antecolic reconstruction was performed in 282 (73%).  Cancer operations were associated with severe (GOO=0, 46%, p<0.001) and moderate preoperative symptoms (GOO1-3, 26%, p<0.001).   GJ with concurrent PG (235/386, 61%) was more frequently performed in asymptomatic patients (205/287 (87%), p<0.001).  Palliative intent was documented in 22% (64/295) and associated with cancer operation without PG (60/60 100%, p<0.001).  Following operation, documented symptom improvement was noted in 85% (84/99) of patients who initially presented with obstructive symptoms.  There was no difference in length of stay (mean 7 days) or major complication rates (14%) between groups(specify which “groups” here).  30-day mortality was associated with operations performed with palliative intent (11/64 (17%), p<0.001).  GJ without PG was associated with postoperative NGT placement more frequently than operations with PG (81/85 (95%), p<0.001).  GJ without PG were also associate with longer duration of tube placement (mean 1 vs 5 days, p<0.001) and more frequent NGT issues requiring replacement (16/85 (19%), p=0.004).  There was no significant difference in rates of delayed gastric emptying (51/386 (13%)) between groups. 

Conclusion: There are distinct differences amongst groups of patients undergoing an operation which includes GJ.  Active symptom management is more frequently required for cancer patients.  30-day mortality is associated with palliative operations.  Regardless of indication, prolonged NGT management is associated with GJ without PG probably due to worse gastric drainage.  Appreciation of such factors not only improves patient selection and counseling, but also will allow more precise analysis of administrative data in the future.

 

50.13 Pre-Hospital Caloric Deficit in Surgical Patients

Posted on January 31, 2019

J. Sadeghi1, K. Duh1,2, R. Barerra1  1North Shore University And Long Island Jewish Medical Center,Manhasset, NY, USA, 2Donald and Barbara Zucker School of Medicine at Hofstra/Northwell,Hempstead, NY, USA

Introduction: The timing, route, source and amount of nutrition for surgical patients with substantial caloric deficits remain active areas of study. There is benefit to starting nutrition early in surgical patients with large caloric deficits, but the data is based on in-hospital nutrition deficits and does not take into account patients’ pre-hospital courses. There has been minimal research and no guidelines set forth regarding pre-hospital nutrition deficits in surgical patients. Large pre-hospital caloric deficits with inadequate or delayed nutritional supplementation may lead to poorer outcome measures including length of stay, functional status, and 30-day readmission rates.

Methods:  We performed a retrospective review of 50 surgical patients over one year admitted to two metropolitan surgical centers with a primary admitting diagnosis of small bowel obstruction, acute pancreatitis, or diverticulitis and assessed their pre-hospital and inpatient caloric deficit. Pre-hospital deficits were estimated using patient-reported days with significant nausea, emesis, and absent oral intake. Inpatient deficits were estimated using total days kept NPO. Patients were classified as either mildly malnourished (2,500-5,000 Kcal) or moderate-severely malnourish (>5,000 Kcal) and compared to patients with no pre-hospital deficit for length of stay, status on discharge as measured by ambulatory status and disposition, and 30-day readmission rate.

Results:The average lengths of stay for the no deficit group, the mild deficit group, and the moderate-severe deficit groups were 7.79, 8.14, and 14 days respectively. The rates of independent functional ambulatory status upon hospital discharge were 72.41%, 69.23%, and 62.5%. The rates of discharge home were 89.65%, 100%, and 85.71%. The 30-day readmission rates were 20.69%, 21.43%, and 42.86%.

Conclusion: Large caloric deficits lead to poorer surgical outcomes, but pre-hospital caloric deficits are not routinely studied. Based on our preliminary results, we found that >5,000 Kcal pre-hospital deficits increase hospital length of stay and 30-day readmission rates. We suggest that pre-hospital caloric deficit should be routinely considered both in determining timing of supplemental nutrition and in future study protocols examining supplemental nutrition.

 

50.11 Laparoscopic Versus Open Common Bile Duct Exploration: Trends And Outcomes in Choledocholithiasis

Posted on January 31, 2019

M. L. Warren1, T. Wyatt1, R. Dev1, B. K. Patel1, J. Luo2, Y. Zhang2,3, K. Y. Pei1  1Texas Tech University Health Sciences Center,Surgery,Lubbock, TX, USA 2Yale School of Public Health,Environmental Health Sciences,New Haven, CT, USA 3Yale School of Medicine,Section Of Surgical Outcomes And Epidemiology,New Haven, CT, USA

Introduction:

 

There is renewed interest in performing primary laparoscopic common bile duct exploration for choledocholithiasis, but endoscopic retrograde cholangiopancreatography has largely replaced common bile duct exploration while surgical volume and experience are likely low.  Despite increasing experience and familiarity with advanced laparoscopic skills, it is unknown whether US surgeons are increasingly adopting laparoscopic common bile duct exploration for common bile duct stones.

 

Methods:

 

The ACS NSQIP database was queried for patients undergoing laparoscopic (CPT code 47564) or open common bile duct exploration (CPT code 47610) for diagnosis of choledocholithiasis (identified by ICD 9 and ICD 10 codes) from 2005 to 2016.  Trends information was evaluated as percentages of total procedures performed from NSQIP participating hospitals.  Standard descriptive statistics was analyzed and multivariable logistic regression were utilized to compare outcomes of interest including complications, mortality, reoperation, and length of stay.

 

Results:

 

A total of 1073 procedures were included for analysis.  Among NSQIP participating hospitals, the majority of explorations were performed laparoscopically but the percentage of laparoscopic common bile duct exploration remains largely unchanged (Figure 1).  After adjusting for patient characteristics, laparoscopic common bile duct exploration was associated with decreased overall complications [OR 0.25 95% CI (0.15-0.40)] and length of stay [OR 0.10 95% CI (0.06-0.16)].  There were no differences in 30-day mortality [OR 0.87 95% CI (0.15-5.00)]or reoperation [OR 0.19 95% CI (0.02-2.23). 

Conclusion:

 

Most NSQIP participating hospitals perform laparoscopic common bile duct exploration but overall experience with common bile duct explorations were low in general.  Laparoscopic exploration was associated with decreased overall complication and length stay.

50.10 Laparoscopic Cholecystectomy Value Calculation – Giving "Value" A Numeric Figure

Posted on January 31, 2019

N. Shahzad1, U. F. Bhatti1, F. Mannan1, N. A. Pasha1, H. Zafar1  1Aga Khan University Medical College,Surgery,Karachi, Sindh, Pakistan

Introduction:

Porter et al. defined "value in healthcare" as health outcomes achieved per dollar spent and the concept revolves around the patient and not the provider. It is challenging to measure the value however as giving numeric value to health outcomes is novel concept. Objective of our study was to calculate and compare "value" delivered by individual surgeons for laparoscopic cholecystectomy.

Methods:

Data was collected for laparoscopic cholecystectomies performed over two years from Jan 01, 2016 till Dec 31, 2017. Only elective cholecystectomies performed for non-inflammed gall bladder were included in the analysis.  Patients who had to be converted to open from laparoscopy were excluded as that increased the cost of care.

We devised formula for value calculation. Some operational definitions are as follows,

Minor post-operative issue: Stay more than 24 hours but less than 5 days, more than 1 clinic follow up visits within 30 days of operation.

Major post-operative Issues: Stay more than 5 days, emergency room visit or re-admission within 30 days of operation due to issues related to cholecystectomy

Numerator: Value of numerator was 100 if no major or minor issues encountered, 50 if some minor issue happened and 0 if any major issue happened.

Denominator: It was ratio of cost of individual cholecystectomy to the average cost of cholecystectomy performed in the study period

Value: Numerator / Denominator

Average value along with 95% and 99% confidence limits were calculated for the duration of study along with value provided by individual surgeons. Data has been plotted in funnel chart.

Results:

A total number of 1840 cholecystectomies were performed by nine surgeons in the study period out of which 1402 met the selection criteria. 817 went home within 24 hours of operation, while 16 patients stayed more than 5 days due to various reasons. 131 patients came to follow up clinic more than once after discharge from hospital. 62 patients had either emergency room visit or were re-admitted within 30 days of admission due to complications related to cholecystectomy. Mean +/- Standard Deviation of value provided was 83.95 +/- 43.07. Fig 1 shows funnel plot with 95% and 99% confidence limits along with values provided by individual surgeons. Value provided by surgeons “F” and “D” was greater than 99% upper confidence limit while value provided by surgeon “C” was below 99% lower confidence limit.

Conclusion:

Value provided by surgeons varies remarkably from one surgeon to another. Underlying factors need to be further explored to improve value.

Limitations:

Formula for value calculation needs to be validated.

Strengths:

First study to give numeric figure to concept of value

50.09 Effectiveness of a Central Line Associated Blood Stream Infection Protocol in a Pediatric Population

Posted on January 31, 2019

J. S. Graham1, M. Mathis2, L. Wilkinson2, S. Anderson2, C. Hutto3, K. Monroe4, A. Jones4, R. Dimmitt5, D. Galloway5, C. Martin2  1University of Alabama School of Medicine,Birmingham, AL, USA 2University of Alabama at Birmingham,Surgery/Pediatric Surgery,Birmingham, Alabama, USA 3University of Alabama at Birmingham,Infectious Disease/Pediatrics,Birmingham, Alabama, USA 4University of Alabama at Birmingham,Emergency Medicine/Pediatrics,Birmingham, Alabama, USA 5University of Alabama at Birmingham,Gastroenterology;Hepatology And Nutrition Services/Pediatrics,Birmingham, Alabama, USA

Introduction: Long-term parenteral nutrition administered by a central venous catheter (CVC) is often needed for pediatric patients with intestinal failure. Central line-associated bloodstream infections (CLABSIs) are a common cause of life-threatening bacteremia and sepsis in this patient population, secondary to long-term CVC use. When a parenteral nutrition (PN)-dependent patient presents with fever and other infection-concerning-symptoms, prompt recognition and care are needed.  Expedited antimicrobial treatment has been shown to decrease mortality and morbidity in patients with sepsis.

Methods: A 36 month, IRB approved retrospective chart review was conducted on TPN-dependent patients with intestinal failure who present with a fever to Children’s of Alabama’s ED and were admitted to the hospital. Outcomes of interest were adherence to protocol, unplanned transfers, and length of stay.

Results: 44 patients were included in the study, 28 were in the first 18-month period and 26 were in the second, with 10 patients in both populations. Post-protocol implementation, mean time from ED admission to antibiotic ordered and ED admission to antibiotic administered were lower (2:17±1.34 vs. 0:46±0.46, p<0.001, and 2:46±1:42 vs. 1:19±0:49, p<0.001), mean time between antibiotic administration and admission to the floor was greater (2:37±1:02 vs. 1:56±1:25, p=0.025), number of infectious disease consultation was greater (23.5% vs. 46.7%, p=0.006), floor to ICU transfers were lower (28.6% vs. 6.5%, p=0.009), readmission within 30 days was greater (5.9% vs. 22.8%, p=0.009) and mean length of stay was similar (7.67±4.82 vs. 6.93±3.25, p=0.283).

Conclusion: Here we show the value and importance of expedited antimicrobial treatment and a multidisciplinary approach to the treatment of each patient. A prospective analysis of the patients being readmitted within 30 days is recommended to determine the source of increased infection incidences and readmission rates.?

 

50.08 Greater rates of postoperative abscess in open appendectomy for complicated appendicitis

Posted on January 31, 2019

M. I. Orloff1, J. Lu1, N. Matolo1, S. Kolakowski1, D. Vyas1, A. Dayama1  1San Joaquin General Hospital,Surgery,French Camp, CA, USA

Introduction:  Laparoscopic appendectomy is the standard of care for non-perforated appendicitis, however its role in complicated appendicitis remains unclear. In this study we compared perioperative outcomes of open appendectomy (OA), laparoscopic appendectomy (LA), and laparoscopic converted to open appendectomy (LCOA) in the U.S. Adult population.

Methods:  We reviewed the ACS-NSQIP targeted appendectomy data sets from 2016 to identify patients with complicated appendicitis, who underwent an appendectomy. Complicated appendicitis was defined as perforated appendicitis with and without abscess. The primary outcomes of our study were intraabdominal abscess, surgical site infection, length of stay, reoperation and 30-day mortality. Multivariate logistic regression was performed to determine the association of surgical approach and intraabdominal abscess formation.

Results: A total of 2826 patients met our inclusion criteria – 2505 underwent LA, 185 underwent LCOA and 149 underwent OA. The rate of surgical site infection was lower in the LA cohort (1.2%) compared to the LCOA (9.4%) and OA (8.8%) cohorts, p < 0.01. The rate of postoperative intraabdominal abscess was 9.1% in the LA, 10.5% in LCOA and 18.2% in OA cohort, p < 0.01. Length of stay was lowest in patients who underwent LA 3.2 days (d), compared to 5.8 d in LCOA and 6.7 d OA cohorts, p < 0.01. The rate of reoperation was 2.2% in the LA cohort compared to 5.5% in the LCOA and 6.8% in OA cohorts, p < 0.01. No difference was seen in mortality between the three cohorts. The multivariate analysis revealed a statistically significant association between intraabdominal abscess formation and the OA cohort (OR 1.98, CI 1.25 – 3.14). However, no statistical difference was observed between the LOCA and LA cohorts with intraabdominal abscess formation (OR 0.97, CI 0.58 – 1.63).

Conclusion: Analysis of a contemporary national dataset showed laparoscopic appendectomy is associated with shorter LOS, less wound complications, and lower rates of postoperative abscess formation when compared to open appendectomy.  This goes against historical comparisons of the two surgical techniques.  The heterogeneity of studies demonstrates the need for randomized controlled trials to better elucidate the optimal management of complicated appendicitis. 

 

50.07 Defining Clinically Relevant Opioid Sparing Effects of Ketamine in the Peri-Operative Period

Posted on January 31, 2019

C. M. Trevino1, K. Gibbons1, C. Mitchell1, W. Peppard1  1Medical College Of Wisconsin,Surgery,Milwaukee, WI, USA

Introduction: Opioids are often prescribed for acute treatment of severe pain in the post-operative setting. Opioids have the propensity to cause addiction and many patients who utilize them become dependent, even patients undergoing surgery. It has been shown that 10-20% of surgical patients who are opioid naïve pre-operatively became dependent on opioids after surgery. Multimodal analgesia regimens have been implemented to limit opioid consumption perioperatively. Ketamine has been studied as an opioid-sparing agent, reducing acute adverse effects, and long-term dependence. The primary objective of this study was to determine the clinical correlation between the opioid sparing effects and incidence of nausea and vomiting in perioperative ketamine use at 24 hours post-op.

Methods: A systematic review was conducted utilizing studies that evaluated perioperative ketamine use compared to an opioid therapy control group. Included studies must have reported total opioid use and incidence of nausea and vomiting at 24 hours post-op in both control and ketamine groups. Studies that were excluded failed to report this data or did not report the data at time interval of interest.

Results: Overall, 24 studies where eligible and completed between 1993-2013, with 1456 patients available for analysis. A total of 753 patients received ketamine perioperatively for multimodal pain management (ketamine group) and 673 patients received traditional opioid pain regimens (control group). At 24 hours, the ketamine group experienced 35% relative reduction of total opioid use compared to the control group. Patients in the ketamine group also experienced less nausea and vomiting compared to the control group (19% vs 30%, p<0.001), leading to a 37% relative risk reduction of nausea and vomiting when ketamine was utilized perioperatively. Despite these findings, there was no significant correlation (correlation coefficient r = -0.31) between post-operative nausea and vomiting with the reduction of opioid use at 24-hours.

Conclusion: The addition of ketamine to perioperative, multimodal analgesia regimens leads to significant reductions in total opioid use and nausea and vomiting at 24 hours postoperatively. While the reduction in opioid use was not significantly correlated with the reduction in nausea and vomiting, these findings remain clinically significant for surgical patients.

 

50.06 The Association of Body Mass Index with Postoperative Outcomes after Elective Hernia Repairs

Posted on January 31, 2019

J. R. Giacolone1, S. Torres-Landa2, J. Cohen3,4, G. Hoeltzel2, R. Swendiman2, D. Dempsey2, N. Williams2, K. Dumon2  1Perelman School of Medicine at the University of Pennsylvania,Philadelphia, PA, USA 2Hospital Of The University Of Pennsylvania,Department Of Surgery,Philadelphia, PA, USA 3Hospital Of The University Of Pennsylvania,Department Of Medicine, Renal-Electrolyte And Hypertension Division,Philadelphia, PA, USA 4University Of Pennsylvania,Perelman School Of Medicine, Center For Clinical Epidemiology And Biostatistics,Philadelphia, PA, USA

Introduction:  Patients operated for a PEH are often either underweight or obese; however, the association between all BMI classes and 30-day outcomes in patients who underwent laparoscopic hernia repairs has not been studied. The aim of this study was to evaluate the association between body mass index (BMI) and post-operative outcomes in elective hernia repairs. 

Methods:  We performed a retrospective study of patients who underwent an elective laparoscopic inguinal, femoral, umbilical, ventral, para-esophageal, epigastric and Spigelian hernia repair in the ACS NSQIP database (2005-2015). Patients were divided into BMI groups (< 18.5, 18.5 – 24.9, 25.0 – 29.9,30.0 – 34.9, 35 – 39.9,and ≥ 40.0 kg/m2). A multivariable logistic regression model was developed to characterize the association between BMI class and outcomes (mortality, readmission, reoperation, and overall complications).

Results: The median (IQR) age of the 9,641 patients who met inclusion criteria was 57 (46-67) and 36.8% were women. Across each BMI group, there were significant differences in age, race, gender, smoking status, frailty index, and ASA class (p < 0.05). Underweight BMI (<18.5) was associated with increased risk of readmission (OR = 1.61, p < 0.05). Patients with a BMI 25.0-29.9 (OR = 0.86), 30.0-34.9(OR = 0.86), 35-39.9 (OR = 0.81), and ≥ 40 (OR = 0.74) (p < 0.05) were associated with decreased readmission rates.  

Conclusion: Underweight patients had an increased risk for readmissions but not for mortality after elective laparoscopic hernia repairs. Higher BMI was associated with a diminished risk for readmission, but not for mortality or reoperations. Overweight patients had a decreased risk for overall complications.  
 

50.05 Anterior Component Separation and Phasix Mesh Placement with or without Panniculectomy: 175 Patients

Posted on January 31, 2019

M. P. Lundgren1, C. Kustera1, D. G. McKeown1, E. G. Rosato1, F. Palazzo1, K. A. Chojnacki1, M. Jenkins1, P. J. Greaney1  1Thomas Jefferson University Hospital,General Surgery,Philadelphia, PA, USA

Introduction:  Panniculectomy at the time of abdominal wall reconstructionis controversial, with current reviews reporting higher surgical site occurrences (SSO) when included. At our institution we prefer anterior component separation (ACS) and Phasix mesh onlay for AWR, and panniculectomy for patients with pannus. Herein, we compare perioperative, SSO and recurrence rates at our institution after our preferred AWR method with and without panniculectomy.

Methods:  Data was gathered retrospectively. Statistical analysis was performed using Fisher’s exact test to determine significance of difference with or without panniculectomy for SSO and perioperative outcomes, and readmission. Student’s t-test was used to evaluate  differences between operative time (OT) and length of stay (LOS).

Results: 175 patients who underwent AWR between September 2014-June 2017 were included. 59 patients underwent AWR with panniculectomy. The mean OT for the panniculectomy group was 4.1 hours versus 3.4 without (p=0.07). The mean LOS for the panniculectomy group was 4.4 days versus 3.4 without (p= 0.02). There were no significant differences in SSO or readmission (See table below). The recurrence rate in the panniculectomy group was 12% (7/59), with a mean time to recurrence of 1.4 years. This was not significantly different from the 17% recurrence rate without panniculectomy (p=0.38), with a mean time to recurrence of 1.5 years.   

Conclusion: Patients who undergo AWR with ACS and Phasix onlay mesh placement, the choice to perform panniculectomy should be based on discussion between the surgeon and patient, as there are no significant differences between SSO or recurrence rates. 

 

50.04 Surgeon-Dependent Factors Influence Rate of Ventral Incisional Hernia

Posted on January 31, 2019

N. S. Patel1, L. A. Israelsson2, J. S. Thompson1, D. J. Zhou1, S. Aravind1, M. A. Carlson1  1University Of Nebraska College Of Medicine,General Surgery,Omaha, NE, USA 2Sundsvall Sjukhus,Surgery,Sundsvalls, Sweden

Introduction:   

Prevailing opinion has de-emphasized the surgeon as a risk factor for ventral-incisional hernia (VIH); however,

recent controlled data has suggested that VIH risk is surgeon-dependent. Our objective was to determine the

relationship of surgeon-dependent factors with VIH incidence in published data.

Methods:

A systematic review was performed on comparative studies (1960–2015) which determined the effect of incision

choice (vertical midline=VMI; transverse=TI, lateral paramedian=LPI), suture use (nonabsorbable=NA, rapidly

absorbable=RA, slowly absorbable=SA), closure technique (mass vs. layered), or stitch length (VMI only; short

vs. long) on the incidence of primary VIH after uncomplicated laparotomy in adults. Exclusion criteria were

follow-up <12 months, <40 incisions/treatment group, and/or presenceof AAA, immunosuppression, mini-

laparotomy, and/or mesh implantation.

Results:

In 42 comparative studies (median incisions/treatment group=115; range=45–1,111) including 32 controlled trials,

1,383 primary VIHs developed from 15,305 incisions (raw VIH rate=9.0%;median rate=7.7%; range=0–29.2%).

Selection of TI or LPI instead of VMI in the incision category or use of short as opposed to long stitch length (for

VMI) produced an ~80% or ~60% decrease in median VIH incidence, respectively (Fig.1).

Conclusion:

Large differences in VIH rate in studies comparing incisional choice or stitch length suggested that these two

surgeon-dependent factors influence VIH incidence. To minimize VIH formation, published data support

selection of TI or LPI for incision, or short stitch length if VMI is selected.

50.03 Drain Placement in Pancreaticoduodenectomy: More May Not Be Better

Posted on January 31, 2019

V. J. Parikh1, K. Baugh1, G. Van Buren1, A. McElhany1, N. Villafane-Ferriol1, E. Williams1, S. Mohamed1, H. Tran Cao1, E. Silberfein1, C. Hsu1, C. Chai1, N. Massarweh1, W. E. Fisher1  1Baylor College Of Medicine,Michael E. DeBakey Department Of Surgery,Houston, TX, USA

Introduction:  Intra-abdominal drains decrease morbidity and mortality in patients who develop a post-operative pancreatic fistula (POPF) following pancreaticoduodenectomy (PD). However, the prolonged use of drains in patients who do not develop a POPF may cause complications. We hypothesized that use of multiple abdominal drains would improve outcomes in patients at high risk for POPF.

Methods:  A prospectively maintained pancreas surgery database was retrospectively reviewed.  Patients undergoing PD were divided into two groups based on the placement of one or two abdominal drains at the time of resection.  Subjects were sub-stratified for risk of POPF in two separate ways: a validated FRS and postoperative day 1 drain fluid amylase concentration (DFA). Within similar risk cohorts, patients with two intra-operative drains were compared to those with one. Outcomes were compared using chi-square or Fisher’s exact tests for categorical variables and Student’s t-test for continuous variables.

Results: A total of 480 patients were included, 204 (42%) had one drain and 276 (58%) had two drains placed at the time of surgery. Using the FRS, 171 patients (36%) were in the negligible-low risk group and 309 (64%) were in the moderate-high risk group. Using DFA, 321 (84%) patients were in the low-risk group and 59 (16%) were in the high-risk group. Regardless of the method of risk stratification, use of two drains compared to one in high risk patients did not decrease the occurrence of post-operative complications. In addition, use of two drains in patients with low risk was associated with increased POPF and intra-abdominal abscesses.

Conclusion: Two intra-operative drains may not mitigate post-operative complications better than one drain in high risk patients following PD and might be associated with greater morbidity in lower risk patients.

50.02 Sepsis is a Risk Factor for Developing Deep Vein Thrombosis After Open Colectomy

Posted on January 31, 2019

W. Royster1, V. Patel1, J. Nicastro1, G. Coppa1, M. Sfakianos1, G. Sugiyama1  1Donald and Barbara Zucker School of Medicine at Hofstra/Northwell,Department Of General Surgery,Manhasset, NY, USA

Introduction:  Patients undergoing colorectal surgery are often at higher risk of developing deep vein thrombosis (DVT) postoperatively. We propose that preoperative sepsis for patients undergoing emergent colectomy is an independent risk factor for developing post operative DVT.

Methods:  We analyzed the National Surgical Quality Improvement Program (NSQIP) Database for all patients who underwent open colectomies (CPT 44140, 44141, 44143, 44145, 44146, 44150, 44151, 44155, 44156, and 44160) between 2005 and 2013. Patients with known malignancy were excluded from this study, as this is a known risk factor for the development of DVTs. Patients were divided into those who presented with SIRS, sepsis or septic shock and those who did not. A Chi square analysis was used to assess the relationship between patients who were septic preoperatively and those who developed DVTs. Then, multivariate logistic regression was used to determine risk factors for the development of DVTs postoperatively.

Results: A total of 88,819 patients were included in this study. 46,626 (52.5%) were female. 66,394 (74.8%) were Caucasian. Patients age ranged from 16 – >89 years old. The majority of patients were age 60 or older (58.0%). A total of 2,517 (2.8%) developed DVTs postoperatively. Sepsis was identified in 16,875 patients (19.0%). Gender (p=0.153), BMI (p=0.143), and alcohol abuse (p=0.690) were not statistically significant risk factors. Patients who presented with sepsis were more likely to develop DVTs postoperatively (5.2% vs 2.3%, respectively p<0.001). In patients who underwent an open colectomy, the greatest risk factors for the development of a DVT were emergency surgery (OR=1.421, p<0.001), COPD (OR=1.307, p<0.001), pneumonia (OR=1.371, p=0.016), and sepsis(OR=1.867, p<0.001).

Conclusion: Patients who underwent colon surgery while septic were more likely to develop a DVT postoperatively. These patients should be selected for early and aggressive DVT prophylaxis in the peri and postoperative setting.

50.01 Outcomes of a Protocol-Guided Approach to Management of Adhesive Small Bowel Obstruction

Posted on January 31, 2019

K. C. Brown1, D. Burneikis1, G. Morris-Stiff1, T. Capizzani1  1Cleveland Clinic,Digestive Disease & Surgery Institute,Cleveland, OH, USA

Introduction: This retrospective study evaluated the outcomes of an evidence-based protocol for management of adhesive small bowel obstruction (aSBO) at an academic, high-volume referral center.

Methods:  

An evidence-based protocol for management of patients with aSBO was developed after thorough literature review. The protocol prescribed serial abdominal exams, nasogastric tube decompression, goal-directed maintenance fluid resuscitation, and electrolyte correction for patients without signs of bowel compromise. Patients failing to progress in the first 48 hours underwent contrasted small bowel follow through (SBFT) study. If SBFT demonstrated obstruction, patients were offered operative intervention; otherwise, they were continued to be observed until resolution of symptoms.

Between April 2014 and October 2015, patients admitted with aSBO were managed according to our evidence-based protocol. In October 2015, the Acute Care Surgery (ACS) service was restructured from a service run by 6 primary ACS surgeons to a service managed by 13 surgeons of varying specialties on a rotating schedule. This transition allowed for direct comparison of protocol-based and non-protocol management of aSBO. Our administrative database was queried for all ACS admissions assigned Diagnosis Related Group (DRG) codes associated with small bowel obstruction. Patients with incarcerated hernias, intraabdominal malignancy, and surgery within 30 days prior to admission were excluded. We compared the outcomes of the protocol-guided group to a non-protocol group admitted between April 2016 and October 2017. Primary outcomes of interest included length of stay, operative intervention rate, days from admission to operative intervention, and 90-day readmission rate.

Results: The protocol and non-protocol groups included 120 and 130 patients, respectively, who met strict inclusion criteria. Patients were well-matched in terms of age, gender, and severity of illness. There was no statistically significant difference between groups with respect to median length of stay (4 days [3-7] vs 4 days [3-7], p=0.781), operative intervention (21.7% vs 32.3%, p=0.081), days to operative intervention (2 days [0.25-3.75] vs 1 day [0-2], p=0.065), or 90-day readmission rate (9.2% vs 13.1%, p=0.436). Complication rates were comparable.

Conclusion: A protocol-guided approach to management of aSBO is safe and leads to a structured practice easily followed by surgical staff. While the use of the protocol resulted in increased utilization of SBFT studies, there was a trend towards a lower rate of operative intervention and fewer readmissions when the protocol was employed.
 

49.20 Advanced age does not preclude good outcomes during surgical treatment of colovesical fistula

Posted on January 31, 2019

B. J. Resio1, J. Reguero Hernandez1  1Yale University School Of Medicine,Surgery,New Haven, CT, USA

Introduction:

It is commonly believed that surgical treatment of colovesical fistula in the elderly carries an increased mortality and morbidity. Thus, patients are often not referred to surgeons for definitive repair and risk undergoing urgent fecal diversion when presenting with urosepsis. The objective of this study was to evaluate current outcomes of colovesical fistula repair in the elderly population with specialized care by colorectal surgeons at an academic tertiary referral hospital and across the country.

 

Methods:

Consecutive patients age 65 and older who underwent surgery for colovesical fistula were identified from chart review of an academic, tertiary referral hospital (2012-2018) and from the National Surgical Quality Improvement Project (NSQIP) Database (2016). Main outcome measures included surgical approach, complications and mortality. More granular outcomes of permanent ostomy, recurrence, anastomotic leaks, complication type, conversion to open and temporary diverting ostomy were analyzed among patients available for chart review at the tertiary referral hospital.

 

Results:

A total of 209 elderly patients underwent elective, partial colectomy for vesico-intestinal fistula at NSQIP hospitals in 2016. Fifty-six percent of cases were laparoscopic, complications occurred in 26% of patients and mortality was 2.4%. Eleven elderly patients presented with sepsis, 82% had complications and mortality was 9%.

 

A total of 21 elderly patients underwent surgery at a single, academic, tertiary referral hospital. Eighteen patients underwent elective surgery, 94% underwent laparoscopic approach, 6% converted to open and 11% underwent a temporary diverting ostomy with primary anastomosis. There was 1 permanent ostomy among the elective group.There were no mortalities, anastomotic leaks or recurrences with a median follow up of 12 months (IQR:4-34). One elderly patient had major complications (arrhythmia, COPD exacerbation, pneumonia) and 22% had minor complications (ileus most common). Three patients presented with urosepsis, underwent urgent diverting colostomy and 2 of 3 were not subsequently reversed (ages 92,96).

 

Conclusions:

Elderly patients who present with urosepsis from colovesical fistula and require urgent surgery may have a higher risk of permanent ostomy, mortality and complications. Elective repair is safe in the elderly across the country, with a low rate of mortality and morbidity. Chances of permanent ostomy or open approach are low at a tertiary center. Surgical treatment of colovesical fistula should be offered to elderly patients.

 

49.19 Incomplete Colonoscopy After Diverticulitis Is Associated With Elevated Rate of Surgical Intervention

Posted on January 31, 2019

A. Studniarek1, J. Nordenstam1, K. Kochar3, V. Chaudhry2, A. Mellgren1, G. Gantt1  2Cook County Health and Hospitals System,Division Of Colon And Rectal Surgery,Chicago, IL, USA 3Advocate Lutheran General Hospital,Division Of Colon And Rectal Surgery,Park Ridge, IL, USA 1University Of Illinois At Chicago,Division Of Colon And Rectal Surgery,Chicago, IL, USA

Introduction:

Current clinical guidelines recommend performing a colonoscopy after resolution of diverticulitis to confirm the diagnosis and to exclude malignancy or other pathology. Incomplete colonoscopies have limited yield of significant pathologies. The aim of this study is to evaluate the relative risk of surgical intervention after incomplete diagnostic colonoscopies in comparison to complete colonoscopic evaluations after diverticulitis.

Methods:

This is a retrospective descriptive analysis of patients who underwent diagnostic colonoscopy after an episode of acute diverticulitis between November 2005 and August 2017 at three major teaching hospitals in Chicago, Illinois. Demographics, computed tomography scans, endoscopy findings, and surgical pathologies were evaluated. Complete colonoscopy was defined as a full cecal intubation, with visualization of the appendiceal orifice and the ileocecal valve. Severity of diverticulitis was classified based on Hinchey classification during the patient’s initial presentation. The primary outcome of this study was surgical intervention following colonoscopic evaluation.

Results:

584 patients (298 male; 51%) underwent a colonoscopy for a history of diverticulitis after resolution of acute symptoms. Median patient age was 53 (range, 22-88) years. Colonoscopy was complete in 488 patients (83%). 82 patients (17%, 82/488) underwent surgery and 406 (83%, 406/488) did not require surgical intervention. Out of those who underwent surgery with complete colonoscopies, 44 patients (54%, 44/82) presented with Hinchey 1 or 2 diverticulitis. Colonoscopy was incomplete in 96 patients (16%, 96/584). 46 of these patients (48%, 46/96) underwent surgery. 31 patients (67%, 31/46) were classified as Hinchey 1 or 2 on the initial presentation. Patients with incomplete colonoscopies had higher relative risk of undergoing surgical intervention (RR ,2.85; 95% CI, 2.14-3.80) than patients with complete colonoscopies (RR, 0.35; 95% CI, 0.26-0.47).

Conclusion:

Diagnostic colonoscopy following an episode of diverticulitis has a high rate of incomplete examinations. The patients who undergo an incomplete colonoscopy after an episode of diverticulitis have a higher probability of undergoing surgical intervention in comparison to the patients who had a complete colonoscopy. A more accurate diagnostic modality and further prospective studies may help avoid unnecessary surgical procedures.

 

49.18 Are Enhanced Recovery After Surgery Pathways Applicable to Patients with Obesity?

Posted on January 31, 2019

A. C. Kale1, D. Gunnells2, M. S. Morris1, J. A. Cannon1, D. I. Chu1, G. D. Kennedy1  1University Of Alabama at Birmingham,Gastrointestinal Surgery,Birmingham, Alabama, USA 2Ochsner Foundation Hospital,Colorectal Surgery,New Orleans, LOUISIANA, USA

Introduction:
Enhanced recovery after surgery (ERAS) pathways are multimodal, perioperative approaches to patient management that have been shown to reduce length of stay (LOS), postoperative complications, and readmissions. Our group has previously shown that ERAS decreases racial/ethnic disparity in outcomes following colorectal surgery.  While it is encouraged to apply these pathways to all patients, it remains to be determined if all principles of the pathways are safe in all patient populations.  Here we have examined outcomes following surgery and ERAS guided management in patients with obesity. We hypothesized that patients with obesity would have worse outcomes and higher rates of complications.

Methods:
This single center, retrospective study utilized the NSQIP database to identify patients who were managed via an ERAS pathway at our institution between 2015-2017. Patients’ BMI was stratified into NIH categories and chi squared and Wilcoxon tests were performed to determine differences in outcomes between obese and normal/overweight categories; patients classified as underweight were excluded. Analyses were also performed to delineate the impact of ERAS on the outcomes of patients with obesity using a BMI matched, pre-ERAS cohort from 2012-2014. Primary outcome was LOS. Secondary outcomes included all 30-day post-operative ACS-NSQIP complications.

Results:
A total of 1000 ERAS and 685 pre-ERAS patients were included in this study. Among ERAS patients, 61% (606/1000) were classified as normal or overweight, while 39% (394/1000) suffered from obesity. Pre-ERAS patients had comparable BMI distributions. We found that patients managed on the ERAS protocol had a significantly shorter postoperative LOS regardless of BMI compared to the Pre-ERAS patient group (5.5 vs. 7.5 days, p<0.01). While Pre-ERAS patients with obesity had higher rates of superficial surgical site infections (SSI) compared to non-obese Pre-ERAS patients, patients with obesity that were managed with ERAS had no difference in SSIs in comparison to the normal/overweight ERAS cohort (Table 1). Overall, patients who received ERAS guided care experienced a higher incidence of wound disruption in comparison to the Pre-ERAS cohort (3 vs. <1%, p<0.01). ERAS patients with obesity demonstrated significantly higher rates of this complication in comparison to non-obese, ERAS patients (Table 1).

Conclusion:
Patients with obesity have similar outcomes as patients who have normal or overweight BMIs when managed on an ERAS protocol. The use of ERAS pathways may decrease SSIs in patients with obesity, but these patients may be more susceptible to wound disruption. These data suggest that the ERAS pathway is safe and benefit all patients regardless of BMI.
 

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