95.01 Radiation Therapy For Patients With Soft Tissue Sarcomas: Who Benefits?

Posted on January 31, 2019

N. Nagarajan1, J. Singh2, K. Giuliano1, F. Gani1, C. Wolfgang1, T. Pawlik3, E. Schneider4, J. Canner1, F. Johnston1, N. Ahuja5  1Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA 2Johns Hopkins Bloomberg School of Public Health,Baltimore, MD, USA 3The Ohio State University,Department Of Surgery,Columbus, OH, USA 4School of Medicine at the University of Virginia,Department Of Surgery,Charlottesville, VA, USA 5Yale University School of Medicine,Department Of Surgery,New Haven, CT, USA

Introduction:
Soft tissue sarcomas (STS) are heterogeneous tumors necessitating multipronged treatment approaches by multidisciplinary teams. However, the evidence for using radiation therapy in STS is variable. Therefore, we studied the association of radiation with survival in patients with STS.

Methods:

STS cases were identified in the Surveillance Epidemiology and End Results (SEER) Program (2002-2012) and categorized into 12 histological subtypes (ICD-O-3). Relative times to cause-specific mortality (censored at 10 years) were examined across patients undergoing surgery only, radiation only, or combination (surgery plus radiation accounting for interaction) using generalized gamma parametric survival functions stratified by histological subtype and controlling for age, sex, race, location, grade, size, local extension, lymph node and distant metastasis.

Results:
A total of 42,409 patients were included. Risk-adjusted survival analyses revealed that surgery alone was associated with significantly increased survival (1.9-5.9 times) compared to no treatment among all histological subtypes (p<0.05). Radiation alone was associated with significantly increased survival (1.4-2.5 times) in aggressive subtypes including leiomyosarcoma (p<0.05). Combination therapy was also associated with significantly increased survival (1.6-5.6 times) across all subtypes compared to no treatment (p<0.05). Compared to surgery alone, combination therapy showed incremental increases in survival for leiomyosarcoma, liposarcoma, angiosarcoma, and synovial sarcoma with only rhabdomyosarcoma showing statistically significant longer survival [Time Ratio:1.5 (95%CI:1.2-1.8),p=0.001](Figure).

Conclusion:
This study demonstrated that combination therapy is similar to surgery alone in most STS subtypes. Combination therapy with radiation appears to be beneficial in aggressive subtypes of STS with up to 50% incremental increase in survival compared to surgery alone.

 

 

93.11 Surgeon Education on Hemostatic Agents

Posted on January 31, 2019

C. Ochoa Chaar1, N. Gholitabar1, M. Devlin1, J. Luo1, Y. Zhang1, H. Hsia1, D. Silasi1, F. Lui1  1Yale University School Of Medicine,Vascular Surgery,New Haven, CT, USA

Introduction: Wide variation in use of Hemostatic agents (HA) by surgeons can significantly affect the cost of care. We postulate that surgeon’s education on HA impacts practice pattern and choice of products and can potentially be incorporated in a cost containment strategy.

Methods: A survey (17 questions) inquiring about the attitudes and preferences of surgeons regarding HA in a multi-hospital healthcare network was conducted electronically. Respondents were divided into 2 groups based on whether they had updated their knowledge and received education on HA (group A) or not (group B).   

Results: There were 148 respondents (25% response rate) in a variate of specialties. (Figure 1) Only 57 surgeons (38.5%) had received updated education on HA (group A). Group A surgeons were significantly more likely to select HA based on literature (33.3% vs 6.6%) while group B surgeons were more likely to rely on what they used in training (28.6% vs 14%) or what is available in the hospital (58.2% vs 47.4%) (P=0.0007). There was little influence by vendor marketing in the 2 groups (A=5.3% vs B=8.8%, P=0.5). Surgeons in group A were significantly more likely to be aware of the costs of HA (47.4% vs 28.6%, P=0.02) and correctly estimate the cost of Surgicel (26.3% vs 13.2%, P=0.05) compared to group B. In the operating room, most surgeons did not routinely open HA (A= 63.2% vs B= 71.4%, P =0.35). However, group A surgeons were more likely to be specific regarding the size and amount of HA requested (A=33.3% vs B=14.3%, P=0.0027). Group A surgeons were more receptive to changing the choice of HA compared to group B (63.2% vs 44%, P=0.03).

Conclusion: Surgeon education on HA is associated with increased awareness of cost and may affect practice pattern in the operating room. Surgeon education can potentially lead to cost-conscious behavior and improve engagement in cost containment strategies.

 

 

92.09 Age: Still a Relevant Independent Predictor of Outcomes in Emergency General Surgery

Posted on January 31, 2019

J. T. Langford1, M. M. Fleming1, Y. Zhang2,3, J. Luo2, K. Y. Pei1  1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA 2Yale University School Of Medicine,Section Of Surgical Outcomes And Epidemiology, Department Of Surgery,New Haven, CT, USA 3Yale School of Public Health,Department Of Environmental Health Sciences,New Haven, CT, USA

Introduction: The average age in the US is increasing every year and as the population gets older so does the patient population undergoing surgery. A growing body of literature is urging against using age alone as a risk stratifying tool and to rely on frailty instead. While frailty has been demonstrated as a good predictor of post-operative outcomes in elective surgery it is uncertain whether this holds true for elderly patients undergoing emergency general surgery. The aim of our study was to determine if age alone could be used to predict post-operative outcomes in elderly patients undergoing emergency general surgery.

Methods: Using the ACS-NSQIP database from 2010-2016 we selected patients that underwent 1 of the 7 surgeries that make up 80% of the field emergency general surgery. These include partial colectomy, small-bowel resection, cholecystectomy, operative management of peptic ulcer disease, lysis of peritoneal adhesions, appendectomy and laparotomy. The primary outcomes measured were overall complication rate and 30 day mortality based on age cohort while controlling for comorbidities and frailty.

Results: 310,643 patients were included in the analysis. Compared to the reference group (age 60-69) there is an increased risk for all complications in the 70-79, 80-89, and ≥ 90 cohorts (OR  1.14 [95%CI 1.11-1.16], OR 1.37 [95%CI 1.34-1.41], OR 1.65 [95%CI 1.57-1.73], respectively). Similarly, there is an increased risk for 30-day mortality (OR 1.47 [95%CI 1.40-1.54], OR 2.37 [95%CI 2.25-2.49], OR 3.69 [95%CI 3.41-3.98], respectively). This trend for increased 30-day mortality is also significant for the 7 procedures individually.

Conclusion: Age can be used as an independent predictor of complications and 30 day mortality in elderly patients undergoing emergency general surgery.

 

88.14 Decreased Patency in Left-Sided Arteriovenous Grafts in a Porcine Model

Posted on January 31, 2019

S. Liu1, T. Wang1, J. Wang2, T. Isaji1, A. Feher4,5, N. Boutagy4,5, A. Sinusas4,5, L. Niklason2,3, A. Dardik1  1Yale University School Of Medicine,Surgery,New Haven, CT, USA 2Yale University School Of Medicine,Anesthesiology,New Haven, CT, USA 3Yale University School Of Medicine,Biomedical Engineering,New Haven, CT, USA 4Yale University School Of Medicine,Cardiology,New Haven, CT, USA 5Yale University School Of Medicine,Translational Research Imaging Center,New Haven, CT, USA

Introduction:
Complications of vascular access for hemodialysis remain a major source of morbidity and cost. Patients unable to have a fistula require a prosthetic graft, most commonly polytetrafluorethylene (PTFE), despite poor primary patency and increased thrombosis, stenosis, and need for reinterventions. Choice of laterality of arteriovenous graft placement is typically dependent on patient handedness, after consideration of adequate vessel diameters. Since temporary dialysis catheters may have reduced patency on the left side, we hypothesized that left-sided arteriovenous grafts may have reduced patency in a pre-clinical model.

Methods:
Ten Yorkshire male pigs (mean weight 48 kg, age 3.4 months) underwent ipsilateral or bilateral placement of arteriovenous grafts from the proximal common carotid artery (CCA) to the distal internal jugular vein (IJV) using PTFE (6 mm diameter, 6-7 cm length). Pigs were observed for 1, 2, or 3 weeks. Select pigs underwent ultrasound measurements of flow and ultrasound and caliper measurements of vessel diameters prior to graft placement, and some pigs underwent computed tomography angiography prior to the terminal procedure. Grafts and peri-anastomotic vessels were excised and analyzed with histology and immunostaining.

Results:
At baseline there was no significant difference in peak systolic or end diastolic velocities between the left and right CCA and IJV but the outer diameters of the CCA were smaller on the left side (4.2 versus 4.7 mm; p=0.0354). 10 left-sided and 8 right-sided PTFE grafts were placed; only 4/10 (40%) were patent on the left and 7/8 (88%) were patent on the right (p=0.03996, Chi-square). Post-operative histology showed thicker peri-anastomotic arterial walls on the left side (0.7 vs. 0.6 mm; p=0.0383) with greater intima-media surface areas (1.1 vs. 0.8 mm2; p=0.0286) compared to the right side. These differences were not seen between the left and right IJV. There was no significant difference in the number of smooth muscle cells, total proliferative cells, or extracellular matrix composition between the left and right sides; however, left-sided grafts had increased luminal macrophages at the arterial anastomosis compared to right-sided grafts (8.4 vs. 2.8 cells/hpf; p=0.0007). 

Conclusion:
Left-sided arteriovenous grafts are associated with significantly lower short-term patency compared to right-sided grafts; left-sided peri-anastomotic carotid arteries had increased wall thickness, medial area and increased numbers of macrophages near the arterial anastomosis despite similar blood flow.  These results suggest that left and right-sided arteries used in arteriovenous grafts may have different remodeling that translates to altered patency, and these differences should be considered when planning graft placement.
 

88.09 Lower Shear Stress Magnitude in Female Mice During Arteriovenous Fistula Maturation

Posted on January 31, 2019

S. Ono1, T. Kudze1, T. Isaji1, T. Hashimoto1, B. Yatsula1, H. Liu1, T. Nishibe2, J. Koizumi3, A. Dardik1,4  1Yale University School of Medicine,Vascular Biology And Therapeutics Program And Department Of Surgery,New Haven, CT, USA 2Tokyo Medical University,Department Of Cardiovascular Surgery,Shinjuku, Tokyo, Japan 3Tokai University School of Medicine,Department Of Diagnostic Radiology,Isehara, KANAGAWA, Japan 4VA Connecticut Healthcare System,Department Of Surgery,West Haven, CT, USA

Introduction: The arteriovenous fistula (AVF) is the preferred method of dialysis access due to its proven superior long term outcomes. However, women have lower rates of AVF maturation than men (38% vs. 60%), preventing optimal AVF use. We used a novel mouse AVF model that recapitulates human AVF maturation to test the hypothesis that there is a difference in male and female AVF maturation.

Methods:   Aortocaval fistulae were created in male and female C57BL/6 mice (9-10 wks). At days 0, 3, 7, 14 and 21, infrarenal aortic and IVC diameters and flow velocity were monitored by Doppler ultrasound and used to calculate the resistance index, blood flow and shear stress. AVF were harvested at day 21 and AVF wall thickness was measured by computer morphometry; proteins were examined using immunofluorescence and mRNA by qPCR.

Results:  Female mice weighed less throughout the whole period (p<0.0001). At baseline, female mice had lower infrarenal IVC velocity (p=0.0005) and smaller magnitudes of shear stress (p=0.0003); although female mice had smaller infrarenal aortic diameter (p=0.0198), there was no significant difference in infrarenal IVC diameter (p=0.5112).  After AVF creation, both the female and male aorta (p=0.5681) and IVC (p=0.5680) dilated similarly and the aortic resistance index decreased similarly (p=0.0743). However, female mice had lower aorta (p=0.0187) and IVC mean velocity (p<0.0001); female mice also showed less blood flow volume in the aorta (p=0.0069) and IVC (p=0.0087) and lower shear stress magnitude in the IVC (p<0.0001) without any significant differences in aortic shear stress magnitude (p=0.31).  There were no significant differences in infrarenal IVC wall thickness either at baseline (p=0.9617) or at day 21 (p=0.2931). Although KLF2 mRNA was decreased in the female AVF on day 21 (p=0.048), there were no differences in protein expression (p=0.5224).

Conclusion: AVF in female mice have lower velocity, blood flow volume and magnitudes of shear stress without any differences in wall thickness or protein expression.  These findings suggest that hemodynamic changes in the fistula may play an important role underlying the diminished rates of AVF maturation in women.

88.05 Ex vivo Isolated Vessel Perfusion for Assessment of Vascular-Targeted Nanomedicines

Posted on January 31, 2019

T. Lysyy1, L. Bracaglia2, A. Vaish1, O. Abousaway1, J. S. Pober4, G. Telides1, M. W. Saltzman2,3, G. T. Tietjen1  1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA 2Yale University,Department Of Biomedical Engineering,New Haven, CT, USA 3Yale University,Department Of Chemical Engineering,New Haven, CT, USA 4Yale University School Of Medicine,Department Of Immunobiology,New Haven, CT, USA

Introduction: Vascular endothelial cells (ECs) are primary targets of and active participants in transplant rejection. We hypothesize that ex vivo treatment of graft ECs with anti-inflammatory or immunosuppressive agents can improve anti-rejection efficacy and reduce off target effects. Nanoparticle (NP) carriers have the potential both to deliver and mediate sustained release of drugs. Retention of polymer NPs in ECs can be improved with antibody-mediated targeting, but clinical optimization of this approach requires relevant experimental models. Cell culture alters the properties of ECs.  We aim to establish a reliable experimental model both to investigate NP targeting in isolated human vessels and to quantitatively evaluate effects of endothelial targeted nanomedicines.

Methods: Twelve de-identified human umbilical cords were obtained after Caesarean sections under a protocol approved by Yale Human Investigations Committee. Umbilical arteries were isolated and 10 cm vascular segments were subsequently connected to the perfusion system (Fig. 1 A). Fluorescent polymeric NPs (150nm) were conjugated to either Ulex europaeus agglutinin I lectin (ULEX) or to mouse IgG1 isotype antibody using EDC-NHS chemistry, using approaches we have optimized (Sci Transl Med 2017). NPs were spiked into intravascular perfusate (M199 media+ serum) at a concentration of 0.5 mg/mL. After 90 min of perfusion, vascular samples were washed and whole-mount specimens were analyzed by quantitative microscopy (n=12 images each).

Results: The perfusion loop design can house six vessel segments with independently manipulated flow rates and intravascular perfusate composition. To demonstrate the utility of this platform for quantitative analysis of NP targeting, we evaluated relative accumulation of ULEX-conjugated NPs compared to a nontargeted formulation (control).  ULEX-NPs were retained to a higher degree compared to nontargeted NPs as detected by quantitative microscopy (Fig. 1 B and C; Area of NP (pixels) 13 454±6796 versus 129.4±61.66 respectively, P<0.0002). These preliminary results demonstrate the capacity of this platform to quantitatively evaluate NP targeting efficacy.

Conclusion: We have developed a medium throughput isolated vessel perfusion system that is inexpensive and easy to produce. It can be adapted to test a variety of relevant targeting parameters, such as vessel size, type, pressure, flow rate, and shear stress. This system has the potential to improve clinical translation of endothelial-targeted nanomedicines by providing a native vascular context that retains the capacity for robust quantification without sacrificing translational relevance. Moreover, this ex vivo approach can facilitate subsequent in vivo experiments by treating human vessels prior to implantation in humanized mouse models.

 

88.03 Penicillin’s Protective Effect on Small Bowel Ischemia is Mediated by H,KATPase

Posted on January 31, 2019

V. M. Baratta1, T. M. Gisinger1,2, M. J. Barahona1, J. Ollodart1, D. Mulligan1, J. P. Geibel1,3  1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA 2Paracelsus Medical University,Department of Medicine,Salzburg, SALZBURG, Austria 3Yale University School Of Medicine,Department of Cellular and Molecular Physiology,New Haven, CT, USA

Introduction: One of the barriers to successful small bowel procurement is the sensitivity of the intestinal mucosa to ischemia. During procurement, the University of Wisconsin Universal Organ Preservation (UW) solution is used for in situ flushing and cold storage to minimize progression to ischemia. In addition, donor intestines undergo selective bowel decontamination with antibiotics and antifungals. Recently, we demonstrated that exposure of the small intestine to Penicillin G can protect from ischemic injury in a rat model. This finding may be helpful during the procurement process for intestinal transplantation. Here, we demonstrate that the protective effect is partly mediated by activation of an H,KATPase, independent of the Nitric Oxide (NO) pathway.

Methods:  The small bowel segments were harvested from rats and perfused with an ex-vivo intestinal perfusion device. Each intestinal segment was maintained at 37°C and perfused both from the luminal and basolateral side. As previously described, FITC-Inulin (fluorescein isothiocyanate-inulin), was used to assess the ischemic conditions of the colonic grafts in real-time. Small bowel segments were perfused with 4-(2-hydroxyethyl)-1-piperazineethanesulfonic acid (HEPES-Ringer) solution. To create an ischemic environment, HEPES-Ringer was pre-saturated with 100% N2 and exposed to the extraluminal components of all rat segments. For the experimental tissues, the intraluminal components were perfused with 5 mM Penicillin G and 10 μM SCH-28080, a known H,KATPase inhibitor. The intraluminal components of the control group were exposed to 5 mM Penicillin G. To test the Nitric Oxide (NO)-dependent mechanism, we used L-NAME (N(ω)-nitro-L-arginine methyl ester), an inhibitor of NO synthesis. The intraluminal compartments of the experimental tissue were exposed to 30 μM L-NAME with 5 mM Penicillin G, while control tissues were exposed to 5 mM Penicillin G.

Results: The small bowel samples exposed to Penicillin G and SCH-28080 exhibited a significant decrease in FITC-Inulin fluorescence, compared with the control colonic tissue exposed to Penicillin G, (39.83 ± 2.601 μM FITC-Inulin vs 47.37 ± 0.7288 μM FITC-Inulin, respectively p 0.0163). We observed no statistically significant difference in the FITC-Inulin concentration between tissues exposed to L-NAME with Penicillin G versus tissues exposed to only Penicillin G.

Conclusion: Our study unveils the mechanism of Penicillin G’s protective effect from ischemia. Our results indicate that Penicillin G’s protective effect against ischemia is through stimulation of the H,KATPase and is not NO-dependent. Therefore, Penicillin G not only has its well-known antimicrobial properties, but also appears to modulate a transport protein. In the future, Penicillin G may be implemented during the early procurement phase of intestinal transplantation to minimize ischemia.

 

85.04 Implementation of a comprehensive initiative to reduce over-prescribing of postoperative opioids

Posted on January 31, 2019

A. S. Chiu1, M. Freedman-Weiss1, P. Yoo1  1Yale University School Of Medicine,Surgery,New Haven, CT, USA

Introduction: Surgeons almost universally prescribe opioids postoperatively for analgesia, and often do so in far excess of what is needed—leaving unused pills susceptible to diversion and abuse. However, surgeons also have the opportunity to help offset the opioid epidemic by leading with practice changes. We sought to decrease the amount of opioid prescribed postoperatively through a multifaceted program.

Methods: Starting in the academic year 2016, an initiative to reduce over-prescribing of postoperative opioids was introduced at a single academic center. Based on the results of a needs assessment survey, this multi-pronged program included: resident education on postoperative analgesia and opioid prescribing, a grand rounds on the opioid epidemic, a change of the default number of opioid pills in an electronic medical record, and the distribution of a postoperative analgesic guideline with recommended doses.

 

The amount of opioid prescribed postoperatively between July 2016 and July 2018 was collected for the five most common short stay general surgery procedures (laparoscopic appendectomy, laparoscopic cholecystectomy, partial mastectomy, and laparoscopic and open inguinal hernia repair). Patients discharged after 48 hours were excluded to avoid confounding of complex hospital stays. To compare different opioids, prescriptions were converted to Morphine Milligram Equivalents (MME). Linear regression was used to evaluate prescribing over time and controlled for patient age, gender, race, insurance, and operation.

Results: There were a total of 6,109 qualifying operations over this 24-month period, including 2,071 laparoscopic cholecystectomies, 1,541 partial mastectomies, 1,404 inguinal hernia repairs (614 open and 790 laparoscopic), and 1,093 laparoscopic appendectomies. The population was predominately female (60.5%), Caucasian (71.0%), and privately insured (54.4%).

The mean opioid dose prescribed during this time was 168.5 MME (SD 102.5). The monthly average steadily declined over time (Figure 1); during the first 3 months, the average postoperative opioid prescription was 196.3 MME compared to 106.3 MME (p<0.01) in the final 3 months. This difference over a 2-year period is the equivalent of 12 pills of 5mg of oxycodone per prescription. Multivariable regression demonstrated a 4.4 MME (95%CI -5.0 to -3.6) decrease in average opioid prescription per month.

Conclusion: A dedicated and comprehensive program aimed at eliminating the over-prescription of opioids by surgeons reduced the amount of postoperative opioid prescribed by nearly half. Surgeons must acknowledge both their role in the societal problem of opioid abuse and their ability to deliver sustained and reproducible improvements.

85.02 Learning from England’s Best Practice Tariff: Process Measure Pay-for-Performance Can Improve Outcomes

Posted on January 31, 2019

C. K. Zogg1,2,3, D. Metcalfe3, A. Judge4, D. C. Perry3, M. L. Costa3, B. J. Gabbe5, A. H. Haider2  1Yale University School Of Medicine,New Haven, CT, USA 2Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 3University of Oxford,Oxford, United Kingdom 4University of Bristol,Bristol, United Kingdom 5Monash University,Melbourne, Australia

Introduction: Since passage of the Patient Protection and Affordable Care Act in 2010, Medicare has renewed efforts to improve the quality of older adult health through the introduction of an expanding set of outcome-based readmission and mortality pay-for-performance (P4P) measures. Among trauma patients, potential P4P has met with mixed success given concerns about the heterogeneous nature of patients that trauma providers treat and resultant variations in outcome measures. A novel approach taken by the National Health Service in England could offer a viable alternative plan. The objective of this study was to assess the effectiveness of the 2007-2010 English provider consensus-driven, process measure-based P4P Hip Fracture Best Practice Tariff (BPT) on improving trauma outcomes.

Methods: Quasi-experimental interrupted time-series and difference-in-difference analysis of 2000-2014 death certificate-linked data from England (Hospital Episode Statistics), Scotland (Scottish Morbidity Records), and the United States (100% Medicare all-payer claims). The study compared before-and-after differences in English temporal trends relative to those of Scotland and the US. Outcomes included: 30/90/365-day mortality, readmission, index hospital length of stay, and time to surgery. The study also assessed projections for the number of lives saved and readmissions averted were the BPT to be implemented in Scotland and the US.

Results: A total of 878,860 English, 97,487 Scottish, and 2,994,748 US index fractures were included among adults ≥65y. Following BPT introduction in England, 30-day mortality decreased instantaneously by an absolute value of -2.6 (95%CI -3.5, -1.7) percentage-points and continued to drop by an average of -0.2 (-0.4, -0.1) percentage-points per year (DID-Scotland: -1.6; DID-US: -2.2). 90-day mortality decreased more precipitously, dropping by an absolute value of -5.6 (-7.1, -4.2) percentage-points and an annual average thereafter of -0.2 (-0.5, 0.0) percentage-points per year (DID-Scotland: -1.9; DID-US: -2.9). Similar improvements were observed in readmission (e.g. 30-day ITSA: -1.4 [-2.3, -0.5]), time to surgery, and length of stay. Projections suggest that were the BPT to be implemented in Scotland and the US (Figure), by 2030, as many as 1,377 Scottish and 11,434 US lives could be saved.

Conclusion: In contrast to outcome-based P4P, process measure P4P such as that implemented through the English Hip Fracture BPT could result in significant improvements in outcomes for US patients while remaining more applicable to heterogeneous trauma populations and acceptable to trauma providers. As efforts to improve older adult health continue to increase, there are important lessons to be learned from initiatives like the BPT

78.02 Multicenter observational analysis of soft tissue infections: organisms and outcomes

Posted on January 31, 2019

A. Louis1, S. Savage2, W. Li2, G. Utter3, S. Ross4, B. Sarani5, T. Duane6, P. Murphy7, M. Zielinski8, J. Tierney9, T. Schroeppel10, L. Kobayashi11, K. Schuster12, L. Timsina2, M. Crandall1  1University of Florida College of Medicine Jacksonville,Surgery,Jacksonville, FL, USA 2Indiana University School Of Medicine,Surgery,Indianapolis, IN, USA 3University Of California – Davis,Surgery,Sacramento, CA, USA 4Cooper University Hospital,Surgery,Camden, NJ, USA 5George Washington University School Of Medicine And Health Sciences,Surgery,Washington, DC, USA 6JPS Health Network,Surgery,Fort Worth, TX, USA 7University of Western Ontario,Surgery,London, ON, Canada 8Mayo Clinic,Surgery,Rochester, MN, USA 9University Of Colorado Denver,Surgery,Aurora, CO, USA 10University of Colorado,Surgery,Colorado Springs, CO, USA 11University Of California – San Diego,Surgery,San Diego, CA, USA 12Yale University School Of Medicine,Surgery,New Haven, CT, USA

Introduction:  Skin and soft tissue infections (STIs) run the spectrum from mild cellulitis to life-threatening necrotizing infections.  The severity of illness may be affected by a variety of factors including organism involved and patient comorbidities.  The American Association for the Surgery of Trauma (AAST) has spent the last five years developing grading scales for impactful Emergency General Surgery (EGS) diseases, including STIs.  The purpose of this study was to characterize patient and infection factors associated with increasing severity of STI using the AAST EGS grading scale.

Methods:  This study was a retrospective multi-institutional trial, with each of 12 centers contributing 100 patients to the data set.  Patient demographics, comorbidities and infection data were collected on each patient, as were outcomes including management strategies, mortality and hospital and intensive care unit (ICU) length of stay (LOS).  Data were compared using Student’s t-test and Wilcoxon Rank Sum tests where appropriate.  Simple and multivariate logistic regression, as well as ANOVA, were also used in analysis.

Results:1,140 patients were included in this analysis.  The mean age of the cohort was 53 years (SD 19) and 68% of the patients were male.  Hospital stay and mortality risk increased with STI grade (Table 1).  The only statistical difference was noted between Group 3 and Group 5 (p=0.002).  Higher EGS grade STIs were significantly associated with infection by Gram Positive Organisms (GPC) (when compared to Gram Negative Rods (GNR); OR 0.09, 95% CI 0.06-0.14, p<0.001 for Grade 5.  Polymicrobial infections were also significantly more common with higher grade STI (compared to STI Grade 1: Grade 2 OR 2.29 (95% CI 1.18-4.41); Grade 3 OR 5.11 (95% CI 3.12-8.39); Grade 4 OR 4.28 (95% CI 2.49-7.35); Grade 5 OR 2.86 (95% CI 1.67-4.87); all p-values were less than 0.001.  GPC infections were associated with significantly more surgical debridements per patient (GNR 1.64 (SD 1.83) versus 2.37 (SD 2.7), p < 0.001).  There were no significant differences in preponderance of organism based on region of the country except in Canada, which had a significantly higher incidence of GNRs compared to GPCs.  

Conclusion:This study provides additional insight into the nature of STIs.  Higher grade STIs are dominated by GPCs, which also require more aggressive surgical debridement.  Understanding the natural history of these life-threatening infections will allow centers to plan their operative and antibiotic approach more effectively.

 

77.07 Earlier is better: Evaluating the timing of tracheostomy after liver transplantation

Posted on January 31, 2019

R. A. Jean1, S. M. Miller1, A. S. Chiu1, P. S. Yoo1  1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA

Introduction: Morbidity and mortality are relatively high following liver transplantation. Furthermore, severe pulmonary complications progressing to respiratory failure, though rare, are associated with increased postoperative mortality and prolonged hospitalization. Although these cases may require tracheostomy, there is uncertainty regarding how soon this should be pursued. The purpose of this study is to quantify the comparative effectiveness of early versus late tracheostomy in postoperative liver transplant patients in relation to in-hospital mortality and length of stay.

Methods:  The National Inpatient Sample (NIS) dataset between 2000 and 2014 was queried for discharges among adult patients who underwent both orthotopic liver transplant (OLT) and post-transplant tracheostomy (PTT). Patients receiving tracheostomy by post-transplantation day 14 were classified as “early” tracheostomies, while those receiving after day 14 were classified as “late". In-hospital mortality was compared between groups using adjusted logistic regression models. Cox proportional hazards regression was used to model the impact of early tracheostomy on post-tracheostomy length of stay (PTLOS), accounting for the competing risk of inpatient mortality.

Results: There were 2,149 weighted discharges after OLT and PTT during the study period, of whom 783 (36.4%) were performed by post-transplant day 14 and classified as “early.” Patients receiving early PTT were more likely to have a Charlson Comorbidity score (CCI) of 3+ compared to those receiving late PTT (early 71.1% vs late 60.0%, p=0.04), but there were otherwise no significant baseline differences between groups. Despite this increased comorbidity, early PTT had significantly lower in-hospital mortality (early 26.4% vs late 36.7%, p=0.01). Unadjusted median PTLOS was 31 days (IQR 20-48 days) for early PTT, versus 39 days (IQR 23-61 days) for late PTT (p=0.03). In adjusted logistic regression, early PTT was associated with 37% decreased odds of in-hospital mortality in comparison to late PTT (OR 0.63, p=0.04). Furthermore, after accounting for competing risk of mortality, early tracheostomy had a 41% higher daily rate of discharge alive during the post-transplant hospitalization (HR 1.41, p<0.0001).

Conclusion: Among patients with OLT, early PTT, despite being performed on patients with significantly higher comorbidity scores, was associated with lower in-hospital mortality, lower PTLOS, and quicker discharge alive. These results support our hypothesis that among patients with respiratory failure after OLT, early consideration of PTT may portend more favorable outcomes than a delayed approach.

 

74.06 Do EGS Outcomes Differ Among Homeless Patients in Medicaid Expansion vs Non-Expansion States?

Posted on January 31, 2019

R. Manzano-Nunez1, J. P. Herrera-Escobar1, C. K. Zogg2, N. Bhulani1, T. Andriotti1, J. C. McCarty1, T. Uribe-Leitz1, M. Jarman1, A. Salim1, A. H. Haider1, G. Ortega1  1Brigham And Women’s Hospital,Surgery,Boston, MA, USA 2Yale University School Of Medicine,New Haven, CT, USA

Introduction:  State decisions not to implement Medicaid expansion under the Affordable Care Act have the potential to leave many homeless individuals without an affordable insurance coverage option, which in turn could be associated with worse outcomes and higher costs. We hypothesize that by placing additional obstacles in the flow of care of homeless patients requiring emergency general surgery (EGS) operations, non-expansion states impact patient outcomes and their health-related decision-making process. 

Methods:  We used 2014 State Inpatient Database claims to identify homeless individuals admitted with a primary EGS diagnosis, as defined by the American Association for the Surgery of Trauma, who underwent a surgical procedure. Data related to homeless status was available for nine states (AZ, CO, FL, GA, MA, MD, NY, WA, and WI). States within this group were divided into those that did and did not implement Medicaid expansion. Multivariable quantile regression (MQR) models at the 50th, 75th and 90th quantiles accounting for variations in age, gender, race/ethnicity, insurance status and Charlson Comorbidity Index were used to examine associations between non-Medicaid expansion states and (1) LOS and (2) total index hospital charges within the homeless population. Multivariable logistic regression (MLR) models, adjusted for the same variables, were fitted to examine the associations between non-Medicaid expansion and discharge against medical advice, surgical complications, and mortality.

Results: A total of 6,930 homeless patients were identified. Of these, 435 (6.2%) were admitted in non-expansion states. Seventy-four percent (n=5,162) were insured through Medicaid (77.4% in Medicaid expansion states; 30.3% in non-expansion states). Homeless individuals living in non-expansion states had significantly higher total hospital charges and longer hospital stays (Table). After adjusting for confounders, MQR showed that non-Medicaid expansion was associated with longer LOS and higher charges (Table). The effect was observed in all quantiles examined.  MLR showed no differences in mortality (OR=1.4, 95% CI, 0.8-2.6; p=0.1) or surgical complications (OR=1.1, 95% CI 0.7-1.8; p=0.4). However, homeless individuals living in non-expansion states did have higher risk-adjusted odds of being discharged against medical advice (OR= 2.1, 95% CI, 1.08-4.05 p=0.02). 

Conclusion: Homeless patients living in Medicaid expansion states had reduced LOS, lower odds of being discharged against medical advice, and overall lower total index hospital charges. Not expanding Medicaid appears to result in the persistence of worse modifiable outcomes and increased hospital charges for an often-overlooked segment of the EGS population least equipped to handle them.
 

65.10 Transcription Factor Profiling Identifies Mediators of Invasion in Follicular Thyroid Cancer

Posted on January 31, 2019

N. G. Nicolson1, J. Paulsson2, C. Juhlin2, R. Korah1, T. Carling1  1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA 2Karolinska Institute,Solna, STOCKHOLM COUNTY, Sweden

Introduction:  Follicular thyroid cancer (FTC) is generally indolent with low risk of recurrence or death, but some cases are of encapsulated angio-invasive (eaFTC) or widely invasive (wiFTC) histological subtypes, portending a significantly worse prognosis. The mechanism and associated biomarkers of this invasive behavior have not been fully elucidated.

Methods:  Tissue samples including minimally invasive FTC (miFTC), eaFTC, and wiFTC tumors, as well as histologically normal thyroid adjacent to benign follicular adenomas, were selected from a cohort (n=21) of thyroid tumor patients. Histology was confirmed by experienced endocrine pathologists to designate the invasiveness of each sample as described in the 2017 WHO Guidelines. Total RNA was isolated, reverse transcribed, and subjected to a quantitative PCR array containing 84 transcription factor probes, with relative expression levels determined by a modified Livak method. Genes differentially expressed in invasive FTC were determined. In silico network analysis was performed to highlight involved signaling networks. Immunohistochemistry was performed to assess spatial expression patterns of selected transcription factors.

Results: Of the 84 transcription factors studied, 30 were differentially expressed between FTC and normal, or between invasive subtypes of FTC. E2F transcription factor 1 (E2F1), a ubiquitous transcription factor, was over-expressed in all 3 FTC subtypes (p<0.01, Figure 1). Specificity factor 1 (SP1), previously shown to modulate invasion in breast, prostate, and gastric cancers, was differentially expressed in eaFTC and wiFTC (p<0.05, Figure 1). Transcription factor 7-like 2 (TCF7L2), an established inducer of epithelial-to-mesenchymal transition and associated cancer invasion, was significantly upregulated in widely invasive tumors specifically (p<0.05, Figure 1). Thirteen transcription factors were differentially expressed in eaFTC and wiFTC compared to miFTC, and network interaction analysis suggested a role for Wnt signaling and associated networks in the invasive phenotype. Immunohistochemistry revealed differential expression of Yin and Yang 1 protein (YY1) and Myc-Associated Factor X (MAX) along the tumor invasive front relative to the central tumor, suggesting that invasiveness may be a local phenomenon rather than a property of the tumor at large.

Conclusion: Invasive FTC is rare but has a high risk of recurrence and death relative to minimally invasive FTC. This study identifies differential transcription factor expression associated with invasive subtypes of FTC and identifies dysregulated signaling pathways by investigating transcriptional regulation. Our study lays the groundwork for novel therapies targeting invasion pathways in FTC.

64.08 Penicillin Induces Colonic H,KATPase via Nitric Oxide Precursors: Novel Target for Diarrheal Control

Posted on January 31, 2019

V. Norz1,2, T. Spingler1,2, T. M. Gisinger1,2, V. M. Baratta2, M. J. Barahona2, J. Ollodart2, D. Mulligan2, J. P. Geibel2  1Paracelsus Medical University,Medicine,Salzburg, SALZBURG, Austria 2Yale University School Of Medicine,Surgery,New Haven, CT, USA

Introduction: Antibiotic-associated diarrhea (AAD) is a well-known complication of antibiotic administration, although the pathogenesis is not clearly elucidated. Symptoms range from mild gastrointestinal disturbances to fulminant gastroenteritis. Surgical patients who receive perioperative antibiotics are at higher risk. Antibiotic-associated diarrhea is thought to be due to an imbalance in the host microbiome, leading to pathogen overgrowth and increased intestinal secretion. We propose a novel pathway of AAD, whereby Penicillin G stimulates intestinal H, KATPase. Activation of H,KATPase leads to intraluminal fluid loss. Here, we demonstrate that L-arginine, a nitric oxide (NO) precursor, works synergistically with Penicillin G to activate H,KATPase. We corroborate this by showing how an inhibitor of the NO pathway, L-NAME, N (ω)-nitro-L-arginine methyl ester, eliminates the secretory effect of L-arginine and Penicillin G.

Methods: Rat distal colons were harvested and placed in solution for crypt isolation. Glands were maintained in a thermostatically controlled perfusion chamber and loaded with a pH indicator dye 2',7'-Bis(2-carboxyethyl)-5(6)- carboxyfluorescein,acetoxymethyl ester (BCECF) to measure intracellular pH in real time. Proton extrusion, a measure of acid secretion of the individual cells, was monitored by observing the recovery of pH, as previously described. A higher pH recovery rate indicates a higher rate of cellular secretion, i.e. diarrhea. Rat colonic crypts cells were perfused with the following solutions: 1.) 4-(2-hydroxyethyl)-1-piperazineethanesulfonic acid, HEPES + 5 mM Penicillin G sodium salt (Control) 2.) HEPES + 10 mM L-arginine 2.) HEPES + 5 mM Penicillin G + 10 mM L-arginine 3.) HEPES + 5 mM Penicillin G + 30 μM L-NAME. Statistical analysis of data was carried out with Graphpad Prism 7.0 software.

Results: The mean rate of pH recovery in the control was 0.00623 ± 0.00026 ΔpHi/min, p 0.0004. L-arginine administration increased H,KATPase activity 0.00097 ± 0.00011 Δ  pHi/min, p 0.0002. L-arginine + Penicillin G administration led to a greater, statistically significant increase in H-KATPase activity (Figure 1, 0.00883 ± 0.00051 ΔpHi/min, p 0.0004). Exposing crypts to a combination of L-NAME and Penicillin G provoked a significant reduction in H,KATPase activity (0.00292 ± 0.0001 ΔpHi/min, p 0.0022).          

Conclusion: It is well-known that antibiotic exposure disrupts the microbiome, leading to diarrhea. We propose a novel mechanism of antibiotic-associated diarrhea through Penicillin G’s activation of the H,KATPase. Maximum fluid secretion was found with Penicillin G and L-arginine, a nitric oxide precursor. In contrast, fluid secretion was significantly decreased when tissues were exposed to L-NAME, a known NO pathway inhibitor. This study may provide new therapeutic opportunities to address AAD in clinical settings by modulation of the colonic H,KATPase.
 

64.05 Sleeve Gastrectomy with Ileal Transposition Increases Peptide YY and Improves Weight Loss in Mice

Posted on January 31, 2019

L. Ying1, G. Breuer1, M. Hubbard1, J. Hwa1, G. Nadzam1, K. Martin1  1Yale University School Of Medicine,New Haven, CT, USA

Introduction: Sleeve gastrectomy with ileal transposition (SGIT) is superior to sleeve gastrectomy (SG) for promoting weight loss in rat and porcine models, and for preventing weight gain in a mouse model of diet-induced obesity. However, it is unknown if SGIT is superior to SG for promoting weight loss and lowering blood glucose in obese mice, and its weight loss mechanism is unclear.

Methods: SGIT was performed on a Pilot Cohort of 5 C57Bl/6J mice (7-8 weeks old), which were followed for 10 weeks to test viability. Whole transcriptome sequencing (RNAseq) was performed on the transposed ileal segments of these mice to identify highly expressed genes potentially responsible for weight loss. Next, SGIT, SG, or sham surgery (SH) was performed on a Study Cohort of 16-week old obese C57Bl/6J mice (40-45 grams, n=12 each). Prior to surgery, mice were grouped to match initial weight and fasting blood glucose. After surgery, mice were fed a low-fat diet and weighed weekly. 4 weeks after surgery, food intake was measured by weighing food over 4 days. 6 weeks after surgery, fasting blood glucose was re-measured. Additionally, after administering a liquid diet bolus via oral gavage, postprandial serum Peptide YY was measured after 15-minutes, 30-minutes, 1-hour, and 2-hours with competitive enzyme immunoassay.

Results: The overall mortality in the Study Cohort was 0%. In the Study Cohort, SGIT mice lost significantly more weight than SG or SH mice (6-week weight in grams±standard error of mean (sem): SH: 35.7±1.1, SG: 31.9±0.7, SGIT: 25.2±0.9). 4 weeks after surgery, SGIT mice consumed significantly less food than SG or SH mice (daily food intake in grams±sem: SH: 3.8±0.3, SG: 2.4±0.4, SGIT: 1.9±0.5). Fasting blood glucose (mg/dl±sem) was not statistically different between SG (77.8±8.6) and SGIT (87.7±7.7) mice 6 weeks after surgery, but both were significantly lower compared to SH mice (134.8±3.7). RNAseq of the transposed ileum from the Pilot Cohort revealed high expression of the ileal brake Peptide YY (PYY). Consequently, postprandial serum PYY was measured 6 weeks after surgery in the Study Cohort. Fasting serum PYY was not significantly different between the three groups. However, after administering a bolus of liquid diet, serum PYY rose more rapidly in SGIT mice than in SG or SH mice (graphic).

Conclusion: In this study, we show that SGIT is superior to SG for promoting weight loss, and similarly effective for lowering fasting blood glucose. SGIT mice also consume less food than SG or SH mice. An early release of Peptide YY, confirmed directly via serum measurement, provides a potential mechanistic explanation for the enhanced weight loss observed in SGIT mice.

63.21 Surgeons Are Leaders in Healthcare. Are They Prepared for the Role?

Posted on January 31, 2019

D. R. Heller1, V. Kurbatov1, M. R. Freedman-Weiss1, G. Chao1, R. A. Jean1, P. S. Yoo1  1Yale University School Of Medicine,Surgery,New Haven, CT, USA

Introduction:  Surgeons function as team leaders on the wards, in the operating room, and at all levels of training and practice. Yet leadership skills are not an ACGME core competency, nor is leadership training a standard curricular requirement for residents. We explored resident perceptions and experiences with leadership to assess for unmet educational needs.  

Methods:  An anonymous survey was electronically distributed to all General Surgery residents at a university-affiliated hospital (Qualtrics Survey Software). Questions centered on perceptions and experiences around physician leadership in healthcare and formal leadership training. Leadership experiences were defined as participation in healthcare-related administrative roles or committees. Leadership training was defined as participation in symposia or conferences teaching leadership theory and skill-building.  

Results: Of 70 residents, 56 (80.0%) responded to the survey. Males comprised 57.1% and each post-graduate year 1–5 had majority representation, ranging from 68.8% – 100%. Almost all respondents, 98.2%, ranked physician leadership in healthcare as somewhat or very important vs. neutral or unimportant. A large majority, 87.3%, ranked leadership training during residency as somewhat or very important. Far less reported exposure to leadership experiences (37.0%), and less still reported receiving leadership training during residency (24.1%). Senior residents had significantly more exposure to leadership experiences (p=0.01) and training (p=0.01), and married residents with higher incomes saw a trend toward association with leadership experiences. Among those who received formal education, roughly half were trained by the hospital/university or external healthcare organizations; only 14.3% reported training by the residency program. When polled about the leadership style most often employed by surgical residents, a majority reported “pacesetting” (31.2%) and “commanding” (22.2%); the “visionary” and “affiliative” styles were least-often employed (7.4% and 9.3%, respectively). 

Conclusion: At a large academic surgical residency, nearly all residents perceive physician leadership in healthcare systems and formal leadership training as important. Yet roughly a third are exposed to leadership roles and a quarter to leadership training at a given point in residency. Since leadership development is not an ACGME requirement, opportunities for experience and education during residency may be lacking, and trainees may preferentially acquire a narrow band of skills rather than the balanced spectrum requisite for effective leadership. Hospitals and training programs should mind this educational gap and aim to expand opportunities for residents during the critical years of professional development. 

63.06 Training Disparities & Expectations of Our Future Workforce: A Survey of Trauma Fellowship Candidates

Posted on January 31, 2019

S. A. Moore1, R. Maduka3, P. M. Reilly2, J. C. Morris2, M. J. Seamon2, D. N. Holena2, L. J. Kaplan2, N. D. Martin2  3Yale University School Of Medicine,New Haven, CT, USA 1University Of New Mexico HSC,Albuquerque, NM, USA 2Hospital Of The University Of Pennsylvania,Philadelphia, PA, USA

Introduction:

Fundamental training in Acute Care Surgery (ACS) is an integral component of general surgery residency and serves as a critical base experience for the added educational qualifications of fellowship.  How this training varies between programs is not well-characterized. We sought to describe the variation in clinical exposure between residencies and characterize the educational expectations (clinical and non-clinical) in a sample of residents applying to an ACS fellowship. We also sought to characterize the expectations of applicants for fellowship and future career plans. We hypothesized that applicants to an academic trauma, surgical critical care, and emergency surgery training program have significant variations in clinical exposure as well as unique and specific expectations for educational experiences.

Methods:
We offered an anonymous 70-question survey focused on residency clinical exposure and self-perceived confidence in key areas of ACS training, as well as fellowship training and career expectations to all applicants interviewed at a large, urban, academic, level one trauma, critical care, & emergency surgery fellowship program. Responses were assessed via absolute numbers and confidence via a 5-point Likert scale; data is reported using descriptive statistics and linear regression models.

Results:
Forty-two out of 44 interviewing applicants completed the survey, for a response rate of 96%. Applicants reported heterogeneous levels of comfort across most ACS domains. There was poor correlation between experience and comfort in several key areas where despite little experience respondents reported high levels of comfort (FIGURE 1). During fellowship training, respondents placed the highest priority on operative experience, with 43% rating this as their highest priority, followed by penetrating trauma experience (33%), a heavy clinical ICU exposure (17%) and leadership training (12%).The majority of respondents (58%) envisioned a career that was comprised of 50% trauma, 25% emergency general surgery, and 25% critical care.

Conclusion:
We found significant variations in both experience and comfort within key ACS domains amongst fellowship applicants. Applicants with little experience still reported high level of comfort with fundamental ACS skills. Collaboration between general surgery residency and ACS fellowship governing bodies may help address areas of limited exposure prior to entry into clinical practice. Understanding the expectations of fellowship applicants is essential in demonstrating the elements of a program that resonate with applicants to aid rendering an informed program selection. ACS fellowship programs must balance these expectations with realistic experiences during training and in the job market.
 

62.05 Evaluating an Evidenced-Based Guideline to Reduce Excessive Prescription of Post-Operative Opioid

Posted on January 31, 2019

M. R. Freedman-Weiss1, A. S. Chiu1, D. R. Heller1, V. Kurbatov1, P. S. Yoo1  1Yale University School Of Medicine,Surgery,New Haven, CT, USA

Introduction:
Prescription opioids are a main contributor to the current opioid epidemic as leftovers often get diverted for non-medical use.  Surgeons are known to dispense far more opioid pills than are needed to treat pain.  In academic institutions, junior residents (PGY-1, 2) write most postoperative prescriptions.  Few residents receive education on opioids, but trainees who did, cited opioid dosage recommendations as the most useful educational point.  Utilizing publsihed data on actual postoperative opioid use, we developed a card of recommendations for surgical residents to use when prescribing postoperative analgesia.  We studied the impact of this initiative and the value of the card, paying particular interest in junior resident use.

Methods:
A pocket-sized postoperative analgesia guideline card was developed, comprising specific recommended opioid doses for common general-surgical procedures, general guidelines for postoperative analgesia, instructions for Narcan use, an equianalgesic opioid chart, and smartphrases in the electronic medical record for use as patient instructions on opioid use, safety, and disposal.  The specific recommended doses were based on published data on actual postoperative opioid use and were approved by experienced surgeons from each included specialty.  The tool was distributed to all general surgery housestaff at a university-affiliated hospital.  Following the distribution of the card, an anonymous electronic survey (Qualtrics Survey Software) regarding its use and impact was distributed.  Descriptive statistics were used for all analyses.

Results:
Of 85 trainees, 62 (72.9%) responded to the survey in full.  Fifty respondents (80.6%) received the opioid guideline card, including 16 PGY-1’s and 10 PGY-2’s.  Of responding PGY-1 and PGY-2 trainees who received the card, 75% and 60% respectively use it, with 46% of responding junior residents accessing the tool on a daily-to-weekly basis.  Overall, 81.6% of included residents reported changing their opioid prescribing practices because of this intitative and 89.8% believe the card should continue to be distributed and used. The most valuable aspects of the card were the specific dosage recommendations (53.1%), the guidelines for analgesia after inpatient stays (40.8%), and the smartphrases for patient discharge instructions (28.6%).

Conclusion:
An evidenced-based guideline for postoperative analgesia, including specific recommendations for opioid doses after common surgical procedures, is useful for surgical residents, specifically junior residents.  Nearly all residents who received this card report that is has influenced their prescribing practices and advise its continued distribution and use.  A comprehensive guideline for postoperative analgesia should be considered for wide-use, specifically among junior residents at training hospitals.  Its impact on offsetting the over-prescription of postoperative opioids should be studied further.
 

60.02 Time to Prothrombin Complex Conctretrate Administration Effect on Intracranial Hemorrhage Outcomes.

Posted on January 31, 2019

L. S. Kuzomunhu1, M. M. Fleming2, R. R. Jean2, K. Y. Pei2  1Yale University School Of Medicine,New Haven, CT, USA 2Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA

Introduction: Prothrombin complex concentrate (PCC) is indicated in patients sustaining traumatic intracranial hemorrhage (ICH) while taking warfarin, but the optimal timing is unknown. This study evaluates the effect of timing to PCC administration on outcomes including intracranial hemorrhage expansion and length of hospital stay.

Methods: We retrospectively reviewed patients presenting with ICH who received PCC at our tertiary care hospital between March 2013 to November 2017. Only patients on warfarin and with repeat computed tomography of head were included. Time to PCC was defined as the time from order entry to patient administration as documented contemporaneously in the electronic health record. Time was stratified as early (≤30 minutes) or late (>30 minutes). Multivariable logistic regression with stepwise selection was used to predict ICH expansion between initial and repeat cross sectional imaging. Linear regression identified predictors for increased hospital and intensive care unit length of stay.

Results: In total, 127 patients with ICH on warfarin were included for analysis. Mean time to PCC administration was 82.3 ± 43.7 minutes. The majority of patients who demonstrated expansion of ICH (31.5% of patients) had admission motor Glasgow Coma Score (GCS) less than 6 (p<0.05), a higher Charlson Comorbidity Index (CCI) (p<0.05) and higher inpatient mortality (p<0.01). On multivariable analysis, only admission motor GCS<6 was independently associated with ICH expansion (OR 3.016, 95% CI 1.158-7.858). Time to PCC (early versus late), admission INR and anticoagulation indication were not associated with ICH expansion. On linear regression admission motor GCS<6 was associated with increased length of ICU stay (β=8.261, SE 2.070, p=0.0001); however no other patient characteristics or PCC administration time was associated with hospital length of stay.

Conclusion: Timing to PCC administration was not associated with ICH expansion or mortality after traumatic ICH. Further multi-institutional studies are needed to evaluate clinical and process measures to streamline PCC administration.

56.05 Does ACS NSQIP Database Report Retained Surgical Instruments During Surgery?

Posted on January 31, 2019

B. K. Patel1, R. Dev1, K. Zhang1, J. Mccauley1, J. Luo3, Y. Zhang2,3, K. Y. Pei1  1Texas Tech University Health Sciences Center,Surgery,Lubbock, TX, USA 2Yale School of Medicine,Surgical Outcomes And Epidemiology,New Haven, CT, USA 3Yale School of Public Health,Environmental Health Sciences,New Haven, CT, USA

Introduction:

 

Intraoperative safety is a top priority among hospitals across the country and significant resources are allocated to preventing retained objects intraoperatively. Despite such efforts including liberal intraoperative safety checks, instrument counts, and radiofrequency scanning, a small percentage of patients unfortunately still require additional surgery to extract retained foreign objects. It is unknown whether the ACS NSQIP database actually reports foreign objects and the purpose of this study is to examine some characteristics common to these events.

 

Methods:

 

The ACS NSQIP database was queried for patients with experienced a retained object intraoperatively (identified by ICD 9 998.4 ICD 10 T81.509A) from 2005 to 2016.  Trends information was evaluated as percentages of total procedures performed from NSQIP participating hospitals.  Standard descriptive statistics was analyzed and characteristics were reported as medians with quartiles or means where appropriate.

 

Results:

 

A total of 236 cases were identified and included for analysis.  Among NSQIP participating hospitals, incidence of retained foreign objects remain largely unchanged averaging 19 cases per year, with the exception of 2016 where only 2 events were noted.  All patients required reoperation for retrieval of object.  The 10 most frequent procedures required as a result of foreign object retention involve abdominal procedures with the majority of secondary procedures involving extraction of retained surgical instruments from the abdomen (Table 1).   Mean operative time was 79.16 minutes with SD of 70.19, majority were non-emergent, and majority were ASA Class 2-3. 

Conclusion:

 

Unintended retained foreign objects during surgery is potentially catastrophic.  It is notable that ACS NSQIP is transparent and reports such events.  Contrary to published literature, patients who suffered retention were not necessarily the most complex medically and did not have the long operative times.

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