21.10 Risk Factors of Mortality Following Abdominal Aortic Aneurysm Repair using Analytic Morphomics

Posted on January 18, 2016

A. A. Mazurek1, J. F. Friedman1, A. Hammoud1, C. Inglis1, J. Haugen1, A. Hallway1, J. Lawton1, J. Ruan1, B. Derstine1, J. S. Lee1, S. C. Wang1, M. J. Englesbe1, N. H. Osborne1 1University Of Michigan,Morphomic Analysis Group, Department Of Surgery,Ann Arbor, MI, USA

Introduction:
Risk stratification for patients undergoing open or endovascular abdominal aortic aneurysm (AAA) repair has focused primarily on utilizing patient comorbidities as predictors of operative outcomes. However, there is often minimal variation in the burden of comorbid disease among patients with AAAs. Analytic morphomics is a novel method of risk-stratification that uses cross-sectional images to quantitatively measure domains of patient health. The utility of morphometric measurements as predictors of surgical outcome has been validated in several patient populations. Previously, AAA mortality after open repair has been associated with total psoas area. This study sought to further understand the role of both core muscle size and adiposity on the risk of mortality following open and endovascular AAA repair.

Methods:
A total of 795 patients underwent open or endovascular AAA repair between 2000 and 2012. 722 patients (91%) had preoperative abdominal CT scans available for analysis. After excluding patients with incomplete medical records, manual chart review was used to identify patient demographics and comorbidities. Validated methods of analytic morphomics, previously described, were used to measure cross-sectional areas and densities of psoas muscle, dorsal (paraspinous) muscle groups and subcutaneous and visceral fat at the vertebral levels T12 through L5. Univariate and multivariate analyses were used to determine which morphometric variables were significant predictors of mortality, controlling for traditional patient factors.

Results:
A total of 610 patients were identified; 322 patients underwent open repairs and 288 underwent endovascular repairs between the years 2000 and 2012. Following open repair, overall mortality ranged from 7% at 90 days to 21.1% at 3 years. Following endovascular repair, overall mortality ranged from 4% at 90 days to 21.3% at 3 years. Morphometric variables associated with mortality between 90 and 1095 days included measures of subcutaneous fat, visceral fat and both dorsal muscle group and psoas muscle density and area. After controlling for patient comorbidities and type of repair, a composite score of morphometric variables continued to be highly associated with mortality between 90 days and 1095 days; important variables included subcutaneous fat density at L2 (OR 1.09, p<0.001) and visceral fat density at L3 (OR 1.08, p<0.001).

Conclusion:
Morphometric measurements of adiposity and muscle mass correlate strongly with intermediate and late-term mortality after both open and endovascular AAA repair. Traditional methods of risk stratification in patients undergoing AAA repair may be augmented using analytic morphomics. These objective measures of frailty may aid in patient decision-making and provide insight into domains of health that clinicians and patients can work to optimize preoperatively in order to maximize positive outcomes for the patient.

21.08 Cells from In Vivo Models of Heterotopic Ossification Exhibit Increased Osteogenic Properties

Posted on January 18, 2016

J. Drake1, S. Agarwal1, K. Shigemori1, S. Loder1, C. Hwang1, S. Li1, Y. Mishina1, S. Wang1, B. Levi1 1University Of Michigan,Ann Arbor, MI, USA

Introduction: Large burns and high-energy trauma can lead to heterotopic ossification (HO), a process by which pathologic, ectopic bone forms within soft tissue. Management of HO is limited by efficacy of available treatments, difficulty identifying at-risk patients, and high recurrence rates following surgical excision. The cellular and molecular basis of HO is unknown. Here we investigate whether the cells themselves or their environment drive HO formation. We demonstrate that human and mouse cells isolated from sites of HO retain increased osteogenic capacity when cultured outside of an inflammatory environment.

Methods: Human cells were cultured from HO and surrounding normal bone. Mouse cells were obtained from two models including trauma-induced and genetic HO. Cells from the trauma induced model were isolated from the tendon transection site of mice which had undergone a dorsal burn with tendon transection (burn/tenotomy) at 1, 2, and 3 weeks after injury, a model that reliably produces HO. In the genetic HO model (Nfatc1-cre/caACVR1fl/wt) normal and HO-derived osteoblasts were isolated from 1, 2, and 3 week old mice. Osteogenic differentiation was assessed for by alkaline phosphatase production, alizarin red stain for mineral deposition, RNA expression, and protein expression. Cell proliferation was also assessed.

Results: Human HO cells showed increased osteogenic signaling compared to human osteoblasts from non-HO bone (Fig. 1). Cells isolated from the burn/tenotomy mice 2 and 3 weeks after injury demonstrated significantly increased cell proliferation, alkaline phosphatase, alizarin red stain, and pSmad 1/5 expression when compared with controls. Similarly, HO-derived cells from our genetic HO model in 2 or 3 week old mice exhibited increased cell proliferation, alkaline phosphatase, alizarin red stain, and pSmad 1/5 expression when compared with non-HO osteoblasts from the same mice (Fig. 2). Finally, targeting these cells with inhibitors of smad5 phosphorylation (LDN-193189) decreased osteogenic capacity by alkaline phosphatase and alizarin red quantification (p<0.05), consistent with its effect on HO formation in our trauma model.

Conclusion: In vitro analysis demonstrates significant differences in cellular behavior with regard to proliferation and osteogenic differentiation in HO models when cells are cultured separate from their in vivo environment. This data suggest that changes in cell behavior drive the process of HO as cell characteristics are preserved after they are removed from their environment. Furthermore, the striking differences in these HO-derived cells from normal cells suggests that they may be used for in vitro assays to study potential therapies targeting HO development.

21.07 Ultrasound is a Sensitive Adjunct to Plain Radiographs in Management of Necrotizing Enterocolitis

Posted on January 18, 2016

S. E. Horne3, S. M. Cruz1,3, S. Nuthakki2, P. E. Lau1,3, D. A. Lazar1,3, S. E. Welty2, O. O. Olutoye1,3 1Baylor College Of Medicine,Department Of Surgery,Houston, TX, USA 2Texas Children’s Hospital,Pediatrics,Houston, TX, USA 3Texas Children’s Hospital,Pediatric Surgery,Houston, TX, USA

Introduction:

Necrotizing Enterocolitis (NEC) is the most common gastrointestinal emergency of the preterm infant with an incidence of 5-10%. It is traditionally diagnosed with a combination of physical examination and plain radiographs of the abdomen. The diagnostic role for ultrasound in NEC is uncertain. We hypothesized that ultrasound (US) is as sensitive as plain radiographs in the diagnosis and management of NEC.

Methods:

The medical records of all infants with NEC in a single pediatric tertiary center from January 2006- January 2013 were reviewed. In order to factor in NEC’s rapid rate of changes in pathologic findings, patients that underwent US within four hours of abdominal XR were included in the analysis. Bell’s Criteria were utilized to stage each patient during his/her course. Clinical, radiologic, surgical and pathological findings were reviewed. Statistical analysis was performed using Student's t-test and Mann-Whitney U test for continuous variables and Fisher's exact for categorical variables.

Results:

During this period, 186 neonates were diagnosed with NEC, of which 26 met inclusion criteria. It was noted that US was done for confirmatory purposes in these 26 patients after plain radiographs did not agree with clinical findings. Plain radiographs and ultrasound were taken within an average of 2.46 ± 1.17 hrs of each other. At the time of XR and US, the Bell’s staging of the patients was Stage 1 in 27% of the cases (n=7), Stage 2 in 42% (n=11), and Stage 3 in 31% (n=8). There were 92% preterm infants, 38.5% had congenital anomalies (i.e. omphalocele, congenital neck mass, and Congenital High Airway Obstruction Syndrome), 19% had cardiac abnormalities, and 23% had patent ductus arteriosus. The survival rate of our NEC population was 65% (n=17). Surgical intervention was undergone in 65% (n=17) of our patients in which the median time between imaging findings and time of surgery was 2 (0-59) days. When comparing both modality for reliability in detecting intestinal ischemia and/or perforation with surgical findings, US had a sensitivity of 72% with a positive predictive value (PPV) of 93% while plain radiographs had a sensitivity of 42% with a PPV of 100%. In all cases that required surgical drainage (n=4), ultrasound findings of complex fluid collections guided the decision for bedside surgical drainage where plain radiograph did not suggest free fluid.

Conclusion:

In this study, ultrasound proved to be helpful in assessing the need for surgical interventions in neonates where diagnosis of advanced NEC is ambiguous. US appeared to be more sensitive in reliably detecting intestinal perforation/ischemia in comparison to plain radiographs. However, both plain radiographs and ultrasound play a key role in the diagnosis and should be considered conjunctively during the management and treatment of NEC.

21.09 Surgical and Post-Operative Risk Factors for Lymphedema Following Lymphadenectomy for Melanoma

Posted on January 18, 2016

S. J. Diljak1, R. D. Kramer1, R. J. Strobel1, B. Sunkara1, D. J. Mercante1, J. S. Jehnsen1, J. F. Friedman1, A. Durham2, M. Cohen1 1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,Department Of Dermatology,Ann Arbor, MI, USA

Introduction: Secondary lymphedema (SLE) is a significant complication following lymphadenectomy in melanoma patients, with a reported incidence between 9-25% for axillary dissection (ALND) and as high as 24-44% for inguinal dissections (ILND). While radiation therapy and tumor burden are positive predictors for arm lymphedema in breast cancer, this has not been as well defined in the melanoma population using large cohorts. The purpose of this study is to identify unique post-operative and surgical risk factors for SLE in patients with regionally metastatic melanoma using the largest cohort to date compiled from a prospectively collected database of melanoma patients following an ALND or ILND.

Methods: From a prospectively collected, IRB-approved database we identified 688 melanoma patients receiving a complete lymphadenectomy (June 2005-June 2015) with 557 patients having either an ALND or ILND. Patients having iliac or bilateral dissections, or pre-op chemotherapy were excluded. Demographic, clinical, and post-op data were reviewed from the electronic medical record (EMR). SLE was defined as being mentioned in more than one post-operative note or a documented referral to the lymphedema clinic. Univariate statistical analysis and odds ratios (OR) with 95% confidence intervals (CI) were used to determine independent post-op and surgical predictors of SLE.

Results: Of the cohort of 557 melanoma patients, 119 (21.4%) developed SLE following lymph node dissection. The cohort was split between ALND (N=322 (57.8%); 10.9% with SLE) and ILND (N=235 (42.2%); 35.7% with SLE). On univariate logistic regression [Table], having an ILND (OR=4.58; CI: 2.95-7.11), post-operative adjuvant (OR=1.61 CI: 1.07-2.42) or radiation therapy (OR=1.81 CI: 1.02-3.22), and developing non-SLE complications (e.g. hematoma, infection, DVT) (OR=1.84 CI: 1.21-2.80), were each significantly associated with an increased risk of developing SLE. Non-SLE post-op complications increased the risk of SLE only in the first 2 months after surgery (OR=2.25 CI: 1.35-3.74). Use of an energy device during surgery, number of nodes removed, blood loss, and operative times were not significantly associated with risk of SLE. The average post-op time to develop SLE was 103 ± 126 days and follow-up was 1.9 ± 2.2 years.

Conclusion: This is the largest study to date evaluating surgical/post-op risk factors for SLE in melanoma patients after ALND or ILND. Post-operative factors significantly increasing the risk of SLE include adjuvant or radiation therapy, having an ILND, or non-SLE post-op complications. We believe that this work, combined with further evaluation of patient pre-op characteristics, will enhance informed clinical decision-making and risk assessment.

21.06 Are NSQIP Hospitals Unique? A Description of Hospitals Participating in ACS NSQIP.

Posted on January 18, 2016

C. R. Sheils1,2, A. R. Dahlke1, A. Yang1, K. Bilimoria1 1Northwestern University,Department Of Surgery,Chicago, IL, USA 2University Of Rochester,School Of Medicine,Rochester, NY, USA

Introduction: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) is a well-recognized program for surgical quality measurement. Given the widespread use of ACS NSQIP in research and recent calls for it to become a platform for national public reporting and pay-for-performance initiatives, it is important to understand which types of hospitals elect to participate in the program. Our objective was to compare the characteristics of ACS NSQIP-participating hospitals to non-participating hospitals in the United States.

Methods: Using the 2013 American Hospital Association data on hospital characteristics, hospitals participating in ACS NSQIP were compared to non-participating hospitals. The 2013 Healthcare Cost Report Information System (HCRIS) dataset was used to calculate hospital operating margin as a measure of financial health. The CMS 2013 Inpatient Prospective Payment System (IPPS) Final Rule Impact File was used to abstract the Medicare and Medicaid Services Value Based Purchasing (VBP) and Disproportionate Share adjustment scores, which were used as proxies for hospital quality and patient population, respectively.

Results: Of 3,872 total U.S. general medical and surgical hospitals, 475 (12.3%) participated in ACS NSQIP. ACS NSQIP hospitals performed 29.0% of operations in the U.S, with a slightly greater share of inpatient operations (32.4%) and a smaller share of outpatient operations (27.1%). Compared to non-participating hospitals, ACS NSQIP hospitals had a higher mean annual inpatient surgical case volume (6,426 vs 1,874; p<0.001), a larger number of hospital beds (420 vs 167; p<0.001), were more often academic affiliates (35.2% vs 4.1%; p<0.001), were more often accredited by JCAHO and CoC (p<0.001), and had higher mean operating margins (p<0.05). ACS NSQIP hospitals were less likely to be designated as critical access hospitals (p<0.001). No significant differences in VBP or Disproportionate Share adjustment scores were found. States with the highest percentage of hospitals participating in ACS NSQIP were states with established surgical quality improvement collaboratives (Figure 1).

Conclusion: Hospitals that participate in ACS NSQIP represent 12% of all U.S. hospitals performing inpatient surgery, yet they perform nearly 30% of all surgeries done in the U.S. ACS NSQIP disproportionately includes larger, accredited, and academic-affiliated hospitals with more financial resources. These findings should be taken into account in research studies using ACS NSQIP, and more importantly, indicate that additional efforts are needed to address barriers to enrollment in order to facilitate participation in surgical quality improvement programs by all hospitals.

21.05 Changes in Liver Allograft Steatosis and its Impact on Early Graft Function and Long Term Survival

Posted on January 18, 2016

J. Davis1, S. Fuller1, S. Kubal1, J. Fridell1, A. J. Tector1, R. S. Mangus1 1Indiana University School Of Medicine,Transplant Division, Dept Of Surgery,Indianapolis, IN, USA

Introduction:
Deceased organ donor liver transplant allografts with steatosis have an increased risk of primary non-function and initial poor function post-transplant. A large percentage of donor livers have significant steatosis. Previous research suggests improvement in steatosis in the immediate post-transplant period. This study compares reperfusion and early post-transplant surveillance biopsies, and correlates the results with initial graft function and long-term outcomes.

Methods:
Records of all liver transplants (LTs) performed at a single center over a 14-year period were reviewed. The original biopsies were reviewed by experienced liver pathologists. Liver biopsies are obtained at the time of transplant and 3 days after transplant. Total steatosis is calculated as the sum of both micro- and macrovesicular steatosis, and is categorized into four study groups: (1) none (0%), (2) mild (<10%), (3) moderate (10-20%) and (4) severe (>20%). For this analysis, change in liver steatosis is calculated as moving from one study group to another. Early post transplant liver function is assessed by biochemical analysis of liver enzymes (alanine aminotransferase (ALT); liver injury), total bilirubin (TB; excretion), international normalized ratio (INR; synthesis). Long-term survival is assessed using Cox regression analysis.

Results:
Data were available for 1572 adult subjects. Among the patients with steatosis, there was a significant and rapid decrease in steatosis. The median group change was greatest for severe steatosis groups (Group 3, >20%: -1.54; Group 2, 10 to 20%: -0.93; Group 1, 1 to 10%: -0.47 (p<0.001). Moderate and severe steatosis was associated with more acute liver injury (p<0.05 for days 1 to 6), and delayed graft function (higher TB and INR (p<0.05 on days 1, 3)). These values decreased for all study groups until they were similar by day 7 (ALT) and day 14 (TB and INR). Systemically, steatotic groups demonstrated an acute decrease in glomerular filtration rate (GFR) from 1 to 3 days post transplant, ranging from -12 to -22% change, compared to only a -5% change for the nonsteatotic group. Graft survival was worse at all time periods for moderate and severe steatosis livers. Subgroup analysis was employed to identify groups that have a more dynamic decrease in steatosis. Those groups with better clearance of severe steatosis included recipients who were younger, more obese, male, and those with fatty liver disease.

Conclusion:
These results confirm a marked post-transplant decrease in allograft steatosis that occurs within 3 days of transplant. Subgroup analysis suggests that younger male patients who are obese or have fatty liver disease are more able to clear steatosis in this period. Allografts with moderate to severe steatosis have worse early injury, delayed graft function and worse early and late survival. Steatotic grafts are associated with a substantial acute decrease in renal function early post transplant.

21.04 Sarcopenia as a Prognostic Factor in Emergency Abdominal Surgery

Posted on January 18, 2016

R. C. Dirks1, B. L. Edwards1, E. Tong1, B. Schaheen1, F. E. Turrentine1, A. L. Shada2, P. W. Smith1 1University Of Virginia,General Surgery,Charlottesville, VA, USA 2University Of Wisconsin,Surgery,Madison, WI, USA

Introduction: Sarcopenia, a loss of skeletal muscle mass associated with aging, is a practical measure of frailty and has been previously identified as a predictor of outcomes in surgical cohorts including cancer resection and elderly patients. We hypothesize that sarcopenia, as measured by preoperative CT scans of the psoas muscle, predicts mortality and morbidity in emergent laparotomy.

Methods: Institutional NSQIP data were queried for adult patients who underwent open emergency abdominal surgery between 2008 and 2013. Patient demographics, clinical variables, and outcomes were extracted from NSQIP. Patients with abdominal CT scans within 30 days prior to surgery were included and the cross sectional areas of the psoas muscles at vertebral level L4 were summed and normalized by patient height. Patients were assigned to sex-stratified tertiles based on this normalized total psoas area (TPA) for analysis, with the lowest tertile being classified as sarcopenic. Kaplan Meier curves were constructed to compare survival between TPA tertiles. Cox Proportional Hazards models stratified by sex and controlling for ASA score, ascites, International Normalized Ratio (INR), functional dependency and work Relative Value Units as a proxy for surgery complexity were used to evaluate the influence of TPA on postoperative mortality.

Results: NSQIP revealed 781 patients undergoing emergent open abdominal surgery and 593 of these (75.9%) had appropriate preoperative CT scans. Median patient age was 61 years (IQR 50-72), median TPA was 1719 mm2 (IQR 1341-2293), and median BMI was 26.7kg/m2 (22.9-33). Bivariable analysis demonstrated that TPA was significantly associated with total postoperative morbidity (p=0.013), increased length of stay (p<0.0001) and 90-day mortality (p=0.0008) but not 30-day mortality (p=0.26). Kaplan Meier curves demonstrated significantly decreased 90-day survival in lowest TPA tertile. A Cox proportional hazards model demonstrated that the impact of TPA was overwhelmed by previously validated predictors of mortality, most notably ASA score.

Conclusion: Sarcopenia, as measured by TPA, is significantly associated with increased 90-day mortality, length of stay, and total morbidity in patients undergoing open emergency abdominal surgery. Since many patients undergoing emergent abdominal surgery have already undergone CT scanning, TPA is readily available to the practicing surgeon at no added risk or cost. As such, sarcopenia is a convenient additional tool for preoperative risk assessment and risk counseling.

21.03 Hospital Teaching Status and Medicare Expenditures for Complex Surgery

Posted on January 18, 2016

J. C. Pradarelli1, C. P. Scally1, H. Nathan1, J. R. Thumma1, J. B. Dimick1 1University Of Michigan,Ann Arbor, MI, USA

Introduction:
Several emerging payment policies penalize hospitals for higher costs. Teaching hospitals may be at a disadvantage given the perception that they deliver care less efficiently.

Methods:
We studied Medicare patients who underwent abdominal aortic aneurysm (AAA) repair (n=74,767), colectomy (n=288,378), or pulmonary resection (n=94,629) from 2009 to 2012. Patients’ hospitals were categorized into quintiles of teaching intensity (very major, major, minor, very minor, and non-teaching hospitals) based on the resident-to-bed ratio. Risk-adjusted 30-day Medicare payments were price-standardized to account for social subsidies and regional variation in costs. Risk-adjusted perioperative outcomes were also assessed.

Results:
Comparing risk-adjusted Medicare payments per episode of surgery, very major teaching hospitals were $13,947 more expensive than non-teaching hospitals for AAA repair ($45,632 vs. $31,685; p<0.001), $19,315 more expensive for colectomy ($52,199 vs. $32,884; p<0.001), and $9,788 more expensive for pulmonary resection ($39,513 vs. $29,725; p<0.001). However, after accounting for social subsidies and regional variation in Medicare payments, very major teaching hospitals were paid only $1,811 more than were non-teaching hospitals for AAA repair ($30,030 vs. $28,219; p=0.35), $4,701 more for colectomy ($35,182 vs. $30,480; p<0.001), and $1,424 less for pulmonary resection ($25,373 vs. $26,796; p=1.00). Very major teaching hospitals generally had higher risk-adjusted rates of serious complications and readmissions, but lower risk-adjusted rates of failure to rescue and 30-day mortality than did non-teaching hospitals.

Conclusion:
After price-standardization to account for intended differences in payments, risk-adjusted Medicare payments for an episode of surgical care were similar at teaching hospitals and non-teaching hospitals for three inpatient operations.

21.02 Amitriptyline Treatment Improves Survival After Trauma and Hemorrhage

Posted on January 18, 2016

H. He1,2, P. L. Jernigan1,2, R. S. Hoehn1,2, A. L. Chang1,2, L. Friend1,2, R. Veile1,2, T. Johannigman1,2, A. T. Makely1,2, M. D. Goodman1,2, T. A. Pritts1,2 1University Of Cincinnati,Trauma And Critical Care,Cincinnati, OH, USA 2University Of Cincinnati,Institute For Military Medicine,Cincinnati, OH, USA

Introduction: Hemorrhagic shock is the leading cause of potentially preventable death after trauma. The optimal treatment for hemorrhagic shock is to reverse circulatory losses, metabolic acidosis, and cellular hypoxia with blood products, but these are often not available for immediate administration. Alternative approaches to initial resuscitation are needed, especially in resource poor environments. Amitriptyline is a serotonin-norepinephrine reuptake inhibitor with anti-inflammatory effects. We have previously demonstrated that treatment of blood products with amitriptyline leads to decreased lung injury after hemorrhage, but the direct effect of amitriptyline in treatment of hemorrhage is unknown. We hypothesized that administration of amitriptyline after trauma and hemorrhage would improve survival in a non-resuscitation injury model.

Methods: Healthy C57/BL6 male mice underwent laparotomy to induce tissue trauma and hemorrhage via femoral artery cannulation to a mean arterial pressure of 25±5mmHg for 60 minutes. After laparotomy closure and decannulation, mice received amitriptyline (0.1 mg/kg) or an equivalent volume of vehicle (50 uL of normal saline) via intraperitoneal injection. For survival analysis, mice underwent the above treatment (n=10/group) and were monitored for 24 hours. For hemodynamic and blood chemistry analysis, mice (n=5/group) underwent the same injuries and treatments as described above and were sacrificed 60 minutes after treatment.

Results: Administration of amitriptyline after trauma and hemorrhage significantly increased 24-hour survival in mice (Figure 1; 70% survival with amitriptyline vs 0% with vehicle; p<0.001). Sixty minutes after trauma and hemorrhage, mice treated with amitriptyline also had significantly increased mean arterial blood pressure (p=0.04). Blood gas analysis revealed that mice treated with amitriptyline had statistically significant improvements in base deficit and serum bicarbonate, consistent with decreased metabolic acidosis.

Conclusion: Our results demonstrate that administration of amitriptyline significantly improves survival in mice after trauma and hemorrhage, even in the absence of resuscitation. We found that amitriptyline increases mean arterial blood pressure and decreases metabolic acidosis after injury. Administration of amitriptyline following traumatic injury could potentially be useful in situations with limited access to blood products.

21.01 Roles of Mentorship and Research in Surgical Career Choice: Longitudinal Study of Medical Students.

Posted on January 18, 2016

A. Berger1, J. Giacalone1, P. Barlow2, M. Kapadia3, J. Keith3 1University Of Iowa,College Of Medicine,Iowa City, IA, USA 2University Of Iowa,Department Of Internal Medicine,Iowa City, IA, USA 3University Of Iowa,Department of Surgery,Iowa City, IA, USA

Introduction: A medical student’s choice to pursue a career in surgery is influenced by many evolving factors and considerations, and likely by experiences during education. We hypothesize that quantifying these variables will reveal trends influencing choice of medical specialty. Our goal is to ascertain trends and factors that can be used to increase interest in surgery, and attract students to pursue a surgical career.

Methods: A questionnaire-based, longitudinal prospective study was conducted at a university program. Surveys were administered to medical students in the class of 2017 prior to the start of the first, second, and third years. The questions cover topics including specialty preferences, debt, mentorship, research, and factors deemed desirable or important in a future career. Residency choices were classified as surgical and nonsurgical. Z-tests for population proportions and odds ratios were calculated using SAS/STAT software.

Results: Data was collected from 143, 139, and 144 students at the beginning of their first, second, and third medical school year, respectively, and response rates were >90%. Students with any research experience prior to medical school were 64% less likely (p=0.016) to have surgical career interests in the first survey. By the third year, however, students expressing interest in surgery were 2.5 times more likely to be actively involved in research (p=0.029) and 8.4 times more likely to have a surgery-related research focus (p=0.0001), as compared to non-surgery classmates. At the beginning of their third year, students with an interest in surgical specialties were 2.2 times more likely to have a self-maintained surgeon-mentor relationship (p=0.031), as compared to students interested in non-surgical specialties. With near significance, students initially expressing interest in surgical specialties are 2.4 times more likely to change their interest to ‘undecided’ in future surveys (p=0.06). Students without both research experience and active surgeon-mentor relationships are 9 times more likely to switch to ‘undecided’ or non-surgical specialties (0.02619). Furthermore, students involved in research, but without a mentor, are 20 times more likely to change their interests to ‘undecided’ or non-surgical specialties (p=0.0012), compared to those with both research and active surgeon-mentor relationships.

Conclusion: Students involved in surgery-specific research are significantly more likely to continue expressing interest in a surgical career if they have a mentor. In the absence of a mentor, students involved in research are more likely to change interests than those not involved in research at all. Our preliminary conclusion is that while research attracts students to consider surgical specialties, meaningful surgeon-mentor relationships are essential to maintain a student’s interest.

11.20 Impact of Teaching Hospital Status on Thyroidectomy Outcomes

Posted on January 18, 2016

S. C. Pitt1, M. A. Nehs2, N. L. Cho2, D. T. Ruan2, F. D. Moore2, A. A. Gawande2 1University Of Wisconsin,Department Of Surgery,Madison, WI, USA 2Brigham And Women’s Hospital,Department Of Surgery,Boston, MA, USA

Introduction: The impact of resident involvement on surgical outcomes is controversial since much of the data are contradictory. Furthermore, the role of resident participation specifically in thyroid surgery is not well understood. Therefore, we sought to determine whether teaching hospitals (THs) had disparate outcomes in a large, population level cohort of thyroidectomy patients.

Methods: We analyzed 9,798 patients who underwent thyroidectomy in the 2011 California State Inpatient (SID) and Ambulatory Surgery Databases (SASD). To assess TH status, the SID and SASD were linked to the California Hospitals Utilization data. Surgical procedures and outcome variables were defined by CPT and ICD-9 codes. Outcomes were analyzed based on TH status using ANOVA, as well as univariate and multivariate logistic regression methods.

Results: The minority of the 9,798 thyroidectomies were performed at THs (20.4%). Those patients treated at THs were similar to those at non-THs, but more likely to have thyroid cancer (42.1% vs. 31.7%), a total thyroidectomy (53.0% vs. 46.7%) or a lateral neck dissection (11.8% vs. 5.0%, p<0.0001 for all). Despite these differences, the overall complication and 30-day readmission rates were similar at TH and non-THs (9.1% vs. 8.9%, p=0.76, and 3.6% vs. 3.8%, p=0.65, respectively). However, when analyzing specific complications, recurrent laryngeal nerve (RLN) injuries were significantly more common at THs (1.9% vs. 0.9%, p<0.0001), while hypoparathyroidism (1.0% vs. 0.7%, p=0.20) and reoperative hematoma (0.7% vs. 0.8%, p=0.55) were comparable. In addition, the volume status of THs did not affect the RLN injury rate when examined as low (<50 cases/yr), medium (50-130 cases/yr), and high (>130 cases/yr) volume hospitals (p=0.15).

Assessment of factors, other than TH status, that were associated with RLN injuries revealed that nerve injuries patients were similar in gender, but significantly (p<0.001 for all) older (61.0 ± 16.4 vs. 53.3 ± 14.7 yrs), non-White (0.8% vs. 2.5%), not privately insured (38.4% vs. 62.7%), more likely to have >1 chronic medical condition (99.0% vs. 74.5%), thyroid cancer (6.7% vs. 1.7%), hypothyroidism (2.5% vs. 1.0%), and undergo total thyroidectomy (1.6% vs. 0.7%), or lateral neck dissection (4.8% vs. 0.9%). Multiple logistic regression revealed that TH status was independently associated with RLN injury (OR 2.43, 95% CI 1.54-3.83) when controlling for age, race, insurance type, comorbidities, thyroid cancer diagnosis, and procedure type.

Conclusion: While overall complication rates are not impacted when thyroidectomy is performed at a TH versus a non-TH, RLN injury rates are twice as high at TH. Whether this difference is due to resident involvement or is a reflection of referral bias and case complexity deserves further investigation.

11.19 Pheochromocytoma with Synchronous Adrenal Cortical Adenoma

Posted on January 18, 2016

M. E. Hasassri3, T. K. Pandian1, I. Bancos2, W. F. Young2, M. L. Richards1, D. R. Farley1, G. B. Thompson1, T. J. McKenzie1 1Mayo Clinic,Division Of Subspecialty General Surgery,Rochester, MN, USA 2Mayo Clinic,Division Of Endocrinology, Diabetes, Metabolism, And Nutrition, Department Of Internal Medicine,Rochester, MN, USA 3Mayo Clinic,Mayo Medical School,Rochester, MN, USA

Introduction:
Pheochromocytoma with synchronous adrenal cortical adenoma (PSCA) is a rare condition and may present with mixed clinical and biochemical features characteristic to each neoplasm subtype. We reviewed our experience at a large tertiary referral center to better understand the clinical and perioperative characteristics of this unique clinical entity.

Methods:
With IRB approval, all patients with a pathologic diagnosis of pheochromocytoma with a synchronous ipsilateral adrenal cortical adenoma from January 1994 through June 2015 were identified. Retrospectively extracted data included indications for adrenalectomy, diagnostic work-up (biochemical and radiographic), operative characteristics, pathologic findings, and postoperative complications.

Results:

We identified 16 cases of PSCA among 413 patients undergoing adrenalectomies for pheochromocytoma (3.9%). Mean patient age was 57 years (range: 29-78); 50% were male. Median BMI was 28.5 kg/m2 (IQR 26.8, 30.8). In 12 cases (75%), the initial primary neoplasm was found incidentally on imaging for an unrelated issue. Only 8 cases (50%) were reported on imaging to have a synchronous ipsilateral neoplasm. The preoperative presumptive diagnosis included 9 pheochromocytomas (56%), 4 cortical adenomas (25%), and 3 PSCA (19%). Paroxysmal clinical symptoms of a pheochromocytoma were documented in 13 (81%) patients. Four patients (25%) were diagnosed preoperatively with clinically relevant autonomous cortisol overproduction (3 ACTH-independent, 1 ACTH-dependent). Two patients (13%) were diagnosed preoperatively with renin-independent hyperaldosteronism and both underwent adrenal venous sampling (AVS) with one patient developing hypertensive crisis during AVS. The initial surgical approach was laparoscopic (81%), open (13%), retroperitoneoscopic (6%). One laparoscopic operation was converted to open due to bleeding. No patient required transfusion, postoperative vasopressor support, ICU care, or reoperation. There was no other major morbidity. On pathology, mean pheochromocytoma size was 2.7 cm (range: 0.8-4.8) and mean cortical adenoma size was 1.8 cm (range: 0.3-4.4).

Conclusion:

An ipsilateral cortical adenoma was found in 3.9% of 413 adrenalectomies with a final pathologic diagnosis of pheochromocytoma. Clinically important cortical hormone secretion was diagnosed in 38% of these patients; 25% had glucocorticoid secretory autonomy and 13% had hyperaldosteronism. Physicians should be aware that adrenal neoplasms with mixed findings on imaging and biochemistry may represent synchronous pheochromocytoma and a functional adrenal cortical adenoma. If cross-sectional imaging is suggestive of cortical and medullary neoplasms, biochemical evaluation for this rare co-occurrence to prevent perioperative complications from resection of an unexpected secretory cortical neoplasm should be performed. This should be done cautiously to prevent precipitation of a pheochromocytoma crisis.

11.21 Systematic Review of Emotional Intelligence in Surgical Education

Posted on January 18, 2016

G. Provenzano1, R. Appelbaum2, A. Bonaroti1,2, M. Erdman1,2, M. Browne2 1University Of South Florida College Of Medicine,Tampa, FL, USA 2Lehigh Valley Health Network,Allentown, PA, USA

Introduction: Emotional intelligence (EI) was first coined in 1990 as a successful leadership skillset comprised of self-management, social awareness, and empathy. EI has wide-reaching applications to the surgical field including teamwork, patient care, and job satisfaction. Positive linkage has been made between higher EI levels in both the patient-doctor relationship and physicians in a leadership role. The purpose of our systematic review was to evaluate the use of EI in surgical education and assess whether its prevalence has grown with the general acceptance of EI in many fields including medicine. A secondary aim was to compare the incorporation of EI in surgical education to other fields of graduate medical education.

Methods: A MEDLINE search was performed for publications containing both ‘surgery’ and ’emotional intelligence’ with at least one term present in the title. Articles were included if EI in surgical education was considered a significant focus. The results were grouped by publication date in 5-year increments to identify temporal trends. A separate series of MEDLINE searches were performed with the phrase ’emotional intelligence’ in any field and either ‘surg*’, ‘internal medicine’, ‘pediatric’, ‘neurology’, ‘obstetric’, ‘gynecology’, ‘OBGYN’, ’emergency’, and ‘psychiatr*’ in the title with no constraints on publication date. OBGYN articles were combined in one category. Articles were included if they discussed resident education as the primary subject.

Results: A total of 25 articles satisfied the MEDLINE search criteria and 7 articles satisfied inclusion criteria. These were sorted by publication date with 0, 1, and 6 articles published between 2001-2005, 2005-2010, and 2010-2015, respectively. Notable trends include: 1) EI is partially inborn, but proven to be learned; 2) Surgical residents have higher EI than the national average; 3) Educational shifts are needed to improve outcomes for the surgeon, patient, health network, and community at large. The comparative data for articles on EI and resident education showed 8 in surgery, 2 in internal medicine, 0 in pediatrics, 0 in neurology, 0 in OBGYN, 0 in emergency, and 4 in psychiatry.

Conclusion: Integration of EI principles is a growing trend within surgical education. Emphasis has been placed on quantitative assessment of EI in residents and residency applicants. Further study is warranted on the integration process of EI in surgical education and its impact on patient outcomes and long-term job satisfaction.

11.18 Monitored Anesthesia Care Versus General Anesthesia in Umbilical Hernia Repairs: A NSQIP Analysis

Posted on January 18, 2016

M. M. Vu1, R. D. Galiano1, J. Souza1, C. Du Qin1, J. Y. Kim1 1Northwestern University Feinberg School Of Medicine,Chicago, IL, USA

Introduction:
Monitored anesthesia care with intravenous sedation (MAC/IV), recently proposed as a good choice for hernia repair, has faster recovery and better patient satisfaction than general anesthesia. However the possibility of oversedation and respiratory distress is a classic concern. There is a paucity of literature examining umbilical hernia repairs (UHR) and optimal choice of anesthesia, despite it being a critical factor driving clinical outcomes. We aimed to evaluate whether MAC/IV versus general anesthesia independently affects postoperative outcomes following UHR.

Methods:
A multi-institutional retrospective analysis of anesthesia type and UHR was performed using National Surgical Quality Improvement Program (NSQIP), a surgical database surveying over 300 institutions, from 2005 to 2013. UHRs were identified as cases with CPT code 49585, 49587, 49652, or 49653, and also ICD-9 code 551.1, 552.1, or 553.1. Only cases performed by general surgery using general anesthesia or MAC/IV were included. Cases with outlying BMI <10 or >100, operative time longer than three hours, any missing values in analyzed variables, or multiple concurrent operations were excluded. General anesthesia and MAC/IV groups were propensity-score-matched (PSM) to reduce treatment selection bias. Preoperative characteristics and postoperative outcomes were compared between the anesthesia-type groups with univariate and multivariate statistics. Tracked outcomes included medical complications, surgical complications, operative duration, and postoperative hospital stays greater than 1 day.

Results:
49,942 cases were analyzed, 13.8% of which were performed under MAC/IV. After PSM, 27,334 cases remained for statistical analysis. PSM removed all observed differences between the intervention groups (p>0.05 for all tracked preoperative characteristics). MAC/IV cases required fewer >1 day hospital stays (3.5% vs 6.3%, p<0.001). Univariate analysis showed overall complication rate did not differ (1.7% vs 1.8%, p=0.569), however MAC/IV cases resulted in fewer incidences of septic shock (<0.1% vs 0.1%, p=0.016). After multivariate regression, MAC/IV cases were revealed to have significantly lower odds of medical complication, with an adjusted odds ratio of 0.654 (p=0.046).

Conclusion:
UHR under MAC/IV causes fewer medical complications and reduces postoperative hospital stays compared to general anesthesia. The implications for surgeons and patients are broad, including improved surgical safety, cost-effective care, and patient satisfaction.

11.17 Serum Albumin Predicts Adverse Outcomes in Patients Undergoing Elective Colectomy for Benign Lesions

Posted on January 18, 2016

O. Trofymenko1, E. Telemi1, R. Venkat1, V. Nfonsam1 1University Of Arizona,Surgery,Tucson, AZ, USA

Introduction: Colorectal cancer is second most common cause of cancer related deaths in the United States. Many patients with benign neoplasms in colon and rectum undergo colectomy to prevent the development of malignancy. Preoperative serum albumin has been used to predict postoperative complication rates in colectomies.

Methods: NSQIP cross-institutional database was used for this study. The database contains records of more than 139 variables from multiple surgery types around United States from 2005 until 2012. 2068 patient records (n = 2,068) with a primary diagnosis of benign colorectal neoplasm who had elective colectomy performed were identified and used in the study. 75.48% underwent laparoscopic (n = 1,561) and 24.52% open (n = 507) colectomies. Preoperative serum albumin is a previously described and validated metric to describe the risk of surgery. Outcome measures included serious morbidity, overall morbidity, Clavien IV (requiring ICU), and Clavien V (mortality) complications.

Results: Median age was 65 years, and BMI was 28.0Kg/m2. 49.4% of patients were males. 45.9% of patients were assigned ASA Class 3 or higher. The median albumin was 4.1 (1.9 – 7.3). As preoperative serum albumin changed from less than 3.5 to 3.5 and above, overall morbidity decreased from 34.1% to 12.6% and serious morbidity decreased from 15.9% to 4.8%, respectively. The Clavien IV complications rate decreased from 9.4% to 2.5%. Mortality rate has decreased from 4.4% to 0.6%. All results were statistically significant at p<0.01. On a multivariate analysis preoperative serum albumin was independent predictor of serious morbidity (Adjusted Odd Ratio (AOR): 0.47, p<0.05), overall morbidity (AOR: 0.48, p<0.01), Clavien IV complication rates (AOR: 0.35, p<0.05) and mortality (AOR: 0.08, p<0.01), independent of age, sex, BMI, ASA class, modified frailty, type of colectomy (laparoscopic or open), and wound class.

Conclusion: As future patients undergo elective colectomies in treatment of benign neoplasm, low preoperative serum albumin should be used as a proxy for postoperative complications helping patients and physicians make a better informed decision with regards to the surgery.

11.16 Ultrasound of Thigh Muscle Can Predict Frailty in Elderly Patients but Not Sarcopenia

Posted on January 18, 2016

O. Al-Kathiri1, S. Y. Salim1, L. M. Warkentin1, A. Gallivan3, P. Tandon4, T. A. Churchill1, V. E. Baracos3, R. G. Khadaroo1,2 1University Of Alberta,Div. General Surgery/ Dept. Surgery,Edmonton, ALBERTA, Canada 2University Of Alberta,Div. Critical Care Medicine/ Dept. Surgery,Edmonton, ALBERTA, Canada 3University Of Alberta,Department Of Oncology,Edmonton, ALBERTA, Canada 4University Of Alberta,Div. Gastroenterolgy/ Dept. Medicine,Edmonton, ALBERTA, Canada

Introduction: Sarcopenia was identified as the loss of muscle mass and function that occurs with aging. It has been associated with high morbidity and mortality in patients over 65 years. Yet it is not part of the routine screening process in geriatric care. Computed tomography (CT) scan at the lumbar site L3 has been used as the gold standard tool to identify sarcopenia. Unfortunately high cost, limited availability, and radiation exposure limits the use of CT. We propose ultrasonography (US) of the thigh muscle as a possible objective, feasible, reproducible, portable, and risk free tool that can evaluate sarcopenia. The aim of this study was to evaluate US as a tool for the assessing sarcopenia in elderly patients.

Methods: We recruited 38 patients over 65 years old, referred to the Acute Care Surgery service. Using Sonosite US, thigh muscle thickness (measured at the midpoint between the greater trochanter, 10cm below and lateral to ASIS) was standardized to patient height. CT scan images at L3 were analyzed through SliceOmatic. Skeletal muscle index was calculated using skeletal muscle surface area. Sarcopenia was defined as skeletal muscle index < 41cm2/m2 for females and <43cm2/m2 or < 53cm2/m2 for males (with BMI <25kg/m2 or >25kg/m2, respectively). Rockwood Clinical Frailty score (1-3 non frail, >4 frail) was used to assess patient condition.

Results: The mean age of our preliminary study group was 78 ± 8 years and 68% (n=26) were females. Demographic, body composition, US and CT data of patients are described in Table 1. Sarcopenia was identified through CT in 69% of the patients. Sarcopenic patients had a greater number of in-hospital complications (48% vs 16.6% in non-sarcopenic, p =0.0001). There was no difference in duration of stay between sarcopenic and non-sarcopenic patients (14 vs 11 days, p=0.06). There were significant differences between sarcopenic and non-sarcopenic females in skeletal muscle surface area (113 ± 9 versus 91 ± 10 cm2, p < 0.001), and skeletal muscle index (35.2 versus 46.3 cm2/m2, p< 0.001). CT scan skeletal muscle index of sarcopenic patients showed significant correlation with frailty score (r2=0.21, p<0.05). US of rectus femoris in females was significantly associated with frailty score (r2=0.19, p=0.008). The receiver-operating characteristic (ROC) for thigh ultrasound was not able to distinguish sarcopenic patients (area ROC curve=0.6, p=0.8).

Conclusion: CT identified sarcopenia was associated with high-risk frail patients. US measured muscle thickness was predictive of frailty but not of CT identified sarcopenia. Further patient recruitment with thigh US is needed to determine the sensitivity of the use of US in screening for sarcopenia.

11.15 Delayed Cholecystectomy for Acute Calculous Cholecystitis – Drawbacks and Advantages.

Posted on January 18, 2016

J. B. Yuval1, H. Mazeh1, I. Mizrahi1, D. Weiss1, G. Almogy1, M. Bala1, B. Siam1, N. Simanovsky2, E. Kuchuk1, A. Eid1, A. J. Pikarsky1 1Hadassah-Hebrew University Medical Center,General Surgery,Jerusalem, N/A, Israel 2Hadassah-Hebrew University Medical Center,Radiology,Jerusalem, N/A, Israel

Introduction: Acute calculus cholecystitis (ACC) is one of the most common diseases in general surgery and is routinely managed by laparoscopic cholecystectomy (LC). Early and delayed LC are the two practiced approaches while there is inconclusive evidence regarding which is superior. At our medical center delayed cholecystectomy is practiced due to logistical constraints. The aim of this study is to evaluate the advantages and limitations of delayed LC in a large tertiary center.

Methods: A retrospective analysis of all patients admitted to our medical center with ACC between the beginning of 2003 and the end of 2012 was performed. Data collected included patient demographics and comorbidities, presenting symptoms, laboratory findings, blood cultures and imaging results. Data also included length of stay (LOS), time until surgery, and surgical complications.

Results: During the study period 1078 patients were admitted to our institution with the diagnosis of ACC. Of the entire cohort there were 593 females (55%) and the mean age was 57±1.5 years. Mean LOS at initial admission, re-hospitalization until surgery, and following delayed surgery were 7.0±0.7, 1.5±0.4, and 3.4±0.8, days, respectively. During the index admission 24% of patients required insertion of a cholecystostomy tube due to lack of improvement with conservative management. Only 640 (59%) patients eventually underwent delayed LC. Mean time from index admission to surgery was 97±12 days and 15% of patients were re-hospitalized in this time period. Conversion rate to open surgery was 5.8% and common bile duct (CBD) injury occurred in 1.1%. Postoperative complications occurred in 9.8% of the patients and the 30-day mortality was 0.6%.

Conclusion: The delayed LC approach is associated with significant loss of follow-up, long LOS, and robust use of PC. Conversion rates are lower than reported in the literature while the rates of bile duct injury and perioperative mortality are comparable.

11.14 Combined Enterectomy and Colectomy for Acute Mesenteric Ischemia Doubles Mortality

Posted on January 18, 2016

J. M. Shellenberger1, J. Clavenger1, L. Hanley1, S. Barnes1, S. Ahmad1 1University Of Missouri,Columbia, MO, USA

Introduction:
Acute mesenteric ischemia is a surgical emergency with a historical 30% thirty-day mortality. We analyzed the largest set of ACS NSQIP data in the literature to identify clinical variables that affect mortality for acute mesenteric ischemia.

Methods:
The ACS NSQIP database was queried from 2005 to 2013 for emergent operations for acute mesenteric ischemia. Inclusion criteria narrowed those cases to enterectomies, colectomies or combined as the initial operation. Univariate correlations were examined between mortality and pre-operative comorbidities, post-operative complications, and operations performed. A multivariate logistic regression model, controlled for age, gender and race was developed to evaluate the most significant univariate correlations.

Results:
5237 cases met the inclusion criteria and constituted the analysis group. Overall mortality rate was 28.7%. There were 1978 cases of isolated enterectomies, 2949 cases of isolated colectomies and 310 cases of combined resections. Mortality rates were 24.2%, 29.4% and 50.6% respectively. The increased risk of death with a combined small and large bowel resection was 2.74 (OR 95% CI 2.17-3.45). Pre-operative variables that most significantly increased the risk of death were ventilator dependence (OR 4.1, 95% CI 4.1-5.5), sepsis (OR 3.37, 95% CI 2.84-3.98), renal failure (OR 2.95, 95% CI 2.16-3.1), blood transfusion (OR 2.39, 95% CI 1.9 – 3.0) and time to OR from hospital admission greater than one day (OR 1.9, 95% CI 1.7-2.2). Post-operative outcomes that most significantly increased the risk of death were cardiac arrest (OR 10.2, 95% CI 6.69-15.48), septic shock (OR 2.4, 95% CI – 1.64-3.51), intra-operative blood transfusion (OR 2.1, 95% CI 1.7-2.5), renal failure (OR 1.87, 95% CI – 1.4-2.6), and post-operative blood transfusion (OR 1.5, 95% CI 1.2-1.9). In our multivariate logistical regression model pre-operative ventilator dependence (OR 3.6, 95% CI 2.9-4.5), sepsis (OR 1.9, 95% CI 1.5-2.4), post-operative septic shock (OR 2.9, 95% CI 2.3-3.7) and cardiac arrest (OR 11.13, 95% CI 7.2-17.2) were most predictive of mortality.

Conclusion:
Our analysis is the first suggestion of an increased risk of death with a combined small intestinal and colonic resection for acute mesenteric ischemia in the literature. This may reflect the extent, severity and progression of disease on initial presentation. Comorbidities, complications and timing of surgical intervention all contribute significantly to outcomes in the emergent surgical management of acute mesenteric ischemia.

11.13 The Effect of Hospital Volume Status on Bariatric Surgery Outcomes

Posted on January 18, 2016

A. A. Nair1, T. Mokhtari1, J. M. Morton2 1Stanford University School Of Medicine,Palo Alto, CA, USA 2Stanford University,General Surgery,Palo Alto, CA, USA

Introduction:

Accreditation for complex surgery has been traditionally based upon surgical volume. This volume initiative had evidence from a direct relationship between hospital volume and surgical outcomes across a variety of procedures. However, the variability of performance among low-volume hospitals has not been thoroughly explored. We investigated whether low volume hospitals are able to reach the same surgical outcomes standards set by high-volume centers.

Methods:

Using ICD -9 codes and the 2010 National Inpatient Survey, we analyzed 194 hospitals performing laparoscopic Roux-en-Y gastric bypass, laparoscopic gastric sleeve gastrectomy, and laparoscopic gastric banding. Hospitals were divided into low volume (LV) hospitals (< 50 cases annually) and high volume (HV) hospitals (≥ 50 cases annually) based on the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program standards (MBSAQIP). All patients with a prior history of cancer, IBD, UC, and FAP were excluded from analysis. All continuous variables were compared using t-test and weighted to represent national estimates. Statistical significance was defined as p < .05.

Results:

Surgical outcomes at 110 LV hospitals and 84 HV hospitals were analyzed. Both groups had similar proportions of complex patients based on the Charlson Comorbidity Index (score ≥ 1: .555 vs. .560, p = .8891). Most strikingly, 20 (18%) low volume hospitals met or exceeded the standards set by high volume centers in length of stay, complications, mortality, and discharge to home. On average, patients at HVH had a shorter inpatient stay (2.42 days vs. 4.21 days, p=.<.001) and had significantly less complications (.2211 vs. .5271, p=.0003) with a smaller proportion of patients experiencing any complications (15% vs 25%, p=.001). No significant difference was found in mortality (.07% vs. .34%, p=.11) or discharge to home (94.6% vs. 91.8%, p=.281).

Conclusion:

Our analysis suggests that a certain number of low volume hospitals are able to achieve the surgical outcomes of high volume hospitals.

11.12 Hand-Assisted Laparoscopic Versus Laparoscopic Colectomy: Are Outcomes and Operative Time Different?

Posted on January 18, 2016

B. F. Gilmore1, Z. Sun1, M. Adam1, J. Kim1, B. Ezekian1, C. Ong1, J. Migaly1, C. Mantyh1 1Duke University,Department Of Surgery,Durham, NC, USA

Introduction:
Hand-assisted laparoscopic (HAL) colectomy is a technique perceived to combine the benefits of laparoscopic surgery, while improving tactile feedback and operative time. Published data are largely limited to small, single institution studies. Our aim was to compare post-operative outcomes between HAL vs. standard laparoscopic (SL) approaches on a population level.

Methods:
The 2012-2013 National Surgical Quality Improvement Program Participant Data Use File was queried for patients undergoing elective SL or HAL colectomy. Patients were classified by surgical approach, underwent 1:1 propensity matching with a nearest neighbor algorithm, and had outcomes compared. An additional subgroup analysis was performed for patients undergoing segmental resections only.

Results:
A total of 13,949 patients were identified, of whom 6,084 (43.6%) underwent HAL colectomy. Following propensity matching, patients undergoing HAL vs. SL colectomy had higher rates of post-operative ileus (8.7% vs. 6.3%, p<0.001), wound complications (8.8% vs. 6.8%, p=0.006), and 30-day readmission (7.5% vs. 6.0%, p=0.002), without any differences in operative time (156 vs. 157 minutes, p=0.713). When considering only segmental colectomies, HAL remained associated with significantly higher rates of wound complications (8.6% vs. 6.5%, p=0.016), post-operative ileus (8.9% vs. 6.3%, p<0.001), and 30-day readmission (7.1% vs. 5.9%, p=0.041). There was again no difference in operative time between HAL and SL (145 vs. 145 minutes, p=0.334).

Conclusion:
Use of hand-assisted laparoscopic colectomy is associated with increased risk of wound complications, post-operative ileus, and readmissions. Importantly, this technique is not associated with any decrease in operative time. Our results suggest that utilization of hand-assisted technique should be discouraged, given its inferior outcomes. However, further investigations are warranted to determine situations where hand-assisted approach may be more appropriate, such as cases with increased technical difficulty.

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