69.10 The Cost of End of Life Care in Colorectal Cancer Patients

Posted on January 31, 2019

M. Delisle1, R. Helewa1, J. Park1, D. Hochman1, A. McKay1  1University of Manitoba,Surgery,Winnipeg, MB, Canada

Introduction:
End of life healthcare for oncology patients has been criticized for being inappropriate and overly aggressive resulting in low value care and inefficient use of limited resources. Strategies exist to improve patient comfort in this critical moment of life and reduce unnecessary expenditures. The objective of this study was to identify factors associated with increased end of life costs in colorectal cancer patients to guide future quality improvement.

Methods:
This is a retrospective cohort study including patients dying of colorectal cancer in a single Canadian province between 2004 to 2012 (ICD-10-CM C18-C21). Data was obtained from a single-payer, provincial administrative claims database and a comprehensive provincial cancer registry. Inpatient hospital costs were calculated using the Canadian Institute for Health Information’s (CIHI) Resource Intensity Weights multiplied by CIHI’s average Cost per Weighted Case in 2014 Canadian dollars. Outpatient costs was the total billed to the provincial government in the last 30 days of life adjusted to 2014 Canadian dollars using Statistics Canada’s Consumer Price Index. Patients with no costs over the last six months of life were excluded to account for loss to follow-up (n=21).

The primary outcome was end of life costs, defined as total inpatient and outpatient costs accrued 30-days before death. Risk adjusted 30-day end of life costs were estimated using a negative binomial regression with the log link function, robust standard errors and an offset variable to account for patients that did not survive 30 days from diagnosis. Covariates included age, sex, cancer stage, socioeconomic status, cancer location (rectal, rectosigmoid, colon), Charlson Co-Morbidity Index, year of diagnosis and death in hospital. Multivariable Logistic regression was used to assess for baseline predictors associated with in hospital death.

Results:
A total of 1,622 patients died of colorectal cancer between 2004 and 2012 (Table 1). The largest variations in cost existed between patients who died in hospital versus those that did not. The median length of stay for patients dying in hospital was 26 days (IQR 13-41). Significant predictors associated with in hospital death included co-morbidities (OR 1.30, 95% CI 1.16-1.45, p<0.01) and more recent diagnosis (OR 1.10, 95% CI 1.02-1.17, p=0.01).

Conclusion:
In hospital deaths are associated with significantly increased end of life costs and the odds of dying in hospital appear to be increasing in this population. This study could not assess if in hospital deaths were also associated with increased patient benefits. Future studies should aim to identify cost effective strategies to optimize end of life care.

69.09 Characterizing the Highest Cost Patients Before and After Enhanced Recovery After Surgery Programs

Posted on January 31, 2019

A. N. Khanijow1, M. S. Morris1, J. A. Cannon1, G. D. Kennedy1, J. S. Richman1, D. I. Chu1  1University Of Alabama at Birmingham,Department Of Surgery, Division Of Gastrointestinal Surgery,Birmingham, Alabama, USA

Introduction:  The overall cost-effectiveness of enhanced recovery after surgery (ERAS) programs have been demonstrated across many institutions, but it is unclear if certain patients account for disproportionate shares of ERAS costs. The purpose of this study was to characterize the cost drivers and clinical features of the highest cost patients undergoing elective colorectal surgery before and after ERAS implementation.

 

Methods:  ERAS was implemented at a tertiary-care single-institution in January 2015. Variable cost data, costs that vary with care decisions, were collected from the institution’s financial department for the inpatient stay of patients undergoing elective colorectal surgery from 2012-2014 (pre-ERAS) and 2015-2017 (ERAS). Costs were adjusted for inflation to 2017 US dollars using the Producer Price Index and compared using Wilcoxon tests between the high cost patients (upper 10th percentile of the total variable costs) and non-high cost patients (lower 90th percentile) for both before and after ERAS. Postoperative complications were identified using National Surgical Quality Improvement Project definitions. Severity of illness (SOI) (minor, moderate, major, and extreme) was used as an indicator of burden of illness.

Results: Of 842 included patients (389 pre-ERAS and 453 ERAS), there was no significant difference in the proportion of high cost patients between the two groups (10.8% vs 9.5% patients, p=0.60). Within the pre-ERAS group, high and non-high cost patients had an average total variable cost per patient of $21,107 and $7,432, respectively ($13,675 difference, p<0.01). Within the ERAS group, high and non-high cost patients had an average total variable cost per patient of $22,737 and $6,810 ($15,926 difference, p<0.01). Over 80% of patients in the extreme SOI group were in the high cost cohort for both pre-ERAS and ERAS patients. Compared to non-high cost patients, high cost pre-ERAS patients had a longer average length of stay (LOS) (13.1 vs 5.2 days, p<0.01) with a great proportion of that time in ICU (19 vs 1%, p<0.01). High cost ERAS patients also had a longer average LOS (15.9 vs 4 days, p<0.01) and proportion of ICU time (14 vs 1%, p<0.01). High cost pre-ERAS patients experienced significantly more post-op complications (p<0.01) including myocardial infarction and pneumonia for pre-ERAS patients and pneumonia, acute renal failure, ventilator dependency, and blood transfusions for ERAS. High cost pre-ERAS patients had higher mean anesthesia costs when compared to high cost ERAS patients ($1,173 vs $841, p<0.01) but lower mean pharmacy costs ($1,453 vs $3,200, p=0.02); there were no significant differences in complications.

 

Conclusion: SOI and post-op complications were key drivers of high costs before and after ERAS implementation. High cost patients continued to experience significantly longer LOS and ICU stays. The need for quality improvement in surgical care remains even in the era of ERAS.

 

69.08 Economic Analysis of ERAS Programs: Lack of Adherence to Standards for Cost Effectiveness Reporting

Posted on January 31, 2019

M. A. Eid1, N. Dragnev1, C. Lamb1, S. Wong1  1Dartmouth Hitchcock Medical Center,General Surgery,Lebanon, NEW HAMPSHIRE, USA

Introduction:

Enhanced Recovery After Surgery (ERAS) is an evidence-based, multimodal pre and post-operative care pathway which results in significant improvements in patient outcomes after major surgery.  Along with the decreased complication rates and recovery times, economic benefit of implementing ERAS has been widely heralded. However, it is unclear how rigorous the associated economic analyses are.  We used the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) guidelines to assess the quality of these studies.

Methods:
Using PubMed and OVID, we performed a systematic literature search to identify economic analyses evaluating the cost effectiveness of ERAS on colorectal, hepatobiliary, and gynecologic surgery in English language journals. The MESH terms  included colorectal surgery, cost analysis, and ERAS. We retrieved 45 articles, of which 17 were found to be directly relevant to the topic.  Each paper was evaluated against the items in the CHEERS guidelines to abstract data which formally included 7 categories with 27 specified criteria, mainly focusing on a study’s methodology (n=16) and how results are reported (n=5).

Results:
Of the 17 publications, including 14 colorectal, 2 hepatobiliary and 1 gynecologic studies, all but one paper described ERAS as being cost-effective; one study made no definitive statement regarding the cost effectiveness. However, none of the studies fully adhered to the CHEERS guidelines. Only 47% of the studies fulfilled at least 14 (50%) checklist items. All of the papers included “an explicit statement regarding the broader context of the study” and most titles identified the studies as economic evaluations. Papers generally performed poorly with regard to checklist items for methods and results. For example, none of the papers reported on choice of discount rates used for costs and outcomes. Overall, of the 16 analytic methods items, there was only an average concordance of 40%. Other key components of economic evaluations such as measurement and valuation of outcomes and assumptions underlying the decision-analytic model were not well reported. 

Conclusion:
Based on our evaluation of economic analyses of ERAS protocols, the quality of these studies is generally quite poor. Less than half of the studies adhered to 50% of the CHEERS reporting guidelines though nearly all of them posited cost savings with ERAS. Although most studies claimed to be cost effective evaluations, the vast majority lacked methodologic quality and appear to be merely cost reports. Cost effective and economic analysis plays a pivotal role in evidence-based medicine, but the current literature may be limited in terms of actually evaluating costs and outcomes of interventions. 

69.07 Cumulative Narcotic Dose Associated With Ultimate Risk of Long Term Opioid Use in Colorectal Surgery Patients

Posted on January 31, 2019

P. Cavallaro1, A. Fields2, R. Bleday2, H. Kaafarani1, Y. Yao1, K. F. Ahmed1, T. Sequist1, M. Rubin1, L. Bordeianou1  1Massachusetts General Hospital,General Surgery,Boston, MA, USA 2Brigham And Women’s Hospital,Boston, MA, USA

Introduction:  Nearly 42,000 people died from opioid overdose and an estimated 40% of overdose deaths involved a prescription opioid in 2016 alone. However, the relationship between postoperative inpatient opioid use and the subsequent risk of long-term opioid abuse remains unknown, with studies focusing primarily on opioid prescriptions at time of discharge. We therefore aimed to evaluate the relationship between inpatient opioid use and ultimate prolonged opioid use (POU) in patients undergoing colorectal surgery.

Methods:  We merged pharmacy records and the prospectively maintained ACS-NSQIP data on surgical outcomes of patients undergoing colectomy from June 2015 to October 2017 across 5 institutions (2 academic, 3 community) participating in a regional Colorectal Surgery Collaborative. Narcotic administration was converted into Morphine Milligram Equivalents (MMEs). Patients using patient-controlled analgesia were excluded.  POU was the primary outcome and was defined as any new opioid prescriptions between 90 and 180 days post-operatively. We compared patient demographics, surgical indications, comorbidities, and postoperative complications, daily MME administration and total inpatient MMEs.

Results: 940 colectomy patients were included in the study (52% female, 43.3% opioid naive, mean age 62.2 years old). 99 patients (10.4%) had POU. On univariate analysis, POU patients had higher ASA (ASA > 3 in 61% vs 44%, p=0.002) and were less opioid naive (23% vs 46%, p<0.001). These patients had longer lengths of stay, more readmissions, and more post-operative complications (P<0.05). POU patients also had higher rates of stomas (p<0.05). POU patients had increased rates of cumulative MMEs administered throughout their more complex hospitalization, even though their daily dosages were similar to non PRU patients (50+/-44 vs 73+/-704, p=0.7). In multivariable analysis, only cumulative use of narcotics —not overall complications or length of stay — was predictive of POU (Top quartile OR 2.0, 95% CI 1.2-3.2; p=0.005). Previous opioid use within the last year was also and independent predictor of POU (OR 2.6, 95% CI 1.6-4.3; p<0.001).

Conclusion: Prolonged narcotic use appears to be associated with previous narcotic exposure and the cumulative does of narcotics administered during the post-operative inpatient hospitalization, and not by the complexity of the surgical procedure or by surgical complications. This underscores the importance of minimizing opioid use through the entire peri-operative course, especially in patients with prior opioid use, post-operative complications, and protracted hospital courses. It also suggests the need for development of longer-lasting postoperative narcotic-sparing strategies, beyond the current ERAS efforts, that are mostly focused on the first 24-48 hours after surgery.  

 

69.06 Association of Enhanced Recovery Pathways with Postoperative Renal Complications: Fact or Fiction?

Posted on January 31, 2019

Q. L. Hu1,2, J. Y. Liu1,3, C. Y. Ko1,2, M. E. Cohen1, K. Y. Bilimoria4, D. B. Hoyt1, R. P. Merkow1,4  1American College Of Surgeons,Chicago, IL, USA 2University Of California – Los Angeles,Department Of Surgery,Los Angeles, CA, USA 3Emory University School Of Medicine,Department Of Surgery,Atlanta, GA, USA 4Feinberg School Of Medicine – Northwestern University,Department Of Surgery,Chicago, IL, USA

Introduction:
Enhanced Recovery Pathways (ERPs) have been shown to dramatically improve perioperative outcomes in colorectal surgery. However, one important factor limiting its widespread adoption is concern regarding postoperative renal complications. Our objective was to evaluate the association of the overall use of an ERP protocol and adherence to its potentially renal-compromising components (e.g., epidural use [hypotension], multimodal pain management [NSAID use], fluid restriction [hypovolemia]) with postoperative renal complications.

Methods:
American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Enhanced Recovery data between 2014 and 2017 were used to identify patients who were managed under an ERP (ERP group). A 1:1 propensity-score match was used to identify control patients during the same time period who were managed without an ERP (non-ERP group). Hierarchical multivariable logistic regression models were used to evaluate the overall association of an ERP (vs. non-ERP) as well as adherence to individual ERP components with postoperative renal complications (either renal insufficiency or dialysis requirement). 

Results:
We identified 36,452 patients who received at least one ERP component, including 16.1% who received epidural analgesia, 87.6% who received multi-modal pain management, and 53.0% who received fluid restrictive care. Compared to non-ERP, ERP management was not associated with postoperative renal complications (1.0% vs. 1.0%; OR 0.96, 95% CI 0.83-1.11). Independent predictors of renal complications included male sex, African American race, higher ASA class, severe obesity, and preoperative co-morbidities, including hypertension, heart failure, diabetes, ascites, and disseminated cancer. Among patients managed under ERPs, adherence with individual potentially renal-compromising components was not associated with renal complications: epidural use (1.0% vs. 1.0%; OR 0.77, 95% CI 0.54-1.11), multi-modal pain management (0.9% vs. 1.3%; OR 0.78, 95% CI 0.59-1.05), and fluid restriction (0.9% vs. 1.0%; OR 1.05, 95% CI 0.79-1.39). Finally, adherence with all three components versus none was also not associated with renal complications (1.2% vs. 1.0%; OR 0.92, 95% CI 0.52-1.65). 

Conclusion:
Management under ERPs and adherence with individual potentially renal-compromising components were not associated with postoperative renal complications. Postoperative renal complication is a serious adverse event, however, clinicians should focus on other modifiable factors precipitating its occurrence other than the use of an ERP.  

69.05 Survival Outcome of RNF43 Mutant-type Differs between Right-sided and Left-sided Colorectal Cancer

Posted on January 31, 2019

Y. Shimada1, Y. Tajima1, M. Nagahashi1, H. Ichikawa1, K. Yuza1, Y. Hirose1, T. Katada1, M. Nakano1, J. Sakata1, H. Kameyama1, Y. Takii2, S. Okuda3, K. Takabe4, T. Wakai1  1Niigata University,Digestive And General Surgery,Niigata, NIIGATA, Japan 2Niigata Cancer Center Hospital,Surgery,Niigata, NIIGATA, Japan 3Niigata University,Bioinformatics,Niigata, NIIGATA, Japan 4Roswell Park Cancer Institute,Breast Surgery,Buffalo, NY, USA

Introduction: Right-sided colorectal cancer (CRC) demonstrates worse survival outcome compared with left-sided CRC, and clinicopathological characteristics of right-sided CRC differ from left-sided CRC. Recently, the importance of RNF43 mutation has been reported along with BRAF mutation in serrated neoplasia pathway. We hypothesized that clinical significance of RNF43 mutation differs between right-sided and left-sided CRCs, and RNF43 mutation associates with tumor biology of right-sided CRC. To test this hypothesis, we investigated the clinicopahotlogical characteristics and survival outcome of patients with RNF43 mutation in right-sided and left-sided CRCs.

Methods: One-hundred-nine microsatellite stable Stage IV CRC patients were analyzed. Thirty-three and 76 patients were right-sided CRC and left-sided CRC, respectively. We investigated genetic alterations using a 415-gene panel, which includes RNF43 and the other genes associated with tumor biology. We analyzed clinicopathological characteristics between RNF43 wild-type and RNF43 mutant-type using Fisher’s exact test. Moreover, we classified RNF43 mutant-type according to primary tumor sidedness, i.e., right-sided RNF43 mutant-type or left-sided RNF43 mutant-type, and compared clinicopathological characteristics between the two groups. Overall survival rates of RNF43 wild-type, right-sided RNF43 mutant-type, and left-sided RNF43 mutant-type were analyzed using log-rank test.

Results:CGS revealed that 8 of 109 patients (7%) had RNF43 mutation. RNF43 mutation was significantly associated with high age (65 or more) (P = 0.020), presence of BRAF mutation (P = 0.005), absence of KRAS and PTEN mutations (P = 0.049 and P = 0.026, respectively). RNF43 mutation was observed in 3 of 33 right-sided CRC (9%) and 5 of 76 left-sided CRC (7%), respectively. Interestingly, RNF43 mutations in right-sided CRC were nonsense mutation (R145X) or frameshift mutation (P192fs, S262fs), while those in left-sided CRC were missense mutations (T58S, W200C, R221W, R519Q, R519Q). All the three right-sided RNF43 mutant-type were high age (65 or more), female, BRAF V600E mutant-type. Right-sided RNF43 mutant-type showed significantly worse OS than RNF43 wild-type and left-sided RNF43 mutant-type (P = 0.007 and P = 0.046, respectively).

Conclusion:Clinicopathological characteristics and survival outcome of patients with RNF43 mutation might differ between right-sided and left-sided CRC. In right-sided CRC, RNF43 mutation is a small, but distinct molecular subtype which is associated with aggressive tumor biology along with BRAF V600E mutation. Future preclinical and clinical studies might have to focus on RNF43 mutation for improving survival outcome in right-sided CRC.

 

69.04 What Drives Surgeon Workload in Colorectal Surgery?

Posted on January 31, 2019

K. E. Law1,2, B. R. Lowndes1,2,3, S. R. Kelley4, R. C. Blocker1,2, D. W. Larson4, M. Hallbeck1,2,4, H. Nelson4  1Mayo Clinic,Health Sciences Research,Rochester, MN, USA 2Mayo Clinic,Kern Center For The Science Of Health Care Delivery,Rochester, MN, USA 3Nebraska Medical Center,Neurological Sciences,Omaha, NE, USA 4Mayo Clinic,Surgery,Rochester, MN, USA

Introduction: Surgical techniques and technology are continually advancing, making it crucial to understand potential contributors to surgeon workload. Our goal was to measure surgeon workload in abdominopelvic colon and rectal procedures and attribute possible contributors.

Methods: Between February and April 2018, following each surgical case surgeons were asked to complete a modified NASA-Task Load Index (NASA-TLX) which included questions on distractions, fatigue, procedural difficulty, and expectation in addition to the validated NASA-TLX questions. All but the expectation question were rated on a 20-point scale (0=low, 20=high). Expectation was rated on a 3-point scale (i.e., more difficult than expected, as expected, less difficult than expected). Patient and procedural data were analyzed for procedures with completed surveys. Surgical approach was categorized as open, laparoscopic, or robotic.

Results: Seven surgeons (3 female) rated 122 procedures over the research period using the modified NASA-TLX survey. Across the subscales, mean surgeon-reported workload was highest for effort (M=10.83, SD=5.66) followed by mental demand (M=10.18, SD=5.17), and physical demand (M=9.19, SD=5.60). Procedures were rated moderately difficult (M=10.74, SD=5.58). There was no significant difference in procedural difficulty or fatigue by surgical approach.
Fifty-four percent (n=66) of cases were rated as meeting expected difficulty, with 35% (n=43) considered more difficult than expected. Mean surgeon-reported procedural difficulty aligned with expectation with a mean procedural difficulty level of 9.29 (SD=5.11) for as expected, 14.39 (SD=4.49) for more difficult than expected, and 5.92 (SD=4.15) for less difficult than expected (F(2,118)=21.89, p<0.001). Surgeons also reported significantly more fatigue for procedures considered more difficult than expected (F(2,118)=8.13, p<0.001) compared to procedures less difficult than expected.
Self-reported mental demand (r=0.88, p<0.001), physical demand (r=0.87, p<0.001), effort (r=0.90, p<0.001), and surgeon fatigue (r=.71, p<0.001) were strongly correlated with procedural difficulty. Furthermore, fatigue was strongly correlated with overall workload and the NASA-TLX subscales (r>0.7, p<0.001). Surgeons most frequently reported patient anatomy and body habitus, unexpected adhesions, and unfamiliar team members as contributors to ease or difficulty of cases.

Conclusion: Self-reported mental demand, physical demand, and effort were strongly correlated with procedural difficulty and surgeon fatigue. Surgeons attributed case ease or difficulty levels to patient and intraoperative factors; however, procedural difficulty did not differ across surgical approach. Understanding contributors to surgical workload, especially unexpectedly difficult cases, can help define ways to decrease workload.

 

69.03 Population-based Analysis of Adherence to Extended VTE Prophylaxis after Colorectal Resection

Posted on January 31, 2019

A. Mukkamala1, J. R. Montgomery1, A. De Roo1, S. E. Regenbogen1  1University Of Michigan,Surgery, Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA

Introduction:  Since 2012, the American College of Chest Physicians (ACCP) has recommended 4 weeks of pharmacologic prophylaxis against venous thromboembolism (VTE) after abdominopelvic cancer surgery. Additionally, there is growing expert consensus favoring extended prophylaxis after surgery for inflammatory bowel disease (IBD). National studies have revealed very low uptake of prophylaxis before adoption of the ACCP guideline, but it remains unclear to what extent it has been adopted in standard practice in recent years. We sought to understand responsiveness to guidelines versus expert opinion by evaluating adherence to extended VTE prophylaxis after colectomy in a statewide registry. 

Methods:  We identified all patients in the Michigan Surgical Quality Collaborative (MSQC) registry who underwent elective colon or rectal resection between October 2015 (when MSQC first began recording post-discharge VTE prophylaxis) and February 2018. MSQC is an audited and validated, statewide population-based surgical registry including all major acute care hospitals in the state. We used descriptive statistics and chi-square tests to compare annual statewide utilization trends for extended VTE prophylaxis with low molecular weight heparin by operative year and by diagnosis among all patients without documented exclusions.

Results: Of 5722 eligible patients, 373 (6.5%) received extended VTE prophylaxis after discharge. Use of extended prophylaxis was similar between patients with cancer (282/1945, 14.5%) and IBD (31/242, 12.8%), but was significantly increased when compared with patients with other indications (60/3051, 1.97%, p<0.001). Overall use during the study period significantly increased among cancer patients from 8.2% in 2015 to 9.0% in 2016 to 18.6% in 2017-18 (p=0.001). Use among IBD patients also significantly increased from 0% to 6.6% to 17.1% (p=0.03). Use among patients with other diagnoses was rare and did not vary over the study period (1.5 to 2.4%, p=0.50). Annual trends are shown in Figure 1.

Conclusion: Use of extended VTE prophylaxis after discharge is increasing, but remains uncommon in spite of guidelines recommending its use for colorectal cancer surgery and expert consensus supporting its use in IBD. Efforts to improve dissemination of guidelines and recommendations may require quality implementation initiatives accompanied by payment incentives to improve adherence.

 

69.02 Statewide Utilization of Multimodal Analgesia and Length of Stay After Colectomy

Posted on January 31, 2019

A. C. De Roo1,2, J. V. Vu1,2, S. E. Regenbogen1,2,3  1University Of Michigan,Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA 2University Of Michigan,Department Of General Surgery,Ann Arbor, MI, USA 3University Of Michigan,Division Of Colorectal Surgery,Ann Arbor, MI, USA

Introduction:
Multimodal analgesia is a critical component of both enhanced recovery protocols (ERP) and efforts to reduce opioid misuse after surgery. Postoperative multimodal pain therapy, using more than one class of pain medication: opioids, acetaminophen, non-steroidal anti-inflammatories (NSAIDs), gabapentinoids, and regional and epidural anesthesia, has been associated with lower pain scores, decreased opioid use, and avoidance of opioid inhibition of gut motility. Whether multimodal analgesia is widely used in practice remains unknown, and its effect on hospital length of stay has not been evaluated outside of controlled trials.

Methods:
Within the population-based, statewide Michigan Surgical Quality Collaborative (MSQC), we evaluated all adult patients undergoing elective colorectal resection between 2012 and 2015. Colectomy has been a targeted procedure for ERP implementation and MSQC collects ERP-specific data elements for colectomy, including details of perioperative analgesia. The primary outcome was mean postoperative hospital length of stay (LOS). To reduce bias from rare, extremely prolonged hospitalizations, we winsorized LOS at 30 days which excluded 27 patients. T-tests were used to evaluate associations between LOS and opioid-only vs multimodal therapy, defined as two or more classes of pain medication used.

Results:
Among the 7249 patients who underwent elective colectomy, 6746 received opioids (93.1%), and 2391 patients (33.0%) received no other analgesia besides opioids. Acetaminophen was used by 2701 (37.2%) patients, NSAIDs in 2551 (35.2%), and epidural, spinal, or regional anesthesia in 1400 (19.3%) patients. Average LOS for patients receiving multimodal analgesia (5.4 days, 95% CI 5.3-5.5) was significantly shorter than for patients receiving opioids alone (6.0 days, 95% CI 5.8-6.2; p<0.001).

Conclusion:
One third of patients undergoing colectomy in the state of Michigan received solely opioid analgesia. Ongoing improvement efforts will aim for near-universal use of opioid sparing pain regimens, in order to reduce opioid-related adverse effects and opioid exposure. Use of opioid-sparing multimodal analgesia, compared with opioids alone, is associated with a small reduction in hospital LOS, perhaps from improved pain control and lower rates of ileus, and could therefore accrue cost savings at a population level.  Multimodal analgesia is also an essential component of efforts to combat opioid use disorders related to surgical encounters and Michigan hospitals have room for improvement.
 

69.01 Achieving the High-Value Colectomy: Preventing Complications or Improving Efficiency

Posted on January 31, 2019

J. V. Vu1, J. LI3, D. S. LIKOSKY2, E. C. NORTON4,5, D. A. CAMPBELL1, S. E. REGENBOGEN1  1University Of Michigan,SURGERY,Ann Arbor, MI, USA 2University Of Michigan,CARDIAC SURGERY,Ann Arbor, MI, USA 3University Of Michigan,SCHOOL OF PUBLIC HEALTH,Ann Arbor, MI, USA 4University Of Michigan,ECONOMICS,Ann Arbor, MI, USA 5University Of Michigan,HEALTH MANAGEMENT AND POLICY,Ann Arbor, MI, USA

Introduction:  As payers increasingly tie reimbursement to value, there is increased focus on both outcomes and expenditures for surgical care. One way of measuring hospital value is by comparing episode payments to adverse outcomes. While postoperative complications increase spending and decrease value, it is unknown whether hospitals that achieve highest value in major surgery also deliver efficient care beyond the prevention of complications. We aimed to identify the contributions of clinical quality and efficiency of perioperative care to high-value strategies for success in episode-based reimbursement for colectomy.

Methods:  This was a retrospective observational cohort study of elective colectomy patients from 2012 to 2016, from 56 hospitals in the Michigan Surgical Quality Collaborative and Michigan Value Collaborative. Hospitals were assigned a value score (proportion of cases without adverse outcome divided by mean episode payment). Adverse outcomes included postoperative complications, reoperation, or death within 30 days of surgery. Risk-adjusted payments for total 30-day episode and components of care were compared using ANOVA between hospitals by value tertile.

Results: We matched 2,947 patients enrolled in both registries, 646 (22%) of which experienced adverse outcomes. Mean adjusted complication rate was 31% (+10.7%) at low-value hospitals and 14% (+4.6%) at high-value hospitals (p<0.001). Mean episode payments for all cases were $3,807 (17%) higher in low-value than high-value hospitals, ($22,271 vs. $18,464 p<0.001). Among cases without adverse outcomes only, payments were still $2,257 (11%) higher in low-value hospitals ($19,424 vs. $17,167, p=0.04).

Conclusion: In elective colectomy, high-value hospitals achieve lower episode payments than low-value hospitals for cases both with and without complications, indicating mechanisms for increasing value beyond reducing complications alone. High-value hospitals had two-fold lower complication rates, but also achieved 11% savings in uncomplicated cases. Worthwhile targets to optimize value in elective colectomy may include enhanced recovery protocols or other interventions that increase efficiency in all phases of care.

 

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

Posted on January 31, 2019

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

Introduction:

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

 

Methods:

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

 

Results:

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

 

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

 

Conclusions:

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

 

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

Posted on January 31, 2019

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

Introduction:

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

Methods:

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

Results:

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

Conclusion:

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

 

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

Posted on January 31, 2019

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

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

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

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

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

49.17 Use of Neoadjuvant Chemotherapy in the Treatment of Locally Advanced Rectal Cancer

Posted on January 31, 2019

M. Simpson1, J. Blank1, A. Szabo2, D. Eastwood2, K. Hu1, K. Ludwig1, C. Peterson1, T. Ridolfi1  1Medical College Of Wisconsin,Department Of Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,Milwaukee, WI, USA

Introduction: Standard treatment for locally advanced rectal adenocarcinomas (stage II-III) includes neoadjuvant chemoradiation followed by surgical resection and adjuvant chemotherapy. Following this standard treatment scheme 10%-30% achieve a complete response (CR) with no primary tumor remaining on either clinical or pathologic exam. To improve CR rates novel treatment approaches of systemic chemotherapy in addition to neoadjuvant chemoradiation have been suggested. In recent studies, these approaches have been shown to improve CR rates, tumor downstaging, and patient compliance. This study aims to quantify the incidence of neoadjuvant chemotherapy use at our institution, determine patient and tumor characteristics associated with the use of neoadjuvant chemotherapy, and evaluate tumor response to neoadjuvant chemotherapy compared to standard treatment.

Methods: A retrospective chart review was conducted on patients with locally advanced rectal cancer treated at the Medical College of Wisconsin between January 1, 2008 and June 6, 2018. Patient demographics, tumor characteristics, staging information, and treatment modalities were abstracted from the electronic medical record. CR was recorded and included both pathologic CR (pCR), defined as no residual tumor in resected samples, and clinical CR (cCR), defined as no evident disease detected on imaging or examination. The association between neoadjuvant chemotherapy and other variables was assessed with chi-square tests for categorical variables and F tests for continuous variables. Statistical significance was defined as a p-value < 0.05.

Results: A total of 835 patients with rectal cancer were identified, of which 178 met inclusion criteria. 134 patients (75%) underwent standard therapy while 44 (25%) underwent neoadjuvant chemotherapy. 93% of patients receiving neoadjuvant chemotherapy had node-positive disease and 30% had T4 disease, compared to 70% with node-positive disease and 9% with T4 disease in the standard therapy group. In the first half of the study period (2008-2012), 3 of 87 patients received neoadjuvant chemotherapy (3%) while in the second half of the study (2013-2018) 41 of 91 patients received neoadjuvant chemotherapy (45%). Among those receiving standard treatments, 26/134 (19%) achieved a CR, while 16/44 (36%) who received neoadjuvant chemotherapy achieved a CR.

Conclusion: The use of neoadjuvant chemotherapy for locally advanced rectal adenocarcinomas was increasingly utilized at our institution from 2008 to 2018. Patients chosen for neoadjuvant chemotherapy typically had more advanced disease yet achieved CR at a higher rate compared to those undergoing standard therapy. These data confirm trends seen at other institutions and provide rationale for further study into the use of neoadjuvant chemotherapy in the treatment of rectal cancer.

49.16 Impact of Enhanced Recovery After Surgery (ERAS) on outcomes following Colorectal Surgery

Posted on January 31, 2019

D. M. Jomaa1, H. Wasvary1,2  1Oakland University William Beaumont School Of Medicine,Department Of Colorectal Surgery,Royal Oak, MI, USA 2Beaumont Health System Research Institute,Department Of Colorectal Surgery,Royal Oak, MI, USA

Introduction: Enhanced Recovery After Surgery (ERAS) is a multidisciplinary program that incorporates best practice guidelines into the perioperative process. Previous studies show adherence to ERAS protocols improve outcomes with respect to hospital stays, complication rates and patient satisfaction.  In August 2015, the Department of Colon and Rectal Surgery implemented an ERAS program at Beaumont Hospital, Royal Oak at the same time the department introduced minimally invasive robotic procedures into their curriculum. Both processes were felt to be important in improving outcomes following colorectal surgeries. The aim of our project was to look at how the implementation of an ERAS program impacted outcomes with respect to length of stay (LOS), and if the method of surgery had any impact on this outcome.

Methods:  Elective colon and rectal procedures between June 2013 and June 2017 (n=654) were reviewed. Patients undergoing surgery prior to ERAS implementation were labeled Pre ERAS (n=102) and those after implementation were labeled Post ERAS (n=452). Charts were reviewed for patient demographics, ASA scores, LOS, BMI, wound class, surgical date and method of surgery. ERAS participants underwent a preoperative evaluation and were educated with regards diet, exercise and best practice processes. During surgery, ERAS patients were given medications to enhance bowel motility, and fluids and narcotics were guided by protocol. Postoperatively, early ambulation, early resumption of food and judicious use of narcotics was followed for the ERAS participants.

Results: No significant differences were noted between the Pre and Post ERAS groups with respect to age, BMI, ASA or gender. Significant differences existed when comparing the two groups for LOS with a median stay of 5 and 4 days for the Pre and Post ERAS groups, respectively (p<0.0001).  The wound classification identified a significantly higher proportion of “contaminated” cases in the Post ERAS era (p<0.001). A higher percentage of robotic cases were done in the Post ERAS era (42%) compared to Pre ERAS (25%) (p<.001). All variables were measured against the outcome of LOS via regression analysis. A univariate analysis showed LOS was significantly reduced for younger, male patients with lower ASA scores and undergoing robotic surgery during the Post ERAS period. No significant differences existed for BMI or wound class.  A multivariate analysis showed higher ASA scores (p=0.003) and female gender (p=0.05) independently predicted a longer LOS (p=0.003). ERAS independently predicted a shorter LOS (p<0.0001). Robotic procedures did not impact LOS when all variables were considered.

Conclusion: The inception of an ERAS program is an independent predictor for reduction in the LOS following surgical resection and this improvement was not influenced by the method of surgery. This data is important when rationalizing the need to put continued resources into the further development of best practice initiatives.

 

49.15 The Significance of Caudal-to-Cranial Approach in Lymphadenectomy in Laparoscopic Right Colectomy

Posted on January 31, 2019

L. Zou1, B. Zheng2, Y. He1, L. Zou1  1Guangdong Hospital of Traditional Chinese Medicine, Zhuhai,Department Of General Surgery,Zhuhai, GUANGDONG, China 2Brookdale Hospital and Medical Center,Department Of General Surgery,Brooklyn, NEW YORK, USA

Introduction: Currently? the medial-to-lateral approach is widely used in laparoscopic right colectomy. However, this approach is unable to dissect lymph nodes located posterior to the superior mesenteric vessels. Our aim is to discuss the necessity and clinical significance of using the caudal-to-cranial approach in laparoscopic right colectomy.

Methods: This is a prospective cohort study. A total of 78 consecutive patients (between 2014 and 2017) with advanced right colon cancer (TNM stage I: 17; stage II: n = 23; stage III: n = 38) requiring a curative right colectomy were subjected to laparoscopic caudal-to-cranial approach. All patients received preoperative nanocarbon injections around the tumor via colonoscopy. Lymph nodes were then analyzed and the positive rate of the lymph nodes was calculated.

Results: In this follow-up study, 45 male and 33 female patients(age 63.6±10.59 years old ) with mean body mass index of 21.7±2.87 kg/m2. The mean operation time was 153.9±25.36 min, and the mean blood loss was 82.0±19.21 ml. The mean tumor size was 5.3±1.1 cm and the mean number of harvested lymph nodes was 19.68±7.56 with an average of 1.53±2.75(7.8%) positive lymph nodes . Of these positive lymph nodes, 1.1±4.69  were posterior to superior mesenteric vessels, with a positive rate of 1.3%. All procedures were successful without any serious intraoperative complications, conversion to open surgery, or surgical mortalities.

Conclusion: There are positive lymph nodes posterior to the superior mesenteric vessels in progressive right colon cancers. We suggest a complete dissection of these lymph nodes to reach radical treatment by using a caudal- to-cranial approach.

 

49.14 Standardized Laparoscopic Surgery for Diverticular Colovesical Fistula

Posted on January 31, 2019

K. Tomizawa1, S. Matoba1, N. Okazaki1, K. Hiramatsu1, Y. Hanaoka1, S. Toda1, H. Kuroyanagi1, H. Kuroyanagi1  1Toranomon Hospital, Gastroenterological Surgery,Tokyo, Japan

Introduction: Colonic diverticular disease is widespread, and its incidence increases with aging. Patients suffering from diverticulitis and colovesical fistula are also increasing. Diverticular colonic resections are frequently more technically demanding than colon cancer due to inflammation. This study aimed to evaluate the safety and efficacy of our standardized laparoscopic procedure. 

Methods: A retrospective analysis was reviewed of 44 consecutive patients undergoing laparoscopic surgery for colovesical fistula during the period October 2006 to July 2018. 

Results:The median age was 61 years and the patients comprised 40 men and 4 women. Surgical procedures were sigmoidectomy: thirty-eight, Hartmann's operation: four, low anterior resection: two, respectively. The median operating time was 201 minutes and the estimated blood loss was 65.5mL. There were no intraoperative complications and conversion to open surgery. No bladder wall repairs were required. Six patients had minor postoperative complications comprising a postoperative abscess and three cases of superficial wound infection and three cases of anastomotic bleeding. The median length of postoperative stay was 11days. No patients had recurrence of diverticulitis or fistula at median follow-up of 5.6 years. 

Conclusion:We demonstrated that laparoscopic surgery for colovesical fistula can be safely performed. Because of its minimally invasive, laparoscopic approach appears to be the ideal choice especially for the colovesical fistula. To our knowledge, this is the largest study of colovesical fistula treated with laparoscopic procedure.

 

49.13 Colon Cancer Survival by Sub-site: a Retrospective Analysis of the National Cancer Database

Posted on January 31, 2019

D. Yu1,2, M. Stem2, J. Taylor2, S. Chen2, B. Safar2, S. Fang2, S. Gearheart2, J. Efron2  1Queen’s University,General Surgery,Kingston, ONTARIO, Canada 2The Johns Hopkins University School Of Medicine,Colorectal Surgery,Baltimore, MD, USA

Introduction:
Recent studies report a shift in the anatomical site of origin of colon cancer from the distal to the proximal colon. The objective of this study was to assess sub-site specific differences of colon adenocarcinomas with respect to patient and tumor characteristics, treatment trends, and overall survival (OS).

Methods:
This study was conducted using data from the National Cancer Database (2004 – 2015). Adult patients > 18 years old diagnosed with stage I to IV colon adenocarcinoma were stratified by primary site of cancer (right, transverse, left, or sigmoid). Primary outcome of interest was 5-year OS analyzed using Kaplan-Meier survival curves and Cox proportional hazard models.

Results:
A total of 642,983 cases were included [right: 330,872 (51.46%), transverse: 66,621 (10.36%), left: 63,947 (10.36%), sigmoid: 181,543 (28.23%)].  A small but significant increase in diagnosis from 2004 to 2015 was found in right-sided and transverse colon cancers (right: 8.04% to 8.57%, transverse: 7.80% to 8.99%, p-value <0.001 for both). Right and transverse colon cancer patients tended to be female, older, have higher frequencies of poorly differentiated tumors (right: 20.99%, transverse 18.82%, left: 14.27%, sigmoid 11.68%, p-value <0.001), and tumors > 5cm (40.51%, 35.76%, 33.77%, 29.79%, respectively, p-value <0.001). When stratified by stage, sigmoid cancer patients were more likely to receive multimodal therapy compared to other sub-sites across all stages. In the unadjusted analysis, right and transverse colon cancers had the worst 5-year OS (53.30%, 54.01%, 55.93%, 58.39%, respectively, p-value <0.001). Similar trends persisted when stratified by stage (FIGURE). In the adjusted Cox analysis, right, transverse, and left colon cancers all had significantly increased risk of mortality in comparison to sigmoid cancer when all stages were combined (sigmoid ref: HR: 1.10, 95% CI 1.08-1.12, HR 1.16, 95% CI 1.13-1.19, HR 1.12, 95% CI 1.09-1.15, p-value <0.001 for all). When stratified by stage, right and transverse colon cancers had the greatest risk of death in stages III and IV (sigmoid ref, stage III: transverse HR 1.21, 95% CI 1.16-1.26, p-value <0.001, stage IV: right HR 1.28, 95% CI 1.24-1.31, p-value <0.001)

Conclusion:
Right-sided and transverse cancers show an increasing trend over the study period. These patients tended to be female, older, have higher frequency of poor differentiation, and larger tumors. 5-year OS was worst in transverse cancers for all stages combined.
 

49.12 Predictive Factors for Complicated Diverticulitis: An Analysis of the NSQIP Database.

Posted on January 31, 2019

G. U. Anyanwu1, N. P. Omesiete1, M. Diri1, V. Nfonsam1  1University of Arizona,Surgery,Tucson, AZ, USA

Introduction:
The incidence of diverticulitis is on the rise in the last few decades. Uncomplicated diverticulitis could be treated with expectant management and at time surgical intervention. Complicated diverticulitis, however, could lead to significant morbidity and mortality in addition to major healthcare cost. The aim of this study is to assess the factors that contributes to an increased risk in developing complicated diverticulitis.

Methods:
A 10-year (2006-2016) retrospective analysis of all patients who underwent surgical intervention for diverticulitis using the NSQIP database was performed. The patients were subdivided to complicated and uncomplicated disease. Demographic factors included age, gender, and race/ethnicity. Additional factors analyzed included diabetes, obesity, COPD, smoking status, chronic steroid use, renal failure, Heart Failure, previous MI, previous cardiac surgery (PCS), and previous Percutaneous Coronary Intervention (PCI). A multi regression analysis was performed to determine the predictors for complicated diverticulitis.

Results:

.A total of 65,032 patients were analyzed; 56,919 with uncomplicated diverticulitis and 8,113 with complicated diverticulitis. Patients aged 70-80 (OR 1.42, p<0.0005), African Americans (OR 1.13, p<0.05) and patients with BMI≥30 (OR 1.10 p=0.0038) had a higher chance of developing complicated diverticulitis. Additionally, diabetes (OR 1.14, p<0.0005); especially if patients were not on insulin therapy (OR 1.24, p<0.005); COPD (OR 1.16, p<0.01), history of smoking (OR 1.29, p <0.0005), HF (OR 1.64, p=0.0001), ARF (OR 1.92, p<0.0005), CRF (OR 1.67, p<0.0005), and chronic steroid use (OR 1.68, p<0.0005) were predisposing factors for complicated diverticulitis. However, we found patients with PCS (OR 0.39, p<0.0005) and past PCI (OR 0.37, p<0.0005) had decreased odds of developing complicated diverticulitis.

Conclusion:

This study demonstrated that blacks, older patients, history of smoking, heart failure, diabetes, elevated BMI and acute/chronic renal failure are risk factors for complicated diverticulitis. These patients might benefit from closer monitoring prior to surgery and modifiable risked could be addressed
 

49.11 Perioperative Outcomes and Predictors of Mortality Following Surgery for Sigmoid Volvulus.

Posted on January 31, 2019

A. Easterday1, A. Person1, S. Aurit1, R. Driessen1, D. Mukkai Krishnamurty1  1Creighton University Medical Center,Department Of Surgery,Omaha, NE, USA

Introduction: Data on perioperative outcomes following surgery for sigmoid volvulus is limited. The aim of this study is to develop a model to predict need for emergent surgery and post-operative mortality following resection for sigmoid volvulus.

Methods: The NSQIP database was queried from 2012-2016 to identify patients undergoing segmental resection for sigmoid volvulus. Pre-, intra-, and post-operative variables were compared. Primary and secondary outcomes were emergent surgery and risk of mortality, respectively. Chi-square and Fischer’s test for categorical variables and the Mann-Whitney test for continuous variables were used. Significant variables for each outcome were entered into a logistic regression model to predict the outcomes. Statistical significance was set at p<0.05. 

Results: A total of 2,086 patients met inclusion criteria and 51.6 percent underwent an elective resection. Median age was 68 years. Laparoscopic resection (30.5% vs. 9.1%; p<0.001) and mechanical bowel preparation (50% vs. 8.7%; p<0.001) were more commonly used in the elective setting. Patients having emergent resection were more likely to suffer from post-operative superficial surgical site infection (p<0.001), pneumonia (p<0.001), cardiac arrest (p=0.038), septic shock (p=0.001), myocardial infarction (p=0.034), and had a higher need for perioperative transfusion (p<0.001). No difference was seen in ileus, anastomotic leaks, readmission or re-operation rates in patients undergoing emergency vs. elective resection. Overall mortality rate was 6.2% (8.5% in the emergent group vs. 4.1% in the elective group; p<0.001). On multivariate analysis, factors associated with increased risk of emergency surgery included female gender (OR 2.01; p<0.001), relative hematocrit elevation (OR=1.058; p<0.001), relative leukocytosis (OR=1.172; p<0.001), acute kidney injury (OR=6.274; p=0.035), pre-operative sepsis (OR=2.037; p<0.001), functional independence prior to surgery (OR=1.525; p=0.011), and bleeding disorders (OR=1.592; p=0.020). Factors predictive of post-operative mortality included increased age (OR=1.064; p<0.001), systemic sepsis (OR=3.848; p<0.001), and emergent surgery (OR=2.086; p=0.007). Independence prior to illness (OR=0.371; p<0.001), higher albumin levels (OR=0.579; p=0.007), and lower BMI (OR=0.952; p=0.037) were shown to be protective. 

Conclusion: Emergent resection for sigmoid volvulus is independently associated with poor post-operative outcomes and mortality. Pre-operative factors that predict need for emergent resection and post-operative mortality identified in this study can be used to aid in shared decision making and counselling for patients admitted with sigmoid volvulus.

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