16.16 Neurocognitive Performance Profile Post-Parathyroidectomy: A Pilot Study of Computerized Assessment

Posted on January 25, 2017

C. Bell1, M. Warrick1, N. Baregamian1  1Vanderbilt University Medical Center,Department Of Surgery,Nashville, TN, USA

Introduction:

Neurocognitive factors are integral to the diagnosis of primary hyperparathyroidism (PHPT), and parathyroidectomy has been shown to improve health-related quality of life, functional and physical capacity, visual-spatial working memory, and reduction of depression and anxiety. Our pilot study performs computerized analysis of neurocognitive executive functions such as memory, attention, speed of processing, and problem-solving in a reliable, measurable way. It examines the Neurocognitive Performance Profile (NCPP) pre- and post-parathyroidectomy by using an online battery of brief, repeatable, modular, well-known neuropsychological assessments (Neurocognitive Performance Testing, NCPT) developed by Lumosity (LumosLabs, Inc).

Methods:

Thirty-three patients with biochemically confirmed PHPT and indication for parathyroidectomy were enrolled and asked to complete online computerized NCPTs at 3 time points (preoperative, early post-operative, and 6-month post-operative) to calculate their overall NCCP and individual test scores by quantifying levels of performance on defined categories of cognition. These scores were normalized to their age-matched controls from the Lumosity database. All patients underwent parathyroidectomy, 24 patients completed pre- and early post-operative NCPTs only, and 10 patients completed all 3 visits. Nine patients were excluded from analysis for incomplete testing.

Results:

Significant difference was observed in overall NCPP scores over three visits using one-way ANOVA (n=10, p=0.043) and post-hoc Tukey’s multiple comparison analysis of pre- vs 6-month post-op performance (n=10, p=0.012). There was significant improvement in visual-spatial memory (Object Recognition, n=10, p=0.015) post-operatively. No significant difference in overall NCPP score was observed in paired comparison of 24 subjects completing only pre- and early post-operative testing, however, significant improvement in speed of processing and memory (Digit Symbol Coding, n=24, p=0.017) in early post-operative period was observed. Biochemical cure was achieved post-parathyroidectomy in all patients (n=24, both serum calcium and parathyroid hormone levels, p<0.0001). Patients reporting neurocognitive symptoms preoperatively (95.8%) and at early postoperative time points (58.3%) expressed significant relief of symptoms (n=24, p=0.001). This effect persisted at 6 months (n=10, p=0.004).

Conclusion:

This pilot study has begun to characterize the types of neurocognitive deficits and post-operative improvements in the overall neurocognitive performance in PHPT patient population in a measurable way. NCPT is a novel method that can provide a long-term metric for objective assessment of neurocognitive changes post-parathyroidectomy and biochemical normalization. NCPT can be a valuable diagnostic and prognostic testing tool for all patients with PHPT, and a large multi-center prospective randomized trial may further elucidate the importance of NCPT.
 

16.15 Withdrawal of Life Sustaining Treatments in Trauma Patients Without Severe Head Injury

Posted on January 25, 2017

J. Leonard1, S. Polites2, A. Glasgow2, N. Martin1, E. Habermann2  1University Of Pennsylvania,Philadelphia, PA, USA 2Mayo Clinic,Rochester, MN, USA

Introduction:   Many trauma patients and their families make the difficult decision to withdraw life sustaining support following injury.  While this population has been studied in the setting of severe traumatic brain injury (TBI), little is known about patients who undergo withdrawal of support (WOS) exclusive of TBI.  The objective of this study was to describe this population of patients and help providers identify patients who would benefit from early involvement of palliative care resources.

Methods:   Patients were identified from the 2013-2014 Trauma Quality Improvement Program who underwent WOC. WOC patients were compared to those who died without WOS and those who survived to discharge. Patients who died within the first 24 hours or had a head AIS of 3 or greater were excluded. 

Results:  WOS after 24 hours occurred in 2301 patients.  The median age was 71 years, 35.7% were women, and 95.4% had a blunt injury mechanism.  Compared with patients who died in-hospital with full supportive measures, WOS patients had a higher ISS (21.6 vs. 12.5, p = 0.001), were more likely to have in hospital complications (71.4% vs. 41.6%, p = < 0.0001), and had a longer ICU length of stay (8.9 days vs. 7.5 days, p = <0.0001).

Conclusion:  WOS occurs in many trauma patients without severe TBI, demonstrating the importance of having palliative care options and resources available for these patients. Direction of resources can be optimized using the characteristics of patients who chose WOS identified in this study.
 

16.14 Improved Outcomes after Operative Intervention for Secondary Lymphedema

Posted on January 25, 2017

E. I. Chang1, J. Balaicuis1, J. Buhler1, W. Morgan1, A. Nadler1, J. M. Farma1  1Fox Chase Cancer Center,Plastic And Reconstructive Surgery,Philadelphia, PA, USA

Introduction: The incidence of lymphedema has been increasing.  There has been increasing enthusiasm and interest for the surgical management of lymphedema in the United States.  Currently, the two most common surgical procedures available include vascularized lymph node transplantation (VLNT) and lymphovenous bypass (LVBP).  We present our early experience of patients undergoing surgical treatment of lymphedema at a tertiary referral center.

Methods: A retrospective review of a single surgeon experience of all patients undergoing surgical management of lymphedema was performed.  Patient demographics including age, cancer type, body mass index (BMI), and history of radiation treatment were recorded, as well as, postoperative outcomes.

Results:A total of 30 procedures were performed in 28 patients for the surgical management of lymphedema.  All patients had grade II-III lymphedema and the majority had received radiation (75.0%).  Treatment for breast cancer was the most common etiology for developing lymphedema in this series (n=15, 53.6%) followed by gynecologic malignancies (n=5, 17.9%) and sarcoma (n=4, 14.3%).  Seven patients underwent VLNT using the supraclavicular lymph node basin and 16 patients had LVBP performed.  Seven patients underwent simultaneous vascularized lymph node transfer in conjunction with autologous tissue breast reconstruction.  All patients reported subjective improvement of the lymphedema after surgery (100%) with decreased episodes of cellulitis.  The average measurable reduction was 76.4% (19.5%-320.0%) over an average follow-up of 7.8 months.  Two patients undergoing VLNT experienced major complications requiring operative intervention (9.1%). 

Conclusion:VLNT and LVBP are safe and effective strategies for the surgical management of lymphedema with early excellent results regardless of the type of malignancy.  This technique provides a novel treatment option that could benefit all patients with lymphedema.  Further studies with longer follow-up are necessary to evaluate the advantages between the two surgical techniques.

 

16.11 The Readability of Psychosocial Wellness Patient Resources: Improving Surgical Outcomes

Posted on January 25, 2017

M. A. Kugar1, A. C. Cohen1, W. Wooden1, S. S. Tholpady1, M. Chu1  1Indiana University School Of Medicine,Indianapolis, IN, USA

Introduction:  Patient education, increasingly achieved with online resources, is an essential component of patient satisfaction and clinical outcomes. The average American adult reads at a seventh-grade level, yet due to the complexity of medical information the National Institute of Health (NIH) and the American Medical Association (AMA) recommend that information be written at a sixth-grade reading level. Because mental illness and limited literacy commonly co-occur, appropriate levels of readability in mental health and psychosocial wellness resources are of great importance. In this study, we investigated the readability of mental health resources currently available through the Veterans Health Administration (VA) web site and the web sites of the 2016-2017 Best Hospitals for Psychiatry according to U.S. News and World Report.

Methods:  An internet search was performed to identify patient information on mental health from the VA (the VA Health Library Encyclopedia and the VA Mental Health Website) and the top psychiatric hospitals. Seven mental health topics were included in the analysis: generalized anxiety disorder (GAD), bipolar, major depressive disorder, post-traumatic stress disorder, schizophrenia, substance abuse, and suicide. Readability analyses were performed using the Flesch Reading Ease score, Gunning Fog, Flesch-Kincaid Grade Level, the Coleman-Liau Index, the SMOG Index, Automated Readability Index, and the Lisear Write Formula, all of which were combined into a Readability Consensus score. A 2-sample T-test was used to compare mean readability scores and statistical significance was set at p < 0.05. 

Results: Twelve of the Best Hospitals for Psychiatry 2016-2017 were identified. Nine had educational material. Six of the nine cited the same resource, The StayWell Company, LLC, for at least one of the mental health topics analyzed. The VA Mental Health web site (http://www.mentalhealth.va.gov) had a significantly higher Readability Consensus than six of the top psychiatric hospitals (p<0.05, p=0.0067, p=0.019, p=0.041, p=0.0093, p=0.0054, p=0.0093). The overall average Readability Consensus for mental health information was 9.55. 

Conclusion: Online resources for mental health disorders are more complex than recommended by the NIH and AMA. Efforts to improve readability of mental health and psychosocial wellness resources could benefit patient understanding and outcomes, and are of particular importance in a population with a high occurrence of low literacy. Surgical outcomes are correlated with patient mental health and psychosocial wellness. Thus, surgical outcomes can be improved with more appropriate levels of readability of psychosocial wellness resources.  

 

16.09 Comparison of Outcomes Among Patients With Abdominal Compartment Syndrome in Medical or Surgical ICU

Posted on January 25, 2017

J. Nguyen1, M. Noory1, L. Capano-Wehrle1, J. Gaughan1, J. Hazelton1  1Cooper University Hospital,Trauma And Surgical Critical Care,Camden, NJ, USA

Introduction:
The causes of abdominal compartment syndrome (ACS) are varied but can result from a range of both medical and surgical pathologies. Early recognition of ACS and prompt surgical treatment in the form of decompressive laparotomy has been shown to improve mortality. We hypothesize that earlier recognition of ACS, and therefore, earlier involvement by the surgical team would improve mortality.

Methods:
A retrospective review of patients ≥18y (7/2010 – 7/2015) who developed ACS and underwent decompressive laparotomy was performed. Patients cared for in non-ICU settings or who developed ACS from abdominal hemorrhage were excluded. Patients were divided into SICU and MICU arms based on their physical location at time of diagnosis. Demographics and clinical data points including hemodynamics, lab values, time to intervention, and outcomes were collected. A timeline was established for each patient from time of suspicion of ACS, time to surgical consult, and time to surgical intervention.

Results:
A total of 20 patients were included(MICU=12; SICU=8). There was no difference in age, sex, and APACHE-2 score at time of suspicion of ACS between the two groups (all p>.05). Median time from admission to suspicion of ACS for MICU patients was 60 hr vs 13 hr for SICU patients (p=.013). Time from suspicion to surgical consult for MICU patients was 60 min vs 0 min for SICU patients (p=.003), however time from surgical consult to surgical intervention was not different (MICU 53 min vs SICU 60 min; p=.396). Outcomes revealed that death occurred in the MICU group at 83% vs 12.5% in the SICU (p = .005).

Conclusion:
Patients in the SICU who developed ACS were more quickly diagnosed than those in the MICU. Furthermore, these patients had a shorter time from suspicion of ACS to surgical consultation and eventual surgical intervention, resulting in improved survival. A multidisciplinary approach, including early surgical consultation, for patients in whom there is a suspicion of ACS could improve mortality.
 

14.19 Patient-related and technical factors determining recovery after emergency appendicectomy

Posted on January 25, 2017

S. G. Thrumurthy1, R. Som1  1King’s College Hospital NHS Foundation Trust,Surgery,London, London, United Kingdom

Introduction:
Appendicectomy remains one of the most commonly performed emergency surgical operations, and postoperative recovery is influenced by various patient-related and technical factors. This prospective study aimed to identify how such factors affect the incidence of complications and the extent of symptom resolution after emergency appendicectomy.

Methods:
Patients who underwent emergency appendicectomy over a six month period were contacted by telephone. A standardised questionnaire was used to ascertain the duration of analgesia use, duration before return to normal physical activity, duration before return to work or school, surgical site infection rates, rates of re-presentation to community physicians or the emergency department, and rates of readmission to hospital. Patients were stratified into those who underwent laparoscopic versus open appendicectomy, smokers verses non-smokers, and body mass index (BMI) < 30 versus BMI > 30.

Results:
A total of 145 patients were included. Patients undergoing open surgery (versus laparoscopic surgery) required analgesia for significantly longer periods (22 days v. 6 days, p = 0.017), and a longer recovery period before full return to normal daily activities (48 days v. 17 days, p < 0.0001) and school/work (33 days v. 13 days, p < 0.0001). Compared to non-smokers, smokers required longer a recovery period before returning to school/work (24 days v. 17 days, p = 0.048), had a significantly higher risk of surgical site infection (relative risk [RR] 2.21, p = 0.029), and a higher risk of re-presenting to the emergency department (RR 3.21, p = 0.003) and being re-admitted to hospital within 3 months of surgery (RR 8.36, p = 0.002). Compared to patients with a BMI under 30, those with a BMI over 30 had a longer recovery period before full return to normal daily activities (49 days v. 24 days, p = 0.041) and school/work (26 days v. 17 days, p = 0.016), a higher rate of surgical site infection (RR 2.13, p = 0.044), and a higher risk of re-presenting to the emergency department (RR 3.09, p = 0.005) and being re-admitted to hospital within 3 months of surgery (RR 6.0, p = 0.008).

Conclusion:
When possible, the laparoscopic approach to appendicectomy should be adopted over open surgery to improve postoperative recovery. Patients who are smokers or obese (BMI > 30) should be warned of prolonged recovery times, and surgeons must be wary that such patients are at greater risk of surgical site infections and needing emergent or inpatient care for postoperative complications. Such patient groups may benefit from early postoperative outpatient follow-up.
 

13.20 The Bifid Recurrent Laryngeal Nerve – Anatomical Details & Operative Implications

Posted on January 25, 2017

J. C. Lee1,2, A. Kiu1, P. Chang1, J. Serpell1,2  1The Alfred Hospital,Department Of General Surgery,Melbourne, VICTORIA, Australia 2Monash University,Endocrine Surgery Unit,Melbourne, VICTORIA, Australia

Introduction:  The identification and preservation of the recurrent laryngeal nerve (RLN) is paramount during thyroid surgery. Due to the slenderness of the branches, a RLN with an extralaryngeal bifurcation is at higher risk of intraoperative injury. When bifid, the motor fibres of a bifid RLN are located mainly in the anterior branch, and the sensory fibres in the posterior branch. However, it has not been documented whether the motor or sensory branch is likely to be thinner and therefore more prone to injury. This study aimed to measure the widths of the bifid RLN trunk and its branches, and to determine their possible associations with demographic factors. 

Methods:  This is a prospective observational study over 18 months at The Alfred Hospital, Melbourne, Australia, in patients undergoing thyroid surgery. The widths of the RLN trunk and branches were measured with Vernier calipers to the nearest 0.1 mm. Demographic data including age, gender, height, weight, and body mass index (BMI) were collected. Nerve widths were compared using Student’s t-test, and RLN widths and demographic data were correlated with Spearman correlation co-efficient (Stata 13).

Results: A total of 150 RLNs were eligible for inclusion during the 12-month study period. Of those, 34 bifid RLNs were identified in 32 patients, and therefore included in the analysis. The main RLN trunk had a mean width of 2.37 (range 1.7 – 4.0) mm. Whereas the mean widths for the anterior and posterior branches were 1.55 (0.8 – 2.5) mm and 1.33 (0.5 – 2.9) mm respectively. Both the anterior and posterior branches were significantly smaller than the main trunk (both p < 0.01). However, the branches were not statistically different from each other in their widths. Body weight and BMI positively correlated to the widths of both the anterior branch (p = 0.003 & p = 0.01 respectively) and posterior branch  (p = 0.02 & p = 0.04 respectively). There was no correlation between age, height and either the main trunk or branches of the RLN.

Conclusion: As expected, the width of the RLN trunk is significantly greater than either of the branches of a bifid RLN. The knowledge of this may help alert the thyroid surgeon to the possibility of a bifid RLN during the process of dissecting along the RLN. More importantly, the similarity in the widths of the branches suggests that it is not possible to determine if a fine nerve branch is likely to be the anterior (motor) or posterior (sensory) branch. Low body weights or BMI may be a clue to possible delicate RLN branches.

 

 

13.19 Postoperative Complications in Patients with Inflammatory Bowel Disease

Posted on January 25, 2017

S. Stringfield1, S. Ramamoorthy1, L. Parry1, S. Eisenstein1  1University Of California,Surgery,San Diego, CA, USA

Introduction:  Patients with Inflammatory Bowel Disease (IBD) are at high risk for postoperative complications. Many patients will receive anti-TNF medications or other biologic medications prior to surgery. There is still controversy as to whether anti-TNFs are associated with complications. Many new biologic medications have not been studied in surgical patients. The purpose of this study is to identify rates and types of postoperative complications in patients with IBD who have undergone abdominal surgery, and identify predictors of these complications. 

Methods:  Retrospective review of patients with IBD who underwent abdominal surgery at our institution June 2014-June 2016. Preoperative, perioperative, and postoperative data was collected. Categorical variables were analyzed using Fisher’s exact test or Chi-square test and continuous variables were analyzed using two sided t-test for independent means. Univariate and multivariate analyses were performed using binary logistic regression. 

Results: We identified 155 abdominal operations performed on IBD patients. Overall complication rate was 40%, with infectious complications the most common with rate of 27% overall. Univariate analysis showed predictors of complications to be age (p=0.028, OR 0.98), BMI (p=0.02, OR 0.93), recent weight loss (p=0.029, OR 2.12), and intraoperative blood loss (p=0.006, OR 0.996). Current use of any biologic medication was not a significant predictor (p=0.144), however vedolizumab use was a predictor (p=0.041, OR 2.46). On multivariate analysis, age (p=0.014, OR 1.03), BMI (p=0.027, OR 1.09), weight loss (p=0.041, OR 2.14), emergent case (p=0.018, OR 2.74), and vedolizumab use (p=0.016, OR 3.27) remained significant predictors of complications. Forty-one percent of patients were on a biologic medication at time of surgery. These patients were more likely to have Crohn’s Disease (59% v 26%, p<0.001), lower preoperative hemoglobin (10.9 v 12.0, p=0.0004) and albumin (3.6 v 3.9, p=0.027), to be on thiopurines (31% v 11%, p=0.003) or steroids (55% v 14%, p<0.001) at the time of surgery, and undergo emergent surgery (36% v 16%, p=0.008). Patients on biologics had a 47% overall and 28% infectious complication rate. Patients not on biologic medications had a 35% overall and 25% infectious complication rate. Complication rates did not vary significantly, except risk of bleeding requiring a transfusion was higher in patients on biologic medications (23% v 11%, p=0.047). 

Conclusion: Patients with IBD have a high rate of postoperative complications. Predictors of complications include age, BMI, weight loss, intraoperative blood loss, and vedolizumab use. Only rates of hematologic complications varied significantly between patients on biologic medications and those not on biologics. 

 

13.18 Body Mass Index is Associated with Surgical Site Infection (SSI) In Patients with Ulcerative Colitis

Posted on January 25, 2017

M. M. Romine1,2, A. Gullick1,2, M. Morris1,2, L. Goss1,2, D. Chu1,2  1University Of Alabama at Birmingham,Gastrointestinal Surgery,Birmingham, Alabama, USA 2VA Birmingham HealthSystem,General Surgery,Birmingham, AL, USA

Introduction:
Controversy persists on the association of Body Mass Index (BMI) with SSI in patients with IBD. Previous studies have been limited by single-institution populations and mixing of Crohn’s disease and Ulcerative Colitis (UC) patients. In this study, we aim to use a national dataset to investigate the association of BMI with SSI specifically in patients with UC. We hypothesize that higher BMI is associated with higher risk for SSI.

Methods:
Using the 2012-2014 ACS-NSQIP Procedure Targeted Database, we identified all patients with UC who underwent colectomy between 2012-2014. Patients with UC were stratified by weight status to underweight, normal weight, overweight and BMI class I (30-34.9), II (35-39.9) and III (>40). Patient demographics, preoperative comorbidities and surgical characteristics were compared. Primary outcomes were wound complications (SSI, organ space SSI, anastomotic leaks) and secondary outcomes were other reported NSQIP-complications. Multivariate analysis was used to identify predictors for wound complications.

Results:
Of 1,487 patients with UC, 39.8% were classified as normal weight as compared to 25.4%, 14.9%, 6.59% and 3.43% for overweight, BMI class I, II and III, respectively. Overall, 10.96% of patients were smokers, 9% of patients were diabetic and 65.77% of patients were on steroids or other immunosuppressant. Patients with higher BMI class were more likely to have diabetes: 6.31% in class I, 10.2% in class II and 13.73% in class III (p value <0.001). At time of surgery, a larger percentage of class III obese patients (27.45%) were classified as ASA 4-5 (p value <0.001). Higher BMI was associated with greater rates of SSI: 7.25% in normal weight class, 8.7% in the overweight class, 9.01% in class I, 18.37% in class II and 27.45% in class III (p-value<0.001). There was no significant difference in organ space SSI (range: 3.92-7.94%) and anastomotic leaks (range: 1.35-6.12%) between the BMI classes (p>0.05). There was an increase in sepsis rate (33.3% vs 15.3%] and respiratory complication rates (23.5% vs 10.2%) with BMI class III vs BMI class II and  continued to decrease with the lower classes (p-value<0.001). On adjustment for covariate differences, BMI remained a significant predictor for SSI with the highest odds in class III (OR 5.0 CI 2.5-10.2) and Class II obesity (OR 3.5 CI 1.9-6.4) when compared to normal BMI individuals.

Conclusion:
Patients with UC and high BMI are at the highest risk for SSI but not for organ space SSI or anastomotic leak rates. Targeting BMI with weight-loss strategies may be one actionable opportunity to reduce post-operative SSI rates.  
 

13.17 Venous Thromboembolism After Incisional Hernia Repair

Posted on January 25, 2017

M. P. DeWane1, A. A. Maung1, K. A. Davis1, J. P. Geibel1, R. D. Becher1  1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA

Introduction: Repair of incisional hernias is one of the most common operations performed by general surgeons. However, outside of its classification as a “major” general surgery operation, little is known about the risk of venous thromboembolism (VTE) after this common procedure. This is concerning as VTE is a leading cause of death in surgical patients. We evaluated VTE rates after emergent and elective incisional hernia repairs to define risk factors, mortality, and determine time to VTE events. We hypothesized that emergent operations would put patients at an increased risk for VTE events.

Methods: Open and laparoscopic incisional hernia repairs were identified in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) participant user files (PUF) over a five year period, from 2010 to 2014. Patient demographics, perioperative variables, and well-established VTE risks were assessed. Logistic regression models determined the risks of VTE development, including the importance of emergent operative classification. Kaplan-Meier and Cox regression analyses determined timing to 30-day VTE events.

Results: A total of 30,372 patients were included in the analyses, 15.7% of whom underwent emergent hernia repair. Compared to elective procedures, incisional hernia operations performed emergently had significantly increased odds for developing VTE (2.16% vs 0.86%; Odds Ratio [OR] 2.51; p<0.0001). Emergent operative classification was found to be an independent predictor of VTE (OR 1.67; p=0.0007) after accounting for common VTE risks. Other VTE risk factors included: respiratory issues such as unexpected or prolonged post-operative intubation (OR 4.12, p<0.0001), need for reoperation (2.52, p<0.0001), and laparoscopic case (OR 1.54, p=0.0287). Variables which did not significantly predict risk of VTE included age, primary vs recurrent hernia, length of operation, need for bowel resection, and obesity. In patients who developed VTE, the risk of mortality was significantly increased (OR 2.57, p=0.0311). Patients presenting in extremis with pre-operative sepsis from incarcerated hernias who required prolonged postoperative ICU stays had a VTE risk 13 times greater than baseline (11.94% vs 0.86%; p<0.0001).

Conclusion: VTE events are significantly more likely to occur in patients undergoing emergent compared to elective incisional hernia repair. Even after controlling for the multiple reasons for this patient-population to develop VTE, emergent operative classification independently predicts VTE, and should be considered a high-risk characteristic. Emergent patients diagnosed with VTE had poorer survival. These findings highlight the importance of VTE prevention and prophylaxis in this high-risk patient population, and suggest that emergent operations may play a role as a thrombogenic stimulus.
 

13.16 Hyperglycemia Following Radical Cystectomy Associated With Shorter Lengths Of Stay And Lower Costs

Posted on January 25, 2017

M. B. Linskey1, D. Brunke-Reese1, E. B. Lehman2, D. I. Soybel1, M. G. Kaag1,3  1Penn State University College Of Medicine,Department Of Surgery,Hershey, PA, USA 2Penn State University College Of Medicine,Department Of Public Health Sciences,Hershey, PA, USA 3Penn State University College Of Medicine,Division Of Urology,Hershey, PA, USA

Introduction:  Post-operative hyperglycemia has been associated with adverse outcomes including increased length of stay (LOS) and increased costs of care. In the cardiac, vascular, general, and trauma surgery populations, post-operative hyperglycemia has also been linked to an increased risk of mortality. Patients without diabetes mellitus who develop acute hyperglycemia post-operatively are at an increased risk of complications compared to their counterparts with diabetes. Radical cystectomy for bladder cancer carries an inherent risk of post-operative morbidity due to the complexity of the procedure and the medical comorbidities of the patients. Morbidity of cystectomy includes frequent readmissions for renal failure, wound occurrences, ileus, failure to thrive, obstruction, and urinary tract infections. We investigate the impact of post-operative hyperglycemia on recovery following radical cystectomy (RC).
 

Methods: A retrospective chart review identified patients undergoing RC between May 2010 and December 2014 with at least one glucose level within 48 hours of surgery. Associations between post-operative hyperglycemia (defined as a first post-operative blood glucose >140mg/dL) and outcomes, including total hospital costs, LOS, and surgical site occurrences were determined.

Results: 176 patients underwent RC; 122 (69%) met our definition of post-operative hyperglycemia. 87 of 128 (68%) patients without diabetes, exhibited hyperglycemia postoperatively. 47 (54%) of these 87 patients required post-operative insulin, including 31 (36%) whose insulin requirement persisting beyond post-operative day 2. On univariate analysis, BMI classification predicted hyperglycemia (obese vs non-obese: Odds ratio (OR) 2.68, [95% Confidence Interval (CI) 1.25-5.75] p=0.01). This association was strong in patients without diabetes (OR 3.55 [95% CI 1.34-9.39] p=0.01), but not significant in those with diabetes. LOS (in days) was shorter in patients who were hyperglycemic post-RC regardless of prior diabetes diagnosis (Difference of medians (DOM) -2.0 [-3.5 to -0.5] p=0.01). This effect remained on multivariable analysis (DOM -2.19 [-3.54, -0.83] p=0.002) controlling for age, gender, race, Charlson score, ASA class, and BMI. Similarly, on multivariable analysis, hospital costs (in US dollars) were lower in patients with post-operative hyperglycemia (DOM -8,863.69 [-12,887.37, -4,840.17] p<0.001).

Conclusion: Post-operative hyperglycemia is common after RC and may occur in patients without diabetes. Contrary to results reported in the general surgery literature, hyperglycemia after RC was associated with shorter LOS and hospital costs. Whether this phenomenon is due to a protective effect associated with hyperglycemia, or is secondary to the aggressive post-operative management afforded these patients, is not yet clear.

 

13.14 Compliance After Bariatric Surgery: Patient-related Factors And Self-reported Barriers

Posted on January 25, 2017

B. Corey1,2, L. Goss1, A. Gullick1,2, D. Breland1, J. Richman1,2, J. Grams1,2  2Birmingham Veteran’s Affairs Medical Center,Surgery,Birmingham, ALABAMA, USA 1University Of Alabama At Birmingham,Surgery,Birmingham, ALABAMA, USA

Introduction:  Patient compliance with attendance at follow-up bariatric appointments is associated with increased weight loss, and reasons for low follow-up compliance are poorly understood. The purpose of this study was to investigate the association of patient-related factors with follow-up compliance after laparoscopic Roux-en-Y gastric bypass (LRYGB).

Methods:  Retrospective review was conducted of all adult patients who underwent LRYGB from 2005-2013 at a single institution. Patients were stratified by follow-up attendance at a total of 8 possible postoperative visits: low 0-2, intermediate 3-5, and high 6-8 visits. Socioeconomic status was determined using 6 measures compared to national census data to generate a neighborhood Summary Z-score. Patients who attended <50% of follow-up visits were mailed a survey to assess reasons for low compliance. Univariate and multivariate analyses were used to compare patient characteristics and compliance. Statistical significance was determined by p <0.05.

Results: Of 756 patients, there were 241 patients in the low, 327 in the intermediate, and 188 in the high compliance groups. The high compliance group was older (p=0.004), white (p=0.020), and had lower preoperative weight (p=0.008) and BMI (p=0.040). There were no differences in overall socioeconomic characteristics based on compliance. On adjusted multivariate analysis, patients were more likely to attend 1 year follow-up appointment if they were older (OR=1.04, CI 1.02-1.05), of lower socioeconomic status (OR=1.04, CI 1.00-1.08), white (OR=1.5, CI 1.03-2.2), had private insurance (OR=1.6, CI 1.02-2.5), and were present at their last appointment (OR=6.30, CI 4.41-8.95); while patients were more likely to attend 2 year follow-up appointment if they were successful at weight loss (OR=1.03, CI 1.00-1.05), if they had shorter driving distance (50-99 miles, OR=2.2, CI 1.4-3.5; <50 miles, OR=1.6, CI 1.0-2.4), or had attended their previous appointment (OR=4.49, CI 3.15-6.40). On survey, patients reported the primary reason they did not follow up was travel time to the clinic (44%), cost of the visits (28%), commitments at work/school (24%), and because of guilt for not following the diet and exercise plan and/or felt ashamed of regaining weight (24%).

Conclusion: Patient-related factors are predictive of follow-up compliance. Based on self-reported reasons, health behaviors and values influence attendance at postoperative bariatric appointments. Since patients self-report travel time and cost as the two primary reasons for failure to follow up, alternative methods of follow-up should be considered such as appointments using telemedicine technology, follow-up “apps” to self-report progress, or stronger collaboration with local primary care physicians. 

 

13.15 Preliminary Experience with Acellular Porcine Liver Matrix in Retrorectus Incisional Hernia Repairs

Posted on January 25, 2017

E. Vo1, C. Y. Chai1,2, D. S. Lee1,2, N. N. Massarweh1,2, K. Makris1,2, L. W. Chiu1,2, H. S. Tran Cao1,2, N. S. Becker1,2, S. S. Awad2  1Baylor College Of Medicine,Houston, TX, USA 2Michael E. DeBakey Veterans Affairs Medical Center,Houston, TX, USA

Introduction:
Acellular dermal matrices have been used since the 1990s for incisional hernia repairs in patients who are considered high risk for surgical site infections (SSI). Porcine dermal matrix is currently the most commonly used biologic mesh. Recently, an acellular matrix derived from decellularized whole porcine liver has been FDA-approved as a new biologic matrix alternative. No studies exist regarding its outcomes. Our objective was to describe our early experience and to compare the short-term outcomes of acellular porcine liver matrix (APLM) with acellular porcine dermal matrix (APDM).

Methods:
Patients undergoing retrorectus incisional hernia repairs were identified from Jan 2013 to Jul 2016 and case-matched in a 2:1 APDM to APLM ratio. Baseline demographics, comorbidities, ventral hernia working group (VHWG) grade, and outcomes such as seroma, hematoma, SSI, dehiscence, length of stay (LOS) were collected. Results were compared between APLM and APDM using univariate analysis with significance set at p<0.05.

Results:
Sixty patients were identified: 20 APLM and 40 APDM with an overall median follow-up of 13.9 months. Cohorts were well-matched in age (APLM 58.6±11.7 vs. APDM 61.5±7.7 years, p=0.26) and BMI (APLM 31.1±6.3 vs. APDM 30.3±5.9, p=0.56). Median VHWG grade (APLM 2.5 vs. APDM 2.0) and ASA (APLM 3 vs. APDM 3), were not statistically significant (both p>0.05). No significant differences in comorbidities were found. Thirty day follow-up demonstrated no difference in SSIs (25% vs. 25%, p=1.00) or readmissions (APLM 10% vs. APDM 17.5%, p=0.70). There was no clinically significant seroma requiring intervention in either cohort. Although LOS was shorter (median APLM 5 (IQR 3-10) days vs. APDM 7 (IQR 6-11) days, p=0.12] and hematoma rates lower (APLM 0% vs. APDM 5%, p=0.60) with the use of APLM, this was not statistically significant.

Conclusion:
There were no significant differences between APLM and APDM with respect to seroma, hematoma, SSI, and LOS. APLM appears to be a safe and feasible alternative for complex ventral hernia repairs. Further study on long-term outcomes is warranted.
 

13.12 Is the Surgical Apgar Score Reliable in Patients on Chronic Beta Blockers?

Posted on January 25, 2017

S. Amodeo1, A. Pinna1,2,3, A. Masi1,2, I. Hatzaras1, E. Newman1,2, S. M. Cohen1, R. S. Berman1, G. H. Ballantyne1,2, H. L. Pachter1, M. Melis1,2  1New York University School Of Medicine,Department Of Surgery,New York, NY, USA 2New York Harbor Healthcare System VAMC,Department Of Surgery,New York, NY, USA 3University Of Sassari,Department Of General Surgery,Sassari, , Italy

Introduction:  The lowest heart rate recorded during surgery is one of the 3 parameters required to calculate the Surgical Apgar Score (SAS), a 10-point prognostication score used to predict postoperative outcomes. We aimed to verify whether SAS maintains its validity in patients undergoing long-term treatment with beta blockers.

Methods:  We queried our institutional clinical database for patients undergoing general surgery procedures between October 2006 and September 2011. Patients on long-term beta blockers were identified and defined the study population. We divided our study population into 4 groups according to their SAS: ≤4, 5-6, 7-8, 9-10. Study end-points were overall morbidity and 30-day mortality. Differences between SAS groups were evaluated with Pearson’s chi-square or ANOVA, as appropriate.

Results: Of the 2125 patients who underwent general surgery over the study period, 568 (26.7%) were taking beta blockers at the time of their operation and represented our study population. They were distributed as follows: SAS ≤ 4: n= 10 (1.8%), SAS 5-6: n= 78 (13.7%), SAS 7-8: n= 181 (31.9%), SAS 9-10: n= 299 (52.6%). There were no differences in age, sex, race, history of smoking or alcohol abuse across SAS groups. Furthermore, no differences were seen in the incidence of diabetes, previous history of transient ischemic attacks, cerebrovascular accidents or peripheral vascular disease. A low SAS was associated with worse functional status (p<0.001), and increased incidence of certain preoperative conditions (congestive heart failure, dyspnea, acute renal failure, ascites: p<0.001; severe COPD: p=0.001; history of esophageal varices: p=0.002; hypertension, history of angina: p<0.05). Accordingly, a low SAS correlated with a higher American Society of Anesthesiologists score (p<0.001). The vast majority of patients with low SAS underwent major or extensive procedures (100% and 85.9% for score ≤ 4 and 5-6, respectively), while high SAS patients mostly underwent minor or intermediate surgery (77.3% for score 9-10). Post-operative morbidity was 60% for score ≤ 4, 46.2% for score 5-6, 27.6% for score 7-8, and 10.4% for score 9-10 (p<0.001). The mean number of complications for each group, respectively, was 1.40 ± 1.7, 1.00 ± 1.4, 0.56 ± 1.2, and 0.15 ± 0.5. Thirty-day mortality rate was 10% for score ≤ 4, 12.8% for score 5-6, 3.3% for score 7-8, and 0.7% for score 9-10 (p<0.001).

Conclusion: Correlation of SAS and risk of surgical complication is maintained in a population of general surgery patients treated with beta blockers. Correlation of SAS with pre-operative conditions and performance status was also confirmed in this patient group.

 

13.11 Duration of Preoperative Hospitalization is Associated With Mortality in Total Abdominal Colectomy

Posted on January 25, 2017

J. Zhang1, A. Lubitz1, M. Philp1, Z. Maher1, A. Pathak1, T. Santora1, L. Sjoholm1, A. J. Goldberg1, E. Dauer1  1Temple University,Department Of Surgery,Philadelpha, PA, USA

Introduction: Total abdominal colectomy (TAC) has been associated with morbidity and mortality rates as high as 62% and 28%, respectively. To date, varying findings regarding risk factors for postoperative complications after emergent colectomy have been reported in the literature. We sought to determine if preoperative length of stay impacts morbidity and mortality in patients undergoing emergent TAC.

Methods:  We conducted a retrospective cohort study of patients undergoing emergent TAC for any indication at our urban quaternary care institution from 2005-2015 (n=94).  Charts were reviewed for patient demographics, preoperative risk factors and Simplified Acute Physiology Score (SAPS), and discrete patient outcomes (leak, abscess, fascial dehiscence, wound infection, hospital length of stay, ventilator days, ICU length of stay and mortality). Patients were then divided into two groups based on whether they underwent TAC prior to hospital day 5 (HD<5) or on hospital day 5 or later (HD≥5). Student’s t-tests were used to compare means for categorical variables, and Chi-squared tests were used to analyze ordinal variables. Statistical analyses were performed using SPSS version 22.

Results: Patients who underwent TAC later in their hospital course had longer total hospital length of stay (Table 1, t=-2.45, df=92, p=0.016) and higher mortality (42.5% v 20.4%, Χ2=5.38, p=0.02). ICU length of stay and ventilator days trended toward being longer in the late group, though these did not reach statistical significance (t=-1.237, df=92, p=0.219 and t=-0.773, df=91, p=0.441, respectively). There was no difference between groups with respect to age, gender, coronary artery disease, hypertension, congestive heart failure, chronic obstructive pulmonary disease, diabetes, chronic kidney disease or stroke. When comparing the early and late operative groups, patient demographics and SAPS did not differ. Intraoperative findings of peritonitis or ischemia also did not differ, nor did postoperative rates of leak, abscess formation, fascial dehiscence or wound infection. Indications for TAC included Clostridium difficile colitis, lower gastrointestinal bleed, large bowel obstruction and inflammatory bowel disease, with more C. diff patients in the early group (Χ2=4.062, p=0.044).

Conclusion: Our data suggest that patients who undergo TAC later in their hospitalization incur longer lengths of stay and greater mortality rates. Age, gender, comorbidities and SAPS scores did not differ among the two groups, suggesting factors external to underlying illness and not reflected in commonly evaluated physiologic markers impact these outcomes. 

 

13.10 The Surgical Apgar Score Identifies Patients at Risk for Prolonged Post-Operative Hospital Stay.

Posted on January 25, 2017

S. Amodeo1, A. Masi1,2, A. Pinna1,2,3, I. Hatzaras1, E. Newman1,2, S. M. Cohen1, R. S. Berman1, G. H. Ballantyne1,2, H. L. Pachter1, M. Melis1,2  1New York University School Of Medicine,Department Of Surgery,New York, NY, USA 2New York Harbor Healthcare System VAMC,Department Of Surgery,New York, NY, USA 3University Of Sassari,Department Of General Surgery,Sassari, , Italy

Introduction:  The Surgical Apgar Score (SAS) is a 10-point score calculated on three intra-operative parameters (lowest heart rate, lowest mean arterial pressure, estimated blood loss), which has been demonstrated to be a reliable predictor of postoperative morbidity and mortality in several types of surgery. We aimed to investigate whether SAS could also predict length of post-operative hospital stay (LOS) in patients undergoing general surgical procedures.

Methods:  We retrospectively evaluated demographics, medical history, type of surgery, and postoperative data for patients undergoing general surgery between October 2006 and September 2011. We categorized our study population into 4 groups according to their SAS: ≤4, 5-6, 7-8, 9-10. The end-point of our study was the length of postoperative hospital stay. We used Pearson’s chi-square or ANOVA, as appropriate, to evaluate differences across SAS groups.

Results: Two thousand one hundred twenty-five patients underwent general surgery during the evaluated period. We excluded 711 patients who underwent outpatient surgery, and included in our analysis the 1414 patients who were admitted post-operatively to the hospital. There were 29 patients in the group SAS ≤ 4, 212 in SAS 5-6, 594 in SAS 7-8, 579 in SAS 9-10. No significant differences in age, sex, race, history of smoking or alcohol abuse among SAS groups were detected. Patients with lower SAS had a worse preoperative functional status (p<0.001) and worse American Society of Anesthesiologists score (p<0.001) than patients with a higher SAS. A low SAS was associated with a higher incidence of certain preoperative conditions (acute renal failure, ascites, history of myocardial infarction, congestive heart failure, severe COPD, dyspnea, history of dialysis: p<0.001; diabetes: p=0.001; history of angina, previous percutaneous coronary intervention, previous cardiac surgery: p<0.05). Most patients with low SAS underwent major or extensive procedures (89.7% and 75.5% for score ≤4 and 5-6, respectively), while high SAS patients mostly underwent minor or intermediate surgery (68.6% for score 9-10). LOS ranged from 0 to 193 days, with a median of 6 days (mean: 11.9 ± 18.8 days). LOS was 29.6 ± 26.5 for score ≤ 4, 24.2 ± 30.8 for score 5-6, 12.1 ± 16.0 for score 7-8, and 6.4 ± 10.9 for score 9-10 (p<0.001). 

Conclusion: In our retrospective analysis SAS correlated with post-operative LOS after general surgery. Moving forward, this information may be used to focus hospital resources (such as social workers and rehabilitation medicine) specifically on patients with low SAS, who are at higher risk for prolonged post-operative length of stay.

 

13.09 A Risk Model and Cost Analysis of Incisional Hernia Following 2,145 Open Hysterectomies

Posted on January 25, 2017

J. M. Weissler1, M. G. Tecce1, M. N. Basta2, V. Shubinets1, M. A. Lanni1, M. N. Mirzabeigi1, M. J. Carney1, L. Cooney1, S. Senapati1, A. F. Haggerty1, J. P. Fischer1  1University Of Pennsylvania,Plastic Surgery,Philadelphia, PA, USA 2Brown University School Of Medicine,Plastic Surgery,Providence, RI, USA

Introduction:  Incisional hernia (IH) is a pervasive complication across surgical specialties and presents a significant burden to both the patient and healthcare system. Morbidity associated with IH permeates all surgical specialties, including gynecologic surgery. Approximately 600,000 women undergo hysterectomy annually in the US and IH is estimated to complicate 8-16.9% of all abdominal hysterectomies. An open approach to abdominal hysterectomy portends increased risk for IH development, however there is a substantial knowledge gap regarding which procedure-specific factors govern risk. The purpose of this study is to assess the incidence and health care cost of surgically repaired IH after open abdominal hysterectomy, identify actionable, perioperative risk factors, and create a predictive risk mode to identify at-risk patients who could benefit from prevention strategies.

Methods:  We conduct a retrospective review of patients who underwent hysterectomy through an open abdominal approach between 1/2005 and 6/2013 at the University of Pennsylvania.  The primary outcome of interest was post-hysterectomy IH.  Univariate and multivariate cox proportional hazard analyses were performed to identify perioperative risk factors.  Patients with prior hernia, less than 1 year follow-up, or emergency surgeries were excluded.  Cox hazard regression modeling with bootstrapped validation, risk factor stratification, and assessment of model performance were performed.

Results: Overall, 2,145 patients underwent open abdominal hysterectomy during the study period. 76 patients developed IH, all of whom underwent hernia repair. 31.3% underwent further reoperation, generating significantly higher costs of care ($71,559 vs. $23,313, p<0.001).  8 risk factors were identified and included in the final adjusted risk model, the strongest of which were presence of a vertical incision (HR=3.73 [2.01-6.92]) and ascites (HR=2.39 [1.40-4.08]). Extreme risk patients experienced the highest incidence of IH after hysterectomy (22%), followed by the high-risk group (9.7%), moderate-risk group (2.7%), and low-risk group (0.8%) (C-statistic=0.82) (Figure 1).

Conclusion: This study presents an internally validated risk model of IH in patients undergoing open hysterectomy after a review of 2,145 cases. The model can serve to accurately stratify patients, facilitate pre-operative counseling, and potentially imply risk reductive techniques.

 

13.08 Financial Burden is Associated with Lower Quality of Life Scores in Adults with MEN-1

Posted on January 25, 2017

B. J. Peipert1, S. Goswami1, S. E. Yount2,3, C. Sturgeon1  1Northwestern University Feinberg School Of Medicine,Surgery,Chicago, IL, USA 2Northwestern University Feinberg School Of Medicine,Medical Social Sciences,Chicago, IL, USA 3Northwestern University Feinberg School Of Medicine,Psychiatry And Behavioral Sciences,Chicago, IL, USA

Introduction: Health-related quality of life (HRQOL) and financial burden among patients with multiple endocrine neoplasia type 1 (MEN-1) is poorly described. It is not known how the financial burden attributed to treatment and disease influences HRQOL in this population. We hypothesized that financial burden attributable to MEN-1 is associated with worse patient-reported outcomes (PROs) reflecting lower HRQOL.

Methods: Adults (≥18 years) recruited from an MEN-1 support group (n=174) completed an online survey that included questions regarding demographics, clinical characteristics, medical/surgical treatment, and various aspects of financial burden. PROMIS-29 was used to assess HRQOL. PROMIS-29 scores across 7 domains (physical function, fatigue, pain interference, anxiety, depression, sleep disturbance, social functioning) were converted to T Scores and compared to normative data for the United States (US) population using a one-sample T-Test. Data are presented as mean T scores ± standard deviation. Subgroup analysis was conducted using Mann-Whitney U for categorical variables and Pearson coefficients for continuous variables. Holms-Bonferroni Sequential Correction was used to control for multiple comparisons.

Results: Eighty-one percent of respondents reported financial burden associated with MEN-1. Respondents reported using up their savings (39%), being contacted by a collection agency (35%), borrowing money (27%), reaching their maximum credit limit (17%), taking out a new loan/mortgage (14%) or declaring bankruptcy (6%) due to the financial burden of MEN-1. Respondents who reported any financial burden due to MEN-1 had worse anxiety (62.9±9.6 vs 53.2±9.4, p<0.001), depression (58.7±10.3 vs 51.2±13.2, p<0.001), fatigue (62.9±10.2 vs 51.2±13.2, p<0.001), pain interference (57.2±11.0 vs 48.7±8.7, p<0.001), physical function (43.0±9.1 vs 52.2±7.6, p<0.001), sleep disturbance (58.3±8.6 vs 52.6±9.4, p<0.01) and social functioning (43.0±9.5 vs 53.2±11.5, p<0.001). Lower PRO scores were significantly associated with greater financial burden (r=0.34-0.52, p<0.001) and the number of negative financial events (r=0.34-0.45, p<0.001) across all domains, which was also true of respondents who were currently unemployed (14%), disabled (13%) or had a history of extended unemployment (37%) (p<0.05). An annual income <$50,000 (34%) was associated with worse anxiety, depression, pain, physical functioning, and social functioning (p<0.05). Monthly cost of prescription medication >$100 was associated with worse PROs across all domains (p<0.05). Skipping medications due to cost (19%) was associated with worse physical functioning and sleep disturbance (p<0.01).

Conclusions: This is the first PRO study to link worse HRQOL to financial burden attributed to the management of MEN-1. The number of negative financial events, unemployment, disability, monthly cost of prescription medicines, and low income were all associated with worse PRO scores in adults with MEN-1.

13.07 The Metabolic Benefit of Bariatric Surgery: Impact of Baseline Disease Status

Posted on January 25, 2017

L. A. Bayouth3, W. J. Pories3, M. B. Burruss3, K. Spaniolas3  3East Carolina University Brody School Of Medicine,Department Of Surgery, Minimally Invasive And Bariatric Surgery,Greenville, NC, USA

Introduction:  Bariatric surgery has been established as a treatment modality for the control and remission of metabolic syndrome. Multiple studies demonstrated that preoperative severity of type 2 diabetes (T2D) affects likelihood of remission postoperatively. Limited data is available for how the severity of other components of metabolic syndrome impact outcomes. The aim of this study is to identify how severity of metabolic syndrome preoperatively affects disease remission following bariatric surgery.

Methods:  We queried the BOLD database from 2005-2011 to identify patients undergoing gastric bypass or sleeve gastrectomy with available 12 month follow up information. Comorbidities at baseline and following surgery were recorded in a five-point Likert scale. A composite score was calculated for patients with all components of metabolic syndrome. Improvement and remission of components of metabolic syndrome (T2D, hypertension, and dyslipidemia) were assessed. Multivariable logistic regression models were built to determine effect of baseline disease, controlling for other baseline characteristics. Odds ratios (OR) with 95% confidence intervals are reported.

Results: Within a cohort of 51,081 patients who underwent bariatric surgery with 12 month follow up, we identified 20,089 (39.3%), 31,695 (62%), and 23,350 (45.7%) patients with T2D, hypertension and dyslipidemia, respectively; 11,075 (21.7%) patients had all three components of metabolic syndrome. Gastric bypass was performed in 46,381 (90.8%) patients. Mean age and BMI for the entire cohort were 47+11.6 and 47.7+8.5, respectively. Comorbidity remission significantly varied by baseline severity score (Fig 1 Comorbidity Remission for T2D, hypertension and dyslipidemia based on composite metabolic score. P<0.001 for all comparisons). After controlling for age, gender, BMI and procedure, the degree of baseline comorbidity independently associated with 12 month remission. In patients with metabolic syndrome, a composite score over 9 (median) was independently associated with lower rate of remission at 12 months (OR 0.46, 95% CI 0.41-0.51). Similarly, score over 9 was independently associated with 12 month remission of T2D (OR 0.37, 95% CI 0.34-0.4), hypertension (OR 0.59, 95% CI 0.54-0.65), and dyslipidemia (OR 0.68, 95% CI 0.63-0.74).

Conclusion: Bariatric surgery leads to remission of metabolic syndrome and individual components in a large percentage of patients. The remission rate at 12 months is significantly affected by preoperative severity of disease. This data proposes that early intervention would lead to significant benefit, improving remission rate. Bariatric surgery should not be reserved as last resort treatment of metabolic syndrome in the severely obese.

13.05 Appendicoliths Increase the Risk of Complications in Laparoscopic Appendectomy

Posted on January 25, 2017

M. Khan1, M. H. Siddiqui1, N. Shahzad1, M. B. Chaudhry2, M. Wajid1, R. Sultan1, W. A. Memon2, H. Zafar1, A. Alvi1  1Aga Khan University Medical College,Surgery,Karachi, Sindh, Pakistan 2Aga Khan University Medical College,Radiology,Karachi, Sindh, Pakistan

Introduction:
Appendicoliths are often found to be associated with perforated and gangrenous appendicitis. However, the relationship between appendicoliths and complications of laparoscopic appendectomy has not been studied. The objective was to determine if the presence of appendicolith/s increased the risk of infectious complications in laparoscopic appendectomy.

Methods:
A retrospective case-control study of patients who received a pre-operative abdominal Computed Tomographic (CT) scan and later underwent laparoscopic appendectomy from 01/2008-12/2015 was completed. Occurrence of post-operative infectious complications, namely surgical site infections and intra-abdominal abscesses were noted.  Patients were divided into two groups, those with appendicitis and appendicoliths (AA) and those who had appendicitis with no appendicoliths (NA) on CT scan.

Results:
In total, 453 patients who underwent laparoscopic appendectomy and had pre-operative CT scan were included. Of these, 123 (27%) patients were in the AA group while 330 (73%) patients were in the NA group. There were no significant differences between the mean age, gender and presence of comorbid conditions in both groups. Post-operative infectious complications were seen in 18 (4%) patients that were found in a significantly greater proportion of patients of the AA group than of the NA group. [AA vs. NA: 9 (7.3%) vs. 9 (2.7%); p value 0.03]. Odds ratio was calculated to be 2.8 (Confidence interval 1.1-7.2). On multivariable regression analysis, presence of appendicolith was significantly associated with the occurrence of post-operative infectious complications. 

Conclusion:
Appendicoliths increase the risk of post-operative infections in patients with appendicitis. For patients diagnosed to have appendicitis with appendicolith, steps to prevent postoperative complications, such as judicious use of post-operative antibiotics, should be considered.
 

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