13.06 Discordance in Hospital Quality Rank Using Traditional Vs. Patient-Preferred Outcomes After Colectomy

Posted on January 25, 2017

A. N. Kothari1, S. A. Brownlee1, E. C. He1, J. Rambo1, D. M. Hayden1, J. M. Eberhardt1, P. C. Kuo1, T. L. Saclarides1  1Loyola University Chicago Stritch School Of Medicine,Surgery,Maywood, IL, USA

Introduction:
Hospital quality is commonly measured using postoperative mortality rates. However, recent data demonstrate that patients may perceive several states of functional disability as worse than death. These include incontinence, ventilator dependence, being bed bound, confusion, and reliance on a feeding tube. The objective of this study was to compare how hospital performance would be ranked using traditional or patient-preferred outcomes for patients undergoing elective colon resections.

Methods:
The Healthcare Cost and Utilization Project State Inpatient Databases for California, Florida, Iowa, and New York were used to identify patients undergoing open colon resection. Traditional measures of postoperative outcomes included 1-year mortality. Patient-preferred measures of postoperative outcomes were based on prior study identifying states of functional disability that patients define as being as bad as or worse than death. Separate risk-adjustment models were constructed for each outcome using mixed-effects logistic regression models fit using patient-level covariates including diagnosis and procedure, and a random-effect term for the hospital. Expected event rates were derived from final models, with observed over expected ratios calculated for each hospital (with 95% confidence interval). 

Results:
A total of 42 116 patients at 663 hospitals met our inclusion criteria. Overall mortality of the study population was 11.0% at 1 year, while 3.5% of patients had functional disability at 1 year. At the hospital level, unadjusted rates of mortality ranged from 0.0 – 24.1% across hospitals, while rates of functional disability ranged from 0.0 – 11.8%. Following risk adjustment, hospitals were ranked based on observed over expected ratios for both mortality and functional disability. There was poor agreement between ranks assigned using each outcome (r=0.22, ICC=0.22 [0.14 – 0.29], kappa=0.006, p<0.001). A total of 69 hospitals were high performing for both outcomes (top quartile) and a total of 72 hospitals were low performing (bottom quartile) for both outcomes.

Conclusion:
Hospital rankings based on traditional outcomes, including mortality, may not adequately assess hospital performance for patient-preferred outcomes related to long-term postoperative functional disability. Transparency regarding the metrics used for publicly reported ranking systems and consideration of functional outcomes are important for adequately measuring the quality of a hospital’s surgical care. 
 

13.04 Can a Change in Surgical Technique Decrease Postoperative Hypocalcemia After Total Thyroidectomy?

Posted on January 25, 2017

D. S. Kim1, A. E. Barber1, R. C. Wang1  1University Of Nevada School Of Medicine,Department Of Surgery,Las Vegas, NV, USA

Introduction:

Hypocalcemia is the most common early postoperative complication of total thyroidectomy, with reported incidences up to 50% in some series, due to injury to or removal of parathyroid glands and/or compromise of parathyroid vascular supply. After observing an incidence of 20% transient hypocalcemia in our previous series, we adopted systematic changes in surgical technique in order to decrease postoperative hypocalcemia without routine calcium supplementation.  

Methods:

This was a prospective cohort study with chart review. 145 consecutive patients undergoing either total or completion thyroidectomy with or without central neck dissection at a tertiary academic center and a community hospital between May 2013 and June 2016 were included. Initial 70 patients underwent total thyroidectomy using standard techniques. Total thyroidectomy using a modified technique was performed on the subsequent 75 patients. This systematic approach consisted of the following sequential steps: mobilization of the medial and inferior thyroid lobe from the trachea to displace the inferior lobe away from the recurrent laryngeal nerve (RLN), exposure and transection of the attachments of the inferior parathyroid gland to the thyroid gland without compromising its blood supply from the inferior thyroid vessels, exposure of the RLN superiorly followed by completion of mobilization of the thyroid from the trachea and larynx, displacement of the thyroid lobe medially and inferiorly, exposure and transection of the attachments of the superior parathyroid gland to the thyroid gland without compromising the blood supply from either the superior or inferior thyroid vessels, and ligation of terminal superior thyroid vessels on one side and then on the contralateral side.  Blunt, blade shaped instruments instead of hemostats were used to dissect around the small parathyroid vessels. Harmonic scissors were used in all patients instead of ligatures whenever feasible. All patients were observed overnight without routine calcium supplementation. Significant biochemical hypocalcemia was defined as total serum Ca < 7.6 mg/dL 12 hours after surgery. Parathyroid hormone was measured in the preoperative, intraoperative and postoperative periods.

Results:

In the standard technique group, 14 of 70 patients (20.0%) developed transient hypocalcemia while 2 patients (2.9%) developed permanent hypoparathyroidism. Following the implementation of the new techniques, the incidence of transient hypocalcemia decreased to 2.7% (n=2/75; χ2=11.1, p<0.001), and there was no incidence of permanent hypoparathyroidism or hypocalcemia. No case of postoperative vocal cord palsy or paralysis was noted in both groups. The durations of surgeries were not significantly different between the two groups.

Conclusion:

The modified thyroidectomy techniques presented in this study improved the preservation of parathyroid gland function and reduced the incidence of postoperative hypocalcemia significantly.
 

13.03 Practice Variation in the Management of Uncomplicated Gastroschisis at U.S. Children’s Hospitals

Posted on January 25, 2017

S. M. Stokes1, S. S. Short1, D. C. Barnhart1, E. R. Scaife1, B. T. Bucher1  1University Of Utah School Of Medicine,Division Of Pediatric Surgery,Salt Lake City, UT, USA

Introduction:  The surgical management of infants with uncomplicated gastroschisis is not well defined. There remains a lack of strong evidence favoring primary versus delayed closure of the abdominal wall defect, and the decision is often based on surgeon preference. We proposed that institutional propensity for a particular closure method would help identify disparities in patient outcomes and resource utilization. 

Methods:  We performed a retrospective cohort analysis of infants with gastroschisis at children’s hospitals from 2010-2014 using the Pediatric Health Information Systems Database. Patients were excluded if they underwent an intestinal resection, had a significant cardiac or neurologic anomaly, or expired during the hospital admission. Patients were classified as either primary closure (≤ 24 hours from admission to closure) or delayed closure (> 24 hours from admission to closure).  The proportion of patients managed in a delayed fashion for each hospital was calculated as the hospital’s delayed closure rate. Primary outcomes included length of stay (LOS), total parental nutrition (TPN) days, and ventilator days. Multivariate hierarchical linear regression with random effects was used to determine the effect of hospital delayed closure rate on the primary outcomes after controlling for various patient and hospital level factors. 

Results: There were 1812 infants treated at 41 children’s hospitals during the study period and 1080 (60%) underwent delayed gastroschisis closure. Infants who underwent delayed closure were more likely to be lower birthweight (2451g vs 2567g, p<0.0001) and younger gestational age (35.9 weeks vs 36.1 weeks, p=0.03). Infants managed in a delayed fashion had longer LOS (43.2±24.1 vs. 35.3±19.6, p<0.001), greater TPN days (32.3±18.4 vs. 27.0±16.4, p<0.001) and greater ventilator days (7.7±10.1 vs. 4.5±3.6, p<0.0001).  The percentage of infants managed in a delayed fashion at each hospital is shown in the Figure and ranged from 27.5% to 100%.  There was no significant correlation between hospital delayed closure rate and average LOS (p=0.67), TPN days (p=0.33), or ventilator days (p=0.96).  After accounting for various patient and hospital level factors, hospital delayed closure rate was not significantly associated with LOS (p=0.09), TPN days (p=0.42) or ventilator days (p=0.84).

Conclusion: Significant practice variation exists in the management of gastroschisis in US children’s hospitals.  An institution’s propensity for a specific closure method is not significantly associated with adverse patient outcomes or increased resource utilization.

 

13.02 Safety and Efficacy of Revision Rouxeny Gastric Bypass after Gastric Banding for Weight Loss Failure

Posted on January 25, 2017

A. Wang1, S. Sprinkle1, M. Cox1, C. Park1, D. Portenier1, J. Yoo1, R. Sudan1, K. Seymour1  1Duke University Medical Center,Durham, NC, USA

Introduction:
The adjustable gastric banding (AGB) was popular as a primary weight loss procedure in the late 2000 but has decreased in popularity due to weight loss failure. With only approximately 50% of patients achieving adequate weight loss, patients may seek revision surgery to improve their outcome despite increased surgical risk. We thus aim to assess the safety and efficacy of revision roux-en-y gastric bypass (RGB) after AGB for weight loss failure. 

Methods:
After IRB approval, retrospective review from September 2004 to October 2014 at a single institution was performed.  Only those with at least 1 year follow up were included in the analysis (n=53). All surgeries were performed laparoscopically by 8 surgeons. Excess BMI loss was calculated as percent decrease in BMI compared to ideal BMI 25. Successful weight loss was defined as excess BMI loss greater than 50%. Continuous variables were compared with t-tests and categorical variables were compared with Wilcoxon rank-sum, Fisher’s exact test, or McNemar’s chi-squared test.

Results:
Average age was 46 +/- 10 years, 15% of patients were male and 64% were Caucasion race. Average length of time between AGB and RGB was 3.8 +/- 1.6 years.  Average length of stay during the revision operation was 2.7 +/- 3.3 days. At 30 days, there were 5 readmissions (3 for poor oral intake, 1 for obstruction, and 1 for cellulitis) and 3 reoperations (2 for obstruction and 1 for bleeding). There were no 30-day mortality, pulmonary embolism, or leak.  Patients did not experience a significant decrease in BMI between baseline BMI at primary AGB surgery and BMI at time of revision (45.3 vs 44.0, p=0.24, CI -0.9 – 3.7). Patients did experience a significant decrease in BMI after revision RGB (44.0 vs 38.12, p<0.0001, CI 3.4-8.4) and 30% (n=16) of patients experienced weight loss success at 1 year. There was no significant difference in medication controlled DMII at 1 year after revision (17% vs 9%, p=0.25, CI -5%-20%); however, the average number of HTN medications decreased at 1 year (0.83 vs. 0.62, p=0.033, 0.02-0.40). 

Conclusion:
In this cohort of patients who underwent AGB to RGB for weight loss failure, patients experienced improved weight loss at 1 year compared to their original operation. Overall, patients required fewer HTN medications at 1 year but had similar rates of medication controlled DMII.  Revisional RGB after AGB can be performed safely with improvement in co-morbidities at 1 year.
 

13.01 Impact of Surgical Site Infections on Recurrence and Quality of Life in Open Ventral Hernia Repair

Posted on January 25, 2017

K. Coakley1, S. Groene1, T. Prasad1, A. Lincourt1, K. Kercher1, V. Augenstein1, B. Heniford1, P. Colavita1  1Carolinas Medical Center,GI And Minimally Invasive Surgery,Charlotte, NC, USA

Introduction:
Surgical site infections (SSI) remain a common problem in the postoperative hernia patient.  These infections add to healthcare costs, however little is known on how SSI impact patient’s quality of life (QOL) following an open ventral hernia repair (OVHR).  Our aim was to assess the effects of SSI on surgical and QOL outcomes following OVHR.

Methods:
A query of a prospective, single-center, hernia-specific database was performed for adult OVHR.  Demographics, operative characteristics, and complications were analyzed using standard statistical methods.  Multivariate regression (MVR) was performed for outcomes controlling for BMI, defect size, and comorbidities. QOL was evaluated pre-operatively, at 2 and 4 weeks, as well as 6- and 12-months using the Carolinas Comfort Scale, a hernia specific assessment tool used to evaluate QOL outcomes. 

Results:
A total of 1,711 OVHR with 239 SSI (14%) were identified.  SSI were seen in patients with a larger BMI (37.0±9.1 vs 32.0±10.6kg/m2; p<0.001) and more comorbidities(3.2±2.2 vs 2.9±2.2;p=0.03).  Patients with SSI’s had larger hernia defects (241.6±242.4 vs 134.2±226.0cm2; p=<0.001), longer OR time (228.0±94.3 vs 150.4±92.0min; p<0.001), and greater EBL (217.3±286.7 vs 97.9±125.2mL; p<0.001).  Table 1 includes additional variables.  Patients with SSI overall had more postoperative complications beyond SSI (72.9 vs 34.9%; p<0.001), specifically mesh infection (9.3 vs 0.3%;p<0.001), unplanned return to the OR(25.1 vs 3.7%;p<0.001), wound breakdown(36.9 vs 6.1%;p<0.001), readmission in 30 days(41.6 vs 5.9%;p<0.001) and recurrence(18.8 vs 4.5%;p<0.001).  There was no difference in 30-day mortality.  MVR demonstrated SSI was an independent predictor of recurrence when controlling for BMI, defect size and comorbidities (Odds Ratio(OR) 4.82; 95% CI 2.725-8.55).  .  At 6 months, SSI was an independent predictor of worse mesh sensation (OR 2.831; 95% CI 1.421-5.640), movement limitation (OR 2.083; 95% CI 1.035-4.192) and overall QOL (OR 2.355; 95% CI 1.174- 4.724).  At 1 year, SSI was independently associated with overall decreased QOL (OR 2.284; 95% CI 1.134-4.600).  

Conclusion:
SSI is associated with recurrence and worse quality of life in univariate and multivariate analysis.  Consistently, OVHR patients who experienced an SSI reported worse QOL scores at all follow up time points, from 2 weeks to 12 months.  Efforts to reduce SSI should be strongly pursued to reduce hernia recurrence and improve patient quality of life.
 

12.20 Predictors of a Histopathologic Diagnosis of Complicated Appendicitis

Posted on January 25, 2017

J. B. Imran1, C. T. Minshall1, T. Madni1, A. El Mokdad1, M. Subramanian1, A. Clark1, H. Phelan1, M. Cripps1  1University Of Texas Southwestern Medical Center,Surgery,Dallas, TX, USA

Introduction: Complicated appendicitis (CA) is defined by the presence of perforation or abscess during appendectomy. This definition guides clinical assessment and has a profound impact on postoperative antibiotic use and hospital length of stay. Despite its utilization, the intraoperative (IO) assessment of CA is fraught with subjectivity. Although histopathologic (HP) diagnosis should be the gold standard in identifying patients with CA, it is not immediately available after an operation to guide postoperative management. Given the subjectivity in the IO assessment and delay in obtaining an HP diagnosis, the objective of this study was to identify predictors of an HP diagnosis of CA. 

Methods: A retrospective review was performed of all patients who underwent appendectomy at our institution from 2011 to 2013. Patients were divided into cohorts consisting of those with CA or uncomplicated appendicitis (UA) based on an HP diagnosis. CA was defined by finding evidence of macroscopic or microscopic perforation or abscess on pathology report. Clinical, IO, and postoperative data were compared using chi-square and Wilcoxon rank-sum tests. We evaluated predictors of an HP diagnosis of CA using a multivariable logistic regression model. 

Results: A total of 239 out of 1066 patients had CA based on IO assessment, while only 143 out of 239 patients (60%) had both an HP and IO diagnosis of CA. On univariate analysis, older patients, patients with type 2 diabetes mellitus, those with a longer duration of pain prior to presentation, the presence of an appendicolith, abscess and appendix size on preoperative computed tomography (CT) imaging, as well as higher median preoperative temperature and serum creatinine were found to have significant differences between complicated and uncomplicated cohorts diagnosed by HP (p < .05). Patients with an HP diagnosis of CA also had less focal right lower quadrant pain and an increased time from presentation to the operating room than those with UA (p < .05). Multivariate analysis revealed that an IO diagnosis of CA was found to be associated with an HP diagnosis of CA (OR 12.32; 95% CI, 8.2 – 18.5). Other risk factors were age (per 10 years; OR 1.25; 95% CI, 1.07 – 1.46), number of days of pain (OR 1.21; 95% CI, 1.07 – 1.37), appendix size (per millimeter; OR 1.10; 95% CI, 1.07 – 1.37), and the presence of an appendicolith (OR 1.65; 95% CI, 1.06 – 2.56) on preoperative CT imaging. 

Conclusion: Age, duration of pain, appendix size and the presence of an appendicolith on preoperative imaging are moderately associated with having an HP diagnosis of CA. The IO assessment is also associated with an HP diagnosis of CA; however 40% of patients were classified incorrectly at the time of surgery. These predictors in combination with improved intraoperative grading could be used to achieve a more timely and accurate diagnosis of CA.  

 

12.19 Judging a Book by its Cover? Effects of Clinic Location on Patient Satisfaction.

Posted on January 25, 2017

C. B. Matsen1, D. Ray1, M. O. Bishop2, A. P. Presson2, S. R. Finlayson1  1University Of Utah,Surgery/General Surgery,Salt Lake City, UT, USA 2University Of Utah,Epidemiology/Internal Medicine,Salt Lake City, UT, USA

Introduction: Patient satisfaction is an important quality metric used by many healthcare systems. Most large academic centers have multiple facilities with outpatient surgical clinics. For providers who see patients at multiple sites, we asked whether satisfaction scores may be affected by where the patient is seen.  We were specifically interested in how the site of the visit might impact satisfaction with the care provider.

Methods: We obtained patient satisfaction data from the Press-Ganey survey over one year for five providers who saw patients at both a university hospital clinic and a comprehensive cancer center in separate buildings on the same campus. Logistic regression models were used to estimate the odds of a perfect satisfaction score (100%) by clinic, adjusting for the patient’s age, gender and the care provider. Seven satisfaction outcomes were analyzed, including the total score and its 6 subdomains (overall assessment, access, moving through visit, nurse/assistant, care provider, personal issues).  All satisfaction measures were dichotomized due to the high rate of perfect satisfaction. We report odds ratios (ORs), 95% confidence intervals (CIs) and p-values. Statistical significance was evaluated at the 0.05 level and all tests were two-tailed.

Results: 424 patient experiences across the two sites (234 at the cancer center, 190 at the university clinic) were analyzed. After adjusting for patient age, sex and care provider, odds of satisfaction were lower in the university clinic relative to the cancer center for all measures, although moving through visit (which asked about delays and wait times) and care provider (which asked about the patient’s experience with the care provider) did not achieve statistical significance (Table 1).  The “personal issues” domain, which queried “the cleanliness of the practice”, had a 54% lower odds of satisfaction at the university clinic than the cancer center (OR=0.46, 95% CI: 0.26-0.8, p<0.001). There were also statistically significant differences in satisfaction among the providers for total satisfaction, moving through visit, nurse/assistant and care provider (all p<0.05).

Conclusion: In our single institution study, patient reported satisfaction was consistently associated with the site of the visit. Patient reported satisfaction with the provider appears to be influenced by both the provider and the site of the visit. The site-specific factors may include additional patient factors that were not adjusted for in our analysis, such as acuity and severity of illness, or other factors related to the setting.

 

12.18 Systematic Implementation of a Colon Bundle Significantly Decreases Surgical Site Infections

Posted on January 25, 2017

F. Gaunay1, T. Adegboyega1, C. Sanz1, M. Berrones1, D. Rivadeneira1  1North Shore University And Long Island Jewish Medical Center,Colon & Rectal Surgery,Manhasset, NY, USA

Introduction:

Surgical site infections (SSIs) represent significant morbidity and financial implications following colon surgery. The objective of this prospective study is to compare clinical outcomes pre- and post- implementation of a dedicated colon surgery bundle to reduce SSIs in our health system.

Methods:

A prospective study was conducted in which a dedicated colon surgery bundle and interdisciplinary team for its implementation was established.  The twenty-five components of the colon surgery bundle were divided into pre-hospital, pre, intra, and post-operative measures.  These included standardized pre-operative mechanical bowel preparation and oral antibiotics and body wash skin cleansing, alcohol-based skin preparation, intra- and peri-operative maintenance of normothermia, therapeutic levels of antimicrobial prophylaxis and optimal tissue oxygenation, glucose control, and the introduction of a clean standardized fascial closure process, and negative pressure wound therapy. Specific enhanced pre-operative patient education was also provided. Consecutive patients who underwent a colorectal procedure between January 2015 and January 2016.  SSIs were recorded and subdivided by surgical wound class.

Results:

SSIs were identified in 11/198 patients (7%) eligible for colon bundle implementation. When compared to the year prior to implementation of the colon bundle, SSIs where identified in 26/175 (15%).  Implementation of the colon bundle led to a significant decrease in SSIs 7% vs. 15%, (p <0.05).  Additionally, SSIs observed in clean-contaminated and contaminated procedures decreased from 34.6% to 14.3% and 38.5% to 14.3%, respectively (p<0.05%). 

Conclusion:

We demonstrate in this prospective study that the implementation of a specific colon bundle resulted in a 54% decrease in post-operative SSIs. The greatest reduction of SSIs was seen in wound classes II and III.  We also show a very high adoption and compliance of the colon bundle with a dedicated implementation of  an interdisciplinary team. This approach to incorporating an advanced surgery bundle for colon and rectal procedures can provide an effective strategy to reduce SSIs.
 

12.17 Focused Parathyroidectomy under Local Anaesthesia – Evaluation of Outcomes and Satisfaction

Posted on January 25, 2017

S. SEN1, K. REKA2, A. J. CHERIAN1, P. RAMAKANT1, P. M. JACOB1, D. T. ABRAHAM1  2CMC HOSPITAL,BIOSTATISTICS,VELLORE, TAMIL NADU, India 1CMC HOSPITAL,ENDOCRINE SURGERY,VELLORE, TAMIL NADU, India

Introduction:

Focused parathyroidectomy is treatment of choice in PHPT (Primary hyperparathyroidism) due to single gland adenoma in patients with concordant imaging on parathyroid scintigraphy and ultrasound.  To avoid delays due to lack of anaesthesia time, this can be performed under local anaesthesia (LA) in a select group of patients

This study was done to evaluate the effectiveness of focused parathyroidectomy under local anaesthesia and mild sedation administered and monitored by surgeon

Methods:

We conducted a prospective observational study of all patients undergoing focused parathyroidectomy under local anesthesia at our institution. All consecutive patients with PHPT from Oct 2015 to July 2016, planned for the same, were evaluated for suitability to perform this procedure under LA after institutional ethics approval. If feasible, they were consented and outcomes were noted.

The study evaluated the following outcomes:

Primary outcomes:Biochemical cure – corrected calcium and PTH in immediate post operative period

Secondary outcomes:Complications – hematoma, nerve injury, hypocalcaemia, failed exploration, wound infection; Scar size; Intra-operative and Post-operative pain – visual analogue score; Post-operative nausea and vomiting; Requirement of analgesia – local anaesthetic used , fentanyl, midazolam dosages; Total duration of procedure – operating time;Overall patient satisfaction- patient satisfaction with anaesthesia, surgery 

Results:

24/46 underwent the procedure under LA with mild sedation.

All patients had a biochemical cure in the immediate post operative period. 1/ 24 patient  was converted to General Anaesthesia (GA) due to bleeding. 1/ 24 patient had voice change post operatively, 14 /24 patients had hypocalcaemia postoperatively requiring oral or intravenous calcium.

The mean length of scar was 4.38 + 0.17 cm. The mean gland weight and maximum dimension were 2502.08 + 466 mg and 2.383+ 0.20 cm respectively. On Visual Analog Score (VAS), the mean score was 2.67+ 0.339and 1.83+ 0.197 in 1st and 2nd post operative day respectively.

Table 1 shows the mean of analgesic requirement

 

The mean ‘operating’ times was 53.33+ 3.453 minutes.

 The mean satisfaction score (1-5, 5 being most satisfied) with LA and surgery were 4.71+ 0.112 and 4.88 +0.069 respectively

Conclusion:

Focused parathyroidectomy under LA could be monitored and performed safely by a surgeon ensuring both biochemical cure and adequate patient satisfaction for a select group of patients

12.16 Using Patient Outcomes to Evaluate Residency Program Performance in Colorectal Surgery

Posted on January 25, 2017

M. M. Sellers1,2, R. L. Hoffman1, C. Wirtalla1, G. C. Karakousis1, R. R. Kelz1  1Hospital Of The University Of Pennsylvania,Center For Surgery And Health Economics Department Of Surgery,Philadelphia, PA, USA 2Mount Sinai School Of Medicine,Depar,New York, NY, USA

Introduction:  The feasibility of ranking residency programs based on the clinical outcomes of their graduates has previously been established. Colorectal resection is amongst the most common operations performed by general surgeons. Our objective was to assess general surgery residency program performance in colorectal surgery education using the objective clinical outcomes of patients operated on by program graduates.

Methods:  A retrospective cohort study was conducted of patients that underwent a colorectal resection in New York or Florida (2008-2011).  After linking with data from the American Medical Association, the cohort included 47,147 patients operated on at 343 hospitals, by 856 surgeons who trained at 74 distinct general surgery residency programs. A hierarchical generalized linear model, risk adjusted for patient, hospital and surgeon characteristics including surgeon specialty, was used to assess the independent association between residency program and adverse events (AE).

Results: The observed AE rates were 3.4% for death, 44.3% for any AE, 39.6% for colorectal-specific AE (CSAE), and 23.4% for prolonged length of stay (pLOS). Patients operated on by surgeons trained in residency programs ranked in the top tertile were significantly less likely to experience an AE than were patients operated on by surgeons trained in residency programs ranked in the bottom tertile (2.8% vs 5.4% for death, 41.6% vs 51.9% for any AE, 36.5% vs 46.3% for CSAE, and 22.9% vs 27.2% for prolonged length of stay (all P < .001)). Adjusted adverse event rates for patients operated on by surgeons trained in top tertile programs were marginally lower than those who were operated on by surgeons trained in bottom tertile programs (see Table). The model C statistics ranged from .76 to .87. The proportion of variation explained by the model ranged from 15.3% to 23.1%. 

Conclusion: Unadjusted outcomes of patients treated by surgeons who trained in programs ranked in the top and bottom tertiles differed significantly across all of the outcomes studied. The magnitude of the differences was small after risk adjustment. General surgery program performance is fairly homogeneous when compared by their graduates’ patients’ outcomes following colorectal surgery.

 

12.15 Laparoscopic Subtotal Cholecystectomy Compared to Total Cholecystectomy: A National Analysis

Posted on January 25, 2017

Y. Kim1, K. Wima1, B. T. Xia1, V. K. Dhar1, D. E. Go1, S. A. Shah1  1University Of Cincinnati,Surgery,Cincinnati, OH, USA

Introduction:  Laparoscopic subtotal cholecystectomy (LSC) is considered a safe alternative to laparoscopic cholecystectomy (LC) if dissection of biliary anatomy is obscured. Recent reports have shown that morbidity rates are similar between the two procedures, but the impact of conversion on resource utilization has not been defined.

Methods:  Using the University HealthSystem Consortium database, we identified 131,082 LC performed from 2009 to 2013, and 487 LSC performed during the same period. A 1:1 propensity score match was performed for 487 LSC procedures based on patient-level differences in clinical and demographic factors.

Results: Compared with LC, patients undergoing LSC were more likely to be male (54.2% vs. 32.3%), elderly (56 vs. 48 years), and have higher severity of illness (SOI) on admission (34.1% major or extreme SOI vs. 22.9%). LSC patients demonstrated a prolonged hospital length of stay (LOS, 4 days vs. 3 days), greater total direct cost ($9,053 vs. $6,398), higher readmission rates (11.9% vs 7.0%), and higher mortality rates (0.82% vs 0.28%, p<0.05 each). After matching, the difference in total direct cost persisted ($9,053 vs $7,581, p=0.0002), but there were no differences in hospital LOS, readmission rates, or overall mortality.

Conclusion: LSC is an important alternative to LC for difficult gall bladders in sicker patients. Our data demonstrate that patient-level factors are responsible for worse outcomes following conversion to LSC, and hospital outcomes are similar after adjusting for these factors.

12.14 Does Re-operative Bariatric Surgery Improve Glycemic Control and Cardiac Risk?

Posted on January 25, 2017

A. Mokhtari1, T. Mokhtari1, L. Voller1, J. Morton1  1Stanford University,Bariatric & Minimally Invasive Surgery,Palo Alto, CA, USA

Introduction:  Re-operative bariatric surgery following non-response to adjustable gastric banding (AGB) or sleeve gastrectomy (SG) is generally accepted and safe with conversion to laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB). While studies have reported reduced weight loss after re-operative procedures, the impact of revisional procedures on comorbidities has yet to be investigated.

Methods:  2,380 patients undergoing bariatric surgery at a single academic institution were prospectively followed in a defined data registry included 42 re-operative subjects with recorded data (13 AGB to SG; 20 AGB to RYGB; 9 SG to RYGB). Biomarkers for diabetes, cardiac risk, and inflammation including HbA1c, total cholesterol (TC), triglycerides (TG), LDL, TG/HDL ratio, and CRP were collected at preop and 6-months postop. 

Results: 

Demographic distribution for participants undergoing revisional surgery was 92% female, mean age 48 years, preop BMI 42.4 kg/m2.  Participants undergoing revisional SG after primary (1°) AGB lost significantly less weight than those undergoing primary SG (6-month percent excess weight loss, %EWL-6 38.0 vs 53.1%, p=0.03). Gastric bands  were present for 46 months with average BMI decrease of 3.3 points over this time and median time between band removal and subsequent re-operative SG was 4.7 months. Participants undergoing revisional RYGB after 1°AGB also lost significantly less weight than those undergoing 1° RYGB (%EWL-6, 47.0 vs 60.3%, p = 0.01); average band duration was 39 months prior to removal with mean BMI decreasing 4.1 points and median time between band removal and subsequent re-operative RYGB 3.7 months. For patients undergoing re-operative RYGB following SG, weight loss at 6 months was also significantly lower than those patients undergoing 1° RYGB (%EWL-6, 45.7 vs 60.3%, p=0.05). Participants experienced improved glycemic control upon bariatric re-operation following 1° AGB as evidenced by improved HbA1c 6-months following re-operative surgery (14.0% decrease after 2° SG and 17.2% following RYGB); there were no significant differences in these HbA1c values between 1° patients and those undergoing either 2° SG or RYGB after 1° AGB. Additionally, at the 6-month time point there was no significant difference in improvements for biochemical cardiac risk factors (including TC, TG, LDL, TG/HDL, and CRP) between re-operative SG and RYGB patients versus those undergoing the respective primary procedure (all p’s >0.05).

Conclusion: Re-operative bariatric surgery is effective with this study demonstrating that in addition to achieving significant weight loss (though less than the corresponding 1° surgery), re-operative bariatric patients experience improvements in glycemic control, biochemical cardiac risk factors, and inflammatory markers comparable to patients undergoing a primary procedure.
 

12.13 Roux-en-Y Gastric Bypass in Elderly Patients: Appropriate?

Posted on January 25, 2017

T. Hassinger1, J. Mehaffey1, L. Johnston1, G. Fasen1, B. Schirmer1, P. T. Hallowell1  1University Of Virginia,Department Of Surgery,Charlottesville, VIRGINIA, USA

Introduction: Numerous studies have established the effectiveness of Roux-en-Y Gastric Bypass (RYGB) for weight loss and comorbidity amelioration. This study evaluated outcomes in patients over the age of 60 with a propensity-matched group of controls. We hypothesized RYGB provides weight-loss benefits with no difference in overall survival.

Methods: All patients over the age of 60 undergoing RYGB at a single institution over a 30-year study period (1985-2015) were evaluated. Using a clinical data repository of all routine outpatient visits at our large academic medical center, we matched patients 4:1 on comorbidities, age, date of visit, and BMI to create our control population. Univariate analysis was performed, and Kaplan Meier survival curves were fitted for the two groups based on social security death data.

Results: Over the past 10 years 107 patients over the age of 60 underwent RYGB, and these were propensity matched with 428 controls. There was no difference in median BMI (45.6±5.3 vs. 47.1±4.3; p=0.45), age (61.6±2.1 vs. 62±2.0; p=0.15), or any other medical comorbidities between the groups. Kaplan Meier survival analysis with Log-Rank test demonstrated no difference in long-term survival (p=0.63) as seen below in Figure 1. Additionally, current BMI was evaluated based on medical record review demonstrating a significant percent excess BMI (%EBMI) reduction for the surgery group compared to the control group (81.8±35.8 vs. 10.3±28.0, p<0.001).

Conclusion: RYGB remains an excellent operation for weight reduction in patients over the age of 60 with no difference in long-term survival among comorbidity-matched controls. This study demonstrates major weight reduction benefit with surgery compared to an age- and comorbidity-matched control group. These data help to more clearly define the role for bariatric surgery in the elderly population and demonstrate outstanding %EBMI reduction.
 

12.12 Oncologic Adequacy of Resection in Elective Versus Emergent Cases of Colon Cancer

Posted on January 25, 2017

N. Tehrani1, S. Ganai1, M. Garfinkel1  1Southern Illinois University School Of Medicine,General Surgery,Springfield, IL, USA

Introduction: The practice of surgery is being increasingly subjected to quality improvement measures, including metrics for oncologic adequacy. The acute care surgeon often does not have the luxury of pre-operative optimization nor the ability to defer intervention but is still subject to these measures. The goal of our study was to evaluate oncologic adequacy as well as perioperative morbidity for resections done for colon cancers presenting electively versus emergently.  We hypothesized that emergent cancer operations will have decreased compliance with oncologic metrics.

Methods: A retrospective chart review was performed of a sample of patients who underwent colectomy for colon cancer at an academic-affiliated community hospital from 2010-2014. Cases of rectal cancer were excluded. Metrics related to oncologic adequacy of the resections, including margins and nodes sampled, as well as perioperative complication rates and blood loss were collected for the two populations.  Fisher’s exact and Student’s T-tests were used to make comparisons between groups with significance defined by p<0.05.

Results: Forty-four patients were identified with 19 emergent and 25 elective cancer resections. There was no difference in proportion of open cases among the two groups (94.7 vs 80%, p=0.21). Emergent and elective cases had no significant difference in presentation with pT3 or pT4 tumors (84.2 vs 56%, p=0.06). Adequate proximal and distal surgical margins—defined as greater than 5cm—were achieved in 94.7% of emergent colectomies and 84% of elective cases (p=0.37). Adequate node sampling (>12 lymph nodes) was achieved in 100% of emergent cases vs 94.7% in elective cases (p=1.00). Greater blood loss was seen in emergent cases (294 vs 167ml, p<0.05). Similarly, emergent cases demonstrated higher perioperative complication rates (78.6 vs 33.3%, p=0.02) as well as ICU admissions (57.1 vs 8.7%, p=0.002).

Conclusions: Contrary to our hypothesis, we demonstrated a similar rate of oncologically adequate resections for emergent colectomies, although this study may be underpowered to detect any clinically-important difference. The study will benefit from expanding our sample size to include all cases of colon cancer contained within local tumor registries for the same time period. Finally, an analysis of long-term recurrence rates controlled for cancer stage is warranted. 

12.11 Association Between Surgical Patient Satisfaction and Non-Modifiable Factors

Posted on January 25, 2017

L. Martin1, M. Gross1, A. Presson1, C. Zhang1, M. Hopkins1, D. Ray1, S. Finlayson1, R. Glasgow1  1University Of Utah,Salt Lake City, UT, USA

Introduction:  Patient satisfaction surveys have become an important tool in measuring physician performance in the area of patient experience.  We hypothesized that non-modifiable patient factors, such as age, gender and travel distance would be associated with outpatient satisfaction scores.

Methods:  Press Ganey Consumer Assessment of Health Providers and Systems (CHAPS) outpatient satisfaction scores from encounters at an academic department of surgery (1/2011-7/2015) were reviewed.  Completed surveys (18,373) from patients (10,652) over 18 years were included.  Data were collected on patient factors including age, gender, race, language, insurance status, travel distance, and marital status. Information about the specialty of the provider, the visit practice setting (ambulatory center clinic, referral center clinic, cancer center clinic) and whether it was the patient’s first visit were collected.  Patients were divided into groups based on the distribution of satisfaction scores—completely satisfied (score =100) or less satisfied (score ≤99).  Generalized estimating equation logistic regression analysis was performed to identify factors predictive of complete patient satisfaction.

Results: Older age was associated with being completely satisfied (OR 2.31; CI 1.43-3.71, p=0.001) [Figure]. Patients seeing their surgeon for the first time were less likely to be completely satisfied than those being seen in follow up (OR 0.83; CI 0.77-0.89, p<0.001).  Compared to patients seen at an ambulatory center clinic setting, there was no difference in complete satisfaction among those patients seen at the cancer center clinic (OR 0.92; CI 0.83-1.03, p=0.14); however, patients seen at the referral center clinic were less likely to be satisfied (OR 0.76; CI 0.69-0.84, p<0.001).  There was no difference in satisfaction among patients seen in General Surgery, Vascular Surgery or ENT clinics. Patients were less likely to be completely satisfied when seen in Urology clinic (OR 0.82; CI 0.74-0.91, p<0.001) and were more likely to be completely satisfied when seen in Plastic Surgery clinic (OR 1.16;  CI 1.03-1.32 p=0.02).  Gender, race, language, insurance status, travel distance, marital status, and a variety of interaction terms were not found to be predictive.

Conclusion: Utilizing satisfaction scores to evaluate providers should take into account non-modifiable factors of the underlying patient population, the specialty of the provider and the practice setting of the clinical visit. 

 

12.10 Monitoring the Skin Microbiota of Colorectal Surgery Patients to Predict Surgical Site Infections.

Posted on January 25, 2017

A. Yeh1, B. Firek1, J. Holder-Murray1, M. J. Morowitz1  1University Of Pittsburgh,Department Of Surgery,Pittsburgh, PA, USA

Introduction:
Wound infections after colorectal surgery occur at a rate of 5 to 30%. A potential contributor for which there is no published literature is the wound microbiome. This study will analyze the role of the skin microbiota in the development of wound infections after colorectal surgery. We will define the temporal and spatial changes of the skin microbiota in the peri-operative period and determine if specific bacterial populations or patterns of microbial diversity are predictive of wound infections.

Methods:
Peri-operative samples were obtained from adult patients undergoing colorectal surgery for cancer, diverticulitis, and IBD. Pre-operative samples included a skin swab at the anticipated site of the surgical incision. Intra-operative samples included skin swabs before and after skin preparation, subcutaneous fat of the extraction incision upon opening and prior to closing, and colon specimen contents. Post-operative samples included skin swabs and stool samples daily until discharge and at the post-operative clinic visit. Bacterial 16S rRNA gene sequences in each sample were amplified, sequenced on the Illumina MiSeq, and analyzed with QIIME. Healthy volunteer samples from the American Gut Project (AGP) were analyzed as a control.

Results:
A mean of 14.3 samples were collected from 9 patients. The average hospitalization was 5.1 days. Six, 1, and 2 patients underwent a left-sided resection, right-sided resection, and total colectomy, respectively. Species richness and evenness on the skin gradually decreased from the pre-operative clinic visit to the day of surgery after skin preparation and remained low in the post-operative period. Principal coordinates analysis comparing differences in microbial composition showed a clustering of pre-operative skin samples with healthy AGP volunteers signifying similar composition. Post-operatives skin swabs clustered distinctly from healthy samples signifying instability in microbial composition. Staphylococcus, a bacterium common in wound infections, was more abundant in the skin swabs post-operatively (see figure). Conversely, Corynebacterium, a common healthy bacterium, was decreased. One patient developed an Enterococcus wound infection. Ileostomy and skin samples prior to the wound infection showed dominance by Enterococcus, possibly signifying a predictive value of microbiota monitoring.

Conclusion:
In our preliminary results, the skin microbiota after colorectal surgery undergoes collapse of its microbial diversity and composition. During the post-operative period, pathogens such as Staphylococcus proliferate at the expense of healthy bacteria. Future work will require additional patient recruitment to determine whether these findings increase the risk of wound infections.

12.09 Outcomes of Intrathecal Analgesia as Part of an Enhanced Recovery Pathway in Colorectal Surgery

Posted on January 25, 2017

A. Merchea1, J. Lovely4, A. Jacob3, D. Colibaseanu1, S. Kelley2, K. Mathis2, G. Spears5, M. Huebner6, D. Larson2  1Mayo Clinic – Florida,Colon & Rectal Surgery,Jacksonville, FL, USA 2Mayo Clinic,Colon & Rectal Surgery,Rochester, MN, USA 3Mayo Clinic,Anesthesiology,Rochester, MN, USA 4Mayo Clinic,Hospital Pharmacy Services,Rochester, MN, USA 5Mayo Clinic,Biostatistics,Rochester, MN, USA 6Michigan State University,Statistics,Lansing, MI, USA

Introduction:  Multimodal analgesia is an essential component of an enhanced recovery pathway (ERP). An ERP that includes the use of single injection intrathecal analgesia (IA) has been shown to decrease morbidity, decrease cost, and shorten length of stay (LOS). Limited data exist on safety, feasibility, and the optimal intrathecal medication regimen in the setting of an ERP for patients undergoing colorectal surgery. Our objective was to characterize efficacy, safety, and feasibility of IA within an ERP program in a large cohort of colorectal surgical patients.

Methods:  A retrospective review was conducted to identify all consecutive patients age ≥ 18 years that underwent open or minimally-invasive colorectal surgery from October 2012 to December 2013. All patients were enrolled in an institutionally derived ERP that included the use of single-injection IA – consisting of opioid-only intrathecal (IA-O) or opioid with a local anesthetic (IA-L). Patient records were reviewed for demographic data, anesthetic management, analgesic efficacy (pain scores, opiate consumption), post-operative ileus (POI), adverse effects, and LOS.

Results: 601 patients were identified. The majority received opioid-only IA (91%, n=547) rather than a multimodal IA regimen. Median (IQR) LOS was 3 (2-5) days. Median (IQR) total oral morphine equivalents (OME) used was 24 (0-83). A greater proportion of patients receiving IA-O utilized zero OMEs compared to IA-L (30% vs. 15%, p=0.03).  Overall, 28% of patients required no additional narcotic other than that included with the intrathecal. There was no difference in LOS or POI based on intrathecal medication received or dose of intrathecal opioid. Pain scores were similar at all time intervals, however the median 48 hour maximum reported pain score was greater in those patients receiving IA-L (7 vs. 6, p=0.045). Overall, development of respiratory depression or pruritus was rare (0.2% and 1.2%, respectively). One patient required blood patch for post-dural headache.

Conclusion: Intrathecal analgesia is safe, feasible, and efficacious in the setting of ERP for colorectal surgery. All regimens and doses achieved a short LOS, low pain scores, and a low incidence of POI.

 

12.08 Shoulder Disability Affects Quality of Life After Thyroidectomy Even Without Lymph Node Dissection

Posted on January 25, 2017

H. Wong1, S. Kaplan1, M. G. White1, M. K. Applewhite2, P. Angelos1, B. Aschebrook-Kilfoy1, R. H. Grogan1  1University Of Chicago,Endocrine Surgery Research Group In The Department Of Surgery,Chicago, IL, USA 2Albany Medical College,Surgery,Albany, NY, USA

Introduction:  Shoulder disability after thyroid surgery without lymph node dissection (LND) is not a commonly appreciated morbidity.  Here we ask participants enrolled in the North American Thyroid Cancer Survivorship study (NATCSS) to define their shoulder disability after thyroid cancer operations and the impact of this impairment on quality of life (QoL).

Methods:  NATCSS participants were asked to self-report shoulder problems.  Those screening positive were provided the Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire, a validated instrument quantifying the severity of upper extremity disability. Responses were compared using t-test and ANOVA analyses.  Known risk factors for shoulder disability such as LND were studied using univariate and multivariate logistic regression.

Results: Of 1,019 respondents, 314 (31.0%) reported shoulder disability following their operations and 161/314 (51.3%) went on to complete the QuickDASH, scoring a mean QuickDASH score of 44.9±19.9, versus 13.0±17.4 in a healthy matched population (p<0.0001). One-hundred twenty (74.5%) of those with self-reported shoulder disability had a QuickDASH score >1 SD above the population mean, while 63(39.1%) had a score >2 SD above the population mean. Those patients with shoulder disability (QuickDASH >1 SD above matched population mean) had a mean age of 58.4±8.0 and are 92.4% female. Eighty-eight (55%) patients with shoulder disability reported a history of LND. Of these, 17 (18%) reported shoulder disability on the opposite side from their LND. In other words, those 73 (45%) patients who did not report a history of LND combined with the 17 patients who reported shoulder disability on the opposite side from their LND make up 90 (56%) patients whose shoulder disability were not explained by a history of LND. On multivariate analysis, female sex (p=0.033) and history of underactive thyroid function (p=0.017) were predictive of an increased QuickDASH score (p=0.036). Increased QuickDASH scores correlated with a decrease in a number of quality of life measurements (p<0.05).

Conclusion: In this retrospective study, 56% of post-operative thyroid cancer patients reported experiencing shoulder disability that did not correlate with having a LND. Elevated QuickDASH scores in these patients quantifies the functional impairment associated with this disability.  Our data also show an associated significant decrease in quality of life. While female gender, and hypothyroidism may be contributing factors, further prospective studies are required to better elucidate the reason for this phenomenon.

 

12.07 Modifiable Factors Related to Pre-Operative Psychosocial Distress Among Colorectal Cancer Patients

Posted on January 25, 2017

M. McLeod1, C. Veenstra1, S. K. Hendren1, P. H. Abrahamse1, D. Jomaa1, A. M. Morris1  1University Of Michigan,Ann Arbor, MI, USA

Introduction: Baseline psychosocial distress among cancer patients is associated with poor patient-provider communication, reduced treatment adherence, longer inpatient stays, and poorer clinical outcomes. We hypothesized that several factors would be independently associated with baseline patient-reported distress, which in turn would be associated with poorer clinical outcomes in the setting of colorectal cancer. 

Methods: Over one year, new colorectal cancer patients at the University of Michigan Comprehensive Cancer center were invited to complete the NCCN Distress Thermometer, Impact Thermometer and Problem List before their first visit. Additional clinical data were abstracted from the electronic medical record: age, sex, race, marital status, comorbidities, cancer stage and type, and clinical outcomes. We performed multivariable analysis to assess factors associated with patient-reported distress, and the association between distress and 30-day complications of surgery. We then conducted semi-structured interviews with patients selected based on quantitative analyses. We queried means of coping with the patient-reported physical, financial, practical, emotional and spiritual challenges posed by their cancer treatment. Interviews were recorded, transcribed, coded and discussed using rapid content analysis.

Results: Among 292 eligible patients with colorectal cancer who consented to participate, initial data abstraction was completed for 225. The average patient age was 61 years (range 27-91), and 58% were male. The mean Distress Thermometer score was 4.15 (range 0 – 10). Female sex (p<0.001), lack of a domestic partner (p<0.05), rectal cancer (p<0.01), and mental health comorbidities (p<0.001) were associated with greater distress in the multivariable analysis. 54% of patients had complications of surgery. Neither multivariable nor bivariate analyses demonstrated a correlation between distress and 30-day complications. In follow-up qualitative interviews, patients indicated that (1) a sense of their surgeon’s commitment to their physical and emotional well-being and (2) the presence of a trusted personal advocate enabled physical and emotional coping. Improved coping resulted in reduced psychosocial distress, and increased engagement in treatment.

Conclusions: These findings indicate the importance of the patient-surgeon relationship and the psychosocial benefit of a trusted personal advocate, usually a spouse, during cancer care. Although there was not a direct correlation between distress and surgical complications, these data support engaging the spouse or important others at the onset of multidisciplinary cancer care during the patient-surgeon interaction. Understanding the role that modifiable factors play in the progression of psychosocial distress provides a platform to facilitate patient coping, engagement, and satisfaction with care.
 

12.05 Concurrent Sleeve Gastrectomy and Hiatal Hernia Repair is Safe and Improves Weight Loss

Posted on January 25, 2017

A. Wang1, M. Turner1, S. Sprinkle1, A. D. Guerron1, D. Portenier1, C. Park1, R. Sudan1, J. Yoo1, K. Seymour1  1Duke University Medical Center,Surgery,Durham, NC, USA

Introduction:
Hiatal hernias are found in 40% of morbidly obese patients. For bariatric surgery candidates with hiatal hernias, the role of concurrent hiatal hernia repair (HHR) during laparoscopic sleeve gastrectomy (LSG) remains uncertain. We hypothesize that concomitant HHR during LSG is a safe procedure. 

Methods:
After IRB approval, retrospective review from August 2011 to December 2013 at a single institution resulted in 410 patients who underwent LSG. Isolated LSG was performed on 221 patients and LSG with HHR was performed on 188 patients. Six surgeons performed all cases with no open conversions. Excess BMI loss was calculated as percent decrease in BMI compared to ideal BMI 25. Continuous variables were compared with t-tests and categorical variables were compared with Wilcoxon rank-sum or Fisher’s exact test.

Results:
Baseline patient characteristic did not significantly differ between groups (Table). Intraoperative assessment revealed 105 patients with mild to moderate hiatal hernias, 52 with moderate sized, 7 with large sized, and 7 with paraesophageal. Intraoperative HHR used anterior approach in 9% of patients, anterior and posterior approach in 7%, and posterior approach in the remainder. Reinforcement with mesh was used in 47% of patients. Operative time was significantly longer in the HHR group (91 vs 76 min, p< 0.0001, CI: 9.9-19.4). When a single surgeon routinely performs HHR (n=147), however, there was no significant difference in operative time compared to sleeve alone (n=31) (88.9 vs 82.2 min, p=0.16, CI -2.7-16.4).  Between groups, there was no difference in estimated blood loss (22.7 vs 20.0 ml, p-0.23, CI -1.8-7.3) or length of stay (1.6 vs 1.8 days, p=0.07, CI -0.4-0.01). Neither group experienced a 30-day mortality, reoperation, pulmonary embolism, or leak and both groups had similar rates of 30-day readmission (n=4). Sleeve with HHR resulted in increased excess BMII loss at 3 months (40.1% vs 36.0%, p=0.003, CI 1.3-6.9) and 6 months (52.5% vs 45.9%, p=0.01, CI 1.6-11.6). 

Conclusion:
LSG with concurrent HHR is safe and does not result in increased short-term mortality or morbidity. When routinely performed, LSG with HHR does not result in increased operative time. In our cohort, LSG with HHR also resulted in increased weight loss, possibly due to improved mobilization and resection of the gastric fundus. 
 

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