51.18 Outcomes of Atypical Genitalia Surgery for Disorder of Sexual Development in Pediatric Population

Posted on January 18, 2018

A. F. Doval1, B. N. Tran1, B. T. Lee1, O. Ganor2  1Beth Israel Deaconess Medical Center,Plastic And Reconstructive Surgery,Boston, MA, USA 2Boston’s Children Hospital,Plastic And Reconstructive Surgery,Boston, MA, USA

Introduction: Infants with a congenital discrepancy between external genitalia, gonadal, and chromosomal sex are classified as having a disorder of sexual development.  The most common form of DSD with atypical genitalia is 46 XX with congenital adrenal hyperplasia; as such feminizing genitoplasty is the standard surgical correction. We examined the trends and outcomes of atypical genitalia surgery for DSD in pediatric population using American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).

Methods: Infants with DSD were identified from NSQIP 2012-2015 using ICD 9 and 10 codes.  Descriptive data about patients’ demographics, types of procedures, surgical specialty performing the surgery, and perioperative complications including bleeding, infection, wound dehiscence, unplanned reoperation, unplanned intubation, and readmission were obtained.

Results: 46 cases of DSD were identified. Most surgical correction occurred at 3-4 years of age in genetically female patients (65%).  Types of reconstructive surgery included feminizing procedures (45.7% including vaginoplasty, clitoroplasty), masculinizing procedures (28.3% including laparoscopic procedure on testis, laparoscopic vaginal hysterectomy, penile repair, vaginectomy, laparoscopic TAH-BSO), or undetermined (26% including adjacent diagnostic laparoscopy, tissue transfer, excision of penile lesions, and enterostomy and external fistulization of intestines).  Postoperative complications detailed 2 incidences of bleeding requiring transfusion, 1 of unplanned intubation, and 1 of prolonged hospitalization.

Conclusion: This study reaffirms the rising awareness of surgical intervention for disorders of sexual development. Most patients were genetically female with congenital adrenal hyperplasia and the most common reconstructive surgery was feminizing genitoplasty. Interestingly, the mean age of reconstruction reflected early genital surgery. Postoperative complications showed that atypical genitalia surgery is safe for pediatric population. 

 

51.14 Clinical Outcomes of Pediatric Patients after Ileal Pouch-Anal Anastomosis

Posted on January 18, 2018

C. C. Huang1, F. J. Rescorla1, M. P. Landman1  1Indiana University School Of Medicine,Department Of Pediatric Surgery,Indianapolis, IN, USA

Introduction:
Ileal pouch-anal anastomosis (IPAA) is the standard surgical reconstruction for patients with familial adenomatous polyposis (FAP) and ulcerative colitis (UC) who undergo total proctocolectomy (TPC). Although FAP and UC patients receive the same reconstruction, their postoperative complications can differ in type and severity. We hypothesize that indication for total proctocolectomy and other preoperative clinical factors are associated with differences in postoperative outcomes following IPAA.

Methods:
A retrospective cohort of pediatric patients who underwent proctocolectomy with IPAA at Riley Hospital for Children from 1996-2016 was identified. Relevant preoperative, operative, and postoperative clinical variables were collected. Univariate analyses were performed to evaluate for relevant clinical differences in outcome. The sample size limited the ability to perform multivariate analyses.

Results:
A total of 79 patients, 17 with FAP and 62 with UC, were identified. Preoperatively, as expected, UC patients had more frequent abdominal pain (p<0.001), more hospitalizations (p=0.004), and lower albumin (p<0.001) than FAP patients.  FAP patients spent an average of 1125±1011 days between initial diagnosis and first surgery compared to 585±706 days by UC patients (p=0.038). FAP patients took an average of 57±38 days to complete TPC with IPAA compared to UC patients at 177±121 days (p=<0.001). At their first postoperative visit, FAP and UC patients did not differ in average number of bowel movements [4.3±2.3 vs. 6.1±3.9, respectively (p=0.083)]. In addition, FAP and UC patients also did not differ in average number of bowel movements at their 6 month postoperative visit [4.7±2.1 vs. 5.6±1.9, respectively (p=0.134)]. Postoperatively, FAP patients are significantly less likely to experience pouchitis (p=0.013), pouch failure (p=<0.001), psychiatric symptoms (p=0.017), and daily antimotility agent use (p=0.003) but more likely to experience bowel obstruction (p=0.001). Within the UC group, preoperative steroid use was associated with superficial surgical infection (p=0.049) but not associated with pouchitis (p=0.872). 

Conclusion:
IPAA is a safe, restorative treatment for FAP and UC patients after TPC. Based on diagnosis and preoperative clinical course, there are differences in morbidity in IPAA patients. This data is limited by sample size and inability to perform multivariable analyses. Clinical data such as these will allow surgeons to help families anticipate their child’s pre- and post-operative course and to maximize successful clinical outcomes.
 

51.15 Intensive Pediatric Weight Loss Program Associated with Decrease in Obesity-Related Biomarkers

Posted on January 18, 2018

C. B. Cummins1, B. Hughes1, O. Nunez-Lopez1, J. Prochaska2, E. Lyons3, D. Jupiter2, K. Perino3, A. Glaser4, R. Radhakrishnan1,4, K. Bowen-Jallow1  1University Of Texas Medical Branch,Department Of Surgery,Galveston, TX, USA 2University Of Texas Medical Branch,Department Of Preventive Medicine And Community Health,Galveston, TX, USA 3University Of Texas Medical Branch,Department Of Nutrition And Metabolism,Galveston, TX, USA 4University Of Texas Medical Branch,Department Of Pediatrics,Galveston, TX, USA

Introduction:
The prevalence of childhood obesity has nearly tripled in the past 50 years, with current estimates of ~ 20% in school-aged children. Multiple biomarkers associated with obesity have been identified and studied recently, including gamma-glutamyltransferase (GGT) and C-reactive protein (CRP). GGT has been shown to be associated with central obesity, increased risk of cardiovascular disease, and metabolic syndrome in adults and adolescents. CRP has been linked to the low-grade systemic inflammatory response in obese adults and children. In this study we examined the short-term outcomes of our intensive multidisciplinary pediatric weight loss program exploring the anthropometric and clinical factors as well as obesity-related biomarkers.

Methods:
Patients were seen in the multidisciplinary clinic every 4-6 weeks by a pediatric surgeon, a pediatric gastroenterologist, a dietician, and a fitness instructor. Referrals were made to a pediatric psychiatrist as needed. Anthropometric and clinical data were obtained at each visit. Obesity-related biomarkers were collected at the initial visit and at selected subsequent visits when clinically indicated.  Biomarkers collected included HcbA1C, total cholesterol, triglycerides, HDL, LDL, GGT, CRP, and insulin levels.

Results:
A total of 70 patients have been evaluated for an initial visit with a total of 25 patients available for 3 month short-term outcome follow-up. Mean baseline weight was 108.5 kg with a mean baseline BMI of 39.5.  Mean weight loss and mean BMI change at 3 months were -0.99 kg (p<0.000005) and -0.84 (p<0.00001), respectively, confirming short term success of the weight loss program. 6 patients had GGT follow up at 3 months with a mean loss of -1.67 U/L (p<0.00001). 4 patients had CRP follow up at 3 months with a mean loss of -0.12 mg/dL (p<0.00001). Additionally, trends in decreased waist circumference, decreased insulin levels, and decreased triglyceride levels were seen but the study is currently under-powered to provide statistical significance.

Conclusion:
An intensive multidisciplinary approach to weight loss in the pediatric population led to both a short-term decrease in weight and BMI and a decrease in obesity-related biomarkers CRP and GGT. Further studies will be necessary to report long-term outcomes as well as confirm trends currently observed in the data.
 

51.13 Comparison of Pediatric and Adult Solid Pseudopapillary Neoplasms of the Pancreas

Posted on January 18, 2018

R. T. Russell1, I. I. Maizlin1, M. B. Dellinger2, K. W. Gow2, A. B. Goldin2, M. Goldfarb3, J. J. Doski4, A. Gosain8, M. Langer7,8, M. V. Raval6, J. G. Nuchtern5, S. A. Vasudevan5, E. A. Beierle1  1University Of Alabama at Birmingham,Pediatric Surgery,Birmingham, Alabama, USA 2Seattle Children’s Hospital,Pediatric Surgery,Seattle, WA, USA 3John Wayne Cancer Institute At Providence St. John’s Health Center,Surgery,Santa Monica, CA, USA 4Methodist Children’s Hospital Of South Texas, University Of Texas Health Science Center-San Antonio,Surgery,San Antonio, TX, USA 5Baylor College Of Medicine, Texas Children’s Hospital,Pediatric Surgery,Houston, TX, USA 6Emory University School Of Medicine, Children’s Healthcare Of Atlanta,Pediatric Surgery,Atlanta, GA, USA 7Maine Children’s Hospital, Tufts University,Surgery,Portland, ME, USA 8University Of Tennessee Heath Science Center,Pediatric Surgery,Memphis, TN, USA

Introduction: Solid pseudopapillary neoplasms (SPPN) are rare pancreatic neoplasms. While constituting only 1-3 % of pancreatic tumors, they comprise the majority (71%) of pediatric pancreatic neoplasms. To our knowledge, there have been no large scale comparative studies between pediatric and adult SPPN. Therefore, we, queried the National Cancer Data Base (NCDB) to compare pediatric and adult patients with SSPN diagnosis, to examine differences in demographics, tumor characteristics, treatment modalities and overall survival. We aimed to determine if survival differences existed between adult and pediatric patients with SPPN.

Methods: The NCDB (2004-2014) was reviewed for cases of pancreatic SPPN. Patients were stratified by age at diagnosis: pediatric (≤21 years) and adult (≥22 years). Once cases lacking survival data were excluded from analysis, demographics, comorbidities, tumor characteristics, diagnostic periods, treatments, and survival rates were compared using pooled variance t-tests and χ2, followed by multivariate Cox proportional hazard model (α=0.05). Log-rank test was used to compare survival.

Results: 468 patients with SPPN were analyzed and categorized according to age-group (pediatric: N=80; adult: N=388). 414 patients (pediatric=61; adult=334) were included in the survival analysis as 54 patients had incomplete survival data, with all 414 utilized in the multivariate analysis. The pediatric patients were primarily female (91%), non-Hispanic White (55%), had no comorbidities (89%), and presented with Stage I disease (59%). Race/ethnicity (p=0.130), gender (p=0.064), socioeconomic status (income: p=0.827; education: p=0.891; insurance status: p=0.933), comorbidities (p=0.136), and disease stage at presentation (p=0.359) were similar between the groups. Following diagnosis, there was no difference in time to initiation of therapy (p=0.083) or time to surgical intervention (p=0.058). No significant difference was found between the groups in type of surgical resection, chemotherapy (p=0.059), or radiotherapy (p=0.082) utilization. Despite the similarities between the age groups, comparison of overall survival (Figure 1) demonstrated improved survival of pediatric SPPN as compared to adult SPPN in every pathologic stage (Stage I: p< 0.001, Stage II: p= 0.045, Stage III: p= 0.018, Stage IV: p=0.009 ).

Conclusions: The results of the current study suggest that pediatric SPPNs are similar to those in adults with regards to demographics, tumor characteristics, and treatment modalities. However, survival was better in children with SPPNs, which may be due to differences in tumor biology and may serve for evidence-based risk stratification of prognosis. 

 

51.03 Early Operative Versus Observational Management in Children with Adhesive Small Bowel Obstruction

Posted on January 18, 2018

J. M. Hyak1, G. A. Campagna1, Z. T. Stone1, B. Johnson1,3, Y. Yu2,3, A. D. Schwartz4, E. H. Rosenfeld2, B. Naik-Mathuria2,3  4Baylor College Of Medicine,Department Of Pediatrics,Houston, TX, USA 1Baylor College Of Medicine,Houston, TX, USA 2Baylor College Of Medicine,Michael E. Debakey Department Of Surgery,Houston, TX, USA 3Texas Children’s Hospital,Department Of Surgery,Houston, TX, USA

Introduction:  

Adhesive small bowel obstruction (ASBO) occurs in 1.1-8.3% of pediatric abdominal surgery patients. Our study compared surgical outcomes of non-operative and operative management of adhesive small bowel obstruction in children and assessed the impact of age on surgical management.

 

Methods:

We retrospectively studied children (age ≤18 years) admitted for ASBO to a tertiary academic children’s hospital from 2011-2015. Children with no prior abdominal surgery, surgery ≤4 weeks prior to admission, and complex medical conditions such as genetic or metabolic diseases were excluded. Patients were stratified by management: early operative (EO; time to surgery ≤12 hours), delayed operative (DO; time to surgery >12 hours) or non-operative (NO; discharged without operation). Rates of perforation and small bowel resection were compared using χ2 test. A receiver operating characteristic (ROC) curve was used to evaluate age as a diagnostic indicator for non-operative management. A p-value <0.05 was considered significant.

Results:

We identified 212 unique patients, comprising 269 total hospitalization, who were admitted for ASBO. Early operation was required in 58/269 (22%), failed non-operative management requiring delayed operation in 83/269 (31%), and successful non-operative management in 128/269 (48%). Mean age at admission (EO 7.7 vs DO 7.8 vs NO 8.7 years, p=0.42) and age at index abdominal surgery (EO 3.0 vs DO 3.3 vs NO 4.2 years, p=0.35) were similar.

 

Incidence of leukocytosis (EO 47.9% vs DO 62.9% vs NO 51.7%, p=0.206) and fever (EO 16% vs DO 8.9% vs NO 6.7%, p=0.298) did not differ between groups. There was no difference in length of stay between DO and EO (21.7±27.5 vs 18.2±22.2 days, p=0.43). Rate of bowel resection was greater in DO versus EO (27.7% vs 12.1%, p=0.026). However, bowel perforation incidence (DO 15.7% vs EO 10.3%, p=0.36) and length of bowel resected (DO 4.6±11.8 cm vs EO 6.2±25.1 cm, p=0.61) were similar. ROC analysis for age at admission yielded AUC 0.56 (p=0.07, 95% CI 0.495-0.633) for discriminating the need for surgery. Optimal criterion value for age was 1.88 years, representing the greatest accuracy in predicting non-operative management of ASBO, with sensitivity and specificity of 86.5% and 32.1%, respectively. Children ≤2 years of age had a higher operative rate than older children (61% vs. 49%, p=0.06).

 

Conclusion:

Though most children with ASBO are initially managed non-operatively, over one third fail conservative management, requiring delayed surgery. This results in significantly higher rates of bowel resection. Age alone did not distinguish children requiring operation from those managed non-operatively. However, we found a trend towards higher operative rate in children ≤2 years. Further studies are needed to evaluate risk factors for failing non-operative management as these children may benefit from early surgical intervention to prevent bowel loss.

51.02 Parent Reported Quality of Life Outcomes in Children with Congenital Diaphragmatic Hernia

Posted on January 18, 2018

J. L. Morsberger1, H. L. Short1, K. J. Baxter1, C. Travers2, M. S. Clifton1, M. M. Durham1, M. V. Raval1  1Emory University School Of Medicine,Division Of Pediatric Surgery, Department Of Surgery, Children’s Healthcare Of Atlanta,Atlanta, GA, USA 2Emory University School Of Medicine,Department Of Pediatrics,Atlanta, GA, USA

Introduction:  With improved survival of patients with congenital anomalies, long-term outcomes including quality of life (QoL) assessment are needed. The aim of this study was to determine long-term outcomes for congenital diaphragmatic hernia (CDH) patients including QoL measures, gastrointestinal symptom burden, surgical reoperation rates, and current health status.

Methods: We performed a retrospective review of surviving patients who underwent CDH repair between 2007 and 2014 at a quaternary children’s hospital. Phone surveys of parents were conducted using two validated measures (Pediatric Quality of Life Inventory (PedsQL) and PedsQL Gastrointestinal Symptoms Module). Additional outcomes of interest were collected including subsequent operations and current health status. Associations with QoL were tested using Wilcoxon Rank-Sum tests and Pearson correlation coefficients, when appropriate.

 

Results: Of 102 CDH patients identified, 56 families (54.9%) were reached with 46 (82.1%) agreeing to participate. The mean age at follow up was 5.8 years. 28 patients (60.9%) had thoracoscopic repair, 10 (21.7%) required ECMO, and 11 (23.9%) had a recurrence. For the overall cohort, median PedsQL score was 91.8 (scale 0-100) with a physical health summary score of 93.8 and a psychosocial health summary score of 91.7. Median PedsQL gastrointestinal score was 95.8. Statistically significant differences were found in PedsQL scores when stratified by surgical approach and defects where the stomach was found in the thoracic cavity (stomach up). No difference was found when stratified by defect side (left vs right), patch vs primary repair, prenatal diagnosis, ECMO, or recurrence (Figure). Older patient age correlated with worse school functioning and heartburn symptoms (Pearson Coefficient -0.31 (p=0.03) for both).

 

Conclusion: Children with CDH have reassuring overall and gastrointestinal QoL scores. Our study shows higher QoL scores in patients who undergo thoracoscopic repair and no difference in outcomes based on recurrence. Given the correlation between older age and poor school function, even longer follow up of patients with CDH is warranted.  

51.01 Pancreatic Islet Cell Tumors in Adolescents and Young Adults

Posted on January 18, 2018

I. I. Maizlin1, R. T. Russell1, M. B. Dellinger2, A. B. Goldin2, M. Goldfarb3, J. J. Doski4, A. Gosain5, M. Langer6, M. V. Raval7, J. G. Nuchtern8, S. A. Vasudevan8, K. W. Gow2, E. A. Beierle1  1University Of Alabama at Birmingham,Pediatric Surgery,Birmingham, Alabama, USA 2Seattle Children’s Hospital,Pediatric Surgery,Seattle, WA, USA 3John Wayne Cancer Institute At Providence St. John’s Health Center,Surgery,Santa Monica, CA, USA 4Methodist Children’s Hospital Of South Texas, University Of Texas Health Science Center-San Antonio,Surgery,San Antonio, TX, USA 5University Of Tennessee Health Science Center,Pediatric Surgery,Memphis, TN, USA 6Maine Children’s Cancer Program, Tufts University,Portland, ME, USA 7Emory University School Of Medicine, Children’s Healthcare Of Atlanta,Pediatric Surgery,Atlanta, GA, USA 8Baylor College Of Medicine, Texas Children’s Hospital,Pediatric Surgery,Houston, TX, USA

Introduction: While pancreatic islet cell tumors (ICTs) are rare pancreatic neoplasms in any age group, less than 10% of them occur in adolescents. While recent studies investigated the most appropriate treatment of pancreatic ICTs, as well as the effect of age on consequent survival, none of the patients examined were in the adolescent and young adult (AYA) category, with most patients in their 6th or 7th decade of life. The question arises, therefore, whether AYA patients would demonstrate a similar improvement in overall survival following ICT diagnosis. Therefore, we utilized a national database to describe the histological and clinical pattern of ICTs in AYA patients, comparing them to their older adult counterparts. Based on the limited studies on older populations, we hypothesized that AYA patients would have better overall survival following ICTs diagnosis.

Methods: A search of all AYA patients (15-39 yo) in the National Cancer Data Base (1998-2012) with ICT diagnosis was performed. Demographics, tumor characteristics, treatment modalities, and outcomes were abstracted and compared to adults (≥40 yo).

Results: After 11 patients were excluded for lack of survival data, 383 patients (56% female) were identified, with a median age of 27 (IQR 16-34) years at diagnosis. Non-Hispanic Caucasians comprised 65% of patients, 14% were Hispanic Caucasians, 14% African Americans, and 7% other ethnicities/races. Islet cell carcinoma was the most common histology (74%, n=285), followed by insulinomas (9%, n=36), gastrinomas (7%, n=28), mixed-cell tumors (6%, n=22), and VIPomas (3%, n=12). 24% of patients presented with early stage disease (Stage I:16%, Stage II:8%); 25% had advanced disease (Stage III:5%, Stage IV:20%). 267 patients underwent surgical resection, consisting of local excision 44%, Whipple procedure 37.5%, and total pancreatectomy 19%. Chemotherapy was utilized in 29% of cases and radiotherapy in 8%. With mean follow-up of 4.7 years, mortality was 36%. Cox regression analysis (n=361) demonstrated no difference in survival between different histologies (p=0.779). Comparison of AYAs to older adults demonstrated similar stage distribution (p=0.054), rates of comorbidities (p=0.727), and utilization of adjuvant therapies (chemotherapy p=0.153, radiation therapy p=0.666), with more extensive resections (p=0.001) in AYA patients as well as lower mortality rates (p<0.001).

Conclusions: This study found that AYA patients with ICTs had similar histologic distributions and comparable utilization of adjuvant therapies to older adult counterparts, but underwent more extensive resections and demonstrated a higher overall survival rate. While requiring further investigation, these results demonstrate a differentiation that may serve for evidence-based risk stratification of prognosis in ICT patients.

 

50.17 Impact of Active Opioid Use on Healthcare Costs for Patients with Intestinal Obstruction

Posted on January 18, 2018

V. K. Dhar1, Y. Kim1, D. E. Go1, K. Wima1, A. D. Jung1, A. R. Cortez1, R. S. Hoehn1, S. A. Shah1  1University Of Cincinnati,Department Of Surgery,Cincinnati, OH, USA

Introduction:  The overuse of prescription opioid medications is a growing epidemic in the United States. Recent studies have shown that preoperative narcotic use impacts hospital cost and outcomes in surgical patients, but the underlying reasons are unclear.

Methods:  A single-center retrospective analysis was performed on surgical patients admitted with a diagnosis of intestinal obstruction between 2010 and 2014. Patients were grouped into active opioid and non-opioid user cohorts. Active opioid use was defined as having an opioid prescription interval overlapping the date of admission. Chronic opioid use was defined by duration of opioid use for 90 days or longer. Admission or intervention due to opioid-related illness was determined through consensus decision of two independent, blinded clinicians. Primary endpoint was to analyze the effect of active opioid use on hospital resource utilization.

Results: During the study period, 296 patients were admitted with a primary diagnosis of intestinal obstruction. Active opioid users accounted for 18.6% of patients, with a median length of opioid use of 164 days (IQR 54-344 days). Of these, 18.2% were on multiple narcotics at time of admission and 76.4% met criteria for chronic opioid use. Compared to non-opioid users, active users were found to have increased median length of stay (8 days vs 6 days, p<0.05) and higher hospital costs ($12,241 vs $8,489, p<0.05) during index admission. Subgroup analysis of active opioid users demonstrated that opioid-related conditions were responsible for ten admissions (18.2%) and two readmissions (3.6%). Among active users requiring surgical intervention, three patients (21.4%) underwent exploratory laparotomy with negative findings. 

Conclusion: Active opioid users, comprising 19% of this cohort of emergency acute care surgery patients, are predisposed to avoidable admissions and interventions for opioid-related illnesses. Efforts to address opioid use in the surgical population may improve patient outcomes and overall healthcare spending.

 

50.18 Management of Rib Fracture Patients: Does Obesity Matter?

Posted on January 18, 2018

A. Lichter1, F. Speranza1, W. Rebekah1, P. Parikh1, R. Markert1, G. Semon1  1Wright State University,Dayton, OH, USA

Introduction: Obesity has been on the rise in recent decades and has created a significant burden on health care. Obesity plays significant role in presentation and management of trauma patients, including management of pneumonia in polytrauma patients. However, role of obesity has not been evaluated for chest trauma patients with rib fractures.  This study, aims to determine its impact and management of patients who sustain rib fractures as a result of a traumatic incident.

Methods: This study was approved by Wright State University’s IRB.  All adult trauma patients who sustained blunt chest wall trauma causing rib fractures and were presented at our Level 1 Trauma Center from 2013-2014. were included in the study. All the patients who survived less than 48 hours, had penetrating injuries to the chest, or had a concomitant head injury were excluded.  Obesity was defined as a body mass index (BMI) of ≥30.  Both obese and non-obese groups were compared using Pearson Chi-Square test for categorical variables and Man-Whitney U Test for continuous variables. We compared both these groups after adjusting for Injury Severity Score (ISS) using logistics regression when the assumptions for this test are met.  

Results:  213 patients met the inclusion criteria with an average 3.6 ribs fracture. Consistent with the national average, 64 (30.6%) were obese. Both obese and non-obese groups of patients did not differ in age (61.6 vs. 59.9, p=0.89).  Obese patients had higher ISS (17.0 vs 13.9, p=0.05), and significantly higher ventilator days (2.1 vs. 1.2, p=0.003), ICU Length of Stay (LOS) (3.3 vs. 1.9, p=0.004), and total hospital LOS (9.6 vs. 6.0, p=0.019) than non-obese group, however, the mortality was not significantly different (p=0.37).  Since ISS was higher in obese group, we controlled for ISS and determined that the obese patients were more likely to require mechanical ventilation both before and after controlling for ISS (34.4% vs. 16.1%, p=0.003).

Conclusion:  Rib fractures remain an important focus in obese patients admitted to trauma centers since they are at increased risk for requiring mechanical ventilation and has worse outcomes, although overall mortality is not affected. Rib fracture protocols that focus on increased pain control, aggressive pulmonary toilet regimens and possible early surgical intervention need to be further investigated specifically in obese patients to decrease the associated morbidity and improve outcomes.

50.19 Predictors of 30 Day Readmission Following Percutaneous Cholecystostomy

Posted on January 18, 2018

M. Fleming1, Y. Zhang2,3, F. Liu2,4, J. Luo2, K. Y. Pei1  1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA 2Yale University School Of Medicine,Section Of Surgical Outcomes And Epidemiology, Department Of Surgery,New Haven, CT, USA 3Yale School Of Public Health,Department Of Environmental Health Services,New Haven, CT, USA 4Beijing 302 Hospital,Beijing, FENGTAI QU, China

Introduction:
High risk patients undergoing cholecystectomy may experience increased morbidity and mortality. Consequently, percutaneous cholecystostomy (PC) has been utilized as a treatment option for acute cholecystitis in this cohort of patients.  Little is known about incidence of and predictive risk factors for readmission following PC; therefore, we sought to determine predictors of readmission after PC.

Methods:
Patients who had PC from 2013-2014 were identified from the National Readmission Database (NRD) by the Healthcare Cost and Utilization Project (HCUP). A 30-day readmission was defined as a subsequent admission within 30 days following the first admission discharge date. Multivariate logistic regression models using stepwise selection were employed to select significant predictive variables. 

Results:
A total of 3,368 patients were identified with 698 (20.7%) readmissions during the study period. Severity of illness directly correlated with readmission risk at 30 days (moderate loss of function OR 1.60 95% CI 1.11 – 2.30, major loss of function OR 1.76 CI 1.23 – 2.52, extreme loss of function OR 2.37 CI 1.62 – 3.46). Additionally, alcohol use (OR 1.45 CI 1.02 – 2.07), congestive heart failure (CHF, OR 1.26 CI 1.01 – 1.57), depression (CI 1.42 OR 1.08 – 1.86), metastatic cancer (OR 1.56 CI 1.05 – 2.30) and peripheral vascular disease (OR 0.73 CI 0.54 – 0.99) were closely correlated with risk for readmission at 30 days. Uncomplicated diabetes (P = 0.05), hypertension (P = 0.93), obesity (P = 0.61), and renal failure (P = 0.47) were not correlated with risk for readmission.

Conclusion:
Percutaneous cholecystostomy has become a crucial tool for the acute care of high risk patients with cholecystitis. However, a significant proportion of patients are readmitted within 30 days following discharge. These patients may benefit from increase care coordination services starting at their index admission and increased communication with the clinical team once the patient is discharged.  Additional studies are needed to determine optimal timing to interval cholecystectomy.

50.16 Automating Post-Operative Care through Patient-Centered Short Message Service (SMS)

Posted on January 18, 2018

S. C. McGriff1, D. Kumar1, P. R. Moolchandani1, M. K. Hoffman2, M. A. Davis2, J. W. Suliburk2  1Baylor College Of Medicine,Houston, TX, USA 2Baylor College Of Medicine,Michael E. DeBakey Department Of Surgery,Houston, TX, USA

Introduction:  Studies have found that in-person postoperative care for low risk operations is both costly for patients and system and not always necessary. Using text messages could be an inexpensive, patient-centered, and safe method to screen patients for complications. We conducted a study to determine the feasibility of using an automated text message system as a screening tool for need for in-person postoperative follow-up.

Methods:  Patients who underwent a laparoscopic operation for non-complicated appendicitis or cholecystitis were recruited and enrolled into the study on day of discharge. The study population was polled to determine preferences for frequency and time of text messaging. Subjects received text messages tailored for patient-centered screening of warning signs of post-operative complication. If screened positive, the participant’s physician was notified. Participants were asked patient satisfaction questions.

Results: During a 5-month period, 44 patients were screened, 39 patients were enrolled: 24 following cholecystectomy operations and 15 following appendectomy operations; 18 received text messages in English and 21 received text messages in Spanish. 2 participants were readmitted with a complication and both were successfully identified by the automated system. 15% of participants elected to cancel their follow-up appointment. 74% of participants with scheduled follow-up appointments attended their appointment. Participant response rate to text messages for the first 10 days following discharge is summarized in Table 1. Of the participants completing the study, 96% indicated they would use the automated text messages again.

Conclusion: This pilot study has shown that an automated text message system as a screening tool for post-op complication is feasible and safe in a safety-net population. Our system was able to capture progression of relevant symptoms of participants and notify the participant’s physician when warning signs were detected. Furthermore, participants would use the text message system again. Given inconsistent response data, there is opportunity for improvement in patient engagement with the communication system. A larger implementation is warranted to demonstrate clinical utility and cost effectiveness.

 

50.14 POSTOPERATIVE RESPIRATORY FAILURE: Safer Surgery IMPROVES OUTCOMES

Posted on January 18, 2018

A. L. Lubitz1, J. A. Shinefeld1, T. A. Santora1, A. Pathak1, E. E. Craig1, A. J. Goldberg1, H. A. Pitt1  1Temple University,Philadelpha, PA, USA

Introduction: Postoperative respiratory failure is an uncommon, but deadly and costly complication. Approximately 30% of patients who suffer this complication die, and the excess cost is estimated to be $50,000.00 per patient. The aim of this analysis is to document that a multidisciplinary Safer Surgery approach can reduce the incidence of postoperative respiratory failure.

Methods: Postoperative respiratory failure was monitored in both the Vizient (University HealthSystem Consortium) and the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) databases. In Vizient the Patient Safety Indicator (PSI)-11 documents the observed (O) rate per 1,000 cases, the expected (E) rate per 1,000 cases, and the O/E ratio for postoperative respiratory failure. PSI-11 data were monitored from Fiscal Years (FY) 2014-2017. In the ACS-NSQIP database both unplanned intubation and ventilation greater than 48 hours are reported as odds ratios and deciles. Data in the 10th decile are classified as “Need Improvement” while 2nd to 9th decile outcomes are “As Expected.” Safer Surgery is a multidisciplinary initiative whose aim is to optimize the preoperative, intraoperative and postoperative phases of care. Patient education and preparation are key elements in this program, as are surgeon, anesthesiologist and nursing interventions. The RECOVER mnemonic was developed to emphasize: R-review materials, E-expand your lungs, C-cough and deep breath, O-oral care, V-vary activity, E-eat safely and R-rest with the head of the bed up. Educational materials are distributed to patients in surgery clinics, Preanesthesia Testing (PAT) and via the patient portal of our electronic medical record system. Multimedia educational materials were produced for patients, residents and nursing staff.

Results:Patient Safety Indicator (PSI)-11 O/E Ratio decreased from 1.36 in FY 14, to 0.77 in FY 15, to 0.48 in FY 16 to 0.43 in FY 17 (Table 1). The Observed PSI-11 mortality was 30% in the first 18 months of the analysis and decreased to 15% in the most recent 18 months. These improvements represent a savings of 11 lives and $1.5 million dollars. Both the ACS-NSQIP unplanned intubation and ventilator greater than 48 hours needed improvement in FY 15 (Table 1). Both of these metrics have improved to “As Expected” in FY 16 (Table 1).

Conclusion:A multidisciplinary Safer Surgery program improved postoperative respiratory failure outcomes at an academic medical center. A bundle of preoperative, intraoperative and postoperative best practices resulted in improved respiratory outcomes.

 

50.11 Gastrografin Challenge Protocol Decreases Length of Stay in Patients with Small Bowel Obstruction

Posted on January 18, 2018

W. Huett1, N. J. Bruce1, W. C. Beck1, M. K. Kimbrough1, J. Jensen1, M. Sutherland1, R. Robertson1, K. W. Sexton1  1University Of Arkansas For Medical Science,Little Rock, AR, USA

Introduction:  The gastrografin challenge (GGC) is a diagnostic tool used to predict the need for surgery in patients with small bowel obstruction (SBO) due to adhesive disease.  The GGC was recently implemented into the management of SBO protocol for surgical services at our institution in the 3rd quarter of 2015. We hypothesized that the length of hospital stay would subsequently decrease for patients receiving our updated protocol utilizing the GGC.

Methods:  In this retrospective analysis of prospectively collected data, the length of stay for patients admitted to surgery services for SBO before and after implementation of the GGC protocol were measured. The GGC clinical protocol could be found on the division website and was implemented using morning report. If contrast reached the colon at 24 hours, nasogastric tube was removed and diet advanced.  If contrast failed to reach the colon at the 24 hour film, operative therapy was recommended. As an additional, temporal control, patients admitted to the medicine service with SBO before and after the surgical services implemented the GGC protocol were examined as well.

Results: A total of 1,468 patients admitted to the surgical services were included in our analysis, as well as 1,026 patients admitted to the medicine service. Implementation of the GGC protocol in the management of adhesive small bowel disease on surgical services reduced the average length of stay by 2 days (7.3± 11.5 days, n=993; vs 5.3 ±  9.6, n=475, p=0.0002).  There were 993 patients in the control group, and 475 patients in the intervention arm.  There was no difference in mean length of stay for patients admitted to the medicine service with SBO in the time before and after implementation of GGC protocol by surgical services (6.3 ±  11.7 days, n=649 control; 7.0 ±  11.8 days, n=377, p=0.8).  In the patients admitted to the surgical services before the protocol, 24% underwent an operation compared to 5% after implementation of the protocol (p<0.0001).

Conclusion: Use of the GGC in the initial, protocol-driven management of adhesive SBO decreases length of stay likely due to a decreased need for operative intervention. 

 

50.07 Neutrophil Lymphocyte Ratio (NLR) Predicts Hospital Length Of Stay In Acute Appendicitis

Posted on January 18, 2018

E. B. Rodas1,2, M. Guillén2, E. Granda2, F. Martínez2, E. B. Rodas1,2  1Virginia Commonwealth University,Acute Care Surgical Services/ Surgery,Richmond, VA, USA 2Universidad Del Azuay,Cuenca, AZUAY, Ecuador

Introduction:
Neutrophil to lymphocyte ratio (NLR) has demonstrated to be a marker of inflammatory response in many conditions including acute appendicitis. We hypothesize that admission NLR could predict hospital length of stay (HLOS) in acute appendicitis.

Methods:
A retrospective cohort study was conducted during 2013 in a tertiary hospital and included all patients admitted through the emergency department with the diagnosis of acute appendicitis treated surgically. A database utilizing SPSS-V19 was created. To evaluate sensitivity of the test we constructed ROC curves; association between variables and risk was evaluated with chi-square and odds ratio.

Results:
During the 12-month period 338 patients were admitted with acute appendicitis. There were 203 (60.05%) male and 135 (39.94%) female patients. Mean age 34.67 ± 11.65 years. When chi-square was applied to increased NLR and HLOS a value of 21.36 (p <0,05), odds ratio 3.019 (CI 1.874-4.864). Also chi-square was applied to NLR and ICU admission, a value of 3.64 (p <0.05) and an odds ratio of 6,18 (CI 0.736 – 51.931). Moreover, the NLR for the different phases of appendicitis was: inflammatory phase (n=87), 7.98 (± 10.40), suppurative (n=142) 11.27 (± 23.54), gangrenous (n=67) 8.15 (± 4.78) and perforated (n=42) 18.44 (± 23.78).

Conclusion:
In acute appendicitis, a higher NLR is associated with an increased in HLOS. The utilization of this simple parameter could potentially be used to allocate resources at the time of admission. Furthermore, NLR trended upward as the disease severity progresses. Additional studies are warranted to validate these findings.
 

50.08 Risk Factors of Mortality in Patients with Necrotizing Soft Tissue Infections in Rwanda

Posted on January 18, 2018

M. CHRISTOPHE1, J. Rickard2,4, F. Charles1,3, N. Faustin1,2  1University Of Rwanda,College Of Medicine And Health Sciences,Kigali, KIGALI, Rwanda 2University Teaching Hospital Of Kigali,Surgery,Kigali, , Rwanda 3Rwanda Military Hospital,Plastic And Reconstructive Surgery,Kigali, KIGALI, Rwanda 4University Of Minnesota,Surgery And Critical Care,Minneapolis, MN, USA

Introduction: Necrotizing soft tissue infections (NSTI) is an emergency surgical condition with severe physiologic and metabolic derangement that predisposes the patient to increased mortality and morbidity worldwide, particularly in developing countries if not diagnosed and treated early.

Methods: This prospective observational cohort study includes all patients aged12 and above who presented at Department of Surgery, University Teaching Hospital of Kigali from April 2016 to January 2017 with NSTI. We describe epidemiology, operative management, and outcomes of care. We evaluated the risk factors for mortality using bivariate and multivariate logistic regression.

Results:We identified 175 patients with confirmed diagnosis of NSTI. The majority of patients (53%) were male and the mean age was 44 years. The median duration of symptoms was 8 days (Interquartile range (IQR): 5-14) .The overall mortality was 26%. The median length of hospital stay was 23days (IQR: 8-41). Multivariate regression analysis revealed four independent predictors of mortality: presence of shock at admission (odds ratio (OR) 14.15, 95% confidence interval (CI):0.96-208.01, P=0.05), chronic kidney disease (OR 8.92, 95% CI:1.55-51.29, P=0.01) infection located to the trunk (OR: 5.60 , 95% CI:0.99-31.62, P=0.05), and presence of skin gangrene (OR 4.04, 95% CI: 1.18-13.76, P=0.02).

Conclusion:NSTI mortality is high. Patients present in late stage, which carries increased mortality and morbidity. It is imperative that increased efforts need to be done in regards to early consultation, diagnosis and surgical management to prevent bad outcomes

 

50.09 Incidence and Histopathologic Variations in Appendiceal Neoplasm Presenting as Acute Appendicitis

Posted on January 18, 2018

R. F. Brown1, K. Cools1, M. Shah1, W. Stepp1, T. Reid1, A. Charles1  1University Of North Carolina At Chapel Hill,Chapel Hill, NC, USA

Introduction: Patients with a primary appendiceal neoplasm (PAN) often present with variable symptoms, including those of acute appendicitis (AA).  However, with the incidence of PAN increasing nearly two-fold over the past ten years, it is vital to evaluate the effect this has on patients who present with AA, but ultimately have PAN.  The purpose of this study is to identify variations in PAN incidentally diagnosed after treatment for AA.

Methods:  A retrospective review of a pathology database was performed identifying all patients who underwent surgical management of AA between January 2000 and December 2015. Pathology reports were reviewed and patients with PAN were identified. Pearson chi-squared test was performed to compare the difference in incidence of PAN after treatment for AA.

Results: Of the 4336 patients surgically treated for AA between 2000-2015, 1.2% (n=51) had PAM.  Between 2000-2005, incidence of PAN in those presenting with AA was 0.5% compared to 1.3% between 2006-2010 and 1.6% between 2011-2015 (p<0.001 for all).  Table 1 demonstrates patient demographic and histopathological variation over these time periods.  This indicates an increase in the proportion of carcinoid, adenocarcinomas, mixed adenoneuroendocrine carcinomas, and other malignant tumors over time.

Conclusions: Our data suggest that the incidence of PAN presenting as AA is significantly increasing over time.  Additionally, there appears to be a shift in the pathologic variation of PAM, with a decrease in mucinous cystadenomas and an increase in adenocarcinoma and mixed adenoneuroendocrine carcinomas. These findings suggest that acute care surgeons must be increasingly aware that every appendectomy is potentially an oncologic procedure.

50.05 Perioperative Factors Influencing Urinary Retention After Laparoscopic Inguinal Hernia Repair

Posted on January 18, 2018

D. F. Roadman1, M. Helm1, M. Goldblatt1, A. Kastenmeier1, T. Kindel1, J. Gould1, R. Higgins1  1Medical College Of Wisconsin,Milwaukee, WI, USA

Introduction:  Post-operative urinary retention (POUR) after laparoscopic inguinal hernia repair has an incidence of 2-30%. POUR can lead to urinary tract infections, longer lengths of stay, and decreased patient satisfaction. The primary objective of this study was to determine the incidence of and perioperative factors contributing to POUR at our institution in patients who underwent a laparoscopic total extraperitoneal (TEP) inguinal hernia repair. 

Methods:  A retrospective chart review was performed of patients who underwent a laparoscopic TEP inguinal hernia repair at our institution from 2009 to 2016. POUR was defined as patients who required indwelling or straight urinary catheterization postoperatively due to an inability to void spontaneously. Univariate analyses were performed on perioperative variables and their correlation with POUR. 

Results: In total, 578 laparoscopic TEP inguinal hernia repair patients were included in the study: 277 (48%) indirect, 144 (25%) direct, 6 (1%) femoral, and 151 (26%) combination of direct, indirect and/or femoral hernias. Of these, 292 (51%) were bilateral and 286 (49%) were unilateral. Overall, 64 (11.1%) of the 578 patients developed POUR, requiring urinary catherization post-operatively. POUR was significantly associated with benign prostatic hyperplasia (BPH), age 60 years or older, urinary tract infection (UTI) within 30 days, and lower body mass index (BMI) (Table 1). Additional pre-operative, intra-operative, and post-operative variables that were not statistically significant determinants of POUR are also listed in Table 1.

Conclusion: Patients greater than 60 years old, with BPH, and a lower BMI were more likely to develop POUR after laparoscopic TEP inguinal hernia repair. Additionally, these patients were also more likely to develop a UTI within 30 days. Identifying patients at higher risk for the development of POUR can help with patient education and expectations. Additionally, future quality initiatives can be explored to minimize the incidence of POUR in high risk patient populations.

 

50.06 Outcomes of Acute Appendicitis in Veteran Patients

Posted on January 18, 2018

O. Renteria1, S. Huerta1,2  1University Of Texas Southwestern Medical Center,Surgery,Dallas, TX, USA 2VA North Texas Health Care System,Surgery,Dallas, TX, USA

Introduction: Some studies indicate that non-complicated acute appendicitis might be treated exclusively with antibiotics instead of an appendectomy.  We hypothesize that conservative treatment might not be appropriate for veteran patients.    

Methods: This a retrospective, single institution analysis at the VA North Texas Health Care system between 7/05 to 6/17 for all patients who underwent an appendectomy (n=345).  Patients who had an appendectomy for cancer, or incidentally for other reasons were excluded (n=35) as were patients with interval appendectomies (n=16) as well as patients with perforated appendicitis (n=14).  Using postoperative complications as a dependent variable, univariate analysis was performed using Fisher’s Exact Test for categorical and Student’s T-Test for continuous variables.  Significant variables were included in a multiple logistic regression model with postoperative complications as the dependent variable. Data are expressed as means ± SD and significance was established at a p≤0.05 (two-sided).

Results: Of patients who underwent an appendectomy for acute appendicitis (n=280; male=90%; age=46.0±15.7 y.o.; BMI=31.2±18.3 Kg/m2), seven had a malignancy in the specimen (2.5%), one had endometriosis and five had been previously treated conservatively.  Without major complications, minor complications occurred in 20 patients (7.1%) and 30-day mortality was zero. LOS was 3.7±4.3 days. On presentation, 91% of patients had a CT scan and 92% underwent a laparoscopic appendectomy.  Conversion rate was 5%.  Age (57.4±13.1 vs. 45.4±15.6 y.o); blood loss (75.6±95.1 vs. 18.4±27.7 cc); ASA (2.6±0.9 vs. 2.2±0.8); tachycardia on initial presentation (95.2±20.6 vs.  85.8±17.1 bpm); and leukocytosis (16.1±4.8 vs. 13.2±4.4 cc/U) [all p’s <0.05] were associated with complications.  Patients with a gangrenous appendix and history of cardiovascular disease were also more likely to have complications.  Blood loss (OR=1.1; 95% CI 1.0 to 1.1) and a history of cardiovascular disease (OR=4.8; 95% CI 1.2 to 19.9) were independent predictors of complications.

Conclusion:  In Veteran patients, the low rate of complications, the risk of harboring malignancy and failure to conservative management argue against managing acute appendicitis with antibiotics compared to an appendectomy.

50.02 BMI as an Independent Risk Factor for Complications after Laparoscopic Ventral Hernia Repair

Posted on January 18, 2018

L. Owei1, R. Swendiman1, S. Torres Landa1, D. Dempsey1, K. Dumon1  1Hospital Of The University Of Pennsylvania,Gastrointestinal Surgery,Philadelphia, PA, USA

Introduction:
A body mass index (BMI) greater than 30kg/m2 is a known independent risk factor for surgical and medical complications following open ventral hernia repair (VHR). This study aims to examine the relationship between BMI and laparoscopic VHR.

Methods:
Data was obtained from the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2015. Patients were stratified into 7 BMI classes, as well as by hernia type (reducible vs. strangulated) and time of repair (initial vs. recurrent). Univariate analyses, namely the Chi-square test for categorical variables and ANOVA or Kruskal-Wallis for continuous variables, were employed to examine the association between BMI class and patient characteristics, comorbidities, recurrent hernia repair, strangulated hernias, and risk of perioperative complication. Logistic regression was used to assess the risk of complication by BMI class with adjustment for potential confounders.

Results:
Of the 57,957 patients who underwent laparoscopic VHR between 2005 and 2015, 61.4% were obese. Patients were stratified into 7 body mass index (BMI) classes: underweight (BMI < 18.5 kg/m2), normal weight (BMI 18.5 – 24.9), overweight (25 – 29.9), obese (30 – 34.5), severely obese (35 – 39.9), morbidly obese (40 – 49.9), and super obese (BMI ≥ 50). When stratified by BMI class, we found significant differences in age, gender, race, comorbidities, and pre-operative characteristics. The overall complication rate was 4.0%, ranging from a low of 3.0% for normal BMI patients, to 6.9% for patients with a BMI ≥ 50 kg/m2. Recurrent repair and strangulated hernias both demonstrated higher complication rates. All complications (surgical and medical) were significantly associated with BMI class (p < 0.0001). This association remained even after adjusting for age, sex, race, comorbidities, recurrent repair, and strangulated hernias. Patients with a BMI ≥ 40 kg/m2 were found to be significantly more likely to have a complication compared to patients with BMIs ≤ 25kg/m2 (Table 1). This risk of complications further increased with increasing BMI class.

Conclusion:
Obesity, especially those in a higher BMI class, is an independent risk factor for surgical and medical complications after laparoscopic VHR. Patients with BMIs ≥ 40kg/m2 are at 1.3 times greater risk for complications. While this group is different from the patients undergoing open VHR, the higher threshold at which BMI becomes a significant risk factor in laparoscopic VHR suggests that a laparoscopic approach should be considered for patients with BMIs ≥ 30kg/m2 to reduce their risk of post-operative complications.
 

50.01 Impact of Acute Care Surgery Service on Diverticulitis Patients Managed with Operative Intervention

Posted on January 18, 2018

M. N. Khan1, M. Hamidi1, A. Jain1, E. Zakaria1, N. Kulvatunyou1, T. O’Keeffe1, A. Tang1, L. Gries1, B. Joseph1  1University Of Arizona,Tucson, AZ, USA

Introduction:
Trauma services are increasingly providing emergency surgery (ES) care by developing “acute care surgery service (ACS)” which is a combination of trauma surgery, broad-based ES, and surgical critical care. ACS implementation has been shown to provide timely care with improved patients outcomes. The aim of our study was to evaluate the impact of ACS on outcomes in patients who underwent ES for acute diverticulitis

Methods:
We reviewed all patients who were admitted with the diagnosis of acute diverticulitis from 2009-2014. Patients who underwent ES (within 24 hours of hospital admission) were included while those who were admitted during ACS implementation year (2011) were excluded. Patients were divided into two groups: (Pre-ACS [2009-2010] and Post-ACS [2012-2014] and were matched in a 1:2 ratio using propensity score matching for demographics, comorbidities and admission vitals and labs. Outcome measures were time to evaluation by the surgeon, time to operating room (OR) from emergency department (ED), hospital length of stay (LOS), complications, mortality and adjusted hospital charges.

Results:
A total of 1216 patients were analyzed. 284 patients underwent operative intervention within 24 hours of admission, of which 207 patients (Pre-ACS, 69; Post-ACS, 138) were matched. Patients in ACS group had lower median time to evaluation by the surgeon (150 minutes vs 313 minutes, p<0.001), less median time to OR from ED (8.3 hours vs 12.4 hours, p<0.001), less median hospital LOS (6.3 days vs 8.1 days, p=0.02) and a less median hospital charges ($52,252 vs $59,543, p<0.001) as compared to the pre-ACS group. However, there was no difference in complications rate (35% vs 37%, p=0.12) and mortality rate (5% vs 6.6%, p=0.18) between the two cohorts.

Conclusion:
Acute care surgery model implementation at our institution lead to earlier time to evaluation by surgeon, less time to OR from ED, a shorter length of hospital stay, and reduction in hospital charges. Acute care surgery model results in better patient outcomes and improved utilization of hospital resources in patients undergoing operative intervention for acute diverticulitis.
 

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