64.13 Outcome Of Abdominal And Colorectal Surgery In Patients With Left Ventricular Assistant Devices

Posted on December 22, 2014

A. A. Asban1, M. Traa1, J. Yoo1, N. Melnitchouk1  1Tufts Medical Center,Colorectal/Surgery/,Boston, MA, USA

Introduction:
Advances in left ventricular assistant device (LVAD) technology have contributed to significant improvements in patient quality of life and life expectancy. Assessment of the safety of abdominal and colorectal surgery in these patients is of particular importance due to their multiple comorbidities, hemodynamic status, and challenges with abdominal positioning of the LVAD driveline.

Methods:
We conducted a retrospective review of 13 patients with left ventricular assistant devices who had undergone abdominal (including colorectal) surgeries at Tufts Medical Center between January 2003 and December 2013. Data collected include type of device implanted, patients’ comorbidities, preoperative coagulation status, intraoperative complications, need for intraoperative blood products transfusion, type of surgery performed, postoperative complications and postoperative coagulation status. The 24-hour survival and thirty-day mortality rates were gathered in addition to their ultimate LVAD outcome.

Results:
A total of 13 patients underwent 17 operations during the study period. These included 5 colorectal (29.5%) and 12 other abdominal (70.5%) surgeries. The mean duration of LVAD support before surgery was 309 days. Thirteen (77%) patients had an LVAD as a bridge to transplant and 4 (24%) as destination therapy. A total of 8 (47%) surgeries were emergency and 9 (53%) elective surgeries. The most common intraoperative complication was arrhythmia (65% operations). The most common post-operative complications were bleeding in 3 (18%) operations, venous thromboembolism in 3 (18%) operations, and surgical site infection in 2 (12%) operations. The mean perioperative INR was 1.39. Intraoperative blood transfusion was required in 4 (24%) operations and FFP in 3 (18%) operations. Eight (44%) operations required blood transfusion in the first week post-operation. All patients survived the procedures with a 24-hour mortality rate of 12% and thirty-day mortality rate of 18%. 24-hour mortality was higher in emergency cases (25%) versus elective cases (0%). None of the deaths were from complications specific to the abdominal or colorectal surgery performed.

Conclusion
The study demonstrates the feasibility of abdominal and colorectal surgery in LVAD patients. Arrhythmia is the most common intraoperative complication while bleeding and venous thromboembolism are the most common postoperative complications. Emergency operations have higher 24-hour and 30 day mortality with most causes of death being nonspecific to the abdominal surgery performed. Surgeons should consider these expected good outcomes before resolving not to perform colorectal or other abdominal procedures on this higher-risk population.
 

64.15 Early Experience Quantifying Perfusion Time after Colectomy Using Endoscopic Fluorescence Imaging

Posted on December 22, 2014

C. Moore1, J. S. Turner1, C. E. Clark1  1Morehouse School Of Medicine,Department Of Surgery,Atlanta, GA, USA

Introduction

Anastomotic leak is seen in up to 20% of low colorectal anastomoses. Factors associated with higher risk of leak are poor blood flow to the anastomosis, contamination, anastomotic technique, tension, and declining distance from the anal verge. Here, we review our early experience with transanal, endoscopic fluorescence imaging to assess anastomotic perfusion time with correlation to early postoperative outcomes.

Methods

We prospectively collected data on adult patients undergoing elective colectomy or colostomy closure with an anastomosis to the rectum at a single teaching hospital. Demographics, operative, and postoperative data were retrospectively analyzed including time to maximal perfusion of the bowel proximal and distal to the anastomosis.  Perfusion was assessed using Pinpoint endoscopic fluorescence imaging system (Novadaq Technologies, Ontario, Canada).

Results

Eight consecutive laparoscopic and open colectomies with colorectal or ileorectal anastomosis were identified in a prospectively maintained database. Two board certified colorectal surgeons performed these cases with a resident at a single urban teaching hospital. The average age of the patients was 57 years old with a mean ASA score of 2.25 and BMI of 23.1. Complicated diverticulitis was the most common preoperative diagnosis followed by rectal and sigmoid adenocarcinoma. One patient had sigmoid colon cancer with attenuated polyposis necessitating a total colectomy. The distance between the anastomosis and the anal verge was on average 11.25 cm. There were no intraoperative complications or diversions. The mean perfusion time for colon or ileum after anastomosis was 50.375 seconds while the mean rectal perfusion time was 47.125 seconds. There were no significant differences between these two perfusion times.  One patient was found to have a leak postoperatively and returned to the operating room for colostomy formation and washout. The average length of stay was 9 days (+/- 6.4) with time to first BM of 5.4 days and first intake of enteral nutrition 5.1 days.

 

Conclusion

The use of transanal endoscopic fluorescence imaging is safe and should be considered in colorectal surgery. There are no differences in perfusion times between the proximal bowel and rectum following colorectal or ileorectal anastomosis. 

 

64.16 Emergency Upper GI Surgery in the United States: Burden of Disease and Ten-year trend – 2001-2010

Posted on December 22, 2014

J. S. Crystal1, V. Y. Dombrovskiy1, S. C. Gale1,2  1Robert Wood Johnson – Rutgers,Surgery,New Brunswick, NJ, USA 2East Texas Medical Center,Surgery,Tyler, TX, USA

Introduction:

Upper gastrointestinal (UGI) disorders, including peptic ulcer disease, are most commonly managed medically, yet patients presenting with emergent UGI conditions often require surgical evaluation and operative intervention. Using a large national database, we sought to assess the “burden of disease” for emergent presentation of UGI disorders and the need for surgical intervention during admission, over a ten-year period. 

Methods:
The Nationwide Inpatient Sample from 2001-2010 was queried for all patients admitted with emergent surgical illness (EGS) as recently defined by the AAST. The study population was selected using UGI-specific ICD-9 diagnosis and procedure codes and limited to patients admitted with urgent or emergent status. Operative rates, mortality, sepsis, and demographics were compiled. T-test and Cochran-Armitage trend test were used; p< 0.05 was significant.

Results:
During the 10-year study period 4,626,204 patients were admitted emergently to US hospitals with UGI disorders.  The average age was 64.7 years; 56% were female.  From 2000 to 2010, UGI admissions decreased as a percentage of total EGS (18.7% to 14.9%; p<0.0001) and while sepsis rates increased from 1.8% to 2.2% (p<0.0001), mortality declined from 2.6% to 1.6% (p<0.0001). During the study period, surgical rates increased markedly from 20.2% to 38.4% (p<0.0001) with a total of 1,438,649 patients (31.1%) requiring surgery. 

Conclusion:
While overall emergent admissions for UGI disorders have declined, surgical rates have increased significantly for those patients admitted. Although more patients present with sepsis, mortality has declined which may reflect improving critical care. These data suggest that general and acute care surgeons should address this growing emergent UGI disease burden with renewed emphasis on gastroduodenal procedures during surgical training and with future prospective inquiry.
 

64.17 Prospective Analysis of Mortality in Non-Trauma Patients Managed With Open Abdomen

Posted on December 22, 2014

S. Ahmad4, L. O’Meara3, E. Klyushnenkova2, T. M. Scalea2,3, J. Diaz2,3, B. R. Bruns2,3  2University Of Maryland School Of Medicine,Surgery,Baltimore, MD, USA 3R. Adams Cowley Shock Trauma Center,Surgery,Baltimore, MD, USA 4University Of Maryland,Department Of Surgery,Baltimore, MD, USA

Introduction:  Abbreviated laparotomy and open abdomen have shown acceptable mortality rates for non-trauma, acute care surgery (ACS) patients with abdominal catastrophe. However, these studies are retrospective and limited in size. In prospective fashion, we aimed to identify demographic and hospital course variables that were associated with in-hospital mortality. 

Methods:  All adult ACS patients managed with open abdomen from June 2013 until December 2013 were prospectively enrolled into an IRB-approved study at a single university medical center. Variables examined include demographics, Charlson Comorbidity Index (CCI), operative interventions, laboratory data, and outcomes. Wilcoxon rank sum, Fisher’s exact, and paired t tests were used to determine differences between survivors and non-survivors. 

Results: 58 patients (32 male, 26 female) were managed with open abdomen over a 6-month period with 25 in-hospital mortalities (43%). There was an association between age and mortality. Patients who died were older than those who survived (median 66 vs. 62 years, p=0.012). Mortality was not associated with gender, BMI (median 33.8), CCI, type of initial surgery, hospital or ICU length of stay (median 24.5 and 18 days, respectively), or time from initial surgery to death (median 16 days). The most common indication for laparotomy was mesenteric ischemia (n=12), followed closely by perforated viscus or pneumoperitoneum (n=11). No single indication for surgery was associated with increased mortality. The most common indication for open abdomen was need for damage control (n=30, 52%); however, presence of contamination or clinical indications for damage control (acidosis, coagulopathy, or hypothermia) had no association with mortality. Ventilator associated pneumonia was associated with increased mortality (p=0.003).  Lower preoperative platelet level (p=0.003) and hemoglobin level (p=0.046) were associated with increased mortality, but white blood cell count, INR, lactate, pH, and base deficit were not. 

Conclusion: This effort represents a large, single-institution, prospective cohort of ACS patients managed with open abdomen. Age, development of ventilator-associated pneumonia, platelet level, and to a lesser degree, hemoglobin level were associated with mortality. Contrary to previous studies, presence of intra-abdominal sepsis and damage control indicators at time of operation were not associated with increased mortality. ACS patients managed with open abdomen, in contrast to trauma, represent an older population with significant medical co-morbidities and a high likelihood of mortality.

 

64.18 Continuous topical irrigation improves delayed primary fascial closure of open septic abdomen

Posted on December 22, 2014

Q. TAO1, J. Ren2, B. Wang1, Y. Zheng1, J. Li2  1Affiliated Zhongda Hospital, Southeast University,General Surgery,Nanjing, JIANGSU, China 2Jinling Hospital, Nanjing University,General Surgery,Nanjing, JIANGSU, China

Introduction: Management of open abdomen (OA) is a formidable challenge, certainly when abdominal sepsis is present. Failure to achieve delayed primary fascial closure is one of the most common complications. This prospective cohort study aims to explore the influence of continuous topical irrigation on the management of open septic abdomen. 

Methods: The patients with abdominal sepsis who underwent OA using vacuum-assisted and mesh-mediated fascial traction (VAWCM) technique, were divided into the irrigation and control groups. The delayed primary fascial closure rate and other outcomes were compared between the two groups. 

Results:Between 2007 and 2013, 73 patients with open septic abdomen were treated with continuous topical irrigation and VAWCM, and 61 cases with only VAWCM. The overall delayed primary fascial closure rate in the irrigation group was significantly increased (63% vs 41%, p = 0.011). The mortality with OA was similar (24.6% vs 23%, p = 0.817). However, time to delayed primary fascial closure (p = 0.003) and length of stay in hospital (p = 0.022) in the survivals were significantly decreased in the irrigation group. In addition to topical irrigation (OR 1.453, 95% CI 1.222 – 4.927, p = 0.011), early enteral feeding (OR 3.357, 95% CI 1.479 – 7.619; p = 0.003) and restricted crystalloid fluid infusion (OR 2.611, 95% CI 1.296 – 5.261; p = 0.007) were independent influencing factors related to successful fascial closure of open septic abdomen.

Conclusion:Continuous topical irrigation could improve the delayed primary fascial closure, but could not decrease the mortality in the patients with open septic abdomen using VAWCM method. Early enteral feeding and restricted crystalloid fluid infusion might be recommended in such population.

 

64.19 Change in Functional Status and Quality of Life in Elders Admitted to an Acute Care Surgery Service

Posted on December 22, 2014

L. M. Warkentin1, T. F. Ali1, S. Gazala1, A. S. Wagg2, R. S. Padwal3, R. G. Khadaroo1  2University Of Alberta,Division Of Geriatric Medicine,Edmonton, ALBERTA, Canada 3University Of Alberta,Division Of General Internal Medicine,Edmonton, ALBERTA, Canada 1University Of Alberta,Department Of Surgery,Edmonton, ALBERTA, Canada

Introduction: Emergency surgery is increasingly common in older patients (≥ 65 years old).  Prior studies have shown that post-operative complications, in-hospital mortality, and an increased requirement for post-discharge care are more common in older patients. Patient-reported outcomes, including assessments of cognitive status, functional capacity and health-related quality of life (HRQL), are understudied. We conducted a six-month prospective cohort study in patients ≥ 65 years admitted to a specialized acute care and surgical emergency service at a single, publicly-funded, tertiary care center in Edmonton, Canada.

Methods: Participants, or their surrogates, completed the Abbreviated Mental Test Score-4 (AMTS-4) to measure cognitive status, Barthel Index to assess functional status, Vulnerable Elders Survey (VES-13) to examine risk of health deterioration, and EuroQol-5 Dimensional Scale (EQ-5D) for HRQL within 24 hours of admission to hospital and 6 months post-discharge. Paired t-tests or McNemar’s tests were used to assess differences in instrument scores between baseline and 6 months.

Results: One hundred fifty-five consecutive patients (including 16 surrogates) were enrolled. Sixteen (10%) patients died within 6 months of discharge and 116 (75%, including 18 surrogates) completed a follow-up assessment 6 months post-discharge. Fifty-two percent of patients were female and mean age was 77 years (SD 8). One hundred and two (66%) patients underwent surgery and 53 (34%) managed non-surgically. Cognitive status improved substantially over 6 months, 72 (52%) patients had AMTS scores showing cognitive impairment at baseline and 4 (4%) patients at 6 months (p < 0.001).  The mean (SD) Barthel Index score was 91.2 ± 14.1 at baseline and 92.8 ± 12.9 at 6 months (p > 0.05). Forty-seven (31%) patients had VES-13 scores indicating risk of health deterioration at baseline, and 33 (28%) patients at 6 months (p > 0.05). Mean (SD) EQ-Index score at baseline was 0.76 ± 0.24, and 0.86 ± 0.19 at 6 months (p > 0.05). Mean EQ-VAS score was 68.4 ± 20.3 at baseline and 72.0 ± 15.1 at 6 months (p > 0.05). Of the 116 patients that completed follow up, 17 patients (15%) required post-discharge escalation of care.

Conclusion: Elderly patients admitted to an acute care surgery service maintained functional capacity and improved quality of life 6-months post-discharge.  Initially low cognitive scores improved substantially in most patients, suggesting that the acute illness led to reversible cognitive impairment.  Our data suggest that the acute care surgery model leads to very low rates of cognitive impairment with good functional and HRQL outcomes in elderly patients presenting with emergent surgical illness.

64.20 Kidney-specific Morphomic Factors are Associated with AKI after Major General Surgery Operations

Posted on December 22, 2014

J. Li1, E. Chang1, N. C. Wang1, D. Cron1, P. Zhang1, S. C. Wang1  1University Of Michigan,Ann Arbor, MI, USA

Introduction: Acute kidney injury (AKI) occurs in approximately 20% of hospitalized adults in the US and is associated with increased morbidity, mortality, and costs for patients of general surgery procedures. Numerous studies have suggested the effectiveness of using patient CT imaging data to predict risk of AKI. Analytic Morphomics, a quantitative approach to processing cross-sectional imaging data, has shown utility in evaluating perioperative risk and postoperative outcome. Thus, we hypothesized that individualized morphomic factors would be significantly associated with AKI after major general surgery procedures.

Methods: 326 adult patients undergoing major, elective, intra-abdominal general surgery operations from January 2008 to September 2011 were selected. Patients undergoing isolated appendectomy or cholecystectomy procedures were excluded, as were patients with a preoperative creatinine value of 1.6 or greater, a history of ESRD, or a prior nephrectomy. Preoperative CT scans within 365 days prior to the operation were analyzed for kidney, vertebral, and fascia-associated parameters such as length, area, volume, and radiodensity. Demographic factors included patient age, gender, and BMI. Univariate analysis was utilized to determine the strength of the association between patient morphomic and demographic factors and development of postoperative AKI as defined by the KDIGO criteria within 30 days of the surgery.

Results: Of the 238 eligible patients, 31 (13%) developed AKI. Average pixel radiodensity of the total kidney (p<0.001) and kidney parenchyma (p<0.001) were found to be significantly lower for the group that developed postoperative AKI than for those that did not. No significant differences between AKI and non-AKI patients were found for total kidney volume (p=0.19), parenchymal volume (p=0.16), anterior body depth (p=0.32), and patient demographic factors (p>0.15). Table 1 contains the results of the univariate analysis including the means between the AKI and non-AKI group for several factors.

Conclusion: For patients undergoing noncardiac, nonvascular surgical procedures, our analysis showed that kidney pixel radiodensity factors are the most significant in predicting postoperative AKI risk.
 

65.01 Risks and Outcomes after Delirium following Cardiac Surgery: Analysis from a National Database

Posted on December 22, 2014

J. Idrees1, N. Schiltz1, E. E. Roselli1, A. Badjatiya1, D. Johnston1, E. G. Soltesz1  1Cleveland Clinic Foundation,Thoracic And Cardiovascular Surgery,Cleveland, OH, USA

Objective:  

Delirium commonly occurs following major surgery in the elderly. It is a known predictor of adverse outcome and increased hospitalization. In this study, we sought to determine the incidence of delirium, the prevalence of risk factors, and impact on healthcare resource use after cardiac surgery using a large administrative dataset.

Methods:

We identified 6,389,977 patients who underwent coronary bypass, valve, or thoracic aortic surgery between 1998 and 2011 from the Nationwide Inpatient Sample database. Multivariable regression was used to identify risk factors for post-operative delirium and risk-adjustment was performed in order to estimate the effect of a delirium on outcomes.

Results:

The incidence of postoperative delirium was 15.0 per 1000 cardiac surgery procedures. Patients with delirium were significantly older (mean age 72 vs. 66 years; p<0.001), male (69.7% vs. 67.6%; p<0.001), and had more Elixhauser comorbidities (6.2 vs. 4.0; p<0.001). Older age, Medicare or Medicaid coverage, and treatment at a teaching hospital were significantly associated with postoperative delirium, while hospital volume was not. Alcohol and drug abuse, depression, psychotic and neurologic disorder, anemia, fluid electrolyte imbalance and weight loss were independent clinical predictors of delirium. Patients who suffered delirium had a longer length of stay (13.8 days vs. 12.8; p<0.001), higher total costs ($52,843 vs. $50,586; p<.001), but lower risk of mortality (0.9% vs. 1.5%, p<0.001) than patients without delirium. Delirious patients were also more likely to be transferred to a skilled nursing facility or require home health care post discharge.

Conclusion:

Our results have shown that postoperative delirium in cardiac surgery patients is associated with increased resource use but lower mortality. Detailed pre-operative assessment and mitigation of certain risk factors can potentially improve outcomes and minimize resource utilization.

 

65.02 Comparing TAVI with Conventional AVR; First Experiences at the Liverpool Heart and Chest Hospital

Posted on December 22, 2014

R. E. Robinson1, T. Theologou1, M. Field1, R. Stables1, O. Al-Rawi1, M. Kuduvalli1, A. Oo1  1Liverpool Heart And Chest Hospital,Cardiothoracic Surgery,Liverpool, MERSEYSIDE, United Kingdom

Introduction:

Transcatheter aortic valve implantation (TAVI) is an alternative method for treatment of severe aortic valve stenosis in high-risk patients.

Recently the TAVI procedure has emerged as an effective alternative method for the treatment of severe aortic valve stenosis in high-risk patients. This innovative technique has been adopted in our institution since 2008 with a beneficial effect on patients who were excluded from conventional surgical management. The aim of this study is to compare the mortality and subsequent 4 year predicted survival rate of TAVI with traditional AVR.

Methods:
One hundred and sixty five patients were operated on between 2008 and 2013 at LHCH. The procedures were undertaken using both the transapical and transfemoral approaches. Retrospective observational cohort study analysis has been performed assessing the mortality and morbidity of this population. The outcome data from the TAVI patients was propensity matched to a conventional AVR group. A Kaplan Meier curve was developed allowing prediction of 4 year survival following the two procedures.  

Results:
122 TAVI patients were propensity matched with an AVR group. The TAVI group had a ICU length of stay of 1 day compared to 2 (p=0.001), an in hospital length of stay of 6 days compared to 8 (p= <0.001) in the AVR group. The TAVI group had an in-hospital mortality of 6 vs. 4 (p=0.52) and a 4-year mortality of 33 vs. 16 (p=0.007).

Conclusion:
TAVI patients have a shorter ICU and in hospital stay when compared to conventional AVR with no statistically significant difference in “in hospital mortality”. There is however a significant difference in 4 year survival when compared with AVR.

65.03 Simplifying Decisions With a New Risk Model for Cardiac Extracorporeal Membrane Oxygenation (ECMO)

Posted on December 22, 2014

G. Peigh1, H. T. Pitcher1, N. Cavarocchi1, H. Hirose1  1Thomas Jefferson University,Philadelphia, PA, USA

Introduction: While the use of cardiac ECMO is increasing in adult patients, an analysis of risk factors is still in its infancy.  Even though standard intensive care unit (ICU) risk scores such as Simplified Acute Physiology Score II (SAPS II), Sequential Organ Failure Assessment (SOFA) and Acute Physiology And Chronic Health Evaluation II (APACHE II), or disease specific scores such as Model for End-stage Liver Disease (MELD), Kidney Risk, Injury, Failure, Loss of Function, ESRD (RIFLE), Predicting death for Severe ARDS On VV ECMO (PRESERVE) and ECMOnet scores exist, they may not apply to cardiac ECMO patients as their risk factors differ from the variables these common scores use.

Methods: Between 2010 and 2014, 107 ECMO procedures were performed at our hospital. 73 procedures were to support patients on cardiac ECMO. Patient demographics, preoperative conditions, and survival were retrospectively analyzed with IRB approval.

Results: Cardiac ECMO was performed on 73 patients (47 males and 26 females) with a mean age of 48 ± 14 years.  The most common etiologies (#) for ECMO were acute myocardial infraction (19), acute on chronic heart failure (14), post-cardiotomy failure (13), malignant arrhythmia (11), and others (16).  The mean duration of ECMO support was 9.2 ± 6.1 days.  47/73 patients (64%) survived ECMO. 27/47 patients (57%) were discharged from the hospital.   The risk factors independently associated with death on ECMO were high lactate levels (p=0.02) and post-cardiotomy failure (p=0.03).  Pre-ECMO SAPS II, SOFA, APACHE II, MELD, RIFLE, ECMOnet and PRESERVE scores were not correlated with survival (Table). Analysis of pre-ECMO risk factors indicated that elevated lactate (>2.0 mmol/dl), metabolic acidosis (HCO3<20 mEq/L), renal dysfunction (RIFLE score of ‘injury’ or above), and having a post-cardiotomy failure predicted death. Applying this data into a new Simplified Cardiac ECMO Score (min 0, max 4) predicted survival (survivors 1.5 ± 1.1; non-survivors 2.4 ± 0.8; p=0.0006). The area under the curve (AUC) was 0.55 for SOFA, 0.60 for APACHE II, 0.54 for SAPS II, 0.57 for MELD, 0.49 for PRESERVE, 0.62 for ECMOnet, 0.60 for RIFLE, and 0.72 for the Simplified Cardiac ECMO score. Although our score has a higher AUC, a small sample size led to an underpowered study. Despite the fact that there is clinical significance, there was not statistical significance between the various AUC curves.

Conclusion: Common ICU or disease specific risk scores calculated for cardiac ECMO patients prior to the initiation of ECMO did not correlate with ECMO survival. Although the Simplified Cardiac ECMO Score needs to be further investigated, it helps predict futile efforts in high-risk populations.

 

65.05 Thoracoscopic Ablation of Persistent Atrial Fibrillation on the Beating Heart

Posted on December 22, 2014

A. Muehle1, D. Chou1, M. D. Te Winkel1, A. Khoynezhad1  1Cedars-Sinai Medical Center,Cardiothoracic Surgery,Los Angeles, CA, USA

Introduction:
Atrial fibrillation (AF) is the most common sustained arrhythmia and is associated with a nearly five-fold increased risk for stroke as well as over two-fold increased risk of death. For symptomatic drug-refractory AF, percutaneous ablation has been used with good success in paroxysmal AF. For patients with persistent AF, the results of catheter ablation are poor. Therefore, surgical AF using minimal-invasive approaches is offered to this cohort. We analyzed our data in thoracoscopically-performed ablation of AF.

Methods:
From January 2012 through March 2014, a total of 27 symptomatic and drug-refractory patients with lone AF underwent a thoracoscopic epicardial ablation on the beating heart using the bipolar radiofrequency energy source. All of them had persistent long-standing AF and besides one patients also a history of at least one percutaneous catheter ablation. Epicardial ablation was performed on 19 men (70%) and 8 women (30%), with a mean age of 64 (range 47 to 82) years. After the ablation, in all patients entrance and exit block was confirmed, the ganglionic plexi were ablated, and the left atrial appendage was excluded.

Results:
The mean operative time was 4.6 h and the mean postoperative length of stay was 6.5 days. In one patient cardiopulmonary bypass was used due to a laceration of the left atrial appendage. There were no hospital deaths, strokes or myocardial infarctions. The heart rhythm was documented in all of them besides 7 patients with a holder-ECG with duration of at least of 7-days. In 2 patients the postoperatively persistent AF was treated with radiofrequency ablation. Pacemaker implantation was done in 3 patients (11%) due to bradycardia (n=2) and sick-sinus syndrome (n=1). There were 2 late deaths (7%) one due to pulmonary embolism (PE) with a previous history of PE and the other patient died due to a major stroke. The follow-up was completed in 81.5% with a mean length of 11 months (range 90 to 793 days) with a freedom of AF in 85%.

Conclusion:
Thoracoscopic AF ablation on the beating heart for treatment of AF is technical feasible and achieve high success rates with low procedure-related morbidity in early follow-up.
 

64.01 Anastomotic Leak After Closure of Loop Ileostomy vs. Small Bowel Resection

Posted on December 22, 2014

J. Chen1, D. T. Huynh1, C. M. Divino1  1Icahn School Of Medicine At Mount Sinai,General Surgery,New York, NY, USA

Introduction:  Loop ileostomies are often created to temporarily protect a distal anastomosis however closure of the stoma can be associated with anastomotic leak(AL) and morbidity. The aim of our study is to compare the anastomotic leak rate after loop ileostomy closure(LIC) with the leak rate after small bowel resection(SBR).

Methods:  A retrospective chart review was performed of patients at our institution from 2005-2014 for patients diagnosed with anastomotic leak after LIC and compared to those who developed an anastomotic leak after a SBR.

Results: The anastomotic leak rate after LIC was 3.16% compared to 1.16% for SBR. This difference in the leak rate between LIC and SBR was found to be statistically significant(p=0.0023). There was no significant difference found between the comorbidities of the two groups.

Conclusion: The anastomotic leak rate after LIC is 2.7 times that of the leak rate after SBR which is significantly different despite the procedures involving the same small bowel to small bowel anastomosis. We hypothesize that this is due to difficulty gaining adequate exposure through the local incision during LIC compared to SBR. 

 

64.02 Design and Experimental Evaluation of an Anti-Leak Feeding Tube

Posted on December 22, 2014

L. G. Gutwein1, R. Helmig2, L. G. Gutwein1  1Indiana University School Of Medicine,Plastic & Reconstructive Surgery,Indianapolis, IN, USA 2University Of Florida,Gainesville, FL, USA

Introduction:  Enteral feeding is commonplace in healthcare.  The present design of a gastrostomy tube is inadequate because leakage of gastric contents onto the skin is usual prompting emergency department visits and unnecessary wounding and infection that may require hospital admission or operative debridement.  It is common practice during the gastrostomy tube procedure to place a silk suture tightly around the neck portion of an external retaining member to increase the frictional force against the gastric tube, because it is widely recognized that, with time, the static friction between the tube shaft and external retaining member will inevitably be overcome by dynamic friction.  As swelling reduces and the tube materials wear, the gastrostomy balloon is able to move away from the gastric wall allowing gastric contents to leak out around the gastrostomy tube and onto the skin.  In view of the current problems, there is a need for a gastric feeding tube device that can be easily adjusted and prevent leakage by maintaining the internal retention balloon or bumper juxtaposed to the gastric mucosa. In this study, we introduce a new gastrostomy tube design and prototype that inhibits leakage by utilizing an adjustable external retaining member which compresses against the feeding tube shaft thereby preventing dynamic friction.

Methods:  A conventional external retaining member of a 22 French gastrostomy tube is tested against a novel compression fitting external retaining member.  Each gastrostomy tube was clamped to a scale and the external retaining member moved by hand to slide along the tubing at a constant rate and the applied force was recorded.

Results: An experimental prototype (Figure) was tested against the conventional design control for 10 experimental repetitions each (Group 1).  The mean forces were 18 and 46 ounces for conventional and experimental designs, respectively. The tube shaft was exchanged and the experiment repeated for 10 repetitions (Group 2).  The mean forces were 15 and 48 ounces for conventional and experimental designs, respectively.  Consistently, the experimental external retaining member demonstrated 2.5-3x the clamping frictional force as compared to the conventional design for Groups 1 and 2 (p=2.57E-13 and p=1.90E-13, respectively).  In the simulated in-situ environment with lubrication along the external shaft of the feeding tube (Group 3), the experimental external retaining member consistently performed superior to the conventional member (p=3.30E-11).

Conclusion: The refined patent-pending design has the potential to revolutionize the feeding tube market by decreasing morbidity and associated healthcare costs.

 

64.03 Laparoscopic Pedicled Omental Flap for Extraperitoneal Revascularization

Posted on December 22, 2014

M. Bruzoni1, G. Steinberg2, S. Dutta1  1Stanford University School Of Medicine,Pediatric Surgery,Stanford, CA, USA 2Stanford University School Of Medicine,Neurosurgery,Stanford, CA, USA

Introduction:  An abundance of angiogenic and immunologic factors make the omentum an ideal tissue for reconstruction and revascularization of a variety of extraperitoneal wounds and defects. Omental harvesting has historically been performed through a large laparotomy with subcutaneous tunneling to the site of disease. Complications of the open procedure include abdominal wound infection, fascial dehiscence, ventral hernia, and postoperative ileus. The use of laparoscopy to harvest the omentum has the potential to reduce such complications. We describe the outcomes of a series of patients undergoing laparoscopic pedicled omental flap mobilization for cerebral revascularization in moyamoya disease.

Methods:  A retrospective chart review of all patients undergoing laparoscopic omental-cerebral transposition for moyamoya disease between 2011 and 2014 was performed.  Clinical indication, surgical technique, operative times, complications, and outcomes at follow-up were reviewed.

Results: Seven consecutive patients ages 5 to 13 years underwent the procedure. The general surgery team performed laparoscopic omental mobilization, extraperitonealization, and subcutaneous tunneling while the neurosurgical team performed craniotomy and cerebral application of the graft. The omental flap measured up to 60 cm in length.  Operative times for the omental transposition ranged from 125 to 200 minutes.  The patients were followed up postoperatively with clinic visits and angiography.  There was one intraoperative complication (mesocolon injury requiring segmental resection in a patient with prior peritonitis) and no postoperative complications.  All patients had significant to complete symptomatic resolution, and demonstrated adequate pedicle-based revascularization on angiography. 

Conclusion: Laparoscopic pedicled omental mobilization and subcutaneous transposition is feasible and effective in children who require cerebral revascularization for moyamoya disease.  Morbidity from a large laparotomy is avoided.  A similar approach to extraperioneal revascularization of other distant sites is plausible.

 

64.04 Submucosal Gastric Tumors: Efficacy of a Combined Endoscopic and Laparoscopic Approach

Posted on December 22, 2014

A. C. Pysher1, R. C. Langan1, S. Ram1, S. Morales1, R. S. Jackson1, R. Jha3, N. Haddad2, F. Al-Kawas2, J. Carroll2, P. G. Jackson1  1MedStar Georgetown University Hospital,Department Of General Surgery,Washington, DC, USA 2MedStar Georgetown University Hospital,Division Of Gastroenterology,Washington, DC, USA 3MedStar Georgetown University Hospital,Department Of Radiology,Washington, DC, USA

Introduction:  Gastric submucosal tumors (SMTs) display a wide spectrum of pathologic and prognostic characteristics ranging from benign to highly malignant. Laparoscopic gastric wedge resections have become a commonly utilized treatment method. However, one of the challenges posed by use of the laparoscopic technique alone, is tumor identification. In this study, we provide a comprehensive analysis of SMTs at our institution and present a novel combined laparoscopic and endoscopic resection technique.

Methods:  A retrospective review of a prospectively maintained SMT database was performed which identified 32 patients with gastric submucosal tumors who underwent a combined laparoscopic and endoscopic resection between 2006 and 2010.  All clinicopatholgic data was analyzed.

Results:  Pre-operative evaluation included upper endoscopy and endoscopic ultrasound with biopsy of visible lesions in all of patients. Operative technique utilized intraoperative endoscopic visualization of the lesion, followed by laparoscopic gastric wedge resection under direct endoscopic visualization. Utilizing the combined endoscopic and laparoscopic technique, SMTs were correctly identified in all cases. Final pathology revealed an R0 resection in 97% of patients (31/32). Mean tumor size was 2.48 cm (range, 0.6 to 6 cm) and final pathology revealed gastrointestinal stromal tumors (GISTs) in 18/32 cases. No intra-operative complications occurred. Post-operative course was uncomplicated in 29/32 patients. 3/32 patients experienced early post-operative complications, which included delayed gastric emptying, ileus, and small bowel obstruction. There were no perioperative deaths. 

Conclusion: In one of the first series reporting a combined endoscopic and laparoscopic technique for SMTs, we found heightened identification of all SMTs not afforded by laparoscopy alone. This approach may have spared patients an open resection. Although we found this technique to be safe and efficacious, further studies should assess this novel approach using large nationally representative databases. 

 

6.15 The Impact of Obesity on Operative Time in Elective Colorectal Surgery Procedures

Posted on December 22, 2014

H. Saiganesh1, D. Stein1, J. L. Poggio1  1Drexel University College Of Medicine,Department Of Surgery, Division Of Colorectal Surgery,Philadelphia, Pa, USA

Introduction: Obesity currently affects more than a third of the US population and is associated with increased surgical complications. Compared to all other subspecialties, colorectal surgery is the most affected by the increasing trend in obese surgical patients. Operative time has been found to have the greatest impact on hospital costs and physician workload. This study was conducted to determine whether obesity has a direct impact on operative time in elective colorectal surgical procedures using a high-powered, nationally representative patient sample.

Methods: A retrospective analysis was conducted on 45,362 patients who underwent open and laparoscopic ileocolic resections, partial colectomies, and low pelvic anastomoses using ACS-NSQIP data from 2005 to 2009. Operative time (in minutes) was the main outcome variable, while body mass index (in kg/m^2) was the main independent variable. Body mass index was divided into three classes: normal (<25), overweight/obese (25-35), and morbidly obese (>35). A univariate linear model was used to analyze the relationship while controlling for confounding factors such as demographics and preoperative conditions. Statistical significance was established at p < 0.05.

Results: Morbidly obese patients were found to have longer operative times than did normal patients across each individual colorectal surgical procedure (p < 0.001), ranging from a mean difference of 17.8 minutes for open ileocolic resections to 56.6 minutes for laparoscopic low pelvic anastomoses with colostomies.

Conclusions: BMI, as an objective measure of obesity, is a direct, statistically significant independent predictor of operative time across elective colorectal surgery procedures. We suggest future studies to further discuss the modification of surgical reimbursement to account for the greater procedural and temporal costs in treating obese patients.

 

6.16 Continous Non-Invasive Assessment of Hemoglobin and Fluid Responsiveness in Obesity and Laparoscopy

Posted on December 22, 2014

M. D. DeBarros1, M. W. Causey1, P. Chesley1, M. Martin1,2  1Madigan Army Medical Center,Department Of General Surgery,Tacoma, WA, USA 2Oregon Health And Science University,Department Of Trauma And Critical Care,Portland, OR, USA

Introduction: During surgery, proper fluid resuscitation and hemostatic control is critical.  Pleth variability index (PVI) is advocated as an accurate means of optimizing intraoperative fluid resuscitation.  PVI is a measure of dynamic change in perfusion index during a complete respiratory cycle.  Non-invasive monitoring of total hemoglobin could provide an accurate means to determine the need for transfusion. We analyzed the impact of insufflation and obesity on non-invasive measurements of hemoglobin and PVI in laparoscopic procedures to validate its usefulness in assessing fluid responsiveness and hemoglobin levels.

Methods: A non-invasive hemoglobin and PVI monitoring device was prospectively analyzed in patients undergoing abdominal operations.   Patients were stratified by open and laparoscopic approach and obesity (BMI≥35).  PVI and hemoglobin values were assessed before, during, and after abdominal insufflation and compared to control patients undergoing open surgery.

Results: 63 patients were enrolled (mean age 42 years; 71% female; mean BMI 36) with 24 patients being laparoscopic non-obese (LN), 20 being laparoscopic obese (LO), and 19 undergoing open operations.  There was no significant blood loss in any case.  Hemoglobin did not change significantly before or after insufflation (Figure 1a). There was false elevation of PVI with insufflation and more pronounced in obese patients (Figure 1b).

Conclusion: Insufflation or obesity was not associated with significant variations in hemoglobin.  Non-invasive monitoring of hemoglobin is useful in laparoscopic procedures in obese and non-obese patients. PVI values should be used cautiously during laparoscopic procedures, particularly in obese patients.

 

6.17 Fluorescent Cholangiography during Robotic Cholecystectomy: Early Experiences at an Urban Hospital

Posted on December 22, 2014

L. Policastro1, R. Huang1, P. J. Chung2, H. Patel2, A. Schwartzman2, R. Lee2, G. Sugiyama2  1SUNY Downstate College Of Medicine,Brooklyn, NY, USA 2SUNY Downstate Medical Center,Department Of Surgery,Brooklyn, NY, USA

Introduction:
Intraoperative cholangiography using contrast fluid is traditionally a useful visual aid during laparoscopic cholecystectomy, but its disadvantages include increased operative time and exposure to radiation. Recently, near-infrared fluorescent cholangiography using indocyanine green (ICG) dye became available to users of the da Vinci surgical platform. It provides a real-time, 3D endoscopic view highlighting the bile ducts. ICG imaging has been utilized safely and effectively during robotic cholecystectomy. Adequate visualization of biliary structures is paramount in patients presenting with advanced gallbladder disease. This study compares operative results in robotic cholecystectomy with and without the use of ICG at an inner-city academic medical center.

Methods:
Eighty-six patients underwent robotic cholecystectomy between June 2013 and July 2014. Use of fluorescent cholangiography began in November 2013 after FDA approval was obtained. Patients were administered 5 mg of ICG on induction of anesthesia. If there was a failure to visualize biliary anatomy, another 2.5 mg was administered. Both single-site and multiport techniques were used. Patient records were compiled retrospectively.

Results:
There were 46 patients in the non-ICG group and 40 in the ICG group. The groups were similar, except that single-site was utilized more frequently with ICG (73% vs. 48%; p=.02), and chronic cholecystitis was slightly more prevalent in the ICG group (88% vs. 83%; p=.07). Overall, the mean BMI was 30.4 ± 6.5, and the rate of acute cholecystitis was 21%. Use of ICG neither lengthened nor shortened operation time (120 min with, 133 min without; p=.22) or robot time (58 min with, 57 min without; p=.85). The rate of conversion to either open or laparoscopic cholecystectomy was favorable (3% with, 13% without), but to qualify this result, logistic regression was used to account for age, sex, BMI, use of single-site, acute and chronic cholecystitis, tobacco use, and alcohol use. While marginally significant (p=.079), the use of ICG was associated with fewer conversions (OR 0.10, 95% CI 0.008−1.30). There was no difference in post-op length of stay (p=.91).

Conclusion:
ICG fluorescent cholangiography during robotic cholecystectomy enables confident identification of biliary structures without impacting operation time. It is helpful in the training of residents and fellows. It is safe for routine use and may reduce conversions, though its overall cost-effectiveness cannot be concretely established without a large randomized study.
 

6.18 The ‘Inside-out’ Technique for Ventral Hernia Repair with Mesh Underlay

Posted on December 22, 2014

A. E. Berhanu1,2, S. G. Talbot1,2  1Brigham And Women’s Hospital,Division Of Plastic Surgery,Boston, MA, USA 2Harvard School Of Medicine,Boston, MA, USA

Introduction: Techniques for mesh installation in hernia repair are varied and can be improved by preventing recurrent herniation, reducing intraoperative visceral injury, and increasing procedural efficiency. We present a method of securing mesh (either prosthetic or biologic) as an underlay concurrent with component separation, with pre-placed sutures on the material, to the overlying fascia through an ‘inside-out’ technique using a Carter-Thomason suture passer. The Carter-Thomason is a sharp, narrow trocar (3mm diameter) with the ability to grasp a suture at the distal end. It was originally designed to aid with closure of laparoscopic ports by facilitating the placement of sutures through fascia around port sites.

Methods:  The ‘inside-out’ technique was performed on 23 patients at a single tertiary academic medical center from November, 2011 to February, 2014.  We have followed these patients for a median of 12.5 months to assess for post-operative complications and hernia recurrence.  The innovative steps in this technique include (1) the preplacement of sutures on the mesh and removal of needles, (2) placement of mesh into the abdomen, and (3) retrieval of each end of the sutures with the Carter-Thomason for safe passage through the fascia from within the abdomen under direct visualization (Figure).

Results: There have been two recurrences (2/23=8.7%), one in a patient at 383 days post-operatively and the other at 311 days post-operatively.  The former recurrence occurred in a patient who underwent repair for a recurrent ventral hernia and the latter patient had significant loss of domain requiring an inlay mesh.  There were no hernia recurrences in patients who underwent repair of a primary ventral hernia with an underlay technique.

Conclusion: The ‘inside-out’ technique for ventral hernia repair with a mesh underlay after component separation using a Carter-Thomason suture passer is easy, safe, and reliable.  We have observed no hernia recurrence in patients who underwent repair for a primary ventral hernia with an underlay technique.  By pre-placing the sutures in the mesh, these can be evenly spread, giving the surgeon better control over the distribution of tension across the repair.  The technique described here seemingly reduces the risk of bowel injury by allowing direct visualization of the entire path of the sharp instrument, the tip of the Carter-Thomason, as it passes through the rectus. Additionally, pre-placed sutures lie between the mesh and posterior rectus fascia, allowing the mesh to shield the viscera from the path of the Carter-Thomason.

6.19 Robotic TAPP Inguinal Hernia Repair: Early Experiences at an Inner-City Academic Medical Center

Posted on December 22, 2014

R. Huang1, L. Policastro1, P. J. Chung2, H. Patel2, A. Schwartzman2, R. Lee2, G. Sugiyama2  1SUNY Downstate College Of Medicine,Brooklyn, NEW YORK, USA 2SUNY Downstate Medical Center,Department Of Surgery,Brooklyn, NEW YORK, USA

Introduction: Laparoscopic inguinal hernia repair was introduced in the 1990s and has been widely adopted. Many studies have shown that the transabdominal pre-peritoneal (TAPP) and totally extra-peritoneal (TEP) approaches to inguinal hernia repair have low recurrence rates and allow for early return to activity due to decreased pain. The robotic surgical platform improves upon standard laparoscopic approaches, providing enhanced dexterity and 3D viewing. Robotic inguinal hernia repair has been previously reported en-passant with prostatectomy, but has not been studied as a stand-alone procedure. We report one of the first case series of stand-alone robotic TAPP inguinal hernia repair at an inner-city academic medical center.

Methods: From December 2013 to June 2014, 26 robotic TAPP inguinal hernia repairs were performed at a single institution. We employed a three port approach, with a camera port at the umbilicus and two 8 mm lateral ports roughly 2 cm above the umbilicus. Patient characteristics, operative times, complications, and hernia recurrence were assessed. Data were compiled retrospectively.

Results: Twenty-six robotic TAPP inguinal hernia repairs were performed, of which seven were bilateral. Twenty-four patients were male and two were female. The mean age of the patients was 59.6 ± 11.2 years. The mean BMI of the patients was 26.3 ± 3.4. The mean incision-to-closure time was 127 ± 42 minutes. The mean robotic operation time was 82 ± 37 minutes. The mean robot docking time was 6 ± 3 minutes. Seven patients had scrotal hernias, three presented with incarcerated inguinal hernias, and an additional two had large hernia sacs. On follow-up, 4 of 26 patients (15%) had postoperative hematomas, while 3 patients (12%) had postoperative urinary retention. One patient (4%) returned with a recurrent hernia. No scrotal hernia patients presented with recurrence.

Conclusion: We present a case series of robotic TAPP inguinal hernia repairs at an inner-city institution and conclude that the procedure is feasible and safe for both routine herniorrhaphy and in advanced scrotal cases. Recurrence and morbidity were low during the early learning curve. Large scrotal and incarcerated inguinal hernias were repairable using the robotic approach. Further prospective study is needed to determine whether robotic inguinal hernia repair should be broadly adopted.
 

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