12.14 Transfusion is a Predictor of Worse Short-term Postoperative Outcomes Following Colectomy

Posted on January 18, 2016

C. M. Papageorge1, G. D. Kennedy1 1University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction: Anemia is an independent predictor of worse postoperative outcomes, however blood transfusion also has known associated risks such as worse cancer outcomes and immune suppression. In this study, we tested the hypothesis that perioperative blood transfusion is an independent risk factor for postoperative complications following colectomy.

Methods: Patients undergoing colectomy from 2012-2013 were selected from the National Surgical Quality Improvement Program (NSQIP) targeted colectomy participant use file. Exclusion criteria included unavailability of preoperative hematocrit value, emergent operations, and ASA Class 5. Patients were divided into four groups based on receipt of perioperative blood transfusion: no transfusion, preoperative transfusion only, intra/postoperative transfusion only, or both. Univariate analysis using Chi-squared tests was performed to compare rates of postoperative complications between the four groups. Propensity scores were calculated separately for receipt of preoperative transfusion and intra/postoperative transfusion. Multivariate analysis was then performed utilizing a propensity score-adjusted multiple logistic regression model to predict 30-day postoperative complications.

Results: A total of 30,680 patients were included in the study, with an overall transfusion rate of 11.6% (n = 3572). On univariate analysis, transfusion was associated with significantly higher rates of postoperative morbidity (Table 1). The risk-adjusted multivariate model confirmed an increased risk of postoperative morbidity associated with preoperative transfusion alone (OR 1.36, 95% CI 1.09-1.71), with intra/postoperative transfusion alone (OR 2.11, 95% CI 1.92-2.31), and with both (OR 2.40, 95% CI 1.82-3.16). When examining the impact of timing of transfusion, intra/postoperative transfusion was independently associated with a higher risk of postoperative morbidity compared to preoperative transfusion (OR 1.55, 95% CI 1.23-1.95). Finally, preoperative transfusion is not associated with a significant change in 30-day postoperative complications in the setting of either mild/moderate anemia (OR 1.17, 95% CI 0.91-1.50) or severe anemia (OR 1.47, 95% CI 0.84-2.59).

Conclusion: In this study, we found that transfusion is an independent predictor of postoperative complications. While it is clear that sicker patients tend to receive transfusions, these findings suggest that at a minimum, transfusion is a marker of worse surgical outcomes, and possibly even contributes to postoperative morbidity. Furthermore, based on this retrospective data, anemic patients do not appear to benefit from preoperative transfusion, and therefore empiric preoperative transfusion may be exposing the patient to unnecessary risks.

12.15 A predictive model for parathyroid autograft during thyroidectomy

Posted on January 18, 2016

J. Y. Liu1, C. J. Weber1, J. Sharma1 1Emory University School Of Medicine,General Surgery,Atlanta, GA, USA

Introduction: A recognized complication of thyroidectomy is the development of permanent hypoparathyroidism (PH). In an effort to prevent this complication, parathyroid glands can be autografted during thyroidectomy. Our aim was to identify factors that increased the likelihood of a parathyroid autograft (PA) during thyroidectomies.

Methods: A database of patients undergoing thyroidectomy between 2008-2014 was queried. Frequency of PA, lobe and location of parathyroid, preoperative diagnosis, and type of procedure performed were analyzed. PA was performed when the parathyroid was inviable or in the specimen, and by finely mincing parathyroids and then injecting with a 14 gauge angiocatheter into the sternocleidomastoid muscle.

Results: 856 patients were analyzed with an autograft rate of 33.5% (n=286). PA occurred more frequently of the inferior parathyroids at 53.7% (n=153) compared to 27% (n=77) of the superior parathyroids and 19.3% (n=55) of both. All parathyroids were identified in 32.5% of cases (n=277). A single parathyroid was autografted in 211 cases, two in 66 and three in 9. On multivariate analysis, total thyroidectomy (TTX) (OR 16.5, p=<0.001), partial thyroidectomy (OR 4.6, p=0.047), and the identification of all parathyroids (OR 4.7, p=<0.001) were associated with increased use of PA. However, gland size, preoperative diagnosis and lymph node dissection did not increase the use of PA. Postoperative PTH was routinely measured in 138 patients undergoing TTX, and the rate of transient hypoparathyroidism was 35.5% (n=49); no patients developed PH.

Conclusion: We conclude PA is an effective adjunct to all thyroidectomies and is strongly associated with a TTX. PA can potentially prevent PH.

12.16 Effects of Anesthesia on Intraoperative Parathyroid Hormone Level in Thyroid and Parathyroid Surgery

Posted on January 18, 2016

D. S. Kim1, A. E. Barber1, R. C. Wang1 1University Of Nevada School Of Medicine,Division Of Otolaryngology-Head And Neck Surgery, Department Of Surgery,Las Vegas, NV, USA

Introduction:
Intraoperative parathyroid hormone (iPTH) assay is frequently employed as a predictive marker for postoperative hypocalcemia in total thyroidectomy and as an outcome measure in parathyroidectomy for primary hyperparathyroidism. However, studies have shown that, while parathyroid hormone (PTH) is primarily regulated by serum calcium levels, it is also partly influenced by alpha-adrenergic stimulation. In fact, the induction of general anesthesia with laryngoscopy and endotracheal intubation has been shown to increase catecholamine secretion significantly, thus causing a surge in PTH. At this time, the implication of these findings is not well understood in head and neck endocrine surgery. The aims of this study were to investigate the effect of anesthesia on iPTH in total thyroidectomy and parathyroidectomy and to understand the implications of the relationship in using iPTH as a surgical outcome parameter.

Methods:
This was a prospective cohort study with chart review. Thirty-seven patients undergoing total or completion thyroidectomy and seventeen patients undergoing parathyroidectomy for primary hyperparathyroidism at a tertiary level academic center and a community hospital between November 2014 and July 2015 were enrolled. PTH was measured at least at four time-points: pre-anesthesia (immediately prior to surgery), pre-incision (following anesthesia induction but before skin incision), post-excision (following complete excision of a thyroid or parathyroid gland) and post-operative (12 hours and beyond). Normal intact PTH was defined as 11.1 – 79.5 pg/ml.

Results:
iPTH increased globally following anesthesia induction and endotracheal intubation. In the total and completion thyroidectomy group, the mean pre-anesthesia and pre-incision PTH were 55.9 ± 15.2 pg/ml and 138 ± 42.2 pg/ml, respectively. The mean percentage increase from pre-anesthesia to pre-incision PTH was 149 ± 92.7% (range: 42 – 494%). In the parathyroidectomy group, the mean pre-anesthesia and pre-incision PTH were 176 ± 179 pg/ml and 254 ± 300 pg/ml, respectively. The mean percentage increase from pre-anesthesia to pre-incision PTH was 30.3 ± 38.6 % (range: 1 – 129%). The differences in PTH increases between two groups were significant (p<0.05). PTH normalized postoperatively in all patients in both groups. No incidence of postoperative vocal cord paresis or paralysis was observed.

Conclusion:
Parathyroid hormone rises following anesthesia induction and endotracheal intubation in total thyroidectomy and parathyroidectomy. However, the response is significantly blunted in patients undergoing parathyroidectomy compared to the total thyroidectomy group. Both phenomena should be taken into consideration when using iPTH as a therapeutic or predictive marker in head and neck endocrine surgery.

12.11 Recurrent inguinal hernia outcomes: A United States population based study (NIS Database 1988-2010)

Posted on January 18, 2016

S. Patil1, R. Chamberlain1,2,3 1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2Saint George’s University,Grenada, Grenada, Grenada 3Rutgers University,Surgery,Newark, NJ, USA

Introduction: The lifetime risk of inguinal hernia in American males is 25%. Nearly 600,000 inguinal hernia surgeries are performed in the US per year. Recurrent inguinal hernia (ReIH) remains a clinical challenge, with an incidence rate of up to 13%. This is the first population based study analyzing demographic, clinical characteristics and outcomes in patients with ReIH.

Methods: The National Inpatient Database (NIS 1988-2010) was queried to identify patients with ReIH. Discharge weights were applied to get National estimates. Three age groups were compared for demographic and clinical differences, using standard statistical methodology.

Results: 248,487 patients were identified with ReIH, with a mean age of 65.9±16.3 years, 60% of patients were >65 years of age, p < 0.001. Majority were males (95.6%) and Caucasians (86.1%). With increasing age ReIH decreased in Blacks and Hispanics, p <0.001. 55.5% had non-elective admissions and was common among all age groups, p <0.001. ReIH was less common in the Western part of the US (13.1%) similar in all age groups. The majority (61.6%) had an uncomplicated presentation, but the incidence of obstruction and strangulation rose with advancing age, p <0.001. The majority presented to Urban (80.5%), non-teaching (67.3%) hospitals. 50.6% received repair with mesh and 39.3% without mesh, the use of mesh increased with increasing age, p <0.001. 89.4% were discharged to home, with the highest discharge to a nursing home in patients > 65 years (8.4%). Overall in-hospital mortality was 0.7%, with highest in patients > 65 years (1.1%). The mean LOS was 3.2±4.3 days, highest in patients > 65 years, 3.8±4.9 days, p <0.001

Conclusion: ReIH is more common in patients > 65 years, males and Caucasians, with mortality as high as 1.2%. The higher nursing home discharges and higher mortality in the elderly population may be related to increasing co-morbidities. ReIH repair without mesh is performed in up to 40% of cases and is a cause for concern, representing a potential unmet educational challenge.

12.12 Outcomes of colorectal surgery performed after solid organ transplant; a single center experience

Posted on January 18, 2016

J. Kaplan1, M. Lin1, H. Chern1, J. Yoo2, J. Reza3, A. Sarin1 1University Of California – San Francisco,Surgery,San Francisco, CA, USA 2University Of California – San Francisco,School Of Medicine,San Francisco, CA, USA 3University Of California – San Francisco,Anesthesiology,San Francisco, CALIFORNIA, USA

Introduction: Solid organ transplant recipients comprise a unique group of patients due to their surgical history, medical comorbidities, and immunosuppressed state. The purpose of this study is to describe the early postoperative outcomes of abdominal colorectal operations in solid organ transplant recipients at an academic medical center.

Methods: A retrospective review was performed of all patients who underwent an abdominal operation on the colon or rectum after solid organ transplantation at a single tertiary medical center between 2000 and 2014. Information regarding demographics, comorbidities, medications at the time of surgery, indications, operative details and 30-day outcomes were recorded.

Results: 2539 patients underwent abdominal solid organ transplant between 2000 and 2014, of which 50 patients were identified that underwent 58 colorectal procedures following the transplant. The median age at colorectal surgery was 55 years and median time from transplantation to colon surgery was 4 years. The most common indication for colon surgery was diverticular disease with most patients having received a kidney, liver or lung. In this series, 45% of cases were performed emergently. Patients undergoing emergent operations were closer to the time of transplant (median time 11 months vs. 7 years, p=0.01) and were less likely to undergo primary anastomosis (7.7% vs. 84.4%, p<0.001). Overall, median length of stay was 8 days and the rate of anastomotic leak was 10% in patients with a primary anastomosis. The 30-day readmission rate was 35% and 30-day mortality rate 3.5%. Emergent surgery was associated with 7.9 times the odds of severe complications (95% CI 1.2-11.9, p<0.05).

Conclusion: Rarely do solid organ transplant patients require colorectal surgery. Though surgery in this cohort can be safely performed in tertiary medical centers, morbidity and readmission rates are high. Emergent surgery is a key negative predictor of adverse events. Transplant patients with known colorectal disease may benefit from earlier elective procedures to prevent the poor outcomes associated with emergent surgery.

12.13 Obesity-Related Comorbidity Outcomes 4 Years After Gastric Bypass And Sleeve Gastrectomy In Veterans

Posted on January 18, 2016

I. Nassour1,3, S. Kukreja1,3, J. P. Almandoz2, N. Puzziferri1,3 1University Of Texas Southwestern Medical Center,Surgery,Dallas, TX, USA 2University Of Texas Southwestern Medical Center,Endocrinology,Dallas, TX, USA 3VA North Texas Health Care System,Surgery,Dallas, TX, USA

Introduction: Veterans Affairs (VA) Health Care System patients undergoing bariatric surgery differ from other groups as having greater: numbers of men, age, and prevalence of metabolic comorbidities. While bariatric surgery significantly improves weight and cardiometabolic risk factors, there is limited long-term evidence of outcomes in men or cohorts with complete follow-up. We evaluated 4-year outcomes of VA patients following Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) in regards to weight, type 2 diabetes mellitus (T2DM), hypertension (HTN), hypertriglyceridemia, low high-density lipoprotein cholesterol (HDL), and complications.

Methods: Consecutive patients who underwent RYGB or SG at the Dallas VA from 2003 to 2011 were retrospectively reviewed. Collected data included demographics, weight, body mass index (BMI), comorbidity diagnoses, medications, and complications. Outcome means for weight and BMI were compared by t-test. Partial remission for T2DM was defined as: hemoglobin A1c <6.5%, without medications. Remission was defined as: blood pressure <140/90 mmHg without medications for HTN; triglycerides <150 mg/dl without medications for hypertriglyceridemia; and HDL >40 mg/dl without medications for low HDL.

Results:256 patients (59% male; mean age 53) underwent RYGB (n=159; 140/159 open technique) and SG (n=97). Ninety-five percent of patients were followed to 4 years after surgery. Mean preoperative weight and BMI were 132 kg (SD=25) and 44 kg/m2 (SD=7) respectively. Baseline comorbity prevalence was 52%T2DM, 83% HTN, 67% hypertriglyceridemia, and 64% low HDL. At 4 years, the mean weight was 104 kg (SD=26; p <0.001) and mean BMI 35 kg/m2 (SD=7; p <0.001). Patients lost more weight after RYGB than SG (68 kg, 95% Cl (60.7, 74.0) vs. 28 kg, 95% CI (21.9, 35.0); p=0.01). T2DM partial remission rates were 35% after RYGB, and 19% after SG. HTN remission rates were 23% after RYGB, and 21% after SG. Hypertriglyceridemia and low HDL remission rates were 34% each after RYGB; 20% and 12%, respectively, after SG. Complications (>30 days post surgery) occurred in 27% of SG patients (n=26) and in 61% of RYGB patients (n=97). Most late complications were micronutrient deficiencies: 42% after RYGB, 26% after SG. Complications requiring reoperation included: hernia, cholecystitis, and obstruction (n=31,RYGB, 31/37 open technique; n=4, SG). Ten deaths occurred 1-4 years after RYGB (n=7) and SG (n=3).

Conclusion:VA patients who underwent RYGB or SG demonstrated significant and durable weight loss with improvement in obesity-related comorbidities at 4-year follow-up. RYGB yielded greater weight loss, and remission rates for T2DM, hypertriglyceridemia, and low HDL. HTN remission rates were similar for both operations. Late required reoperations after gastric bypass were associated with the open vs. laparoscopic approach. Micronutrient deficiencies are prevalent after both operations.

12.08 Risk Factors For Postoperative Hematoma After Inguinal Hernia Repair: An Update

Posted on January 18, 2016

M. H. Zeb1, M. M. El Khatib1, A. Chandra1, T. Pandian1, N. D. Naik1, D. S. Morris2, R. L. Smoot1, D. R. Farley1 1Mayo Clinic,Division Of Subspecialty General Surgery,Rochester, MN, USA 2Mayo Clinic,Division Of Trauma Critical Care & General Surgery,Rochester, MN, USA

Introduction:
Groin hematoma following inguinal herniorrhaphy (IHR) is an infrequent complication that can cause significant patient discomfort, require reoperation, and delay postoperative recovery. While we reported a decade ago on potential predictors for groin hematoma, we sensed an increase recently in the hematoma frequency in our practice. We aimed to reassess our experience with groin hematoma following IHR and provide a more updated assessment of the risk factors inherent to this complication.

Methods:

We retrospectively identified all adult patients (age ≥18 years) who developed groin hematoma following IHR at our institution between the years 2003-2015. Patients were matched to age and gender controls in a 1:1 ratio. Patient characteristics and operative details were extracted from the medical record. Univariate analyses (using Pearson’s chi-square test) were performed to assess for differences in baseline characteristics (BMI, medications, medical history, hernia operative technique). A p value ≤0.05 was considered statistically significant. A multivariable model was then constructed in stepwise fashion to assess for independent predictors of groin hematoma.

Results:
From 6608 inguinal hernia repairs, 96 patients developed a groin hematoma. The hematoma frequency increased from our previous study (1.4 % vs. 0.9%, p<0.01). Mean age in this cohort was 64.6 years (range: 18-92) and 84.3% were male. 48% of cases developed the hematoma within 48 hours of surgery. There was no significant difference in the location (left, right, bilateral), type (direct, indirect, pantaloon, first repair, or recurrent), or technique of hernia repair (Bassini, Lichtenstein, mesh plug, laparoscopic, or McVay) between study and control groups. Univariate analysis identified warfarin usage (OR 3.5, 95% CI [1.6, 6.4], p<0.01), valvular disease (OR 11.6, 95% CI [2.6,51.3], p<0.01), atrial fibrillation (OR 2.6, 95% CI [1.2,5.5], p=0.01), hypertension ( OR 2.03, 95% CI [1.1, 3.6], p=0.02), recurrent hernia (OR 3.7, 95% CI [1.4, 9.7], p<0.01), and coronary artery disease (OR 2.1, 95% CI [1.0, 4.4 ], p=0.05) as significant preoperative factors. The proportion of patients with warfarin usage decreased since our prior report (31% vs. 42%, p=0.2). On multivariable regression, warfarin usage and recurrent hernia were independent predictors of groin hematoma development.

Conclusion:
Groin hematoma after IHR has increased in frequency over the last decade at our institution. In our cohort, independent risk factors for the development of groin hematoma included warfarin use and recurrent hernia. Patients on warfarin therapy before elective IHR should be thoroughly assessed for appropriate cessation and resumption of anticoagulation prior to surgery. Surgical hypervigilance and meticulous hemostasis remains prudent in all patients undergoing IHR and especially those with recurrent inguinal hernia.

12.09 Comparison of two- and three-dimensional display for performance of laparoscopic total gastrectomy

Posted on January 18, 2016

S. Kanaji1, M. Nishi1, H. Harada1, M. Yamamoto1, K. Kanemitsu1, K. Yamashita1, T. Oshikiri1, Y. Sumi1, T. Nakamura1, S. Suzuki1, Y. Kakeji1 1Kobe University Graduate School Of Medicine,Division Of Gastrointestinal Surgery, Department Of Surgery,Kobe, HYOGO, Japan

Introduction: One of the major limitations of conventional laparoscopy is lack of depth perception. Introduction of 3D display might remove this technical obstacle and improve laparoscopic skills. There has been some reports demonstrated benefit of 3D imaging during simple laparoscopic procedure, such as cholecystectomy. It is still unclear whether 3D display also improve surgeons’ skill in complicated laparoscopic surgery. We attempt to analyze the effect of 3D technology on operative performance during laparoscopic total gastrectomy (LTG) for gastric cancer and to assess its advantages over 2D laparoscopy.

Methods: Consecutive 18 patients (3D group: n=10, 2D group: n=8) who underwent LTG followed by esophagojejunostomy with overlap method were analyzed. All cases were operated by same established manner by a single surgeon experienced in laparoscopic gastric surgery. The surgical outcomes were compared between 3D and 2D group. Further, we compared 3D with 2D in each laparoscopic scenes (lymphadenectomy and reconstruction) by the performance time, the frequency of any bleeding required hemostasis, and the frequency of reset surgical view by assistant’ forceps.

Results: All surgeries were completed without any complications. The total laparoscopic time was shorter in 3D group than 2D group (158 vs 195 min, P=0.045) and total blood loss was almost the same (86 vs 54 g, P=0.27) in between 2 group. The operative time was shorter in 3D group than 2D group during lymphadenectomy around celiac artery (26 vs 41 min, P<0.01) and esophagojejunostomy with overlap method (30 vs 49 min, P=0.04). The frequency of reset surgical view by assistant’ forceps were fewer only in lymphadenectomy around celiac artery (n=5.6 vs n=8.6, P<0.01).

Conclusion: Our results showed that LTG using the stereoscopic vision of 3D display can be done in shorter operative time. We consider LTG using 3D display is useful due to improve the surgical skill during difficult situation, such as lymphadenectomy around celiac artery where need handling in tangential view, and reconstruction using suturing technique in narrow space.

12.10 Location of Abnormal Parathyroid Glands: Lessons from 824 Parathyroidectomies

Posted on January 18, 2016

M. LoPinto1, G. A. Rubio1, Z. F. Khan1, T. M. Vaghaiwalla1, J. I. Lew1 1University Of Miami,Division Of Endocrine Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA

Introduction: Despite effective preoperative localization of single abnormal parathyroid glands for targeted parathyroidectomy (PTX) in patients with primary hyperparathyroidism (pHPT), localization failure by imaging studies can nevertheless occur. Knowledge of parathyroid gland location remains paramount, and provides the surgeon with a starting point for PTX when preoperative gland localization is unsuccessful. This purpose of this study was to determine any difference in the anatomic location for single abnormal parathyroid glands, which may help guide the surgeon in PTX when preoperative localization is unavailable or negative in patients with pHPT.

Methods: A retrospective review of prospectively collected data of 824 consecutive patients with pHPT who underwent initial PTX at a tertiary medical center was performed. All patients had elevated serum calcium and parathormone (PTH) levels above normal reference range, and single gland disease. Eutopic location of abnormal parathyroid glands in each patient was determined at time of operation, correlated with operative and pathology reports, and confirmed by operative success. Operative success was defined as continuous eucalcemia for >6 months after PTX. Patients with MEN, secondary, tertiary or familial hyperparathyroidism, multiglandular disease (MGD), parathyroid cancer and ectopic glands were excluded. Data were analyzed by chi squared and Z test analyses.

Results: Of these patients, single abnormal parathyroid glands were not evenly distributed among their 4 eutopic locations in the neck (left superior, n=128 (15.5%), left inferior, n=259 (31.4%), right superior, n=131 (16%), right inferior, n=306 (37.1%); p<0.0001). Abnormal inferior parathyroid glands were significantly more common than abnormal superior glands, respectively (n=565 (68.6%) vs. n=259 (31.4%); p <0.0001). Overall, there was no significant difference in abnormal gland laterality (right, n=437 (53%) vs. left, n=387 (47%), p=0.08). However, in the subset of men, the most common location for abnormal parathyroid glands was right inferior position (43.5%, 95% CI 36.3-50.8% p<0.0001).

Conclusion: This large series of patients with pHPT suggests that single eutopic abnormal parathyroid glands are more likely to be found in the inferior location. In women, this finding can be used in conjunction with intraoperative selective venous sampling and/or parathyroid hormone monitoring for further lateralization of abnormal gland position. In men, however, if an abnormal parathyroid gland is not localized preoperatively, the right inferior location should be explored first. Nevertheless, success of such operations remains predicated on knowledge of parathyroid anatomy and the experience and judgement of the surgeon.

12.04 Early versus Late Hospital Readmission after Combined Major Surgical Procedures

Posted on January 18, 2016

Y. Kim1, F. Gani1, A. Ejaz2, L. Xu1, J. K. Canner1, E. B. Schneider1, T. M. Pawlik1 1Johns Hopkins University School Of Medicine,Baltimore, MD, USA 2University Of Illinois At Chicago,Chicago, IL, USA

Introduction: Most studies report data on readmission within 30-days of discharge from the same hospital following a single procedure. Readmission after combined multiple surgical procedures is common, but data comparing patterns of readmission are rare. We therefore sought to define the incidence of early versus late hospital readmission among patients experiencing combined major surgeries.

Methods: Patients discharged after ten major surgical procedures (CABG, AAA, carotid endarterectomy, aortic valve replacement, esophagectomy, gastrectomy, pancreatectomy, pulmonary resection, hepatectomy, colorectal resection) between 2010 and 2012 were identified from a large employer-provided health plan. Unplanned readmissions among patients who underwent combined surgical procedures were analyzed.

Results: 3,358 patients experiencing combined major surgeries were identified? median patient age was 59 years, 69.6% were male, and 53.6% had Charlson Comorbidity Index (CCI) of ≥2. Median length-of-stay (LOS) was 8 (IQR 6-13) days. 2,933 (84.4%) of patients were discharged home of which 41.0% (n=1,162) were discharged home under care. 3.8% (n=127) of patients had died during the index hospitalization. Among the 723 (21.5%) patients who experienced readmission, 465 (13.8%) had a readmission within 30-days while 258 (7.7%) were readmitted within 31-90 days (Figure). Median time to readmission was 19 (IQR 8-44) days. In-hospital mortality (1.7% vs. 1.5%) and length-of-stay(4 vs. 3 days) were comparable among patients readmitted early and late(both P>0.05). On multivariable analyses, CCI (≥2: Odds Ratio [OR] 1.63, 95%CI 1.37-1.94), LOS (OR 1.02, 95%CI 1.01-1.03) and postoperative complication (OR 1.26, 95%CI 1.06-1.51) were associated with 90 day readmission. The most common reason for early and late readmission were postoperative infection (12.7%) and pneumonia (3.9%), respectively.

Conclusion: More than one third of readmissions occurred beyond 30-days after combined major surgical procedures. Assessment of only 30-day same hospital readmissions underestimates the actual impact of readmission among patients undergoing complex procedures.

12.05 The Need For Specialized Geriatric General Surgery Centers​

Posted on January 18, 2016

A. A. Haider1, P. Rhee1, N. Kulvatunyou1, T. O’Keeffe1, A. Tang1, R. Latifi1, G. Vercruysse1, J. Mohler1, M. Fain1, B. Joseph1 1University Of Arizona,Trauma Surgery,Tucson, AZ, USA

Introduction:
Emergency general surgery (Acute appendicitis, cholecystitis, and diverticulitis) remains one of the most common diagnoses seen by general surgeons. As the US population ages, the number of geriatric patients that present with this diagnosis is also on the rise. The aim of this study was to determine if hospitals that manage higher proportion of geriatric patients have better outcomes.

Methods:
The National Inpatient Sample was abstracted for all geriatric patients (≥ 65 years) with a diagnosis of acute appendicitis, cholecystitis, or diverticulitis from the years 2004 to 2011. Only hospitals with annual EGS volume of ≥ 500 patients were included. Hospitalized were categorized into 5 groups by the proportion of geriatric EGS patients seen. Multivariate regression models and observed-expected ratios were used to calculate the risk-adjusted mortality rates (RAMR) and risk-adjusted failure-to rescue rates (RAFTR).

Results:
A total of 253,800 patients from 817 hospitals were included. Mean age was 76.9 ± 7.8 years, 40.0% were male, and mean Charlson Comorbidity Index was 1.03 ±1.4. Overall mortality rate was 3.2% and failure-to-rescue rate was 2.4%. Geriatric patients had 43% lower odds of mortality (OR, 0.57; 95% CI, 0.43–0.76), and 49% lower odds of failure-to-rescue (OR, 0.51; 95% confidence interval, 0.37–0.71) if they are treated at centers managing a high proportion of geriatric EGS cases.

Conclusion:
Geriatric patients who are managed at hospitals that manage a higher proportion of geriatric patients have better outcomes. These findings supports the idea for the need of specialized geriatric centers that handle predominantly geriatric surgical cases.

12.06 Outcomes of Resection of Locoregionally Recurrent Colon Cancer: A Systematic Review

Posted on January 18, 2016

T. Chesney1, A. Nadler2, S. A. Acuna3,4, C. J. Swallow1,5 1University Of Toronto,Division Of General Surgery, Department Of Surgery,Toronto, ON, Canada 2Fox Chase Cancer Center,Department Of Surgical Oncology,Philadelphia, PA, USA 3University Of Toronto,Institute Of Health Policy, Management And Education,Toronto, ON, Canada 4St. Michael’s Hospital,Li Ka Shing Knowledge Institute And Department Of Surgery,Toronto, ON, Canada 5Mount Sinai Hospital,Division Of General Surgery, Department Of Surgery,Toronto, ON, Canada

Background: The role of resection for locoregionally recurrent colon cancer (LRCC) is unclear. Given that surveillance efforts aim to detect recurrence early to allow further intervention, we systematically reviewed all published evidence for the outcomes of resection of LRCC.

Methods: a systematic search was performed in MEDLINE, EMBASE, and Cochrane Library to identify studies that reported overall survival following resection of LRCC and included 10 or more patients. We present the pooled re-recurrence, and 3-year and 5-year overall survival (OS) rates along with a narrative synthesis of primary tumour and LRCC characteristics, treatment of LRCC and its associated morbidity.

Results: Nine case series were identified reporting outcomes of 543 patients; one of which was population-based. Although a significant proportion of patients (42.2%) who underwent resection experienced morbidity, the 30-day post-operative mortality was low (2.6%). An R0 resection was achieved in half of the patients (48.3%) who underwent surgical resection with good survival rates (3-year OS 57.6%, 95% CI: 39.2–76.0; 5-year OS 52.1%, 95% CI: 32.2-72.0). Patients with microscopic residual disease (R1) had poorer survival (3-year OS 26.8%, 95% CI: 12.3–41.2; 5-year OS 11.4%, 95% CI: 2.0-24.7). Macroscopic residual disease (R2) had no 5-year survivors. The pooled re-recurrence rate was 25.1% overall.

Conclusion: The literature for resection of LRCC is limited to case series. The summarized studies suggest LRCC resection can be performed safely and half of patients in whom a complete resection is achieved survive for 5 years or more. These outcomes in highly selected patients exceed those normally associated with LRCC. However, the evidence available does not allow us to ascertain whether this is the result of the surgical resection or patient selection.

12.07 Resident Participation in Fixation of Intertrochanteric Hip Fractures: Analysis of the NSQIP Database

Posted on January 18, 2016

A. L. Neuwirth1, M. G. Neuwirth1, R. N. Stitzlein1, R. R. Kelz1, S. Mehta1 1Hospital Of The University Of Pennsylvania,Philadelphia, PA, USA

Introduction: Intertrochanteric (IT) hip fracture fixation can be accomplished using either extramedullary (sliding hip screw) or intramedullary implants. Operative fixation techniques for hip fractures are taught with graduated levels of responsibility and involvement for the residents. Given the substantial morbidity and mortality associated with hip fractures in the elderly, understanding the effect of resident participation is important both to mitigate risk and to best prepare the next generation of surgeons. The goal of this study was to determine the effect of resident participation on outcomes in the treatment of IT hip fractures.

Methods: Patients who underwent operative treatment for IT hip fractures with either extramedullary (CPT 27244) or intramedullary (CPT 27245) fixation were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Patients were grouped and analyzed according to surgical fixation type and status of resident participation (RP) for the procedure. Primary outcomes were death and serious morbidity, secondary outcomes included operative time, total anesthesia time, hospital length of stay and time to discharge. Non-parametric analysis was performed using Chi-squared and Wilcoxon ranked sum tests, as well as multivariate logistic regression analysis to examine the association between RP and significant outcomes.

Results: In 8,384 patients who underwent IT hip fracture fixation, data for RP was available for 21% of all cases (n=1764), with a rate of 31.3%. Residents at the PGY4 level most frequently assisted (26.9%). For all IT hip fractures, there were no statistically significant differences in 30-day mortality (7.8% vs 6.3%, p=.264), morbidity (43.2% vs 44.9%, p=.506) or overall death or serious morbidity (49.1% vs 48.1%, p=.699) in the RP and non-RP groups. The RP group did demonstrate a significant increase in some secondary outcome parameters (see Table). There was no significant difference in overall death or serious morbidity rate when EM (42.9% vs 47.6%, p=.296) and IM (51.8% vs 48.4%, p=.271) fixation were analyzed independently.

Conclusion: RP in IT hip fracture fixation was not associated with an increase in morbidity and mortality for either EM or IM fixation. RP was associated with increased operative and anesthesia times in both EM and IM fixation, and with increased length of stay and time to discharge following operation in the IM group. Patients with IT hip fractures are at high risk for perioperative complications regardless of RP. While attending supervision is necessary, residents can and should be involved in the care of these patients without concern that resident involvement negatively impacts perioperative morbidity and mortality.

12.01 Urinary tract infection present at the time of surgery increases risk of postoperative complications

Posted on January 18, 2016

C. J. Pokrzywa1, C. M. Papageorge2, L. Durbak2, G. D. Kennedy2 1University Of Wisconsin,School Of Medicine And Public Health,Madison, WI, USA 2University Of Wisconsin,General Surgery,Madison, WI, USA

Introduction: It has been suggested in the orthopedic surgery literature that preoperative urinary tract infection (UTI) may be associated with surgical site infections secondary to hematogenous spread of bacteria. However, association between preoperative UTI and postoperative complications has not been evaluated in general surgery populations. We hypothesized that UTI present at the time of surgery is associated with higher incidence of short-term postoperative morbidity in patients undergoing elective general surgery.

Methods: Patients undergoing elective general surgical procedures from 2011-2013 were selected from the national American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) participant use file. Exclusion criteria included emergent procedures, ASA class 5 or unknown, preoperative ventilator-dependence, SIRS, sepsis, septic shock, and missing preoperative UTI data. Patients were divided into two cohorts based on presence or absence of UTI at the time of surgery and were then matched 1:2 (case:control) on age, ASA class, and primary CPT. Univariate analysis was performed using Chi-squared or Fisher’s exact tests to compare the two cohorts with regards to patient demographics, comorbidities, and postoperative complication rates. Postoperative morbidity was analyzed using multiple logistic regression to control for baseline differences between the two groups.

Results: A total of 434,802 patients were identified for inclusion in the study, with an overall preoperative UTI rate of 0.08% (n = 363). After matching, there were 353 patients with UTI and 706 without UTI. The two groups were similar with regards to age, BMI, ASA class, and most comorbidities. There were more females, more Caucasians, fewer Hispanics, more inpatients, and higher frequency of dependent functional status, wound infection, weight loss, and preoperative transfusion in the UTI group. On univariate analysis, the UTI group had a significantly higher incidence of overall morbidity, infectious complications, and non-infectious complications (Table 1). The multivariate analysis confirmed a higher odds ratio of overall postoperative morbidity associated with preoperative UTI when controlling for baseline differences between the two groups (OR 1.504, 95% CI: 1.025-2.207).

Conclusions: We demonstrated an increased rate of 30-day complications in general surgery patients with UTI present at the time of surgery. As surgeons strive to provide safer, higher-quality care, these findings suggest there may be value in attempting to identify and treat UTI preoperatively in patients scheduled for elective general surgery procedures.

12.02 Do suspicious USG Features and BRAF-V600E Mutation Correlate in Papillary Thyroid Cancer Patients?

Posted on January 18, 2016

F. Murad1, M. Anwar1, Z. Al-Qurayshi1, Z. Abd Elmageed1, R. Kholmatov1, K. Tsumagari1, O. Emejulu1, E. Kandil1 1Tulane University School Of Medicine,Department Of Surgery,New Orleans, LA, USA

Introduction:

BRAFV600E mutation is commonly present in patients with papillary thyroid cancer (PTC) and correlates with a higher risk of metastasis and disease recurrence. Herein, we aim to examine the correlation between suspicious ultrasonographic features of the thyroid nodules and BRAFV600E mutation in patients with PTC.

Methods:

This is a retrospective study of patients with PTC who underwent surgery by a single surgeon who also performed routine preoperative ultrasound examination. Malignant specimens were tested for the BRAF V600E mutation by PCR. Suspicious USG features were correlated with BRAF V600E mutation using student's t test for continuous variables and Fisher's exact test for categorical variables. Significance level was set at p<0.05.

Results:

Out of 608 patients who underwent thyroid surgery, 19.6% (119) were diagnosed with PTC. BRAF V600E mutation was positive in 50.7% of PTC cases. Nodular microcalcifications on ultrasonography were found to be significantly associated with BRAFV600E mutation (OR: 4.50; 95% CI: 1.48-13.67, p= 0.008). Other ultrasonographic features, such as internal vascularity, irregular margins, and hypoechogenicity were not associated with BRAF V600E mutation. (p= 0.60, 0.78, and 0.20, respectively). There was also no significant correlation between BRAF mutation and gender, race or age (p= 1.00, 0.30, and 0.91, respectively).

Conclusions:

Microcalcifications on ultrasonography were correlated with a positive BRAF V600E mutation in patients with PTC. However, larger multi-institutional studies are warranted to further investigate this correlation.

12.03 Preoperative Predictors of Discharge to a Higher Level of Care Following Colon Resection

Posted on January 18, 2016

A. N. Stumpf2, C. M. Papageorge2, G. D. Kennedy2 2University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction: Preoperatively anticipating the discharge destination of patients contributes to quality patient-doctor conversations regarding long term goals and quality of life. Additionally, previous literature has found that early identification of discharge destination may decrease the hospital length of stay and improve patient care planning. The purpose of this study was to identify preoperative predictors of discharge to higher level of care in patients undergoing colectomy.

Methods: Patients undergoing colectomy in 2012-2013 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) targeted colectomy database. Exclusion criteria included death before discharge; discharge to a facility that was already home; unknown discharge destination; discharge to a separate acute care facility; outpatient surgery; and ASA Class 5 or unknown. Two cohorts were established based on discharge destination. One group included all patients discharged to home, while the other consisted of those discharged to an increased level of care (ILC), which was defined as a skilled or unskilled nursing facility or rehab that was not originally home. Univariate analysis was performed using Chi-squared tests for categorical variables and Student’s t-tests for continuous variables to identify patient characteristics, comorbidities, and operative factors associated with discharge to ILC. Variables with p-value <0.1 on univariate analysis were included in a multivariate model in order to identify the variables with the largest independent contribution to discharge destination.

Results: A total of 36,492 patients were included in this study, with a rate of discharge to ILC of 11.2% (n = 4111). The mean age of the ILC group was 73 years of age, compared to 60 years in those discharged to home (p=<0.001). On univariate analysis, the ILC group had a significantly higher incidence of emergent cases, renal failure, insulin-dependent diabetes, preoperative wound infection, and preoperative systemic sepsis. Multivariate analysis (Table 1) confirms a higher odds ratio of several comorbidities when controlling for cohort differences at baseline.

Conclusion: As expected, discharge to an ILC was associated with a more dependent functional status, preoperative ventilator-dependence, and higher ASA class. These findings may contribute to a more informed discussion of postoperative expectations and planning in patients being considered for colectomy.

11.19 Pheochromocytoma with Synchronous Adrenal Cortical Adenoma

Posted on January 18, 2016

M. E. Hasassri3, T. K. Pandian1, I. Bancos2, W. F. Young2, M. L. Richards1, D. R. Farley1, G. B. Thompson1, T. J. McKenzie1 1Mayo Clinic,Division Of Subspecialty General Surgery,Rochester, MN, USA 2Mayo Clinic,Division Of Endocrinology, Diabetes, Metabolism, And Nutrition, Department Of Internal Medicine,Rochester, MN, USA 3Mayo Clinic,Mayo Medical School,Rochester, MN, USA

Introduction:
Pheochromocytoma with synchronous adrenal cortical adenoma (PSCA) is a rare condition and may present with mixed clinical and biochemical features characteristic to each neoplasm subtype. We reviewed our experience at a large tertiary referral center to better understand the clinical and perioperative characteristics of this unique clinical entity.

Methods:
With IRB approval, all patients with a pathologic diagnosis of pheochromocytoma with a synchronous ipsilateral adrenal cortical adenoma from January 1994 through June 2015 were identified. Retrospectively extracted data included indications for adrenalectomy, diagnostic work-up (biochemical and radiographic), operative characteristics, pathologic findings, and postoperative complications.

Results:

We identified 16 cases of PSCA among 413 patients undergoing adrenalectomies for pheochromocytoma (3.9%). Mean patient age was 57 years (range: 29-78); 50% were male. Median BMI was 28.5 kg/m2 (IQR 26.8, 30.8). In 12 cases (75%), the initial primary neoplasm was found incidentally on imaging for an unrelated issue. Only 8 cases (50%) were reported on imaging to have a synchronous ipsilateral neoplasm. The preoperative presumptive diagnosis included 9 pheochromocytomas (56%), 4 cortical adenomas (25%), and 3 PSCA (19%). Paroxysmal clinical symptoms of a pheochromocytoma were documented in 13 (81%) patients. Four patients (25%) were diagnosed preoperatively with clinically relevant autonomous cortisol overproduction (3 ACTH-independent, 1 ACTH-dependent). Two patients (13%) were diagnosed preoperatively with renin-independent hyperaldosteronism and both underwent adrenal venous sampling (AVS) with one patient developing hypertensive crisis during AVS. The initial surgical approach was laparoscopic (81%), open (13%), retroperitoneoscopic (6%). One laparoscopic operation was converted to open due to bleeding. No patient required transfusion, postoperative vasopressor support, ICU care, or reoperation. There was no other major morbidity. On pathology, mean pheochromocytoma size was 2.7 cm (range: 0.8-4.8) and mean cortical adenoma size was 1.8 cm (range: 0.3-4.4).

Conclusion:

An ipsilateral cortical adenoma was found in 3.9% of 413 adrenalectomies with a final pathologic diagnosis of pheochromocytoma. Clinically important cortical hormone secretion was diagnosed in 38% of these patients; 25% had glucocorticoid secretory autonomy and 13% had hyperaldosteronism. Physicians should be aware that adrenal neoplasms with mixed findings on imaging and biochemistry may represent synchronous pheochromocytoma and a functional adrenal cortical adenoma. If cross-sectional imaging is suggestive of cortical and medullary neoplasms, biochemical evaluation for this rare co-occurrence to prevent perioperative complications from resection of an unexpected secretory cortical neoplasm should be performed. This should be done cautiously to prevent precipitation of a pheochromocytoma crisis.

11.20 Impact of Teaching Hospital Status on Thyroidectomy Outcomes

Posted on January 18, 2016

S. C. Pitt1, M. A. Nehs2, N. L. Cho2, D. T. Ruan2, F. D. Moore2, A. A. Gawande2 1University Of Wisconsin,Department Of Surgery,Madison, WI, USA 2Brigham And Women’s Hospital,Department Of Surgery,Boston, MA, USA

Introduction: The impact of resident involvement on surgical outcomes is controversial since much of the data are contradictory. Furthermore, the role of resident participation specifically in thyroid surgery is not well understood. Therefore, we sought to determine whether teaching hospitals (THs) had disparate outcomes in a large, population level cohort of thyroidectomy patients.

Methods: We analyzed 9,798 patients who underwent thyroidectomy in the 2011 California State Inpatient (SID) and Ambulatory Surgery Databases (SASD). To assess TH status, the SID and SASD were linked to the California Hospitals Utilization data. Surgical procedures and outcome variables were defined by CPT and ICD-9 codes. Outcomes were analyzed based on TH status using ANOVA, as well as univariate and multivariate logistic regression methods.

Results: The minority of the 9,798 thyroidectomies were performed at THs (20.4%). Those patients treated at THs were similar to those at non-THs, but more likely to have thyroid cancer (42.1% vs. 31.7%), a total thyroidectomy (53.0% vs. 46.7%) or a lateral neck dissection (11.8% vs. 5.0%, p<0.0001 for all). Despite these differences, the overall complication and 30-day readmission rates were similar at TH and non-THs (9.1% vs. 8.9%, p=0.76, and 3.6% vs. 3.8%, p=0.65, respectively). However, when analyzing specific complications, recurrent laryngeal nerve (RLN) injuries were significantly more common at THs (1.9% vs. 0.9%, p<0.0001), while hypoparathyroidism (1.0% vs. 0.7%, p=0.20) and reoperative hematoma (0.7% vs. 0.8%, p=0.55) were comparable. In addition, the volume status of THs did not affect the RLN injury rate when examined as low (<50 cases/yr), medium (50-130 cases/yr), and high (>130 cases/yr) volume hospitals (p=0.15).

Assessment of factors, other than TH status, that were associated with RLN injuries revealed that nerve injuries patients were similar in gender, but significantly (p<0.001 for all) older (61.0 ± 16.4 vs. 53.3 ± 14.7 yrs), non-White (0.8% vs. 2.5%), not privately insured (38.4% vs. 62.7%), more likely to have >1 chronic medical condition (99.0% vs. 74.5%), thyroid cancer (6.7% vs. 1.7%), hypothyroidism (2.5% vs. 1.0%), and undergo total thyroidectomy (1.6% vs. 0.7%), or lateral neck dissection (4.8% vs. 0.9%). Multiple logistic regression revealed that TH status was independently associated with RLN injury (OR 2.43, 95% CI 1.54-3.83) when controlling for age, race, insurance type, comorbidities, thyroid cancer diagnosis, and procedure type.

Conclusion: While overall complication rates are not impacted when thyroidectomy is performed at a TH versus a non-TH, RLN injury rates are twice as high at TH. Whether this difference is due to resident involvement or is a reflection of referral bias and case complexity deserves further investigation.

11.21 Systematic Review of Emotional Intelligence in Surgical Education

Posted on January 18, 2016

G. Provenzano1, R. Appelbaum2, A. Bonaroti1,2, M. Erdman1,2, M. Browne2 1University Of South Florida College Of Medicine,Tampa, FL, USA 2Lehigh Valley Health Network,Allentown, PA, USA

Introduction: Emotional intelligence (EI) was first coined in 1990 as a successful leadership skillset comprised of self-management, social awareness, and empathy. EI has wide-reaching applications to the surgical field including teamwork, patient care, and job satisfaction. Positive linkage has been made between higher EI levels in both the patient-doctor relationship and physicians in a leadership role. The purpose of our systematic review was to evaluate the use of EI in surgical education and assess whether its prevalence has grown with the general acceptance of EI in many fields including medicine. A secondary aim was to compare the incorporation of EI in surgical education to other fields of graduate medical education.

Methods: A MEDLINE search was performed for publications containing both ‘surgery’ and ’emotional intelligence’ with at least one term present in the title. Articles were included if EI in surgical education was considered a significant focus. The results were grouped by publication date in 5-year increments to identify temporal trends. A separate series of MEDLINE searches were performed with the phrase ’emotional intelligence’ in any field and either ‘surg*’, ‘internal medicine’, ‘pediatric’, ‘neurology’, ‘obstetric’, ‘gynecology’, ‘OBGYN’, ’emergency’, and ‘psychiatr*’ in the title with no constraints on publication date. OBGYN articles were combined in one category. Articles were included if they discussed resident education as the primary subject.

Results: A total of 25 articles satisfied the MEDLINE search criteria and 7 articles satisfied inclusion criteria. These were sorted by publication date with 0, 1, and 6 articles published between 2001-2005, 2005-2010, and 2010-2015, respectively. Notable trends include: 1) EI is partially inborn, but proven to be learned; 2) Surgical residents have higher EI than the national average; 3) Educational shifts are needed to improve outcomes for the surgeon, patient, health network, and community at large. The comparative data for articles on EI and resident education showed 8 in surgery, 2 in internal medicine, 0 in pediatrics, 0 in neurology, 0 in OBGYN, 0 in emergency, and 4 in psychiatry.

Conclusion: Integration of EI principles is a growing trend within surgical education. Emphasis has been placed on quantitative assessment of EI in residents and residency applicants. Further study is warranted on the integration process of EI in surgical education and its impact on patient outcomes and long-term job satisfaction.

11.15 Delayed Cholecystectomy for Acute Calculous Cholecystitis – Drawbacks and Advantages.

Posted on January 18, 2016

J. B. Yuval1, H. Mazeh1, I. Mizrahi1, D. Weiss1, G. Almogy1, M. Bala1, B. Siam1, N. Simanovsky2, E. Kuchuk1, A. Eid1, A. J. Pikarsky1 1Hadassah-Hebrew University Medical Center,General Surgery,Jerusalem, N/A, Israel 2Hadassah-Hebrew University Medical Center,Radiology,Jerusalem, N/A, Israel

Introduction: Acute calculus cholecystitis (ACC) is one of the most common diseases in general surgery and is routinely managed by laparoscopic cholecystectomy (LC). Early and delayed LC are the two practiced approaches while there is inconclusive evidence regarding which is superior. At our medical center delayed cholecystectomy is practiced due to logistical constraints. The aim of this study is to evaluate the advantages and limitations of delayed LC in a large tertiary center.

Methods: A retrospective analysis of all patients admitted to our medical center with ACC between the beginning of 2003 and the end of 2012 was performed. Data collected included patient demographics and comorbidities, presenting symptoms, laboratory findings, blood cultures and imaging results. Data also included length of stay (LOS), time until surgery, and surgical complications.

Results: During the study period 1078 patients were admitted to our institution with the diagnosis of ACC. Of the entire cohort there were 593 females (55%) and the mean age was 57±1.5 years. Mean LOS at initial admission, re-hospitalization until surgery, and following delayed surgery were 7.0±0.7, 1.5±0.4, and 3.4±0.8, days, respectively. During the index admission 24% of patients required insertion of a cholecystostomy tube due to lack of improvement with conservative management. Only 640 (59%) patients eventually underwent delayed LC. Mean time from index admission to surgery was 97±12 days and 15% of patients were re-hospitalized in this time period. Conversion rate to open surgery was 5.8% and common bile duct (CBD) injury occurred in 1.1%. Postoperative complications occurred in 9.8% of the patients and the 30-day mortality was 0.6%.

Conclusion: The delayed LC approach is associated with significant loss of follow-up, long LOS, and robust use of PC. Conversion rates are lower than reported in the literature while the rates of bile duct injury and perioperative mortality are comparable.

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