11.16 Ultrasound of Thigh Muscle Can Predict Frailty in Elderly Patients but Not Sarcopenia

Posted on January 18, 2016

O. Al-Kathiri1, S. Y. Salim1, L. M. Warkentin1, A. Gallivan3, P. Tandon4, T. A. Churchill1, V. E. Baracos3, R. G. Khadaroo1,2 1University Of Alberta,Div. General Surgery/ Dept. Surgery,Edmonton, ALBERTA, Canada 2University Of Alberta,Div. Critical Care Medicine/ Dept. Surgery,Edmonton, ALBERTA, Canada 3University Of Alberta,Department Of Oncology,Edmonton, ALBERTA, Canada 4University Of Alberta,Div. Gastroenterolgy/ Dept. Medicine,Edmonton, ALBERTA, Canada

Introduction: Sarcopenia was identified as the loss of muscle mass and function that occurs with aging. It has been associated with high morbidity and mortality in patients over 65 years. Yet it is not part of the routine screening process in geriatric care. Computed tomography (CT) scan at the lumbar site L3 has been used as the gold standard tool to identify sarcopenia. Unfortunately high cost, limited availability, and radiation exposure limits the use of CT. We propose ultrasonography (US) of the thigh muscle as a possible objective, feasible, reproducible, portable, and risk free tool that can evaluate sarcopenia. The aim of this study was to evaluate US as a tool for the assessing sarcopenia in elderly patients.

Methods: We recruited 38 patients over 65 years old, referred to the Acute Care Surgery service. Using Sonosite US, thigh muscle thickness (measured at the midpoint between the greater trochanter, 10cm below and lateral to ASIS) was standardized to patient height. CT scan images at L3 were analyzed through SliceOmatic. Skeletal muscle index was calculated using skeletal muscle surface area. Sarcopenia was defined as skeletal muscle index < 41cm2/m2 for females and <43cm2/m2 or < 53cm2/m2 for males (with BMI <25kg/m2 or >25kg/m2, respectively). Rockwood Clinical Frailty score (1-3 non frail, >4 frail) was used to assess patient condition.

Results: The mean age of our preliminary study group was 78 ± 8 years and 68% (n=26) were females. Demographic, body composition, US and CT data of patients are described in Table 1. Sarcopenia was identified through CT in 69% of the patients. Sarcopenic patients had a greater number of in-hospital complications (48% vs 16.6% in non-sarcopenic, p =0.0001). There was no difference in duration of stay between sarcopenic and non-sarcopenic patients (14 vs 11 days, p=0.06). There were significant differences between sarcopenic and non-sarcopenic females in skeletal muscle surface area (113 ± 9 versus 91 ± 10 cm2, p < 0.001), and skeletal muscle index (35.2 versus 46.3 cm2/m2, p< 0.001). CT scan skeletal muscle index of sarcopenic patients showed significant correlation with frailty score (r2=0.21, p<0.05). US of rectus femoris in females was significantly associated with frailty score (r2=0.19, p=0.008). The receiver-operating characteristic (ROC) for thigh ultrasound was not able to distinguish sarcopenic patients (area ROC curve=0.6, p=0.8).

Conclusion: CT identified sarcopenia was associated with high-risk frail patients. US measured muscle thickness was predictive of frailty but not of CT identified sarcopenia. Further patient recruitment with thigh US is needed to determine the sensitivity of the use of US in screening for sarcopenia.

11.17 Serum Albumin Predicts Adverse Outcomes in Patients Undergoing Elective Colectomy for Benign Lesions

Posted on January 18, 2016

O. Trofymenko1, E. Telemi1, R. Venkat1, V. Nfonsam1 1University Of Arizona,Surgery,Tucson, AZ, USA

Introduction: Colorectal cancer is second most common cause of cancer related deaths in the United States. Many patients with benign neoplasms in colon and rectum undergo colectomy to prevent the development of malignancy. Preoperative serum albumin has been used to predict postoperative complication rates in colectomies.

Methods: NSQIP cross-institutional database was used for this study. The database contains records of more than 139 variables from multiple surgery types around United States from 2005 until 2012. 2068 patient records (n = 2,068) with a primary diagnosis of benign colorectal neoplasm who had elective colectomy performed were identified and used in the study. 75.48% underwent laparoscopic (n = 1,561) and 24.52% open (n = 507) colectomies. Preoperative serum albumin is a previously described and validated metric to describe the risk of surgery. Outcome measures included serious morbidity, overall morbidity, Clavien IV (requiring ICU), and Clavien V (mortality) complications.

Results: Median age was 65 years, and BMI was 28.0Kg/m2. 49.4% of patients were males. 45.9% of patients were assigned ASA Class 3 or higher. The median albumin was 4.1 (1.9 – 7.3). As preoperative serum albumin changed from less than 3.5 to 3.5 and above, overall morbidity decreased from 34.1% to 12.6% and serious morbidity decreased from 15.9% to 4.8%, respectively. The Clavien IV complications rate decreased from 9.4% to 2.5%. Mortality rate has decreased from 4.4% to 0.6%. All results were statistically significant at p<0.01. On a multivariate analysis preoperative serum albumin was independent predictor of serious morbidity (Adjusted Odd Ratio (AOR): 0.47, p<0.05), overall morbidity (AOR: 0.48, p<0.01), Clavien IV complication rates (AOR: 0.35, p<0.05) and mortality (AOR: 0.08, p<0.01), independent of age, sex, BMI, ASA class, modified frailty, type of colectomy (laparoscopic or open), and wound class.

Conclusion: As future patients undergo elective colectomies in treatment of benign neoplasm, low preoperative serum albumin should be used as a proxy for postoperative complications helping patients and physicians make a better informed decision with regards to the surgery.

11.12 Hand-Assisted Laparoscopic Versus Laparoscopic Colectomy: Are Outcomes and Operative Time Different?

Posted on January 18, 2016

B. F. Gilmore1, Z. Sun1, M. Adam1, J. Kim1, B. Ezekian1, C. Ong1, J. Migaly1, C. Mantyh1 1Duke University,Department Of Surgery,Durham, NC, USA

Introduction:
Hand-assisted laparoscopic (HAL) colectomy is a technique perceived to combine the benefits of laparoscopic surgery, while improving tactile feedback and operative time. Published data are largely limited to small, single institution studies. Our aim was to compare post-operative outcomes between HAL vs. standard laparoscopic (SL) approaches on a population level.

Methods:
The 2012-2013 National Surgical Quality Improvement Program Participant Data Use File was queried for patients undergoing elective SL or HAL colectomy. Patients were classified by surgical approach, underwent 1:1 propensity matching with a nearest neighbor algorithm, and had outcomes compared. An additional subgroup analysis was performed for patients undergoing segmental resections only.

Results:
A total of 13,949 patients were identified, of whom 6,084 (43.6%) underwent HAL colectomy. Following propensity matching, patients undergoing HAL vs. SL colectomy had higher rates of post-operative ileus (8.7% vs. 6.3%, p<0.001), wound complications (8.8% vs. 6.8%, p=0.006), and 30-day readmission (7.5% vs. 6.0%, p=0.002), without any differences in operative time (156 vs. 157 minutes, p=0.713). When considering only segmental colectomies, HAL remained associated with significantly higher rates of wound complications (8.6% vs. 6.5%, p=0.016), post-operative ileus (8.9% vs. 6.3%, p<0.001), and 30-day readmission (7.1% vs. 5.9%, p=0.041). There was again no difference in operative time between HAL and SL (145 vs. 145 minutes, p=0.334).

Conclusion:
Use of hand-assisted laparoscopic colectomy is associated with increased risk of wound complications, post-operative ileus, and readmissions. Importantly, this technique is not associated with any decrease in operative time. Our results suggest that utilization of hand-assisted technique should be discouraged, given its inferior outcomes. However, further investigations are warranted to determine situations where hand-assisted approach may be more appropriate, such as cases with increased technical difficulty.

11.13 The Effect of Hospital Volume Status on Bariatric Surgery Outcomes

Posted on January 18, 2016

A. A. Nair1, T. Mokhtari1, J. M. Morton2 1Stanford University School Of Medicine,Palo Alto, CA, USA 2Stanford University,General Surgery,Palo Alto, CA, USA

Introduction:

Accreditation for complex surgery has been traditionally based upon surgical volume. This volume initiative had evidence from a direct relationship between hospital volume and surgical outcomes across a variety of procedures. However, the variability of performance among low-volume hospitals has not been thoroughly explored. We investigated whether low volume hospitals are able to reach the same surgical outcomes standards set by high-volume centers.

Methods:

Using ICD -9 codes and the 2010 National Inpatient Survey, we analyzed 194 hospitals performing laparoscopic Roux-en-Y gastric bypass, laparoscopic gastric sleeve gastrectomy, and laparoscopic gastric banding. Hospitals were divided into low volume (LV) hospitals (< 50 cases annually) and high volume (HV) hospitals (≥ 50 cases annually) based on the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program standards (MBSAQIP). All patients with a prior history of cancer, IBD, UC, and FAP were excluded from analysis. All continuous variables were compared using t-test and weighted to represent national estimates. Statistical significance was defined as p < .05.

Results:

Surgical outcomes at 110 LV hospitals and 84 HV hospitals were analyzed. Both groups had similar proportions of complex patients based on the Charlson Comorbidity Index (score ≥ 1: .555 vs. .560, p = .8891). Most strikingly, 20 (18%) low volume hospitals met or exceeded the standards set by high volume centers in length of stay, complications, mortality, and discharge to home. On average, patients at HVH had a shorter inpatient stay (2.42 days vs. 4.21 days, p=.<.001) and had significantly less complications (.2211 vs. .5271, p=.0003) with a smaller proportion of patients experiencing any complications (15% vs 25%, p=.001). No significant difference was found in mortality (.07% vs. .34%, p=.11) or discharge to home (94.6% vs. 91.8%, p=.281).

Conclusion:

Our analysis suggests that a certain number of low volume hospitals are able to achieve the surgical outcomes of high volume hospitals.

11.14 Combined Enterectomy and Colectomy for Acute Mesenteric Ischemia Doubles Mortality

Posted on January 18, 2016

J. M. Shellenberger1, J. Clavenger1, L. Hanley1, S. Barnes1, S. Ahmad1 1University Of Missouri,Columbia, MO, USA

Introduction:
Acute mesenteric ischemia is a surgical emergency with a historical 30% thirty-day mortality. We analyzed the largest set of ACS NSQIP data in the literature to identify clinical variables that affect mortality for acute mesenteric ischemia.

Methods:
The ACS NSQIP database was queried from 2005 to 2013 for emergent operations for acute mesenteric ischemia. Inclusion criteria narrowed those cases to enterectomies, colectomies or combined as the initial operation. Univariate correlations were examined between mortality and pre-operative comorbidities, post-operative complications, and operations performed. A multivariate logistic regression model, controlled for age, gender and race was developed to evaluate the most significant univariate correlations.

Results:
5237 cases met the inclusion criteria and constituted the analysis group. Overall mortality rate was 28.7%. There were 1978 cases of isolated enterectomies, 2949 cases of isolated colectomies and 310 cases of combined resections. Mortality rates were 24.2%, 29.4% and 50.6% respectively. The increased risk of death with a combined small and large bowel resection was 2.74 (OR 95% CI 2.17-3.45). Pre-operative variables that most significantly increased the risk of death were ventilator dependence (OR 4.1, 95% CI 4.1-5.5), sepsis (OR 3.37, 95% CI 2.84-3.98), renal failure (OR 2.95, 95% CI 2.16-3.1), blood transfusion (OR 2.39, 95% CI 1.9 – 3.0) and time to OR from hospital admission greater than one day (OR 1.9, 95% CI 1.7-2.2). Post-operative outcomes that most significantly increased the risk of death were cardiac arrest (OR 10.2, 95% CI 6.69-15.48), septic shock (OR 2.4, 95% CI – 1.64-3.51), intra-operative blood transfusion (OR 2.1, 95% CI 1.7-2.5), renal failure (OR 1.87, 95% CI – 1.4-2.6), and post-operative blood transfusion (OR 1.5, 95% CI 1.2-1.9). In our multivariate logistical regression model pre-operative ventilator dependence (OR 3.6, 95% CI 2.9-4.5), sepsis (OR 1.9, 95% CI 1.5-2.4), post-operative septic shock (OR 2.9, 95% CI 2.3-3.7) and cardiac arrest (OR 11.13, 95% CI 7.2-17.2) were most predictive of mortality.

Conclusion:
Our analysis is the first suggestion of an increased risk of death with a combined small intestinal and colonic resection for acute mesenteric ischemia in the literature. This may reflect the extent, severity and progression of disease on initial presentation. Comorbidities, complications and timing of surgical intervention all contribute significantly to outcomes in the emergent surgical management of acute mesenteric ischemia.

11.09 Outcomes of Appendectomy Performed on Weekend or on the Next Day of Admission

Posted on January 18, 2016

Z. Al-Qurayshi1, E. Kandil1 1Tulane University School Of Medicine,Surgery,New Orleans, LA, USA

Introduction: Time from hospital admission to operative intervention has been suggested to be a crucial risk factor for a number of surgical interventions. In this study, we aim to compare the post-appendectomy outcomes for operations performed on the next day of admission or on weekend to same day and weekday operations respectively.

Methods: A cross-sectional study utilizing the Nationwide Inpatient Sample (NIS) database for 2004-2009. ICD-9 codes were used to identify all patients who underwent appendectomy for acute appendicitis.

Results: 341,376 discharge records were included. 55,485 (16.3%) patients had appendectomy on the next day of admission, while 70,701 (24.7%) patients had the operation on weekends. Next day operations were more likely to be associated with postoperative complications [OR: 1.22, 95%CI (1.14, 1.30), p<0.001]. A hospital stay of more than 3 days was also more common for next day interventions (p<0.001). Appendectomies performed on weekends had a higher risk of complications compared to other days [OR: 1.09, 95%CI (1.02, 1.17), p=0.009]. Teaching, and urban hospitals were more likely to perform the appendectomy on the next day of admission (p<0.05). Older patients (>65 years), females, Blacks and Hispanics, and those on Medicaid , all were at higher risk of next day intervention (p<0.001 each). The average cost of next day operations was higher compared to same day operations ($9,422.10±138.25 vs. $8,278.00±84.75, p<0.001).

Conclusion: Appendectomies performed on next day of admission or on weekend are associated with disadvantageous outcomes. Demographic and economic factors, besides the hospital attributes, place certain subpopulations at higher risk of next day appendectomies.

11.10 Effect of a Preoperative Decontamination Protocol on Surgical Site Infections in Elective Surgery

Posted on January 18, 2016

E. T. Vo1,2, C. N. Robinson1,2, D. M. Green1,2, B. L. Ehni1,2, P. Kougias1,2, A. Lara-Smalling2, N. Logan2, S. S. Awad1,2 1Baylor College Of Medicine,Department Of Surgery,Houston, TX, USA 2Michael E. DeBakey Veterans Affairs Medical Center,Department Of Surgery,Houston, TX, USA

Introduction: Surgical site infections (SSIs) are associated with an increase in postoperative length of stay, cost, unplanned readmissions, and mortality. Despite adherence to Surgical Care Improvement Project (SCIP) criteria, the rate of SSIs remains high. Therefore, several efforts have been directed towards preoperative strategies to reduce SSIs. We have previously demonstrated that a decontamination protocol using chlorhexidine gluconate (CHG) washcloths and intranasal povidone-iodine (PI) is effective in decreasing SSIs in patients undergoing elective orthopedic surgery. Our objective was to determine the impact of this decontamination protocol on SSIs in patients undergoing elective surgery across four surgical services.

Methods: A retrospective review of a prospectively maintained database was used to identify patients undergoing elective surgery from 2013 to 2015. The preoperative decontamination protocol consists of patients watching an educational video on decontamination at the preoperative visit and applying the CHG washcloths and oral rinse the night before and the morning of surgery, and the intranasal PI the morning of surgery. Participating services included general surgery (GS), neurosurgery (NS), orthopedic surgery (OS), and vascular surgery (VS). Widespread implementation of this protocol at our center began in 10/2014. Rates of SSI were captured through the Veterans Affairs Surgical Quality Improvement Program from 10/2013 to 6/2014 during the pre-intervention period and from 10/2014 to 6/2015 during the post-intervention period. Outcomes were compared by wound class (clean vs. clean contaminated) and by surgical specialty. During the entire study period, there were no differences in patient management or SCIP compliance. Univariate analysis was performed using chi-square.

Results: A total of 4952 cases were evaluated (pre=2529, post=2423), of which 1682 were OS (pre=805, post=877), 1483 GS (pre=737, post=746), 941 VS (pre=534, post=407), and 846 NS (pre=453 post=393). Clean cases totaled 4194 (pre=2125, post=2069) and clean contaminated cases totaled 758 (pre=404, post=354). Overall, the SSI rate was significantly lower in the intervention group (pre=1.6% vs. post=0.9%; P=0.03). By surgical specialty, there was a significant decrease in SSIs in OS (pre=1.4% vs. post=0.3%; P=0.02) and a trend towards lower SSI rates in GS (pre=2.3% vs. post=1.9%; P=0.56), VS (pre=1.5% vs. post=0.5%; P=0.14), and NS (pre=1.1% vs. post=0.8%; P=0.57). By wound class, there was a significant decrease in SSIs in clean cases (pre=1.1% vs. post=0.4%; P=0.01), and a trend towards lower SSI rates in clean contaminated cases (pre=4.2% vs. post=3.7%; P=0.71).

Conclusion: Our data demonstrates that widespread implementation of a preoperative decontamination protocol decreases SSIs among patients undergoing elective surgery, specifically for surgeries with a clean wound class. This protocol may be a preventative strategy for SSIs and warrants further study.

11.11 Assuring Survival of Safety-Net Surgical Patients

Posted on January 18, 2016

H. A. Pitt1,2, A. J. Goldberg2, A. S. Pathak2, J. A. Shinefeld1, S. M. Hinkle1, S. O. Rogers2, V. J. DiSesa1,2, L. R. Kaiser1,2 1Temple University,Health System,Philadelpha, PA, USA 2Temple University,Department Of Surgery,Philadelpha, PA, USA

Introduction: Survival of surgical inpatients is a key quality metric. Patient, surgeon and system factors all contribute to inpatient mortality, and sophisticated risk adjustment is required to assess outcomes. When mortality of general surgical patients was determined to be high at a safety-net hospital (53% Medicaid/Medical Assistance), a comprehensive approach was undertaken to improve patient survival. The aim of this analysis is to demonstrate that risk-adjusted mortality can be improved at an essential hospital through implementation of numerous best practices.

Methods: General surgical service line mortality was measured in the University HealthSystem Consortium (UHC) database from January 2013 through March 2015. Ten best practices were sequentially undertaken to reduce observed (O) and/or increase expected (E) mortality. These quality efforts included a) recruitment of new surgeons, b) participation in ACS-NSQIP, c) hardwiring Surviving Sepsis elements, d) increasing the number of diagnostic codes submitted, e) standardizing documentation in Preoperative Anesthesia Testing, f) expanding Palliative Care consultations, g) implementing an aspiration prevention protocol, h) initiating 100% mortality review, i) adopting an Early Warning System to detect sepsis and j) enhancing patient selection and preparation for surgery. UHC mortality rank, O, E and O/E ratios as well as early deaths were compared with control charts for the 27-month analysis. Statistical significance was set at the p<0.05 level. Case Mix Index, a financial metric which correlates positively with patient severity and procedure complexity, was monitored over the same time period.

Results:UHC general surgery mortality rank improved from the bottom decile to the top quartile among 102 Academic Medical Centers. Mortality data by quarter (Q) are presented in the Table.

During this time, Case Mix Index increased from 2.48 in Q1 2013 to 2.91 in Q1 2015.

Conclusion:Risk-adjusted mortality and early deaths decreased significantly over 27 months in general surgery patients. During this time, patient and procedure complexity increased by 17 percent as measured by Case Mix Index. Systematic implementation of quality best practices assured surgical patient survival at a safety-net medical center.

11.05 Frailty Predicts Postoperative Morbidity and Mortality after Colectomy for Ulcerative Colitis

Posted on January 18, 2016

E. Telemi1, O. Trofymenko1, R. Venkat1, V. Nfonsam1 1University Of Arizona,Surgery,Tucson, AZ, USA

Introduction: The rates of ulcerative colitis, an inflammatory bowel disease, have been on the rise in U.S. for last several decades. Colectomy can be performed when other treatment options cannot provide reasonable quality of life to patients with ulcerative colitis or if dysplastic changes are identified on colonoscopy. Frailty has been used to assess the risks of colectomy in patients with various diagnoses.

Methods: NSQIP cross-institutional database was used for this study. The database contains records of more than 139 variables from multiple surgery types around United States from 2005 until 2012. 650 patient records (n = 650) with a primary diagnosis of ulcerative colitis were identified and used in the study. 34.0% underwent laparoscopic (n = 221) and 66.00% open (n = 429) colectomies. Modified frailty index (mFI) is a previously described and validated 11-variable frailty measure used with NSQIP to assess frailty. Outcome measures included serious morbidity, overall morbidity, Clavien IV (requiring ICU), and Clavien V (mortality) complications.

Results: Median age was 47 years, and BMI was 25.2Kg/m2. 52.8% of patients were males. 43.8% of patients were assigned ASA Class 3 or higher. The median mFI was 0 (0 – 0.54) and median. As mFI increased from 0 (non-frail) to 0.36 and above, the overall morbidity and increased from 26.2% to 68.8% and serious morbidity increased from 16.6% to 68.8%, respectively. The Clavien IV complications rate increased from 3.8% to 56.3%. Mortality rate has increased from 0.2% to 6.3%. All results were statistically significant at p<0.01. On a multivariate analysis mFI was independent predictor of serious morbidity (Adjusted Odd Ratio (AOR): 16.9, p<0.05) and Clavien IV complication rates (AOR: 117.5, p<0.01), independent of age, sex, BMI, ASA category, preoperative albumin, type of colectomy (laparoscopic or open), emergency status of surgery, and wound class.

Conclusion: Morbidity and mortality risks after colectomy in patients can be predicted using frailty. This can help physicians and patients with ulcerative colitis better stratify risks while considering surgical treatment options for these patients

11.06 Are Lipomatous Tumors Metabolically Active? The Impact of Tumor Resection on Diabetes

Posted on January 18, 2016

F. Fallahian1,4, A. Ardestani1, C. Raut1,2,3, A. Tavakkoli1,2, E. Sheu1,2 1Brigham And Women’s Hospital,Boston, MA, USA 2Harvard Medical School,Boston, MA, USA 3Dana Farber Cancer Insititute,Boston, MA, USA 4University Of Missouri-Kansas City School Of Medicine,Kansas City, MO, USA

Introduction: The metabolic and immunologic properties of adipose tissue are linked to the pathogenesis of type 2 diabetes mellitus. Lipomatous tumors, such as liposarcomas, are rare but can reach significant size. We hypothesized that some lipomatous tumors are metabolically active and can alter systemic glucose homeostasis.

Methods: We performed a retrospective study of patients who underwent surgical excision of a lipomatous tumor at a tertiary cancer referral center (2004-2015). We divided patients into non-diabetics, well-controlled diabetics (HbA1c < 7), and poorly-controlled diabetics (HbA1c ≥ 7). We compared patient demographics, tumor characteristics, and measures of glycemic control among these groups both before and after tumor resection.

Results: 203 patients underwent 235 operations for lipomatous tumors. No differences were observed in tumor characteristics in patients with and without diabetes. However, tumor characteristics differed significantly between the well-controlled and poorly-controlled diabetics (Table 1). Patients with poorly-controlled diabetes had larger tumors that were more likely to be malignant and well-differentiated. Interestingly, we identified seven patients whose diabetes significantly improved with tumor resection. Overall, in the poorly-controlled diabetic group, there was a significant improvement in random blood glucose (109 mg/dL vs. 176 mg/dL, p < 0.05), without an associated change in BMI or number of diabetes medications, following tumor resection.

Conclusion: Development of a lipomatous tumor alone does not lead to diabetes. There was an association, however, between larger, malignant tumors and poorly-controlled diabetes. In a subset of patients, tumor resection improved glycemic control, suggesting that selected lipomatous tumors may be metabolically active.

11.07 Incidence of Central Venous Port Complications and Associated Factors

Posted on January 18, 2016

K. M. Babbitt1, C. S. Gunasekera1, P. P. Parikh1, R. J. Markert1, M. B. Roelle1, M. C. McCarthy1 1Wright State University,Department Of Surgery,Dayton, OH, USA

Introduction:
The requirement for reliable central venous access for chemotherapy administration and repeated phlebotomy has led to an increase in the placement of central venous ports. We investigated the incidence of complications associated with port placement and other factors.

Methods:
A retrospective chart review of ports placed at a large community hospital over a five-year period was performed. Demographics, BMI, preoperative diagnosis, port site, site of venous access, duration of port period, stage/nature of port complication, and use of steroids, TPN, and chemotherapy were collected. Chi square, Mann-Whitney, and Fisher’s Exact tests were used to analyze the data (SPSS Statistics 23.0, IBM, Armonk, NY).

Results:
Of 289 total patients, 68.2% were female. The mean age, BMI, and port duration were 57.6±13.5 years, 30.1±8.5 kg/m², and 291.7±192.5 days, respectively. The port sites were well balanced between the right and left chest wall (51.9% and 48.1%). Right chest wall placement had double the complication incidence compared to left chest wall placement (16.7% vs. 7.9%, p=0.024). Complications most commonly associated with right chest wall placement were port pocket infection and catheter related blood stream infection. Complications did not differ by venous access (internal jugular vein=13.8% vs. subclavian=11.1%, p=0.49). Complication incidence was nearly three times greater in steroid users vs. non-users (22.2% vs. 8.3%, p=0.016). Complication incidence did not differ between patients given or not given chemotherapy (p=0.24) or TPN (p=0.69). Moreover, there was no relationship between age, gender, port site, and venous access site and those complications that occurred five or more times (port pocket infection, catheter-related infection, and malfunctioning ports).

Conclusion:
These results suggest that the placement of ports in the right chest wall and steroid use could lead to a higher incidence of complications. The application of these findings could decrease complications related to port placement and improve both patient care and outcomes.

11.02 Trends in Surgical Management and Postoperative Outcomes of Emergency Surgery for Diverticulitis.

Posted on January 18, 2016

L. Durbak1, G. D. Kennedy1, E. H. Carchman1 1University Of Wisconsin,School Of Medicine And Public Health,Madison, WI, USA

Introduction: The risk of developing diverticulosis by the age of 80 is virtually 100%. Up to 20% of individuals with diverticulosis will require hospitalization with 20-50% of these patients requiring operative intervention, resulting in an estimated annual cost of $2.6 billion. This study aims to examine the postoperative outcomes in the setting of emergent surgical management of diverticulitis, and then try to examine if these changes correlated with changes in surgical practice.

Methods: Data was obtained from the ACS NSQIP PUFs from 2005 to 2013. Inclusion criteria were patients undergoing emer-gency surgery with a post-operative diagnosis of diverticula of the colon or diverticulitis with or without mention of hemorrhage. Multivariate regression models were developed using trends in pre-, intra- and postoperative variables identified through univariate analyses. The impact of practice variables were analyzed using multivariate regression models, adjusting for biases in surgical approach due to preoperative patient factors by including propensity scores for each practice variable.

Results:Preoperative comorbidities dyspnea, dependent functional status, ascites and >10% weight loss significantly decreased over the study period. Intraoperative variables ASA class 2 and clean/contaminated wound class significantly decreased over the study period. ASA class 3 and the dirty/infected wound class increased. Of the postoperative variables considered, length of stay, ventilator dependency, and renal insufficiency decreased while organ space surgical site infection and sepsis increased. Multivariate analyses of pre- and intraoperative variable as explanatory factors of postoperative complications suggested several significant relationships, notably ascites and dyspnea with worse outcomes and ASA classes 2 and 3 with better outcomes. The odds ratios for laparoscopy and stoma creation over time were statistically significant but very close to 1 (95% CI between 1.00-1.09).Laparoscopy was significantly associated with decreased odds of several surgical complications, regardless of propensity score adjustment. The stoma creation variable was associated with increased odds of surgical complications, but these associations disappeared after propensity score adjustment. The drain placement variable was only significantly associated with an increased odds of sepsis.

Conclusion: In conclusion, this analysis suggests that a lack of substantial change in surgical practices for patients presenting with diverticulitis in the emergency setting is associated with a lack of consistent improvement in patient outcomes. This research adds to the existing evidence of the benefits of laparoscopic management of diverticulitis in the emergency setting.

11.03 Gallstone Pancreatitis and Choledocholithiasis: Bilirubin Levels and Trends

Posted on January 18, 2016

D. D. Yeh1, P. Fagenholz1, N. Chokengarmwong1, Y. Chang1, K. Butler1, H. Kaafarani1, D. R. King1, M. DeMoya1, G. Velmahos1 1Massachusetts General Hospital,Trauma, Emergency Surgery, And Surgical Critical Care/Department Of Surgery/Harvard Medical School,Boston, MA, USA 2Massachusetts General Hospital,Department Of Medicine,Boston, MA, USA

Introduction: Gallstones escaping the gallbladder into the common bile duct (CBD) can cause complications such as pancreatitis or biliary stasis with risk of cholangitis. Evaluation for and treatment of retained CBD stones may be performed using pre- or post-operative endoscopic retrograde cholangiopancreatography (ERCP) or intra-operative cholangiogram (IOC). Ideally, these investigations should be limited to only cases with high pre-test probability of retained stones, as routine investigation may result in unnecessary procedures and prolonged hospitalization. We hypothesized that initial levels and trends in serum bilirubin levels are predictive of diagnostic yield of CBD investigations in patients presenting to the Emergency Department with evidence of gallstone pancreatitis (GP) or choledocholithiasis (CDL).

Methods: We performed a retrospective analysis of a prospectively collected registry of all patients undergoing cholecystectomy for GP or CDL by the Acute Care Surgery team at our academic, tertiary hospital from June 2010 to January 2014. Demographic, laboratory, radiologic, and operative data were collected. Patients were divided into groups according to diagnosis and whether or not they had retained CBD stones on ERCP or IOC. Summary statistics were used to describe continuous variables and compared with Wilcoxon rank sum, while proportions were calculated for categorical variables and compared with chi square. Statistical significance was defined as two-sided p<0.05.

Results: 64 patients underwent cholecystectomy for GP and 49 patients underwent cholecystectomy for CDL. Overall rate of retained CBD stones was low for GP and high for CDL (22% vs. 81%, p<0.001). For GP, the maximum total bilirubin (TB) and max direct bilirubin (DB) values were significantly different between patients with and without retained stones (Table). For CDL, initial TB, subsequent TB, max TB, initial DB, subsequent DB, and max DB were significantly different between groups (Table). Hospital and post-op LOS were not significantly different.

Conclusion: For GP and CDL, initial levels and trends in serum bilirubin levels are significantly different between patients with and without retained stones on CBD investigation. These labs may be useful in predicting if a CBD stone has already passed and whether or not CBD investigation will be worthwhile time, effort, and complication risk.

11.04 Does Concomitant Thyroidectomy Increase the Perioperative Complications of Parathyroidectomy?

Posted on January 18, 2016

C. M. Kiernan1, C. Schlegel1, S. Kavalukas1, C. Isom1, M. F. Peters1, C. C. Solorzano1 1Vanderbilt University Medical Center,Nashville, TN, USA

Introduction:
Concomitant thyroid pathology has been reported in 17-84% of patients with primary sporadic hyperparathyroidism (HPT). However, it remains unclear whether the perioperative risks of concomitant thyroidectomy are greater than those of parathyroidectomy alone. This study examines the frequency of coexisting thyroid disease, concomitant thyroidectomy rates and complications of patients who underwent parathyroidectomy for HPT.

Methods:
A retrospective review of prospectively collected data on 709 patients who underwent parathyroidectomy for HPT over a 5-year period at a high volume center was performed. Patients who underwent parathyroidectomy were compared to patients who underwent parathyroidectomy with a concomitant thyroid procedure (total thyroidectomy or thyroid lobectomy). Patients who underwent previous parathyroid or thyroid operations were excluded. Chi-square, fisher’s exact, student’s t-test and Wilcoxon rank-sum test were utilized to compare cohorts.

Results:

641 patients met inclusion criteria. 49% of patients had thyroid disease on preoperative ultrasound and 20% of such patients were deemed to require a concomitant thyroid procedure. 574 patients (90%) underwent parathyroidectomy alone and 67 patients (10%) underwent parathyroidectomy with a concomitant thyroidectomy. There were no differences in age, gender, ASA class, preoperative calcium, PTH, or vitamin D levels between groups. When compared to parathyroidectomy alone, parathyroidectomy with a concomitant thyroid procedure was associated with longer operative times (median 57 vs. 91mins, p<0.01), increased rate of overnight stay (17% vs. 69%, p <0.01), and increased rate of transient hypocalcemia (3% vs. 15%, p<0.01). There were no differences in the rate of postoperative emergency department visits (3% vs. 6%, p=0.15), readmissions (1% vs. 3%, p=0.09) or permanent hypoparathyroidism (0.5% vs. 0%, p=0.55). Overall, there were 5 operative failures, all occurred in the parathyroidectomy alone group. There were no postoperative hematomas or recurrent laryngeal nerve injuries in either group.

Conclusion:
In this study, parathyroidectomy with a concomitant thyroid procedure was associated with longer operative times, increased rate of overnight stay and increased transient hypocalcemia. However, a concomitant thyroid procedure during parathyroidectomy for HPT did not increase the risk of recurrent laryngeal nerve injury, postoperative hematoma, permanent hypoparathyroidism or immediate operative failure.

10.19 Disparities in the Receipt of Rehabilitation: A National Inspection of Acute Care Surgery Patients

Posted on January 18, 2016

M. A. Chaudhary1, A. Shah3, C. K. Zogg1, D. Metcalfe1, O. Olufajo1, E. J. Lilley1, A. Ranjit1, A. B. Chapital3, D. J. Johnson3, J. M. Havens2, A. Salim2, Z. Cooper1, A. H. Haider1 1Brigham And Women’s Hospital,Center For Surgery And Public Health, Harvard Medical School, Harvard T H Chan School Of Public Health,Boston, MA, USA 2Brigham And Women’s Hospital,Division Of Trauma, Burns And Surgical Critical Care,BOSTON, MA, USA 3Mayo Clinic In Arizona,Department Of Surgery,Phoenix, AZ, USA

Introduction:
Post-acute rehabilitation is increasingly recognized as a vital component of surgical care, necessary to restore patients’ pre-disease functional status. Unequal receipt of such care may prevent full recovery in underprivileged patients. Disparities in utilization of Acute Care Surgery (ACS) have been documented, but little is known about disparities in post-discharge rehabilitation services. This study sought to determine whether disparities exist in the receipt of post-discharge rehabilitation in ACS patients.

Methods:
The Nationwide Inpatient Sample (2007-2011) was queried for adult patients (≥18y) with an ACS primary diagnosis, including trauma and emergency general surgery (EGS) conditions defined by the American Association for the Surgery of Trauma (AAST). Two trauma subgroups – traumatic brain injury (TBI) and spinal cord injury (SCI) – were analyzed separately, as evidence suggests that they have specific rehabilitation needs. Patients that died in hospital were excluded and inpatients who survived were assessed for differential receipt of post-discharge inpatient rehabilitation. Multivariable logistic regression models were used to determine independent predictors of discharge to rehabilitation, adjusting for influence of patient- (age, race, gender, insurance status, income, disease severity, complications) and hospital- (volume, teaching status, location, bed size, geographical region) level covariates and accounting for clustering of patients within hospitals. Trauma, TBI and SCI models were further adjusted for Injury Severity Score (ISS).

Results:
A total of 5,228,453 patient records were included, weighted to represent 26,353,162 patients nationwide. Among ACS patients, 27.4% (n=1,460,934) were admitted for trauma and 72.6% (n=3,872,622) for EGS. Of these 133,439 (2.6%) were discharged to rehabilitation facilities. In the sub-groups, 7.7% of trauma, 0.6% of EGS, 6.5% of SCI and 2.3% of TBI patients were discharged to rehabilitation facilities. Black and Hispanic patients had 15-43% lower risk-adjusted odds of rehabilitation discharge relative to White patients, for both trauma and EGS diagnosis. Similarly, Medicaid beneficiaries (OR: 0.90 [0.87-0.93]) and uninsured patients (OR: 0.38 [CI: 0.37-0.40]) were less likely to be discharged to inpatient rehabilitation after trauma. ACS Patients treated at teaching (OR: 1.44 [CI: 1.42-1.46]) and urban (OR: 1.80 [CI: 1.75-1.83]) hospitals were more likely to be discharged to rehabilitation facilities. These findings persisted in the SCI sub-group analysis but became non-significant for the TBI group.

Conclusion:
Historically disadvantaged minorities, Medicaid beneficiaries, and those treated at rural and non-teaching centers had disparate receipt of inpatient rehabilitation, which may limit recovery. Further work should investigate the implications of these findings on post-operative and post-injury functional and quality-of-life outcomes.

10.20 Is Hospital Teaching Status Associated with Outcomes in Patients Admitted with EGS Conditions?

Posted on January 18, 2016

S. Jiao1,2, C. K. Zogg1, J. W. Scott1, L. L. Wolf1, A. Shah2, M. A. Chaudhary1, N. Changoor1, A. Salim3, E. B. Schneider1, A. H. Haider1 1Brigham And Women’s Hospital,Center For Surgery And Public Health, Harvard Medical School, Harvard T H Chan School Of Public Health,BOSTON, MA, USA 2Mayo Clinic In Arizona,Department Of Surgery,Phoenix, AZ, USA 3Brigham And Women’s Hospital,Division Of Trauma, Burns And Surgical Critical Care,BOSTON, MA, USA

Introduction:
Differences in outcomes between teaching (TH) versus non-teaching hospitals (NTH) have been reported among emergency general surgery (EGS) patients. Using a nationally representative sample, this study examined associations between hospital teaching status and surgical outcomes among EGS patients.

Methods:
Adult patients (≥18y) with a primary ICD-9 code for an EGS condition were identified in the 2007-2011 Nationwide Inpatient Sample. Analyses included only patients with complete data (except for race) who were non-electively admitted and underwent operative procedures. Cases were categorized into those managed at TH versus NTH and assessed for differences in patient- and hospital-level factors. Stratified analyses were conducted within the following diagnostic groups: colorectal pathology, intestinal obstruction, appendiceal disorder, hernias and vascular pathology. Outcomes included: major complications, in-hospital mortality, non-routine discharge, length of stay (LOS), and total hospital cost. Data were weighted to obtain national estimates, and clustering of patients within hospitals was accounted for. A combination of coarsened-exact matching and multivariable logistic/linear (family gamma, link log) regression was used to adjust for potential confounding.

Results:
A weighted total of 18,915,504 adult patients with complete data were admitted to inpatient care with EGS conditions between 2007-2011, 40.26% of whom were treated at THs. Overall, 6,395,624 (33.81%) underwent operations of which 69.02% were non-elective (64.82% in TH and 72.06% in NTH). The most common diagnoses within each of the 5 diagnostic groups listed were: diverticulitis, intestinal/peritoneal adhesion with obstruction, acute appendicitis, ventral hernia and arterial embolism, respectively. The odds of mortality was higher for all operatively managed EGS patients in TH (OR 1.07, 95% CI 1.01-1.13), which was also true for the most common diagnoses for colorectal pathologies (OR 1.40, 95% CI 1.13-1.73) and intestinal obstructions (OR 1.18, 95% CI 1.02-1.36), but not for the other 3 conditions. Interestingly, the odds of extended LOS was increased among patients with the most common diagnoses in colorectal pathology, intestinal obstruction and hernias if treated at TH, but was decreased for acute appendicitis. Treatment at TH was associated with increased odds of having total cost exceed the 75th percentile among patients with intestinal obstruction or ventral hernia.

Conclusion:
Differences in patient diagnosis-specific case-mix may account for much of the previously reported variability in EGS outcomes between TH and NTH. Future research should carefully consider the broad spectrum of diagnoses that constitute EGS conditions.

11.01 A Nomogram to Predict Perioperative Blood Transfusion Among Patients Undergoing Abdominal Surgery

Posted on January 18, 2016

Y. Kim1, F. Gani1, F. Bagante1, G. A. Margonis1, D. Wagner1, L. Xu1, S. Buttner1, J. O. Wasey2, S. M. Frank2, T. M. Pawlik1 1Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA 2Johns Hopkins University School Of Medicine,Anesthesiology And Critical Care Medicine,Baltimore, MD, USA

Introduction: Stratifying a patient’s risk for perioperative packed red blood cell (PRBC) transfusion when planning major abdominal surgery is of interest to both patients and providers. We sought to identify preoperative factors associated with receipt of PRBC to create a nomogram that predicts an individual’s risk of transfusion with major abdominal surgery.

Methods: A nomogram to predict receipt of perioperative transfusion was constructed using a cohort of patients who underwent hepato-pancreatico-biliary (HPB)(n=2,792) and colorectal (n=2,171) surgery between 2009-2014. Discrimination and calibration of the nomogram was tested using area-under-the-curve (AUC) receiving operator curves and calibration plots.

Results: Among 4,963 patients undergoing either a HPB (56.3%) or colorectal (43.7%) procedure, 1,549 received ≥1 unit of PRBC for a perioperative transfusion rate of 33.1%. On multivariable analysis, age ≥65years (OR=1.5), race (Black: OR=1.6, Asian: OR=1.9), male sex (OR=1.1), preoperative Hb ≤8g/dL (vs. >12g/dL: OR=27.5), preoperative INR>1.2 (OR=2.6), Charlson score>3 (OR=1.9), and procedure type (colon surgery, referent: minor hepatectomy OR=1.1, rectal surgery OR=1.4, major hepatectomy OR=1.7, distal pancreatectomy OR=2.1, whipple procedure OR=2.7) were associated with risk of transfusion (all P<0.05). A nomogram was constructed to predict receipt of transfusion using these variables (Figure). Discrimination and calibration of the nomogram revealed good predictive abilities (AUC 0.76). Bootstrap validation of model accuracy revealed minimal evidence of model overfit.

Conclusion: Independent preoperative variables were used to create a nomogram to predict the likelihood of PRBC transfusion. This nomogram may be useful in stratifying a patient’s risk of needing a blood transfusion around the time of major abdominal surgery.

10.16 Economies of Scale in the Provision of Minimally Invasive Surgery

Posted on January 18, 2016

L. Kuo1, K. D. Simmons1, R. R. Kelz1 1Hospital Of The University Of Pennsylvania,Surgery,Philadelphia, PA, USA

Introduction: Minimally invasive surgery (MIS) is often associated with higher costs than open operations due to expensive equipment. Institutions that perform higher volumes of an operation are associated with improved clinical outcomes, such as shorter lengths of stay and fewer postoperative complications, over low-volume institutions, and these improved outcomes may translate into lower associated costs. We sought to examine if economies of scale existed in the provision of MIS surgery.

Methods: A unique inpatient database using discharge data from three high-volume surgical states (California, Florida and New York) over a five-year period was used. Four common general surgery operation groups, for which the MIS approach offers improved or equivalent outcomes to the open technique, were selected: cholecystectomy, appendectomy, bariatric, and antireflux. For each operation, the per-hospital number of MIS operations and the associated wage-adjusted cost was obtained. Hospitals were categorized as low-volume (lowest 20%), moderate, and high volume (highest 20%) for each of the five MIS operations. The median associated wage-adjusted cost was compared between low, moderate and high-volume categories for each operation using the Kruskal-Wallis. The Bonferroni correction was used to adjust for multiple comparisons.

Results: For cholecystectomy, appendectomy, and antireflux procedures, low-volume institutions had a significantly higher median cost than moderate- and high-volume institutions. For cholecystectomy and appendectomy, high-volume institutions had the lowest median cost. For antireflux operations, moderate-volume institutions had the lowest median cost, although the difference may not be clinically significant. For bariatric procedures, cost increased with volume. See Table 1.

Conclusion: Economies of scale exist between low- vs. moderate- and high-volume institutions for all operations studied except bariatric. The highest-volume institutions did not always have the lowest associated costs. Costs associated with bariatric operations increased with volume, which may be related to restrictions on where high-risk patients receive bariatric surgery.

10.17 WHipple-ABACUS, A Simple, Validated Risk Score for 30-Day Mortality After Pancreaticoduodenectomy

Posted on January 18, 2016

E. Gleeson1, M. F. Shaikh1, A. E. Poor1, P. A. Shewokis1, J. R. Clarke1, D. S. Lind1, W. C. Meyers1, W. B. Bowne1 1Drexel University College Of Medicine,Surgery,Philadelphia, Pa, USA

Introduction: Pancreaticoduodenectomy (PD) is a high-risk procedure. There is need for simple validated risk models to better identify 30-day mortality. The goal of this study was to identify independent, preoperative risk factors and to develop a simple risk score to predict 30-day mortality after PD.

Methods: We reviewed all patients who underwent PD from 2005-2012 in the ACS-NSQIP databases. Logistic regression was used to identify preoperative risks for 30-day mortality from a development cohort ([DEVEL] random 80% of the database). The WHipple-ABACUS score was created using weighted beta coefficients and predictive accuracy was assessed on the validation cohort ([VALID] the remaining 20%) using a receiver operator characteristic curve and calculating the area under the curve (AUC).

Results: The 30-day mortality rate was 2.7% for patients who underwent PD (n=14,993). The DEVEL identified 8 independent risk factors: hypertension with medication, history of cardiac surgery, age > 62, bleeding disorder, albumin <3.5g/dL, disseminated cancer, use of steroids and systemic inflammatory response syndrome (SIRS). The score created from weighted beta coefficients (see Figure) had an AUC=0.71 (95%CI 0.66 to 0.77) using the VALID. Using the WHipple-ABACUS score: WHipple-ABACUS = hypertension With medication + History of cardiac surgery + Age>62 + 2*Bleeding disorder + Albumin<3.5g/dL + 2*disseminated Cancer + 2*Use of steroids + 2*SIRS, mortality rates increase with increasing score (p<0.001).

Conclusion: While other risk scores exist for 30-day mortality after PD, we present a simple, validated score developed using exclusively preoperative predictors that surgeons should use to optimize co-morbidities and inform patients of risk with this procedure.

10.18 Colonic Volvulus: An ACS-NSQIP Analysis

Posted on January 18, 2016

S. E. Koller2, E. A. Busch2, M. M. Philp2, H. Ross2, H. A. Pitt1,2 1Temple University,Health System,Philadelpha, PA, USA 2Temple University,School Of Medicine,Philadelpha, PA, USA

Introduction: Volvulus is uncommon and frequently occurs in older, frail patients who may be more likely to experience adverse surgical outcomes. Most analyses are single-institution studies performed over long time periods or come from administrative databases with poorly defined surgical outcomes. Thus, the aims of this study were to characterize the risk factors associated with poor outcomes in surgically managed volvulus patients using a large, contemporary database with well-defined 30-day outcomes.

Methods: The 2012 and 2013 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) Participant Use Files were employed for this analysis. Standard ACS-NSQIP definitions were used for patient, procedure and outcome data. Eight preoperative variables were combined as a composite to determine patient frailty. Patients with five more of these variables were determined to be frail. Primary outcomes of interest were overall and serious morbidity as well as 30-day mortality. Secondary outcomes included anastomotic leak and return to the operating room (OR). STATA 13.1 was used for univariate analyses and multivariable logistic regression.

Results:Colorectal resection was performed for volvulus in 903 of 29,219 patients (3.1%). The mean age was 49.5 years, but 334 patients (37.0%) were 75 years or older. Three hundred seventy-eight were men (41.9%), 691 were Caucasian (76.5%) and 95 were African American (10.5%). Ninety-five were frail (10.5%) and fourteen had significant weight loss (1.6%). Fifty-eight percent of the operations were performed emergently. A stoma was performed in 164 patients (18.2%), most frequently with partial colectomy (27.2%). Outcomes for all patients as well as for those who were frail or had a stoma are presented in the Table.

Factors that were independently associated with overall morbidity included age 75 years or more (OR 1.62, 95% CI 1.16-2.26, p<0.01), male sex (OR 1.49, 95% CI 1.09-2.02, p<0.02), African American race (OR 1.62, 95% CI 1.01-2.58, p<0.05) and weight loss (OR 5.04, 95% CI 1.50-16.97%, p<0.01). BMI, emergent procedure and operative approach did not influence overall morbidity.

Conclusion:Outcomes of colonic resection for volvulus are worse in the elderly and frail as well as in African Americans and men. Performance of a stoma may reduce the risk of an anastomotic leak. The decision to perform surgery in these high-risk patients should be undertaken with caution.

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