67.14 Revisional Bariatric Surgery in African Americans: Short Term Outcomes

Posted on January 18, 2016

J. S. Kendall1, G. Ortega1,2, K. Williams1, K. Hughes1, E. E. Cornwell1, T. M. Fullum1, D. D. Tran1 1Howard University College Of Medicine,Washington, DC, USA 2Johns Hopkins University School Of Medicine,Baltimore, MD, USA

Introduction: African Americans have the highest incidence of obesity compared to other groups, and some have benefitted greatly from weight loss operations. Unfortunately there has also been an increase in the need for revisional surgeries due to unsatisfactory weight loss or weight regain. We report the short term outcomes of revisional bariatric surgeries in African Americans at a tertiary academic medical center.

Methods: We conducted a retrospective study of eligible subjects identified at Howard University Hospital. Patients included were those who underwent revisional bariatric surgery over a 5 year period from August 2008 to July 2013. Data on the patients’ demographics, body mass index (BMI), and comorbid conditions were recorded prior to the surgery and at 1, 6, and 12 months post-surgery.

Results: 364 patients underwent bariatric surgeries during the time frame of the study. 77 (21%) of the 364 were revisional bariatric surgeries. The original surgery was Roux En Y gastric bypass (RNY) in 74 (97%) patients, laparoscopic adjustable gastric banding (LGB) in 2 (3%) patients, and biliopancreatic diversion (BPD) in 1 (1%) patient. The mean pre-op BMI before the original procedure was 54.3 kg/m2, and the mean nadir bmi was 33.4 kg/m2. The mean revisional pre-op BMI was 42.1 kg/m2 and the mean BMI 12 months post-revision was 34.8 kg/m2. Average percent excess weight loss (%EWL) was 32.1% 12 months post-revisional surgery. Paired sample t-test comparing the means of the nadir BMI after the original surgery to the BMI 12 months post-revisional surgery showed no statistical difference (p>0.05). 7 (9%) patients developed post-operative complications. 2 (3%) patients showed post-operative bleeding but only one required a transfusion. 2 (3%) patients developed an incisional hernia through the revisional surgery incision, needing reparative surgery. 1 (1%) patient developed a small bowel obstruction. 1 (1%) patient developed a gastrojejunal stricture needing repair, and 1 (1%) patient developed sepsis from a staple line leak that was repaired. There were no mortalities.

Conclusion: Revision bariatric surgery produces similar results to the original procedure, and is feasible and safe for African Americans who have experienced weight regain or unsatisfactory weight loss after the original bariatric procedure.

67.15 Short Term Outcomes of Abdominal and Colorectal Surgery in Patients with Heart Transplant

Posted on January 18, 2016

A. Asban1, M. Traa1, N. Melnitchouk2 1Tufts Medical Center,Colorectal Surgery,Boston, MA, USA 2Brigham And Women’s Hospital,Boston, MA, USA

Introduction:
Due to the increase in the successful rate of heart transplant surgery as well as dramatic improvement of immunosuppression medications, the risk and complications of a abdominal and colorectal surgery were poorly described in literature.

Methods:
This is a single institution study of 32 heart transplant recipients who underwent abdominal, including colorectal, operations at Tufts Medical Center between 2003 and 2013. Medical records were reviewed for comorbidities, immunosuppression status, duration post-transplant, type of surgery, type of anesthesia, intraoperative complications, estimated blood loss, postoperative complications, length of stay, readmission and reason of readmission and 30-day mortality rate.

Results:

Over the 11-year study period, 32 patients with heart transplant at Tufts Medical Center underwent a total of 50 colorectal (20%) and other abdominal (80%) operations. Colorectal operations included left colectomy, exploratory laparotomy with lysis of adhesion, small bowel resection and examination under anesthesia and fulguration of anal condyloma. The most common procedure overall were incision hernia (40%) and diaphragmatic hernia (18%). 74% of the surgeries were elective and 26% emergencies. 94% of cases were performed under general anesthesia. The study population was 87.5 male and 12.5% female wit mean age of 55 years. In 50% of patients the indication for heart transplant was ischemic heart disease. 58% of patients had undergone abdominal surgery previously, 100% of patients were on immunosuppression, and 46% were on steroids. The median time elapsed since transplant was 765 days (range 1-3,563 days). Intraoperative complications were limited to bleeding (2%) and hypotension (2%). Postoperative complications included deep surgical site infection (4%) and superficial surgical site infection (2%), none of which happened in the colorectal surgery group. Of the bowel resection with anastomoses there were no anastomotic leaks reported. There were no major cardiac events noted in the perioperative period although sinus tachycardia was common intraoperatively. The mean length of stay was 4 days, with an 8% readmission rate for post operative surgical causes (including management of surgical site infection or pneumonia). Thirty-day mortality rate was 0%

Conclusion:
Our experience suggests that abdominal and colorectal surgery in heart transplant recipients is relatively safe. The incidence of surgical site infections was comparable to the general population, and there were no anastomotic leaks in our small sample despite immunosuppression. Surgeons should evaluate heart transplant patients for abdominal and colorectal surgery as they would any other patient presenting for emergency or elective care.

67.16 Racial Disparities in Presentation and Management in Hyperthyroidism Patients Prior to Surgery

Posted on January 18, 2016

J. Kim1, T. S. Wang1, K. M. Doffek1, A. A. Carr1, D. B. Evans1, T. W. Yen1 1Medical College Of Wisconsin,Surgical Oncology,Milwaukee, WI, USA

Introduction: Racial disparities in thyroid cancer are well-documented. However, there is a paucity of information on racial differences in the management of benign thyroid disorders. We sought to determine whether racial disparities exist in the etiology, presentation, and management of hyperthyroid patients prior to surgical intervention.

Methods: A retrospective chart review of a prospectively collected database was performed of hyperthyroid patients who underwent thyroidectomy at a single institution from 01/2009 to 02/2014. Data collected included patient demographics, etiology of hyperthyroidism, type and duration of hyperthyroid symptoms (unintentional weight loss, palpitations, heat intolerance, anxiety, emotional lability, tremor, muscle weakness and eye symptoms), thyroid hormone levels, and use of antithyroid medications and radioactive iodine prior to surgery. Racial differences for etiology, presentation, and pre-surgical management were examined by chi-square or Kruskal-Wallis test.

Results: Of the 191 patients, the majority (73%) were white; 18% (n=34) were black and 9% (n=17) other or unknown races. The most common etiologies of hyperthyroidism were Graves’ disease (51%), toxic multinodular goiter (34%), and toxic thyroid nodule (10%). There was no difference in the etiology of hyperthyroidism by race. At least one symptom was reported in 159 (83%) patients. By race, there was no difference in the presence of reporting at least one symptom, the presence of each of the eight symptoms, the maximum duration of symptoms, or the median duration of each symptom, except for heat intolerance. The median duration of heat intolerance was longer in the non-white patients (10 months in Blacks and 13 months in other races) compared to three months in white patients (p=0.03). The total number of symptoms per patient differed by race; non-white patients reported more symptoms than white patients (4-4.5 vs. 3; p=0.03). There was no difference in preoperative TSH or free T4 values by race. Prior to surgery, 135 (71%) patients received antithyroid medication; there was no difference in receipt or duration of medication by race. Only 14 (7%) patients received radioactive iodine treatment prior to surgery; there was no difference by race.

Conclusion: In this cohort of largely white patients, we found no racial differences in the etiology of hyperthyroidism, presence and duration of symptoms, biochemical level of disease, and preoperative management, except the findings that non-white patients reported longer duration of heat intolerance and presented with more symptoms than white patients. Prospective studies in larger, more racially diverse populations that include hyperthyroid patients who are managed either medically or surgically are needed.

67.11 Seasonal Variation in Acute Cholecystitis: A Fourier Transform Analysis.

Posted on January 18, 2016

Z. Fong1, D. B. López1, R. La Placa2, G. Jin1, K. D. Lillemoe1, D. C. Chang1 1Massachusetts General Hospital,Surgery,Boston, MA, USA 2Massachusetts Institute Of Technology,Department Of Physics,Cambridge, MA, USA

Introduction:
Seasonal variation has previously been demonstrated in multiple facets of surgery, such as acute vascular events and diverticulitis, as well as surgical outcomes. We investigated whether seasonal variation exists for acute cholecystitis.

Methods:
The National Inpatient Sample (NIS) database was queried for emergent admissions with a diagnosis of acute cholecystitis from 2003-2011, and aggregated into monthly averages. Fourier analysis of the monthly data was performed to detect periodic patterns in the data, a signal processing technique that is historically employed in areas of physics and engineering, and is a way of expressing a function (in this case, hospital admissions over time) as a sum of sinusoids. Comparison of sinusoid amplitudes (signal versus noise) allowed us to discern dominant cyclical patterns. Our findings were further confirmed with linear regression analysis.

Results:
There were 75,585 patients admitted emergently with a diagnosis of acute cholecystitis. Unadjusted analysis of the data demonstrated a trend towards increasing number of annual cholecystitis admissions. Fourier transform analysis detected a strong signal with cycle length of 12 months (coefficient ratios of 3.78 and 2.88 for unsmoothed and smoothed periodogram respectively). This annual cycle peaked in August (mean of 756.33 admissions), and was lowest in February (mean of 632.67 admissions). Linear regression confirmed that months July – October were associated with higher number of admissions, with the lowest coefficient in February (-50.89, p<0.001) and the highest coefficient in August (72.78, p<0.001) relative to January (figure).

Conclusion:
A seasonal pattern exists in the incidence of acute cholecystitis, with peaks in the Fall. The Fourier Transform technique was able to isolate unique pattern from fluctuating trends over time, and may have important clinical implications as it is extended into intraoperative and intensive care hemodynamic monitoring in the future.

67.12 Impact of BMI on Operating Room Times and its Financial Implications

Posted on January 18, 2016

H. Hanif1, F. Agullo1,2, T. Yeager1, G. Coleman1, I. Mallawaarachchi1, A. Nassiri1, V. Molinar1, A. Molinar2, A. Tyroch1, H. Palladino1,2 1Texas Tech University Health Sciences Center,Surgery And Biomedical Sciences,El Paso, TEXAS, USA 2Southwest Plastic Surgery,El Paso, TEXAS, USA

Introduction: Obesity has been the main focus of many public health efforts in the United States. It is a global epidemic with approximately 33% of adults being obese. Obesity both directly and indirectly leads to increases in health care expenditures and resources. Increased consumption of surgical services by obese patients compared to their non-obese counterparts for routine general surgery procedures has been analyzed. Our aim was to investigate the relationship between Body Mass Index (BMI) and the time required to complete standard tasks in the operating room during elective cholecystectomy and to identify the financial impact.

Methods: Our study investigated operative time differences in different BMI groups. Comparisons of continuous variables according to dichotomized BMI were done using a two group t-test or Wilcoxon rank-sum test, while one way analysis of variance or Kruskal Wallis test was used to compare continuous variables according to multi categorical BMI. Linear regression models were developed for all three outcome variables (operating room, anesthesia and surgery times) using multi-category BMI as the main exposure adjusted for age, gender, ethnicity, number of comorbidities, airway type and smoking history.

Results: We included 2068 patients in our study, 1037 patients with BMI<30 and 1025 patients with BMI≥30. The data was further classified according to the WHO obesity classification. The average operating room, anesthesia and surgery times (in minutes) for BMI<25 were 114.4, 124.6, 81.3 respectively and for BMI≥40 were 134.3, 140.5, 96.2. The times of all three outcome variables were significantly different between the two groups with P-values < 0.001. BMI, age, gender and ethnicity continued to be significant in all the final models. When age, gender and ethnicity were adjusted for in our final model, the coefficients for BMI≥40 category compared to BMI<25 category for operating room, anesthesia and surgery times were 22.0 (P-value<0.001), 18.2 (P-value<0.001) and 16.7 (P-value<0.001) respectively (Table 1).

Conclusion: As shown by our data there is significant increase in operative room, anesthesia and surgery times in patients with higher BMI which in turn leads to greater perioperative resource usage and increased hospital cost. We propose a change in CPT coding to compensate for the increased utilization of resources.

67.09 Crohns Disease: Comparing Outcomes Following Colorectal Surgery.

Posted on January 18, 2016

S. Groene1, C. Chandrasekera1, T. Prasad1, A. Lincourt1, B. T. Heniford1, V. Augenstein1 1Carolinas Medical Center,Division Of Gastrointestinal And Minimally Invasive Surgery,Charlotte, NC, USA

Introduction: Given the pathophysiology of Crohns disease as well as the fact that patients undergoing surgery are often immunosuppressed, it is often felt that there are more adverse outcomes for patients with Crohns disease who undergo colorectal resections compared to those without the disease. The aim of this study was to compare outcomes of patients with and without Crohns disease following colorectal resections.

Methods: Review of the Carolinas Medical Center (CMC) NSQIP data for colorectal procedures performed from 2013 to 2015 was conducted. Patients were classified as having Crohns disease (CD) based upon ICD-9 codes (555.9, 555.2, 555.1). Demographics, pre-operative co-morbidities, minor and major complications were evaluated using standard statistical methods.

Results: There were 637 patients in the sample; 23 patients with the diagnosis of CD and 614 without CD. Mean age was 37.3±15.2 vs 61.2±13.4 (p<0.001) and the mean BMI was 23±6.2 vs 28.6±7.6 (p<0.001) for those with and without CD, respectfully. Those with CD were more likely to have a pre-operative weight loss of ≥10 pounds (17.4% vs 4.3%; p=0.02) and use pre-operative steroids (56.5% vs 5.9%; p<0.001). Those without CD had a higher rate of pre-operative hypertension (54.4% vs 8.7%; p<0.001). Post-operatively, patients with CD had a higher rate of wound disruptions (8.7% vs 0.7%; p=0.02). There were no significant differences in post-operative surgical site infections, pneumonia, UTIs, sepsis, anastomotic leaks, unplanned returns to the OR, cardiac or renal disease, length of stay and 30 day mortality between those with and without CD.

Conclusion: Patients with Crohns disease tended to be younger and leaner than those who underwent surgery without the disease. Furthermore, they had more pre-operative weight loss and used steroids. Although patients with CD had more post-operative wound disruptions, colorectal resections can be undertaken without otherwise-significantly increased risks.

67.10 Outcomes Of Surgical Procedures In Patients Testing Positive For Cocaine On Urine Screening

Posted on January 18, 2016

U. Kannan2, M. M. John2, R. Gupta2, S. B. Remersu2, D. T. Farkas2 2Bronx- Lebanon Hospital Center,Surgery,Bronx, NY, USA

Introduction:
To review the outcomes following surgical procedures in patients testing positive for cocaine on preoperative urine toxicology screening

Methods:

The practice in our hospital is that patients with urine toxicology positive for cocaine are assessed clinically. If they are acutely toxic or they have a prolonged QTc interval on their electrocardiogram (EKG) the surgery is canceled unless it is an absolute emergency.The electronic medical records (EMR) were retrospectively reviewed for the years 2003-2014. Patients who underwent a surgical procedure whose urine toxicology screening was positive for cocaine were included. Only patients with a positive test on the same admission prior to the surgical procedure were included. Patients who did not receive general anesthesia were excluded. Patient demographics and the 30 day cardiovascular and neurological complications were collected and analyzed

Results:

There were 146 patients in total. After excluding the procedures without general anesthesia, there were 81 patients that were analyzed. There were 53 males and 28 females. The median age was 47 years (18-69 years). 21 procedures were elective and 60 were admitted through the emergency department. There were 54 general surgery cases, 8 orthopedic cases, 4 gynecologic, and 3 each of vascular, otolaryngology, dental, neurosurgical and urology cases.

Cardiovascular complications were noted in 4 patients (2 arrhythmias, non-ST elevated myocardial infarction (NSTEMI) and exacerbation of congestive heart failure) while neurological complications were seen in 2 patients (seizure and cerebrovascular accident). There was one mortality. The complications were reviewed and in most cases attributable to the illness and not cocaine (e.g. mortality after craniotomy for severe hemorrhagic stroke). The two arrhythmias (atrial fibrillation and supraventricular tachycardia) and the NSTEMI were the only ones possibly attributable to cocaine, and all three of these patients had other pre-existing cardiac comorbidities that could have contributed as well.

Conclusion:

A positive urine test for cocaine is not an absolute contraindication to surgery. In patients who are not acutely toxic and without a prolonged QTc interval, complications do not appear to significantly exceed that which would be expected in the population at large. The decision to proceed with surgery needs to be individualized to the patient and the indication for surgery.

67.06 Extreme Obesity Increases Surgical Site Infections But Not Major Complications After Renal Surgery

Posted on January 18, 2016

M. A. Mann1, M. Grimes1, M. L. Blute1, K. Zorn1, T. M. Downs1, S. L. Best1, F. Shi1, D. F. Jarrard1, S. Y. Nakada1, E. Abel1 1University Of Wisconsin,Urology,Madison, WI, USA

Introduction: Extreme or class 3 obesity (BMI ≥ 40) may be associated with increased morbidity following surgery. The objective of this study was to evaluate if patients with extreme obesity had worse perioperative outcomes following renal surgery.

Methods: Comprehensive medical records were reviewed for all patients treated with partial nephrectomy, radical nephrectomy or nephroureterectomy at our institution from 2000-2014. Complications occurring within 90 days were recorded and classified according to the Clavien-Dindo system. Univariable and multivariable models were used to evaluate the association of obesity with major complications (≥Clavien 3a), surgical site infections (SSI), blood transfusion (BT) rates and readmission rates.

Results: A total of 1109 patients were evaluated including 114 (10.3%) patients with BMI ≥40. Perioperative complications were identified in 279 (25.5%) patients including major complications in 80 (7.3%). Patients with BMI ≥40 were not at increased risk for major complications (p=0.2). Independent predictors of major complications included Charlson Comorbidity Index and surgical approach (open vs. minimally invasive).

A total of 217 (19.6%) patients received BT during the initial hospitalization following surgery. BMI ≥40 was not associated with increased risk of BT (p=0.9) SSI were observed in 60 (5.5%) patients. Patients with BMI ≥40 had an increased risk of SSI, OR 2.3 (95% CI 1.2-4.5).

A total of 59 patients (5.4%) were readmitted to the hospital with 30 days following surgery. BMI ≥40 was not associated with increased risk of readmission (p=0.4)

Conclusion: Extreme obesity is associated with increased risk of wound complications but not a higher risk of major complications, BT, or hospital readmission following renal surgery. When feasible, minimally invasive surgery may be associated with lower major complication rates.

67.07 Predicting Survival in the Separation of Conjoined Twins

Posted on January 18, 2016

D. K. Robie1, D. K. Robie1 1Mayo Clinic – Florida,Surgery,Jacksonville, FL, USA

Introduction:
The separation of conjoined twins requires thorough preoperative assessment, detailed operative planning, optimization of each twin’s medical status and multidisciplinary team preparation. Since each set of conjoined twins is unique and the condition is extremely rare, both surgeon and institutional experience will be limited. Our recent experience in separating omphalopagus conjoined twins highlighted the importance of these preparatory steps. The purpose of this review is to identify the key prognostic indicators that impact on survival.

Methods:
PUBMED was searched for publications on conjoined twin separations and operations performed between 1988 and 2015 were included in this review. Data gathered included type of conjoining; age at operation; whether emergent or elective separation; if emergent the primary indication for surgery; complexity of organ sharing; mortality and cause of death; survival. Significance of categorical variables on survival was determined using univariate analysis and the mean and median time to the separation operation determined.

Results:
There were 109 separations reviewed. Type of conjoining and % of total as follows: Omphalopagus (OP) 51 (47%), Thoracopagus (TP) 25 (23 %), Ischiopagus (IP) 22 (20%), Parapagus (PP) 5 (5%), Pygopagus (PGP) 4 (4%) and Craniopagus (CP) 2 (2%). Elective separation, survival and age at separation (range; median and mean in months (ms)): 29 OP sets (1 d to 12 ms, 1.25 ms, 3.6 ms) with 95% survival, ; 13 TP sets (1 m to 16ms, 4.5 ms, 6.3 ms) with 81% survival, 20 IP sets (1d to 26 ms, 10.5 ms, 12 ms) with 92.5% survival. Emergency separation and survival: 22 OP sets with 54% survival, 13 TP sets with 29% survival, 2 IP sets with 25% survival. Causes of death in total group(n): planned sacrifice 1, dependent parasite 2, severe congenital heart disease 13, pulmonary 7, sepsis 9, other 9 and unknown 7. Seven infants died intraoperatively and 7 died preoperatively. Indication for emergency separation and % survival; preop twin demise 7 sets (43%), clinical deterioration of one or both twins 16 (24%). 26 infants had severe congenital heart disease (5 with cardiac fusion) with 19 % survival. Predictors of adverse outcome; TP type, emergency separation, preoperative twin demise and presence of severe congenital heart disease.

Conclusion:

Survival following separation of conjoined twins is dependent on the type of conjoining, emergency versus elective separation, the presence of severe cardiac anomalies and the immediate condition of the infants prior to surgery. When time allows, efforts should be focused on maximizing the clinical condition of the infants prior to separation. It is important that the treatment team and the family are aware of the prognosis based on the unique aspects of the individual set of twins.

67.08 Total thyroidectomy does not affect bodyweight

Posted on January 18, 2016

J. C. Lee1,2, P. Chang1, R. Glick1, J. W. Serpell1,2, S. Grodski1 1Monash University,Endocrine Surgery Unit, The Alfred,Melbourne, VIC, Australia 2Monash University,Department Of Surgery,Melbourne, VIC, Australia

Introduction: Weight gain after thyroid surgery is a commonly encountered patient concern in clinical practice, but there is little published data on this topic. Therefore this study aimed to determine bodyweight (BW) change following total thyroidectomy (TTx), and comparing perceived to actual changes. Secondarily, the study also aimed to determine patient satisfaction regarding thyroxine dosing post-operatively.

Methods: Following institutional review board ethics approval, patients were recruited from the Monash University Endocrine Surgery Database between January 2013 and June 2014. All patients who underwent TTx at the Alfred Hospital were eligible. Pre-operative data were extracted from patient files (including BW, TSH, medications), while post-operative data were obtained by surveying the participants 6 to 18 months after surgery (including BW, medications, satisfaction scores). Clinically relevant change in BW was defined as 2 kg gain or loss. Data was analysed using standard statistical methods, including Student’s t-test, Chi-squared, and Fisher’s Exact tests as appropriate.

Results: A total of 107 patients satisfying the inclusion criteria were invited to participate, and were posted the questionnaire. A response was received from 79 patients (74%). The mean age of the respondents was 56 (range 15 – 84) years, with 3 times more females than males. The majority of participants had TTx for benign indications, and 19% had TTx for confirmed or suspected malignancy. Pre-operatively, 32 (42%) patients had a diagnosis of either toxic multinodular goiter or Graves’ disease, and 28 of them were on an anti-thyroid medication. Nearly half (34, 43%) of the participants had stable BW after TTx, while 24 (30%) gained an average of 6.8 kg (9% gain), and 21 (27%) lost an average of 7.8 kg (9.3% loss). There was poor concordance between perceived and actual BW gain or loss. Pre-operative thyrotoxicity did not appear to have any bearing on post-operative BW change. Anti-thyroid medications, gender and TSH levels were also not shown to be predictors of post-operative BW change. Taking their BW and thyroxine dosing into account, the majority of patients (81%) were satisfied with their post-operative management. There was no correlation between satisfaction scores and BW gain or loss.

Conclusion: Bodyweight change following TTx is unpredictable, and only less than one-third of patients experience weight gain. Pre-operative factors, including thyrotoxicosis, were not found to be predictors of post-operative BW change after thyroidectomy. Regardless of their BW status, the majority of patients were satisfied with their post-operative course after total thyroidectomy.

67.03 Parathyroidectomy or Cinacalcet Therapy for Secondary Hyperparathyroidism in End-stage Renal Disease

Posted on January 18, 2016

Q. TAO1, Z. Ji1, Z. Zhu1, R. Tang2, B. Liu2 1Affiliated Zhongda Hospital, Southeast University Medical School,General Surgery,Nanjing, JIANGSU, China 2Affiliated Zhongda Hospital, Southeast University Medical School,Nephrology,Nanjing, JIANGSU, China

Introduction: In this prospective cohort study, efficacy and safety of parathyroidectomy (PTX) were compared with that of cinacalcet-centred therapy (CCT) for the treatment of chronic kidney disease (CKD)-associated secondary hyperparathyroidism (SHPT) in end-stage renal disease (ESRD).

Methods: Adult patients with Stage 5 CKD between Feberary 2012 and December 2013 at our institution who met the indications for PTX, with an intact parathyroid hormone (iPTH) level ≥ 1000pg/ml associated with hypercalcemia and/or hyperphosphatemia for at least 50% of that period, were included. Baseline characteristics and iPTH, calcium, phosphorus and alkaline phosphatase (ALP) at baseline, 3 and 6 months were compared between the two groups (PTX versus CCT) using the χ2 and paired t-tests.

Results: Of the total population of 112 patients who satisfied KDOQI criteria for PTX, only 34 (30.4%) received PTX, the others received CCT. At baseline, PTX patients had higher iPTH (P=0.011) and ALP (P=0.027). Complete follow-up data at 3 months were available on 85 patients (PTX = 27; CCT =58). PTX had significantly reduction in iPTH (92 versus 56%) compared with CCT. A greater proportion of patients receiving PTX achieved target iPTH levels throughout the study compared with the patients receiving CCT (P=0.002 after 3 months; P=0.013 after 6 months). Changes from baseline in calcium and phosphate levels and proportion of patients achieving target values of bone markers were not significant for either intervention. Findings were consistent at 6 months.

Conclusion: PTX can reduce iPTH levels more than CCT in the patients who met indications for PTX. No significant difference in circulating bone markers reductions were found between these two groups.

67.04 Compliance with American Thyroid Association Guidelines for Total Thyroidectomy in Graves' Disease

Posted on January 18, 2016

S. T. Akram1, D. M. Elfenbein2, H. Chen3, D. F. Schneider1, R. S. Sippel1 1University Of Wisconsin School Of Medicine And Public Health,Department Of Surgery,Madison, WI, USA 2University Of California, Irvine School Of Medicine,Department Of Surgery,Irvine, CALIFORNIA, USA 3University Of Alabama – Birmingham School Of Medicine,Department Of Surgery,Birmingham, Alabama, USA

Introduction:
The American Thyroid Association (ATA) has issued specific pre-operative guidelines for patients undergoing thyroidectomy for treatment of their Graves’ disease. Our goal is to determine if compliance with ATA guidelines for thyroidectomy for Graves’ disease is associated with better outcomes.

Methods:
A retrospective review of a prospectively maintained database was performed to identify 228 patients with Graves’ Disease who underwent a total thyroidectomy between August 2007 and May 2015. Data was then extracted including patient demographics and clinical characteristics and treatment-related morbidity. Patients were considered to be in compliance with the ATA guidelines if they were treated pre-operatively with SSKI and were either rendered euthyroid with methimazole (T4<1.5 ng/dl) or if that was not feasible were treated with a β-Blocker. Analysis of these data was performed using Stata v11 statistical software.

Results:
The mean age of all patients in our study was 39 ± 1 years and 82% were female. The majority of patients were treated with methimazole (84%) and β-blockers (54%). All patients underwent a total thyroidectomy, and the mean OR time was 114 ± 3 minutes and mean estimated blood loss (EBL) was 45 ± 7 mL. About one third of patients (36%) had a complication following thyroidectomy. Transient hypocalcemia was the most common complication (27%). At the time of surgery, 52% of all patients were found to be in compliance with the ATA guidelines. Patients that were not prepped according to the ATA guidelines had more intraoperative tachycardia (episodes of heart rate exceeding 120) (0.3 vs. 4.6, p = 0.05), but thankfully had no difference in peak SBP (p = 0.64) or in number of episodes of SBP >180 (p=0.31). ATA prepped and non-prepped patients had similar EBL (45.9 vs. 47.3 mL, p = 0.93), mean OR time (113.1 vs. 117.4 minutes, p = 0.45), and length of stay (0.6 vs. 0.7 days, p = 0.46). ATA prepped and non-prepped patients had similar complication rates, including transient hypocalcemia (29.9% vs. 24.4%, p = 0.40), prolonged hypoparathyroidism (1.0% vs. 3.3%, p = 0.28), hoarse voice/temporary RLN palsy (2.2% vs. 3.1%, p = 0.37), prolonged RLN paralysis (3.1% vs. 2.2%, p = 0.70), hematoma formation (3.13% vs. 0%, p = 0.09), or returning to the OR (2% vs. 1.1%, p = 0.60).

Conclusion:
Our data suggests that compliance with ATA guidelines for thyroidectomy preparation is not a necessary prerequisite for a successful postoperative outcome. While preparation according to the guidelines decreased the frequency of intraoperative tachycardia, it did not impact intraoperative hypertension, OR time, blood loss, or post-operative complications. The use of SSKI and methimazole to prepare patients for thyroidectomy did not improve outcomes at a high volume center.

67.05 Early Laparoscopic Cholecystectomy for Acute Cholecystitis in the Elderly is Safe and Cost Effective

Posted on January 18, 2016

P. P. Patel1, J. M. Velasco1 1Northshore University Health System,Skokie, IL, USA

Introduction:
Early laparoscopic cholecystectomy (LC) for acute cholecystitis in the elderly has proven to be safe, however it has not been universally adopted. In spite of published guidelines, percutaneous cholecystostomy or delayed LC with antibiotic treatment has been increasingly utilized as the initial step in the management of these patients. In this era of fiscal scrutiny, specific cost benefits of early LC have not been well examined, particularly in the elderly. This study examines whether early LC in the elderly results in efficient and effective care when compared to alternative management approaches.

Methods:
A retrospective chart review of patients admitted to a four-hospital single university affiliated health system from January 1, 2009 to December 31, 2011 was completed. Patients older than 65 with histologically documented acute cholecystitis were selected. Eligible patients (237) were distributed into three groups based on initial treatment of cholecystitis: early LC within 7 days, delayed LC, or percutaneous cholecystostomy. Patient charges, including diagnostic tests, pharmacy and consultation fees, length of stay, and number of hospital admissions were compared between groups. Statistical analysis was completed by ANOVA allowing comparison of the means of the three patient groups.

Results:

Patients who underwent an early LC had an average LOS just over six days totalling appoximately $50,000 in charges, while those who had delayed cholecystectomies were admitted for two days longer with charges totalling approximately $70,000. The percutaneous group had stays significantly longer averaging two weeks with charges totalling over $100,000. Patients who underwent a delayed management strategy had a higher rate of recurrent events, requiring more interventions that resulted in a statistically significant cost increase.

Conclusion:

Early laparoscopic cholecystectomy completed within 7 days of presention is the most cost-effective treatment for acute cholecystitis in the elderly.

66.20 Comparing CT versus Diagnostic Laparoscopy in Suspected Anastomotic Leaks

Posted on January 18, 2016

J. K. Horwitz1, D. T. Huynh1, T. F. Barrett1, V. S. Tung1, C. M. Divino1 1Mount Sinai School Of Medicine,Department Of Surgery,New York, NY, USA

Introduction: An anastomotic leak (AL) is a serious complication of gastrointestinal surgery. Once identified, anastomotic leaks may be definitively managed with percutaneous drainage or re-exploration. The aim of our study is to compare CT imaging versus diagnostic laparoscopy (DL) as initial management strategies for evaluating patients with clinically suspected anastomotic leaks.

Methods: Patients who developed an AL at The Mount Sinai Hospital from 2003-2015 were identified retrospectively. Patients who were managed with an exploratory laparotomy without a prior CT or DL were excluded. The remaining patients were stratified into two groups based on the initial management of the suspected AL, CT versus DL. The sensitivities of the two diagnostics were compared as well as the outcomes, including: length of stay (LOS), SICU admission/LOS, 30-day mortality, requirement for a 2nd reoperation, and readmission. The groups were compared using the Fisher’s exact test and χ2 for categorical variables and the Mann-Whitney-Wilcoxon test for continuous variables.

Results: 184 patients who suffered ALs and met our inclusion criteria were identified. Within this group, 162 initially received a CT while 22 directly underwent a diagnostic laparoscopy. No differences were found between the groups’ age, sex, ASA, BMI, or comorbidities. The sensitivities of CT and DL were found to be 52.5% and 72.7%, respectively. No differences were found between the groups’ SICU admission rates, 30-day mortality, requirement for a 2nd reoperation, or readmission. A significant difference in LOS was observed between the two groups (p=0.007) with a median LOS of 18 days and 13 days for CT and DL, respectively. SICU LOS was also found to be significantly longer in the CT group (p=0.046) with a median SICU LOS of 6 and 3 days for CT and DL, respectively.

Conclusion: Suspected ALs must be approached with urgent and decisive action. Our data supports diagnostic laparoscopy as an effective and safe initial approach to clinically suspected anastomotic leaks, as demonstrated by a higher sensitivity and shorter LOS relative to CT imaging.

67.01 Size of recurrent laryngeal nerve affects vocal cord paralysis after thoracoscopic esophagectomy.

Posted on January 18, 2016

Y. Saito1, H. Takeuchi1, K. Fukuda1, R. Nakamura1, T. Takahashi1, N. Wada1, H. Kawakubo1, Y. Kitagawa1 1Keio University,Department Of Surgery,Shinjuku-ku, TOKYO, Japan

Introduction:
Recurrent laryngeal nerve paralysis is one of the most frequent and serious complications after esophageal cancer surgery. Recurrent laryngeal nerves are thin, about 1 to 2mm in size. In this study, we hypothesized that thin recurrent laryngeal nerve may affect postoperative vocal cord paralysis. We evaluated relations of left recurrent laryngeal nerve size and postoperative left vocal cord paralysis.

Methods:
This follow-back study included a total of 44 patients who underwent thoracoscopy assisted esophagectomy with lymphadenectomy along the recurrent laryngeal nerve from May 2012 to December 2013. When we exposed recurrent laryngeal nerves, we used single use scissor tips (Microline Surgical, Inc.). Diameter of the nerves were measured using the digital video recording of surgical procedures by the ratio between scissor and left recurrent laryngeal nerve. Median size of left recurrent laryngeal nerve for the 44 patients was 1.51mm. To evaluate relations of left recurrent laryngeal nerve size and postoperative vocal cord paralysis we compared patients with thin nerve and those with thick nerve. Twenty two patients had left recurrent laryngeal nerves under 1.5mm in size (thin group) and 22 patients had the nerves over 1.5mm (thick group). The average age was 63.2 years old (a range of 35-78), and 34 men and 10 females were included. For evaluation of vocal cord paralysis, a direct laryngoscopy and/or X-ray fluoroscopic test of swelling were performed after the operation.

Results:
There was not significant difference in the background factors, including age, sex, body-mass index, performance status, stage, histological type, or the location of tumor, in both groups. Operation time did not have the significant difference in both groups. The amounts of bleeding at thick group was significantly small. There was not the significant difference in metastasis of lymph nodes along left recurrent laryngeal nerve or the number of dissected lymph nodes along left recurrent laryngeal nerve in both groups. Incidence of postoperative left recurrent laryngeal nerve paralysis (Clavien-Dindo classification ≥ 1) was significantly higher (n=14, 63.6%vs n=5, 22.7%; p=0.006) in thin group.

Conclusion:
The recurrent laryngeal nerve paralysis was easy to be caused in the case that recurrent laryngeal nerve was thin.

67.02 The Perception of Diminished Surgical Outcomes Elderly Patients – Is it Really Age Related?

Posted on January 18, 2016

S. Groene1, C. Chandrasekera1, T. Prasad1, A. Lincourt1, B. T. Heniford1, V. Augenstein1 1Carolinas Medical Center,Division Of Gastrointestinal And Minimally Invasive Surgery,Charlotte, NC, USA

Introduction: The general belief concerning elderly patients undergoing surgery is that they are at higher risk for post-operative complications than their younger counterparts. Few studies, however, differentiate age from the associated co-morbidities of aging. The aim of this study was to compare outcomes of patients undergoing colorectal resection stratified by age.

Methods: An extensive review for colorectal procedures performed from 2013 to 2015 at a single institution was conducted utilizing a NSQIP database. Patients who were ≤60 years old were compared to those who were ≥75 years old. Demographics, pre-operative co-morbidities, minor and major complications, and mortality were evaluated using standard statistical methods.

Results: Over the 2 years, 373 patients qualified for the study; 278 were ≤60 years, and 95 were ≥75 years. Mean age for the younger group was 47.8±9.7 vs 80.8±4.4 for the older group. BMI was 28.8±8.3 vs 25.6±4.5 (p=0.003), respectively. Both groups were similar in gender and race. The older patients tended to be more hypertensive (72.6% vs 33.8%; p<0.001) with higher rates of diabetes (22.1% vs 8.6%; p<0.001) and COPD (14.7% vs 1.8%). In the older group, 81.1% were ASA class 3-4 vs 45% in the younger group (p<0.001). The younger group had a higher rate of smokers (26.3% vs 7.4%; p<0.001). There was no difference in the percentage of laparoscopic cases; however, the older group underwent more right-sided colectomies (55.7% vs 31.2%; p<0.001) and more emergent cases (16.8% vs 8.6%; p=0.03). The older group required more post-operative transfusions (24.2% vs 13.7%; p=0.02), had a higher rate of 30 day mortality (6.3% vs 1.1%; p=0.01) and had a longer post-operative length of stay (11.7±8.4 days vs 9.5±9.6 days; p<0.001). However, after controlling for ASA class and emergent surgery status, multivariate analysis indicated that there were no significant differences between the older or younger groups in terms of post-op transfusions or LOS. Given the low incidence of deaths (N=9), MV analysis was not feasible for this outcome. There were no differences in post-operative surgical site infections, pneumonia, urinary tract infection, myocardial infarction, renal failure, DVT/PE, unplanned intubations, anastomotic leak, unplanned return to the OR and mortality after 30 days between older and younger patients.

Conclusion: Patients who were ≥75 years old had a higher prevalence of pre-operative co-morbidities and required more emergent operations. After controlling for ASA class and emergent status, there was no significant difference in outcomes between patients ≤60 years old or those ≥75 years old. The perception of increased risk of surgery associated with elderly patients appears to related to their pre-op comorbidities rather than their age.

66.18 Colectomy in Michigan: the Relationship Between Surgical Site and Urinary Tract Infection

Posted on January 18, 2016

J. E. Papin IV1,2, K. H. Sheetz1, D. A. Campbell1,2, M. J. Englesbe1,2 1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2Michigan Surgical Quality Collaborative,Ann Arbor, MI, USA

Introduction:
Following colectomy, the development of surgical site infections (SSI) and urinary tract infections (UTI) are common, morbid, and expensive. However, it is unclear to what extent associations between postoperative UTI and SSI affect patient outcomes. The purpose of this study was to determine whether post-operative UTI is an independent risk factor for subsequent SSI.

Methods:
Using data from the Michigan Surgical Quality Collaborative, we identified 30,727 patients undergoing colon resection within 73 hospitals between 2008 and 2015. We evaluated the independent effect of an initial postoperative UTI on the incidence of SSI using multivariate logistic regression adjusting for patient demographic, clinical, and case-specific Surgical Care Improvement Program (SCIP) process compliance.

Results:
In our study cohort, 1.2% of patients developed a postoperative UTI and 10.0% developed a postoperative SSI. Unadjusted rates of SSI were higher in patients with an initial post-operative UTI (22.7% v. 9.9% p<0.01). In multivariate models, post-operative UTI was an independent risk factor for the development of SSI (OR 3.35, 95% CI 2.50-4.48).

Conclusion:
Post-operative UTI is an independent risk factor for the development of SSI after colectomy. Though poorly characterized, quality improvement initiatives aiming to decrease the incidence of UTI may influence SSI rates following colectomy. These associations warrant further investigation and may allow for streamlining of practices designed to reduce postoperative infections.

66.19 Predicting Wound Complications with Preoperative CT Scans

Posted on January 18, 2016

R. J. Strobel1, C. S. Lee1, J. F. Friedman1, D. R. Grenda1, C. W. Inglis1, B. A. Derstine1, S. M. Bahroloomi1, A. M. Hammoud1, K. C. Leary1, A. R. Peltier1, S. C. Wang1, M. J. Englesbe1 1University Of Michigan,Department Of Surgery, Michigan Morphomic Analysis Group,Ann Arbor, MI, USA

Introduction: Wound complications – such as incisional hernia, ventral hernia, and wound dehiscence– are common following major abdominal surgery. Despite advances in surgical care, these complications remain prevalent. We hypothesized that analytic morphomics, a novel objective risk assessment tool, would explain the relationship between preoperative tissue composition and postoperative wound complications.

Methods: This is an observational study of 1,409 patients undergoing major abdominal surgery and who had a preoperative CT scan, all selected from the Michigan Surgical Quality Collaborative Database. The primary outcome is a composite of local wound complications, including incisional hernia, ventral hernia, wound dehiscence and major wound complications. Analytic morphomic measures of a single slice at the L4 vertebral level were investigated, along with variables related to patient demographics, medical history, admissions status, and comorbid disease. A p < 0.05 threshold in univariate analysis was employed for considering variables to be included in multivariable analysis.

Results: Wound complications occurred in 11.9% of patients. Analytic morphomic variables associated with wound complications are detailed in the figure. The final, single-slice model was assembled via backwards stepwise selection, and included 4 preoperative variables: subcutaneous fat area @ L4 (odds ratio [OR] = 1.67, 95% confidence interval [Cl] 1.03-2.78, P = 0.040), pack-years (OR = 1.18, 95% CI 0.99-1.38, P = 0.046), albumin (OR = 0.84, 95% CI 0.72-1.00, P = 0.044), and immunosuppressive therapy (OR = 1.97, 95% CI 1.15-3.26, P = 0.010).

Conclusion: Patients with a large subcutaneous fat area have a higher risk of wound complication. This may inform surgeon decision-making in the operating room.

66.15 Falls From Heights: Children Fare Better Than Adults

Posted on January 18, 2016

J. L. Carpenter1, T. L. Wiebe1, J. R. Rodriguez1, B. J. Naik1 1Texas Children’s Hospital,Division Of Pediatric Surgery, Department Of Surgery,Houston, TX, USA

Introduction: Falls are one of the leading mechanisms of injury in both children and adults. We hypothesize that children have better outcomes following falls than adults.

Methods: The 2007-2011 National Trauma Data Base (NTDB) was queried for ICD-9 code 882.0 (‘fall from height’). Patients were divided into three age groups (0-4 years, 5-14 and 15+) for comparison. Continuous outcomes were compared using ANOVA and categorical outcomes using chi-square test. Multivariate logistic regression using covariates of vital signs at presentation, Glasgow Coma Scale (GCS), Injury Severity Scale (ISS), and the need for an urgent operation was also performed to compare age groups.

Results: There were 44,416 patients identified; of these, 82% of patients were male and 15% were children <15 years of age. The mean age was 36.2 ± 20.1 years. ICU admission was required for 29% and urgent operation for 10%. Infants and toddlers had a higher rate of closed head injury than adults (5% versus 3%, p<0.001) and a concurrently higher ICU admission rate (45% versus 36%, p<0.001). The length of ICU stay (days), number of unplanned intubations, urgent operation rate, mortality, hospital length of stay (days), and ISS were all lower in children than adults (Table 1). Presenting GCS and ISS were significant predictors of ICU admission and mortality in both children and adults (p<0.001); however, vital signs on presentation were only predictive of these outcomes in the adult population (p=0.02).

Conclusion: Falls from heights are common in both children and adults. Based on our review of the NTDB, children incur less severe injuries and have better overall outcomes than adults yet have a higher rate of ICU admission. Abnormal vital signs at presentation may not be predictive of serious injury in children and may sometimes lead to over-triage for these patients.

66.16 Outcomes of Surgical Management of Acute Perforated Ulcer Disease in the NSQIP Database 2005 to 2013

Posted on January 18, 2016

J. Biggs1, S. Barnes1, S. Osterlind1, E. Dalton1, L. Hanley1, S. Ahmad1 1University Of Missouri,Surgery,Columbia, MO, USA

Introduction:
The management of peptic ulcer disease (PUD) has evolved from a primarily surgically managed disease to a medically managed one with advances in endoscopic therapies and treatment of H. pylori infection. While the incidence of hospital admissions for PUD may have changed over the decades, ulcer disease remains a significant cause for mortality, with perforation having a mortality of approximately 11-16%, and morbidity of approximately 30%. The incidence of acute perforation of PUD remains around 4-11 cases per 100,000/year and is the most common etiology for pneumoperitoneum identified on radiography. We utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database Participant User File (PUF) to study preoperative, demographic and postoperative variables that may be associated with morbidity and mortality after emergent surgical management of acute perforated PUD.

Methods:
The adult ACS-NSQIP database participant user files were queried from 2005 to 2013. Those cases performed emergently with a postoperative diagnosis of peptic ulcer disease were extracted. Using SPSS, correlations were then derived between patient factors, postoperative complications, and survival. P-values <0.01 were considered significant.

Results:
We extracted 5666 emergent cases with a postoperative diagnosis of perforated PUD. There were 723 deaths yielding a 30 day mortality rate of 12.8%. The mean age of the study population was 61. The most frequent postoperative complications were failure to wean from the ventilator within 48 hours (19.3%), need for blood transfusion (12.2%), septic shock (9.8%), and return to the operating room (9%). Non-survivors were more likely to be female, older, have a higher ASA classification, be functionally dependent and receive surgical treatment later within the hospital stay (Table 1). Females were more likely to be older, malnourished and receive transfusions despite a similar incidence of postoperative complications when compared to males. In a multinomial logistic regression model the patient factors with the highest risk for mortality were post-operative cardiac arrest (OR 13.7, 95% CI 7.4-25.3), septic shock (OR 4.1, 95% CI 2.9-5.7) and renal failure (OR 3.9, 95% CI 2.4-6.6).

Conclusion:
According to the NSQIP database, the mortality rate for emergent operations in perforated peptic ulcer disease was 12.8% which is consistent with prior studies. Older and female patients are at higher risk of death. This disease process appears to concentrate among older patients with a median population age of 61. Earlier diagnosis and surgical intervention improves survival. Poor nutritional status and certain post-operative complications may decrease the likelihood of survival.

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