66.17 Assessing the Critical Factors of SBAR as used in General Surgery Handoffs

Posted on January 18, 2016

H. J. Hawthorne1, T. N. Cohen1, W. D. Cammon1, J. Bingener2, S. Hallbeck1, J. Kang3, P. Santrach4, S. A. Elliott5, R. C. Blocker1 1Mayo Clinic,Center For The Science Of Health Care Delivery,Rochester, MN, USA 2Mayo Clinic,Department Of Surgery,Rochester, MN, USA 3Mayo Clinic,Office Of Leadership And Organization Development,Rochester, MN, USA 4Mayo Clinic,College Of Medicine,Rochester, MN, USA 5Mayo Clinic,Department Of Nursing,Rochester, MN, USA

Introduction: To improve a common source of communication breakdown in patient care, the Institute for Healthcare Improvement published a standardized handoff communication tool known as ‘SBAR’ (Situation (S), Background (B), Assessment (A) and Recommendation (R)). This study explored the use of SBAR for handoffs between surgical team members 6 years after implementation in a large tertiary care center.

Methods: Healthcare systems engineering researchers observed 23 operative procedures in June 2015. Case duration, presence and duration of handoffs, were recorded for the following participants – circulating registered nurses (RN), certified surgical technicians (CST), certified surgical assistants (CSA), and anesthesia providers including certified registered nurse anesthetist and anesthesiologists (CRNA/ANES). To evaluate the use of SBAR during handoffs, a binary approach to determine existence or nonexistence of each SBAR component (S, B, A, R) was applied and analyzed using nonparametric statistics.

Results: Of the 23 procedures (M = 219 min, SD = 92), 20 included at least one handoff during the operative procedure. Within these 20 cases, 127 handoffs were observed of which 119 could be assessed for SBAR use. CSAs performed fewer handoffs (10%) than CSTs (26%), anesthesia providers (30%) and RNs (34%) (p=0.0014). Of the 119 handoffs (M = 61sec, SD = 52), 90% included information about the patient’s situation, 58% discussed clinical background, 64% provided an assessment and 55% made a recommendation. SBAR components included in each handoff varied significantly by the role involved; specifically differences exist between CRNA/ANES and CSAs when evaluating use of ‘B’ (p=0.032), ‘A’ (p=0.048) and average number of SBAR factors included (p=0.043). When the core team member present at the start of the case handed off, information about the situation was included in 94%, background in 69%, assessment in 68% and recommendation in 68% of handoffs. The average number of SBAR factors used differed by who provided the handoff (original →relief, relief →original, relief →relief) (p=0 .0018), driven by the use of ‘B’.

Conclusion: This pilot study suggests that in a busy OR a handoff by a team member may occur every 35 minutes and adoption of the SBAR structure during surgical procedures differs by role and situation. Team members adjusted for prior knowledge (e.g. ‘B’) by the core team. The study was not scoped to investigate the effect of surgeon briefings on the differential use of SBAR or the effect of differential use of SBAR on the occurrence of non-routine events.

66.12 Utility of Post-Reduction Hospital Admission for Intussusception in Pediatric Population

Posted on January 18, 2016

Y. Puckett1, J. Greenspon1, C. Fitzpatrick1, D. Vane1, S. Bansal1, M. Rice1, K. Chatoorgoon1 1Saint Louis University School Of Medicine,Pediatric Surgery,St. Louis, MO, USA

Introduction: The standard practice in pediatric patients diagnosed with intussusception radiographically has been reduction via enema and admission for a period of nil per os and observation. However, little data exists that supports this practice. With the recent heavy emphasis on effective medical resource allocation, it is possible that this practice may be potentially eliminable. The objective of this study was to conduct a retrospective review for recurrence rates after enema reduction in children while in hospital, to examine the cost that is incurred by admission, and to examine whether post-reduction admission to hospital is necessary.

Methods: A retrospective chart review was performed on all patients aged 0-4 years old diagnosed with intussusception based on ICD-9 codes over the last twenty years at a single center pediatric hospital. Study included children 0-4 years of age who were treated for intussusception on first encounter with air contrast or barium enema that were subsequently admitted to the hospital for observation. Study excluded patients older than 4 years of age, those who were readmitted for recurrence after 48 hours, patients whose intussusception did not successfully reduce with enema on first try, and those who went to the operating room because of peritonitis on exam or perforation on enema. Early recurrence was defined as recurrence within 48 hours post-reduction.

Results: A total of 171 patients out of 272 met inclusion criteria. Out of 171 patients who were admitted to the hospital for observation post-reduction, only one experienced an early recurrence (0.6%). The median length of stay for all patients was 2 days with an interquartile range of 1-2. The average cost incurred per day for intussusception admission was determined to be $404.00 at our hospital.

Conclusion: Intussusception in a child that is successfully reduced via enema has a low rate of recurrence and is usually followed by prompt resolution of symptoms. An abbreviated period of observation in the emergency department post intussusception reduction may result in costs savings of approximately $808/patient.

66.13 International Trends in Incidence Rates of Thyroid Cancer from 1973-2007

Posted on January 18, 2016

B. C. James1, R. H. Grogan2, E. L. Kaplan2, P. Angelos2, B. Aschebrook-Kilfoy3 1Indiana University,Endocrine Surgery/Surgery/Indiana University,Indianapolis, INDIANA, USA 2University Of Chicago,Endocrine Surgery/Surgery/University Of Chicago,Chicago, IL, USA 3University Of Chicago,Department Of Public Health Sciences,Chicago, IL, USA

Introduction:
The incidence rate of thyroid cancer worldwide has been increasing at a dramatic rate. However, previous studies have shown that the rates in some countries appeared to be leveling off in recent years. We sought to evaluate recent trends in incidence rates and predict that these rates have continued to rise.

Methods:
Trends in the incidence rates of thyroid cancer were obtained from the WHO Cancer Incidence volumes 4-9, which contain incidence data reported by selected population-based cancer registries covering areas within Asia, Oceania, Africa, Europe, and the Americas between 1973 and 2007. Thyroid cancer classification was based on ICD-8, ICD-9, and ICD-10 for volumes 4,5-8,9-10, respectively. Percent change was calculated for each population to show the relative change in incidence rate by gender, histologic subtype, and mortality rate between 1973 and 2007.

Results:
Thyroid cancer rates increased from 1973 to 2007 for 18 of the 19 countries examined. The average increase in thyroid cancer incidence across populations was 88% in males and 108% in females. The largest increase was in New South Wales, Australia (266.67% in males and 365.22% in females). In contrast, thyroid cancer rates in Sweden decreased by 18% in males and 5% in females. Significant variation in incidence rates was present within every continent, and each country showed independent patterns of increase across continents. There was no correlation between underlying thyroid cancer incidence rates and the increase in incidence rate. A consistent ratio of three to one between females and males was observed in all populations at all time periods.

Conclusion:
This study has shown that there has been a global increase in thyroid cancer incidence rates between 1973 and 2007. Rates rose even in countries that are not technologically advanced, therefore we hypothesize that both environmental factor and detection bias are at play.

66.14 Preoperative Comorbidity Associated with Postoperative Complications Following Ventral Hernia Repair

Posted on January 18, 2016

R. Conway1, M. Zhao3, Y. Zeng2, J. Keith1 1University Of Iowa Hospitals & Clinics,Department Of General Surgery,Iowa City, IA, USA 2University Of Iowa,Department Of Biostatistics,Iowa City, IA, USA 3University Of Iowa,Carver College Of Medicine,Iowa City, IA, USA

Introduction: Ventral hernia-repair (VHR) is a common surgical procedure and often performed on patients with comorbid conditions such as chronic obstructive pulmonary disease (COPD), history of smoking, and previous surgical complications. Postoperative complications following VHR present patient morbidity and high cost to the medical system. Therefore, our aim was to determine if any correlation exists between preoperative co-morbid conditions and postoperative outcomes in patients undergoing VHR.

Methods: A retrospective chart review of 304 patients who underwent VHR at UIHC from 2010-2011 was performed. Multiple variables were investigated including the presence of ventral hernia recurrence, surgical site infection, readmission, and need for reoperation. A multivariable logistic regression model was developed to examine potential effects of independent variables on postoperative outcomes.

Results: A history of smoking (OR=1.03, p=0.004) and prior surgical site infection (OR=2.88, p=0.02) were associated with a significant increase in surgical site infection following VHR. Recurrence following VHR was significantly more likely in patients with a history of prior abdominal surgery (OR=1.31, p<0.001). A history of COPD increased the risk for second readmission following VHR (OR=11.9, p=0.02). Prior surgical site infection (OR=3.33, p=0.002) and history of COPD (OR=3.32, p=0.03) were associated with a significant increase in reoperation following VHR. (Table 1)

Conclusion: A preoperative diagnosis of COPD and a history of prior abdominal surgery, prior surgical site infection, and smoking all increase the risk for postoperative complications in patients who undergo VHR. More studies are needed to better understand the pathophysiology involved and how to reduce postoperative complications in VHR.

66.09 Pneumonia is Associated with a High Risk of Death Following Pancreaticoduodenectomy

Posted on January 18, 2016

R. T. Nagle1, H. Lavu1, E. L. Rosato1, C. J. Yeo1, J. M. Winter1 1Thomas Jefferson University,Department Of Surgery,Philadelphia, PA, USA

Introduction: Pancreatectomy is associated with a high complication rate of approximately 40%, and a mortality rate ranging from 1-10%. While many specific complications have been extensively studied, postoperative pneumonia has received relatively little attention.

Methods: We performed a single-institution, IRB-approved retrospective analysis of patients who underwent pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) from 2002 to 2014. Patient data were extracted from electronic medical records. Postoperative pneumonia was defined here as a radiographic finding of an infiltrate followed by antibiotic therapy. Pneumonia was further stratified by cause including ventilator-associated, aspiration, or community acquired. The incidence of post-pancreatectomy pneumonia, predictive factors, and its impact on post-operative outcomes were determined.

Results: 1526 patients underwent a pancreatectomy, including 1090 PDs (71%) and 436 DPs (29%). There were a total of 47 (4.3%) and 11 (2.5%) cases of pneumonia, respectively. The majority of the pneumonias were attributed to aspiration (87.2% and 81.8% in the two cohorts). Pneumonias were graded using the Clavien-Dindo classification, and were more frequently severe (grades 4 or 5) in the PD group (55.3% vs 9.1% with DP, p=0.006). In the PD group, univariate predictors of postoperative pneumonia included male gender (odds ratio (OR) 2.7, p=0.003), age (OR 1.03, p=0.041), COPD (OR 5.0, p<0.001), smoking history (OR 2.0, p=0.022), delayed gastric emptying (DGE, OR 10.3, p<0.001), and persistent oxygen requirement on post-op day 3 (OR 4.4, p<0.001). In a multivariate model, COPD (OR 3.2, p=0.036), DGE (OR 9.1, p<0.001), and persistent oxygen requirement on post-op day 3 (OR 3.2, p=0.005) remained significant predictors. Pneumonia rates in patients who experienced ISGPS grades B and C DGE were particularly high (51.8%) compared with grade A or no DGE (8.67%, p<0.001). In the PD group, postoperative pneumonia was associated with a prolonged length of stay (median 18 days, vs 7 days in the absence of pneumonia, p<0.001) and an extremely high 90-day mortality (38.9% vs. 3.9% in the absence of pneumonia, p<0.001). In a multivariate regression model of 90-day mortality after PD (Table 1), postoperative pneumonia was the most robust predictor of postoperative death (OR 24.1, p<0.001).

Conclusion: Pneumonia following PD is an uncommon but highly morbid event, with a substantially increased risk of death. Patients with pre-existing pulmonary disease are at increased risk, and severe DGE may lead to postoperative pneumonia due to an elevated aspiration risk. These data underscore the importance of cautious dietary progression and aspiration precautions in these individuals.?

66.10 Changing Risk Factors For Pediatric Cholecystectomy

Posted on January 18, 2016

Y. Puckett1, K. Chatoorgoon1, C. Fitzpatrick1, D. Vane1, J. Greenspon1 1Saint Louis University School Of Medicine,Pediatric Surgery,St. Louis, MO, USA

Introduction: Reports from other pediatric centers have defined obesity and Hispanic ethnicity as important risk factors for symptomatic cholelithiasis in children. We aimed to determine if other risk factors exist and if obesity and ethnicity are true risk factors versus symptoms of a more global etiology.

Methods: A retrospective review was performed on all children 0 to 19 years old who underwent a cholecystectomy from 1993-2014 in St. Louis, Missouri. Data was divided into 2 cohorts: Group I (1993-2003) and Group II (2004-2014). Age, gender, body mass index (BMI), weight group, race, ethnicity, indication for cholecystectomy, and type of gallstones were collected. Data was analyzed using Pearson’s-chi square test and and Fisher’s exact test for categorical variables and the Mann-Whitney U test for continuous variables.

Results: 452 patients underwent a cholecystectomy from 1993 to 2014. There were 171 patients in Group I and 281 patients in Group II. The rate of hemolytic disease requiring cholecystectomy was essentially unchanged (G1=70, G2=67) (p<.0001). Biliary dyskinesia was an indication only in the second group (G1=0,G2=28) (p<.0001). Cholecystectomy for non-hemolytic gallstones increased 82% (101-184) (p<.0001). Incidence of cholecystectomy remained stable in underweight children (G1=20, G2=21) (p<.003) however incidence of cholecystectomy in normal (G1=35, G2=53), overweight (G1=9, G2=24), obese (G1=23, G2=58) and severely overweight (G1=14, G2=28) children increased dramatically (p<.003). Mean BMI for the two groups increased slightly, (G1=23, G2=27.5) (p<.002), but essentially remained within the normal range.

Conclusion: At our institution, children undergoing cholecystectomy were found to have a normal BMI overall. However, the prevalence of overweight children undergoing cholecystectomies increased dramatically. In spite of significant increases in obesity in this population, the overall normal BMI of both groups suggests that diet rather than obesity may be the most significant etiology in the increased incidence of cholelithiasis in this pediatric population.

66.11 The i2b2 Cohort Discovery Tool Outperforms a Prospectively Maintained Internal Database

Posted on January 18, 2016

E. Toy1, C. Y. Peterson1, K. A. Ludwig1, T. J. Ridolfi1 1Medical College Of Wisconsin,Department Of Surgery – Division Of Colorectal Surgery,Milwaukee, WI, USA

Introduction: Designing high-quality clinical studies is often limited by poor understanding of study cohorts and populations, information that is difficult to obtain easily and efficiently, thus leading to poor recruitments and under-powered studies. The Informatics for Integrating Biology and the Bedside (i2b2) Cohort Discovery Tool provides an easy to use, self-service way for researchers to query an externally maintained database that draws information from the electronic medical record, stored in the i2b2 Clinical Translational Research Informatics Data Warehouse (CTRI-CDW). Search criteria can include nearly any piece of information in the medical record from demographics, diagnoses and procedure codes, laboratory test results, pharmacy orders and dispenses, as well as free text within clinical documents. In response to a query, the tool can return an approximate number of patients matching the search criteria without revealing identifying information. Searches can be stored online and de-identified information is released after IRB approval. Over eighty academic medical centers nationally have the i2b2 Cohort Discovery Tool integrated with the electronic medical record. The aim of the current project was to assess the performance of this tool when compared to a manually curated internal colorectal surgery database.

Methods: Both the manually curated internal database and the i2b2 Cohort Discovery Tool were queried by procedure name and/or corresponding for procedures occurring from February 2008 to April 2014 performed by a single surgeon. Procedures and CPT codes were grouped into three categories: 1. Low anterior resection ( CPT codes 44145, 44207, 44146, 44208), 2. Abdominal perineal resection (CPT codes 45110, 459395) and 3. Segmental colectomy (CPT codes 44140, 44141, 44143, 44144, 44160, 44204, 44206, 44205). Number of patients identified within each cohort were then compared.

Results: For low anterior resection, the internal database identified 83 patients while the i2b2 Cohort Discovery Tool identified 155. For abdominal perineal resections the internal database identified 28 patients while the i2b2 cohort Discovery Tool identified 97. For segmental colectomy, the internal database identified 176 patients while the i2b2 Cohort Discovery Tool identified 662 patients.

Conclusion: The i2b2 Cohort Discovery Tool outperformed the manually curated internal database on all queries, in part due to an early empahsis on neoplasms within the internally maintained database. The i2b2 Cohort Discovery tool has the potential to replace prospectively maintained departmental databases and has the potential to foster large multi-institutional studies as it is available in over eighty academic medical centers nationwide.

66.08 Do inter-hospital transfers for soft tissue infection improve care or outcomes?

Posted on January 18, 2016

J. C. Chen1, E. Finlayson2, K. F. Rhoads1 1Stanford University,Surgery,Palo Alto, CA, USA 2University Of California – San Francisco,Surgery,San Francisco, CA, USA

Introduction: Soft tissue infections (STI) are common and may require extensive surgical debridement and critical care management. Inter-hospital transfer may occur due to perceived need for higher level of care for these patients. In trauma, cardiology and stroke care, inter-hospital transfers have demonstrated benefit; however, the role of transfers in STI outcomes is unclear. The purpose of the current study is to determine whether transferring patients with STI is associated with differences in care or outcomes.

Methods: Patients with STI were identified by ICD9 codes in the 2011 California patient discharge database. Transfers between facilities were identified using a unique record linkage number for each patient. Retrospective analysis compared length of stay (LOS), rate of surgical intervention, ICU admission, sepsis and death between transferred and non-transferred patients.

Results: There were 39,820 patients identified with STI. Approximately 8% (3,311) were transferred from the original presenting facility and admitted to a different hospital. Patients who were transferred were younger than non-transferred patients (52.9 +/- 22.8 years vs. 55.2 +/- 20.9, p<0.0001). Patients with ‘other’ insurance, including Indian Health Service and Tri-Care military insurance, were transferred at the highest rates (13.4%). About 9% of patients with public insurance (Medicare and Medicaid) were transferred. The lowest transfer rate was for patients with no insurance (3.3%). There was a lower rate of surgical intervention among transferred patients (22.5%) versus non-transferred patients (26%; p<0.0001). Transferred patients had longer median LOS (4 vs. 3 days, p<0.0001), but there were no differences in ICU care (0.33% vs. 0.53%, p=0.13), sepsis (0.45% vs. 0.67%, p=0.14), or inpatient death (0.42% vs. 0.33%, p=0.35).

Conclusion: Inter-hospital transfers are expensive and in the management of STI they are not associated with any clinical advantage in care or mortality. Early initiation of antibiotics at the presenting hospital might achieve similar outcomes with lower resource utilization.

66.04 Frailty and Indication Alter Outcomes of Colorectal Surgery

Posted on January 18, 2016

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

Introduction: Frailty has been documented to adversely influence the outcomes of colorectal surgery. The potential role that the indication for surgery may have on morbidity and mortality has not been adequately studied. In addition, the interplay between frailty and indication has not been explored. Thus, the aim of this analysis was to define the influence that patient frailty and surgical indication have on the outcomes of colorectal surgery.

Methods: The American College of Surgeons- National Surgical Quality Improvement Program (ACS-NSQIP) Participant Use Files were queried for patients undergoing colorectal surgery in 2012 and 2013. Frailty was defined as five or more of eight preoperative variables including functional status, ASA 4 or 5, hypoalbuminemia, heart failure, COPD, diabetes mellitus, hypertension and male gender. Ten surgical indications included acute or chronic diverticulitis, bleeding, cancer without or with obstruction, IBD (Crohn’s or ulcerative colitis) enterocolitis, benign polyps or volvulus. Overall morbidity, serious morbidity and 30-day mortality were defined by ACS-NSQIP. Other known risk factors including age, BMI, race, emergent surgery and operative approach also were analyzed. Univariate analyses and multivariable logistic regression were performed in STATA 13.1.

Results:Of 29,219 patients undergoing colectomy, 2,077 (7.1%) were frail. The incidence of frailty varied from 1% for 1,994 Crohn’s patients to 38% among 138 patients with enterocolitis. Frailty increased mortality (p <0.05) for every indication except Crohn’s disease as well as serious morbidity (p<0.05) for all indicators except Crohn’s and benign polyps. The interplay between frailty and indication in the five groups with the worst mortality outcomes is presented in the Table.

In multivariable analyses both frailty (Odds Ratios 1.57-2.98) and surgical indication (Odds Ratios 1.11-1.47) remained independent predictors of overall morbidity, serious morbidity and mortality (all p<0.01).

Conclusion:The incidence of frailty varies dramatically among the multiple indications for colectomy. Both patient frailty and surgical indication influence the outcomes of colorectal surgery.

66.05 Predictors of Inguinodynia Following Open Inguinal Herniorrhaphy

Posted on January 18, 2016

P. M. Patel1, A. Mokdad1, T. Pham1,2, S. Huerta1,2 1University Of Texas Southwestern Medical Center,Dallas, TX, USA 2VA North Texas Health Care System,Surgery,Dallas, TX, USA

Introduction: Inguinodynia (pain ≥ 3 months following surgery) following open repair of inguinal hernias continues to be an important complication. We hypothesize that there are factors that can predict inguinodynia. This data could be used to identify techniques that aim at its prevention.

Methods: This a retrospective, single institution, single surgeon experience at the VA North Texas Health Care system between July 2005 to July 2015. All patients underwent the same standardized mesh repair. Using inguinodynia as the dependent variable, univariate analysis (UA) was performed using Fisher’s Exact Test for categorical and Student’s T-Test for continuous variables. Clinically relevant variables and variables with a p≤0.2 were entered included in a logistic regression model with inguinodynia as the dependent variable. Data are expressed as means ± SD and significance was established at a p ≤ 0.05 (two-sided).

Results: During the study period, 804 patients underwent open inguinal hernia repair (99 ± 0.3 % male, 60.4 ± 12.4 years-old, BMI 26.7 ± 4.2 Kg/m2, 72.9% Caucasian, American Society of Anesthesiologists average 2.5, morbidity rate of 7.8 ± 0.9%) by the same surgeon. Fifteen patients experienced inguinodynia (1.9 %). Median follow up was 4.7 ± 2.7 years. Patients who experienced inguinodynia were more likely to have a bilateral hernia repair (26.7 ± 11.4% vs 8.1 ± 1.0%, p=0.01), repair of a recurrent hernia (26.7 ± 11.4% vs 7.0 ± 0.9%, p <0.001), and a simultaneous femoral hernia repair (13.3 ± 8.8% vs 1.0 ± 0.4%, p <0.001). Patients with inguinodynia were more likely to be younger (52.7 ± 10.1 years vs 60.5 ± 12.4 years, p=0.02), current smokers (73.3 ± 11.4% vs 32.6 ± 1.7%, p <0.001), have a positive cardiac health history (16.5 ± 1.3% vs 40.0 ± 12.6%, p=0.02), on anticoagulants (20.0 ± 10.3% vs 3.5 ± 0.7%, p <0.001), and have a post-operative complication (40.0 ± 12.6 % vs 7.2 ± 0.9%, p <0.001). Multivariate analysis identified a concurrent repair of a femoral hernia (OR and 95% CI: 12.2; 1.8-82.0) or recurrent hernia (4.6; 1.2-17.7), a current history of smoking (3.9; 1.1-14.1), younger age (6.4; 1.4-33.7) and post-operative complications (6.5; 2.0-21.4) as independent predictors of inguinodynia.

Conclusion: Younger patients and patients who have a bilateral, recurrent, or a concurrent repair of a femoral hernia as well as those who experience a morbidity are at risk of inguinodynia. Patients who smoke should be encouraged to quit prior to repair.

66.07 Impact of Resident Involvement in Whipple Procedures; An Analysis of 7,605 Cases.

Posted on January 18, 2016

K. L. Haines1, C. D. Goldman1, J. Franko1 1Mercy Medical Center,Surgery,Des Moines, IA, USA

Introduction: Recent decades have shown a substantial reduction in mortality and morbidity of Whipple procedures. Perioperative outcomes are thought to be volume-and surgeon-related. Therefore, using the NSQIP dataset, we examined effects of resident/trainee participation in Whipple procedures on mortality and morbidity.

Methods: The NSQIP database was queried for patients undergoing Whipple from 2008-2012. Data was categorized by resident participation (operation with resident versus attending only). Proportion of complications in each group was compared using chi-square test. Logistic regression model was built to analyze impact of multiple covariates on perioperative mortality within 30-days and first postoperative day. Data are presented as proportions and mean±SD.

Results: 12,104 Whipples were reported to NSQIP between 2008-2012. After excluding cases with missing data on resident participation, 7,605 were available for analysis. These cases were divided into two groups: attending alone (group A, n=1105) versus attending with resident (group B, n=6500). Patient comorbidities and demographics were the same between the groups. Operative time was increased with resident involvement (364±139 vs. 380±132 minutes, p<0.001). Length of stay was significantly decreased when residents were involved (13.7±15 vs. 12.7±12 days, p<0.0001). When comparing attending alone versus with resident, there was no significant difference in patient outcomes including incidence of renal failure (p<0.0001), septic shock (p<0.0001), reintubation (p<0.0001), death on operative day (p<0.0001), 30-day mortality (p<0.0001), and readmission rates (p<0.0001). Resident participation was not a significant 30-day mortality predictor in unadjusted (OR=0.73; CI 0.51-1.04, p=0.087) or risk-adjusted models (adjusted OR 0.79; CI 0.55-1.14, p=0.22).

Conclusion: Resident involvement did not influence mortality and morbidity rates of Whipple procedure in this study. Resident participation is associated with longer operative time, but also significantly shortened hospital stay. Reduction in length of stay for this complex operation may reflect that, contrary to oft-reported criticisms in the literature, present-day residents are, in fact, taking ‘ownership’ of the patients under their care.

66.01 Evaluation of POSSUM score for predicting morbidity after hepatectomy for hepatocellular carcinoma

Posted on January 18, 2016

K. Akahoshi1, T. Ochiai1, H. Ito1, S. Matsumura1, Y. Mitsunori1, A. Aihara1, D. Ban1, A. Kudo1, S. Tanaka1, M. Tanabe1 1Tokyo Medical And Dental University,Bunkyo-ku, Tokyo, Japan

Introduction: The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) scoring system is one of surgical risk scoring systems to predict postoperative morbidity and mortality, which was originally developed by Copeland in 1991 as a scoring system for surgical audit. The aim of this study was to analyze predictive value of POSSUM scoring system in patients undergoing surgical treatment for hepatocellular carcinoma (HCC).

Methods: All patients who underwent liver resection for HCC in our hospital between September 2010 and February 2012 were enrolled in this study. Various preoperative, intraoperative and postoperative patients’ data were collected retrospectively. POSSUM score was calculated, and estimated morbidity and mortality rates were compared with actual incidences of morbidity and mortality.

Results: A total of 100 patients, with 74 males and 26 females, were studied. The average age was 68.7 years old (range 52-84). Postoperative complications were seen in 31 of 100 patients (31%). There were 2 postoperative in-hospital deaths (2%). Bile leakage was the most common complication (9 cases). Univariate and multivariate analysis revealed that preoperative anemia (HR= 3.886; 95%CI: 1.499 – 10.073, p=0.005) and major hepatectomy (HR= 2.675; 95%CI: 1.064 – 6.729, p=0.037) were independent risk factors of postoperative complications. POSSUM scoring system predicted morbidity risk effectively. Correlation analysis demonstrated that observed morbidity rates were significantly correlated with estimated morbidity rates by POSSUM score (r=0.917). Estimated mortality rates were difficult to evaluate, due to the small number of postoperative in-hospital deaths.

Conclusion: POSSUM scoring system could effectively predict the risk of postoperative morbidity in patients underwent hepatectomy for HCC. POSSUM is expected to be a useful risk assessment system of liver surgery.

66.02 Is papillectomy for early ampullary carcinoma justified? – Analysis of 65 resected cases –

Posted on January 18, 2016

T. Ochiai1, T. Miura2, S. Tanaka1, S. Yamazaki2, A. Kudo1, N. Noguchi2, T. Irie2, D. Ban1, A. Aihara1, S. Matsumura1, Y. Mitsunori1, H. Ito1, K. Akahoshi1, M. Tanabe1 1Tokyo Medical And Dental University,Bunkyo-ku, Tokyo, Japan 2Ohta Nishinouchi General Hospital,Koriyama, FUKUSHIMA, Japan

Introduction:
Pancreatoduodenectomy was the standard treatment for ampullary carcinoma, regardless of staging, previously. With recent advances of diagnostic modalities, accuracy of preoperative staging of ampullary neoplasm has been improved, therefore, limited resection of early ampulla of Vater carcinoma has been performed such as; endoscopic papillectomy and transduodenal papillectomy. In this study, we studied consecutive 65 cases of pancreatectoduodenectomy and analyzed tumor staging and prognosis.

Methods:
From January 2000 to December 2014, consecutive 65 patients with carcinoma of the papilla of Vater underwent pancreatoduodenectomy (PD), pylorus preserving pancreatoduodenectomy (PPPD), substomach preserving pancreatoduodenectomy (SSPPD) or total pancreatecomy (TP) with dissection of regional lymph nodes in Tokyo Medical and Dental University Hospital (28 cases)and Ohta Nishinouchi General Hospital (37 cases). We retrospectively analyzed surgical procedures, macroscopic and microscopic curability, clinicopathologic variables and survival.

Results:
A total of 65 patients underwent PD, PPPD, SSPPD or TP, aged 44 to 88 years and consisted of 40 males and 25 females. The surgical procedure was PD in 28 case (43.1%), PPPD in 26 (40.0%), SSPPD in 10 (15.4%) and TP in 1 (1.5%). Patients were grouped according to UICC TNM-staging as stage IA (n=14, 21.5%), stage IB (n=12, 18.5%), stage IIA (n=10, 15.4%), stage IIB (n=22, 33.8%), stage III (n=4, 6.2%), or stage IV (n=3, 4.6%). The overall and disease-free 1-, 3-, 5-, 10- year survival rates were 91.4%, 70.9%, 50.9%, 48.1% and 81.5%, 59.7%, 48.7%, 42.9% respectively. In univariate analysis, age, the depth of tumor infiltration, lymph node involvement, differentiation, stage, curability and operative procedures were significantly different. In multivariate analysis, age (OR 1.08), lymph node metastases (OR 4.02), curability (OR 5.91) were significantly different in prognosis. Metastatic disease to regional lymph nodes was present in 41.5% patients. Moreover, 4 out of 11 (36.4%), with invasion to the sphincter of Oddi in pT1, revealed lymph node metastases.

Conclusion:
Although accuracy of preoperative staging of ampullary neoplasm has been improved, evaluation of minimal invasion of the Oddi’s sphincter is considered still difficult in general. As 36.4 % cases of invasion to the sphincter of Oddi in pT1 revealed lymph node involvement, pancreatoduodenectomy with lymphadenectomy should be required for cancer patients.

66.03 Predictors and Outcomes of Operations Performed on Young Adults at Free-Standing Children’s Hospitals

Posted on January 18, 2016

C. A. Gutierrez1, P. P. Chiu2, R. Dasgupta3, H. C. Jen4, D. H. Rothstein1,5 1State University Of New York At Buffalo,Department Of Surgery,Buffalo, NY, USA 2Hospital For Sick Children,Department Of Surgery,Toronto, Ontario, Canada 3Cincinnati Children’s Hospital Medical Center,Department Of Surgery,Cincinnati, OH, USA 4Tufts Medical Center,Floating Hospital For Children,Boston, MA, USA 5Women And Children’s Hospital Of Buffalo,Department Of Surgery,Buffalo, NY, USA

Introduction:
While free-standing children’s hospitals may provide superior care to young and specialized patients, it is not clear whether this salutary benefit extends to young adults treated at those same institutions. This study asks what patient and hospital factors influence the type of hospital providing surgical care to young adults, and what factors influence postoperative complications in this group.

Methods:
A retrospective cohort study was performed using the 2012 Kid’s Inpatient Database to quantify and qualify operations performed on patients aged 18-20 years. Obstetric operations were excluded. Patient variables included age, gender, race/ethnicity, payer status, type of operation performed and illness severity (as measured by the All Patient Refined-Diagnosis Related Groups severity score). Hospital variables included U.S. region, urban/rural location and specialty designation. Outcomes included operations performed at a free-standing children’s hospital and complications. Odds ratios (OR), along with 95% confidence intervals (C.I.), were calculated using multivariate logistic regression analysis to adjust for confounders.

Results:

Among patients aged 18-20, non-whites (OR = 0.83, 95% C.I. 0.77-0.89), those with private insurance (OR = 0.71, 95% C.I. 0.66-0.77), and those receiving care in rural areas (OR = 0.67, 95% C.I. 0.60-0.75) were less likely to undergo operations at free-standing children’s hospital than other hospitals. Patients undergoing elective operations (OR = 5.93, 95% C.I. 5.52-6.38), those living in the Midwest or West U.S. regions compared to the Northeast, and those with progressively higher APR-DRG severity scores were more likely to undergo operations at free-standing children’s hospitals.

Postoperative complications in this group of patients were more likely to occur when operations were performed at free-standing children’s hospitals (OR = 1.68, 95% C.I. 1.41-1.99), were elective (OR = 1.62, 95% C.I. 1.44-1.82), or involved non-white patients (OR = 1.12, 95% C.I. 1.00-1.26). Payer status, rural hospital location and U.S. region did not appear to influence complication likelihood. Higher APR-DRG severity scores were associated with progressively higher odds of incurring postoperative complications.

Conclusion:
Race/ethnicity, payer status, hospital location and APR-DRG severity scores may play a role in determining the type of hospital where young adult patients receive surgical care. Paradoxically, receiving care at a free-standing children’s hospital may confer a higher risk of postoperative complications in this specific group as compared to care at other types of hospitals. Further stratification of patients by type of operation required or region of country may help direct resource utilization and improve outcomes. More work is needed to determine optimal delivery of care for patients who are poised for transition between pediatric and adult surgical services.

65.20 Not All Massive Transfusions Are Created Equal: Characterizing Variable Transfusion Trajectories

Posted on January 18, 2016

E. W. Etchill1, M. C. Vespe2, A. Hassoune4, J. L. Correa Lopez3, M. R. Rosengart1, A. B. Peitzman1, M. D. Neal1 1University Of Pittsburgh School Of Medicine,Surgery,Pittsburgh, PA, USA 2Carnegie Mellon University,Statistics,Pittsburgh, PA, USA 3Universidad de Caldas,Surgery,Manizales, Caldas, Colombia 4American University Of Beirut,Surgery,Beirut, Beirut, Lebanon

Introduction: Massive transfusion is currently defined as the transfusion of at least 10 red blood cell (RBC) units in 24 hours. Unlike in trauma, the transfusion patterns for massively transfused nontrauma patients have not been explored. However, most institutions have recently implemented identical transfusion protocols for both trauma and nontrauma patients. We hypothesized that distinct subpopulations of massively hemorrhaging patients exist based on patterns of product transfusion.

Methods: We used cluster-based modeling to characterize transfusion patterns in massively transfused trauma and nontrauma patients. Massively transfused nontrauma patients from a single institution were identified and classified into the following groups: cardiovascular (CV), gastroenterology (GI), transplant, and spine surgery. We identified distinct trajectories for product delivery and compared the distribution of patients in each trajectory by transfusion indication.

Results: 363 patients were included for analysis, including 298 nontrauma patients. The median age was 54 years. GI surgery patients accounted for 34% of nontrauma patients, while CV patients comprised 23%. Transplants accounted for 32% and spine procedures 7%. Thirty day mortality among all patients who completed a 24 hour transfusion period was 27%. All patients received an average of 17 cumulative units of blood cells, 14 units plasma, and 14 units of platelets.

Three distinct trajectories were extracted (Figure 1). Most trauma (85%) and cardiovascular surgery (63%) patients fit into trajectory 1, while most GI (57%) and transplant patients (63%) comprise trajectory 3. Trajectory 2 primarily consists of a subset of GI (29%) and transplant (31%) patients. The difference in distribution of patients in each trajectory is statistically significant (p < 0.004). Three plasma and four platelet transfusion ratio trajectories were also extracted and exhibit similar variability.

Conclusion: We identified three patterns of product transfusion among all massively transfused patients. Trauma and cardiovascular patients are more likely to receive the majority of their blood products early, while GI and transplant patients receive products over a longer period of time. There is also a subset of GI and transplant patients that may not be adequately resuscitated during the initial attempts, ultimately leading to greater transfusion requirements. Future investigation into the impact of additional clinical characteristics on transfusion trajectories, as well as the effect of trajectories on patient outcomes, will allow us to more appropriately investigate and resuscitate this heterogeneous massive transfusion population.

65.21 Motorcycle Riders Versus Passengers: Who Suffers More?

Posted on January 18, 2016

T. Soleimani1, T. A. Evans1, S. I. Fernandez1, L. Spera1, R. Sood1, B. L. Zarzaur1, S. S. Tholpady1 1Indiana University School Of Medicine,Division Of Plastic Surgery,Indianapolis, IN, USA

Introduction

Numerous studies demonstrate the utility of safety equipment (helmets) in prevention of serious traumatic injury related to accidents involving motorcycles. Few studies have focused on whether the pattern of injury is different and if the protective benefit is the same in passengers when compared to riders. This study was designed to evaluate these differences in usage of helmets and subsequent patterns of injury between the riders and passengers of motorcycles.

Methods

Using 2007-2010 National Trauma Databank (NTDB), motorcycle trauma patients were identified by ICD-9 codes (Ecodes: E810-E819). The injured patients were divided into two groups: motorcycle riders or passengers (fourth digit 2 and 3 respectively). Demographics, helmet use, injury severity, and outcomes including mortality, major complications, and length of hospital stay (LOS) were compared and contrasted. Major complications were defined as acute renal failure, ARDS, cardiorespiratory arrest, coma, pneumonia, sepsis, cerebrovascular accident, and surgical site infection.

Results

A total of 79,818 riders and 5,896 passengers were identified. Riders were more likely to be older (mean: 40.4 vs. 38.8 years), male (91.9% vs. 17.1%), obese (2.4% vs. 1.9%), and non-white (17.8% vs. 13.6%). They were also more likely to be under influence of drugs (51.2% vs. 47.5%). They were significantly more likely to wear helmet (66.2% vs. 57.5%). For riders, older age, white race, and female gender were associated with higher rates of wearing helmet. For passengers, the rate of helmet use was not associated with age and had reverse association with white race and female gender.

The mean Glasgow coma scale (GCS) was similar between riders and passengers (mean: 13.2 vs. 13.1) however the Injury Severity Score (ISS) was slightly higher for the riders (mean: 12.9 vs. 13.7). The rate of major complications was significantly higher among the riders (8.1% vs 6.1%) even after adjusting for potential confounders. There were no significant differences in rates of mortality (4.6% vs 4.1%) and LOS between the riders and passengers. The unadjusted ICU admission rate was slightly higher for the riders (34.2% vs 32.7%). However, after adjusting for other potential confounders, the riders and passengers had no significant difference in rate of ICU admission.

Conclusions

This is one of the first studies to study demographics and outcomes of motorcycle passengers when compared to riders. There is a very small protective effect in being a passenger when major complications are considered, but mortality, LOS, and ICU admissions were all similar. Interestingly, while the outcomes are similar, the demographics of helmet use were different. Being young, white, and female all were associated with being an unhelmeted passenger; these trends should be prospectively followed and intervened upon as changes in this population’s behavior would yield significant life and quality of life dividends.

65.18 Relevance of Multidisciplinary Colorectal Tumor Board − A Prospective Study

Posted on January 18, 2016

A. Sasidharan1, K. Trencheva1, C. Merchant1, J. W. Milsom1, P. J. Shukla1 1Weill Cornell Medical College,Colorectal Surgery,New York, NEW YORK, USA

Introduction: In our Institutional Colorectal Multidisciplinary Team (MDT), selective referral of patients by treating physicians is made. The primary aims of this study were to evaluate the reasons for referral of patients with colorectal cancer to a multidisciplinary colorectal tumor board, and to evaluate whether the plan of care was changed as a result of tumor board review. The secondary aim was to compare the characteristics of patients who were referred to the MDT versus those who were not.

Methods: This was a prospective study involving subjects ≥ 18 years of age with colorectal cancer treated at our hospital from January to July 2015. Subjects who were referred to the MDT were compared to those who were not referred (but underwent surgical treatment). Demographics, preoperative and postoperative data, and surgical pathology results of the two groups were collected. Outcomes were analyzed at 1 and 3 months for both the referred (after discussion at MDT) and non-referred (after surgery) subjects. Univariate and multivariate logistic regression was performed to analyze the data.

Results: There were 106 subjects in the referred group and 35 in the non-referred group. The most common reasons for referral were: discuss management plan (89.6%), review radiology (70.7%), review pathology (53.7%) and discuss timing of surgery (1.8%). After discussion at MDT, plan of care changed in 32.1% (34/106) of the subjects. The revised plan was implemented in 67.6% (23/34) and was not implemented in 26.4 % (9/34) of the subjects. 2/34 are awaiting the commencement of treatment as recommended. The reasons for non-implementation were: patient’s choice, treating physician’s decision and age. The following variables were found to be significant in univariate analysis between the 2 groups, with p-value < 0.05: age, history of previous surgery, previous chemotherapy, previous abdominal surgery, tumor location and stage of cancer. Multivariate logistic regression with "referral to MDT’ being the outcome is reported in Table1.

Conclusions: The main reason for referral to MDT was to discuss management plan. Plan of care changed in nearly one third of the subjects as a result of MDT review. Tumor location and Stage of cancer are significant factors determining MDT referral.

65.19 TIMING OF VENOUS THROMBOEMBOLISM PROPHYLAXIS AFTER TRAUMATIC BRAIN INJURY: A SURVEY OF EAST MEMBERS

Posted on January 18, 2016

B. STROLLO1, G. Bennett1, M. Chopko1, W. A. Guo1 1State University Of New York At Buffalo,Surgery,Buffalo, NY, USA

Introduction: Patients with traumatic brain injury (TBI) are at a significant risk of developing venous thromboembolism (VTE). However, early pharmacologic prophylaxis risks progression of neurological site bleeding. Thus far, no national standard exists to guide for safely initiating pharmacologic prophylaxis of VTE after TBI. We designed this study to survey the EAST members on their practice patterns regarding timing of pharmacologic VTE prophylaxis after TBI.

Methods: Over 1 month, EAST members were emailed to participate in an online survey. Participants reported demographics, and responses to questions regarding VTE prophylaxis and timing of prophylaxis in 2 clinical scenarios of TBI.

Results:The response rate was 30.9%. The majority of the participants were from Level 1 trauma centers and academic teaching hospitals. Most respondents (75%) reported starting chemical VTE prophylaxis with a consensus between the neurosurgery and trauma/critical care services. While 76% of respondents reported experience of seeing pulmonary embolism without pharmacologic VTE prophylaxis, only 44% witnessed progression of TBI after chemical VTE prophylaxis. About half of surgeons surveyed considered their practice of VTE prophylaxis in TBI patients to be conservative. Almost 50% reported no standardized protocol in their institutions. While 1/3 of the members believed there are guidelines from EAST, another 1/3 were not aware of any guidelines available for VTE prophylaxis after TBI. Responses to questions regarding timing of pharmacologic VTE prophylaxis in a hypothetical patient are shown in Figure.

Conclusion:Currently there is a substantial variation in the practice patterns among EAST members regarding timing of pharmacologic VTE prophylaxis in TBI patients. This survey reinforces the need for prospective observational and randomized control trials to determine best practice of VTE prophylaxis in patients after TBI.

65.15 Limitations of the ACS NSQIP in Intracranial Aneurysm Management

Posted on January 18, 2016

H. Hong1, R. R. Kelz2, M. J. Smith1 1University Of Pennsylvania,Neurosurgery,Philadelphia, PA, USA 2University Of Pennsylvania,Surgery,Philadelphia, PA, USA

Introduction: Patients with intracranial aneurysm (ICA) may be suitable for either surgical or endovascular repair. The limited generalizability of existing studies comparing the two treatment modalities underlines the importance of using observational data to delineate optimal standards of practice. The multi-institutional American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) is considered the best available data source for surgical outcomes research, yet its utility in evaluating care for patients with ICA is unclear. This study assesses whether the current form of the NSQIP is sufficient for analyses on ICA-specific procedures.

Methods: A retrospective cohort study of patients undergoing surgical clipping (CPT codes 61697, 61698, 61700, 61702) or endovascular coiling (CPT 61624, 61635, 75894) of ICA was conducted using the ACS NSQIP participant use file 2006-2013. Prior to the analysis, a focus group of clinical experts was convened to identify significant preoperative and postoperative variables for ICA management. The availability of the data elements was tabulated. Univariate analysis using the chi-squared test was performed to compare patient, disease, and procedure characteristics. A multivariate logistic regression model was then developed to determine the factors associated with the primary outcome measure, 30-day combined death or stroke rate (30dDS).

Results: A total of 974 adult patients undergoing surgical clipping for ICA repair were identified for inclusion during the 8-year period. Zero entry of endovascular repair was found. A considerable number of potential risk factors (e.g. subarachnoid hemorrhage, ventriculostomy need, shunt need, family history of aneurysms, the Hunt and Hess grading, morphology, location, size, and number of aneurysms) and outcome measures (e.g. vasospasm, follow-up radiographic result, modified Rankin scale, Glascow outcome scale) were not available for analysis. For the clipping cohort, the overall 30dDS was 12.7% with 63 deaths and 80 strokes. In the multivariate model, only two variables—hypertension requiring antihypertensive medication and coma state prior to the operation—maintained significant association with higher risk of 30dDS (OR=2.4, 95% CI 1.2-5.1 and OR=6.8, 95% CI 2.2-22.8 respectively).

Conclusion: The study show that the current form of NSQIP is inadequate as data source for evaluating quality of ICA-related procedures. While a rudimentary outcomes study for surgical clipping of ICA is feasible, the database misses endovascularly treated patients and many variables of significant import to patients with ICA. To improve the utility of the database for this disease, the NSQIP might consider an ICA-specific pilot study including patients undergoing procedures outside of the operating room and making use of the expanded custom fields to capture the missing disease-specific risk factors and outcomes.

65.16 Readmission Rates Following Lower Extremity Bypass Vary Significantly Based on Surgical Indication

Posted on January 18, 2016

C. Jones1, A. Gullick1, D. I. Chu1, B. Pearce1, M. Morris1 1University Of Alabama – Birmingham,Department Of Surgery,Birmingham, AL, USA

Introduction:
Readmission rates following vascular surgery are among the highest within surgical specialties, and lower extremity bypass has the highest readmission rate of vascular surgery procedures. Understanding risk factors for and ultimately predicting readmission within this population could have significant clinical impact. We hypothesize that readmission rates following lower extremity bypass differ based on the indication for surgery.

Methods:
We queried the 2012-2013 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) procedure targeted vascular cohort to identify all patients who underwent lower extremity bypass. Patients were stratified by surgical indication: Aneurysm, Claudication, Critical limb ischemia rest pain, Critical limb ischemia tissue loss, or Other. Patients with a postoperative length of stay greater than 30 days or death within 30 days were excluded. Chi-square and Wilcoxon Rank Sums tests were used to determine the differences among categorical and continuous variables, respectively. The primary and secondary outcomes were unplanned readmissions and postoperative complications, respectively. Predictors of readmission were identified with logistic regression using a negative binomial model, and multivariable analysis was used to adjust the odds ratio of readmission for surgical indication.

Results:
Of the 4,676 lower extremity bypasses that were performed, 94.1% were elective and 5.1% were emergent. The cohort consisted of 65.2% males, 34.8% females, 72.2% whites, and 16.5% blacks. The overall 30-day readmission rate was 15.9%. Readmission rates varied significantly based on the indication for surgery. On unadjusted comparison, 20.2% of patients with tissue loss were readmitted compared to 16.8% with rest pain, 12.3% with aneurysms, and 9.8% with claudication (p<0.0001). Unadjusted postoperative cardiac and respiratory complications as well as major bypass reinterventions varied significantly based on surgical indication (Table). Significant adjusted odds ratios of readmission were 1.617 for tissue loss versus claudication (p=0.0003) and 1.533 for rest pain versus claudication (p=0.0013). Several odds ratios for readmission based on adjusted predictors of readmission were significant for surgical indications (Table).

Conclusion:
The risk for readmission after lower extremity bypass and postoperative complications vary significantly based on the surgical indication. All lower extremity bypasses are not performed for one diagnosis. If hospitals are to be penalized for high readmission rates, then the readmission rates following lower extremity bypass should be adjusted for surgical indication.

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