65.17 Effect of Cardiovascular Risk Factors on Microembolization Rates During Carotid Revascularization

Posted on January 18, 2016

C. E. Pina1, J. Li1, B. Rawal1, C. Giannarelli2, C. Faries1, V. Mani3, A. Vouyouka1, P. Krishnan2, R. Tadros1, J. Badimon2, Z. A. Fayad3, M. L. Marin1, J. Wiley2, P. L. Faries1 1Icahn School Of Medicine At Mount Sinai,Vascular Surgery,New York, NY, USA 2Icahn School Of Medicine At Mount Sinai,Cardiovascular Research Institute,New York, NY, USA 3Icahn School Of Medicine At Mount Sinai,Translational And Molecular Imaging Institute,New York, NY, USA

Introduction: Carotid revascularization poses inherent periprocedural risks to patients that must be weighed carefully against the benefits of preventing plaque embolism and stroke. Intracerebral microembolization of atherosclerotic plaque of the middle cerebral artery (MCA) is one of the major factors leading to increased cerebrovascular events and morbidity after minimally invasive and surgical carotid revascularization. Identification of specific demographic cardiovascular risk factors for increased microembolization can be useful in guiding decisions regarding choice and timing of procedure.

Methods: A total of 150 patients will be enrolled in this study. A preliminary analysis was done in 42 patients (male 74%; mean age 69.5) undergoing carotid endarterectomy (CEA, n=23) or carotid angioplasty and stenting (CAS, n=19). The ipsilateral MCA was intraoperatively monitored for microembolic signals (MES) using transcranial Doppler. Demographic analysis of 4 common cardiovascular risk factors (diabetes, hypertension, hyperlipidemia, smoking history) and presence of stroke symptoms was performed retrospectively.

Results: Results show a significant difference between patients with symptomatic stroke undergoing CAS and higher MES rates (63 + 31 vs. 30 + 10, p=0.004). We also found a non significant increase in average MES rates in CEA patients with diabetes (134 + 278 vs. 39 + 27), hypertension (83 + 202 vs. 63 + 80), hyperlipidemia (113 + 239 vs. 30 + 21), smoking history (111 + 230 vs. 24 + 14) or with stroke symptoms (151 + 306 vs. 42 + 45) compared to CEA patients negative for each risk factor or stroke, respectively.

Conclusion: Our preliminary data demonstrates statistically significant increased MES rates in symptomatic CAS patients compared to asymptomatic CAS patients. We did not see any significant increase in average MES during CAS for patients positive for diabetes, hypertension, hyperlipidemia, smoking history, and presence of stroke symptoms compared to patients negative for these risk factors. A positive trend towards higher MES rates in CEA patients with comorbidities compared to those without did not reach statistical significance probably due to lack of power. The study is ongoing and we are correlating this data with changes in neurocognitive status as detected by the Montreal Cognitive Assessment and the presence of micro-infarcts on cerebral DW-MRI.

65.12 How do Surgical Providers use Social Media? A Mixed-Methods Analysis using Twitter

Posted on January 18, 2016

N. Nagarajan1, B. J. Smart2, M. Dredze3, J. L. Lee5, J. Taylor1, J. A. Myers2, E. B. Schneider1, Z. D. Berger4, J. K. Canner1 1Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA 2Rush University Medical Center,Department of Surgery,Chicago, IL, USA 3Johns Hopkins University School Of Medicine,Department Of Computer Science,Baltimore, MD, USA 4Johns Hopkins University School Of Medicine,Department Of General Internal Medicine,Baltimore, MD, USA 5Johns Hopkins Bloomberg School Of Public Health,Baltimore, MD, USA

Introduction:
Providers, patients and advocates are increasing using social networking sites likes Twitter to disseminate information and to aid in healthcare decision-making. In surgery, despite anecdotes about enthusiastic adoption by providers, there is a lack of robust qualitative and quantitate data on the utilization of Twitter for professional use. Therefore, this study aims to identify surgical providers on Twitter and to analyze their usage patterns.

Methods:
Individual tweets on surgical topics were pulled from Twitter from March 27th to April 27th, 2015 using a comprehensive list of surgery-related hashtags. Following this, the unique profiles of users who generated these tweets were identified. Further, key word matching was used to isolate those who self-identified (in profile ID/screen name/biography) as being involved in a surgical field. The Twitter profiles of these selected ‘surgical providers’ were analyzed to extract information on pre-determined themes. Data was extracted on multiple qualitative and quantitative fields, including: sex, location, user-type, affiliation, surgical specialty, multimedia use, followers/following, number of tweets, list membership and time on twitter. Standard descriptive statistical analyses were used to summarize the findings.

Results:
A total of 17,783 surgery-related tweets were pulled in the study period from 7,713 unique users. Following this, 726 profiles (9.4%) were identified as ‘surgical providers’. The cohort had a heterogeneous mix of user-type (surgeons/students/physicians/researchers/institutions) with varied affiliations (academic/community/private/non-profit/government) and specialties (general surgery/breast surgery/plastic surgery/orthopedics/surgical oncology/surgical health systems). The median time on twitter for profiles in this cohort was 40.7 months and ranged from 3 months to 8.5 years. Overall, a majority of the users were from North America (58.3%), followed by Europe (21.2%) and Asia (12.0%). This cohort had cumulatively tweeted 1,814,017 times; the median number of tweets per user was 625, with users tweeting as few as 8 and as many as 112,648 times. The median number of followers for a profile (334 [range: 7-142,580]) was similar to the number that they themselves followed (323 [range: 3-66,731]). Users were also members of a number of lists (median 11 [range: 0-3,672]) that are created based on common interests and topics that they tweet on.

Conclusion:
Surgical providers on Twitter come from varied affiliations/specialties but are predominantly from developed countries in North America and Europe. Most profiles (71.1%) were created in the last 5 years, which may point to a growing understanding of the utility of this interface for building professional networks as well as for effective patient education. More in-depth content and network analyses are necessary to develop strategies for using social media to improve knowledge sharing, communication and collaboration between surgical providers, patients and patient advocates.

65.13 Patient perspectives about follow-up care and weight regain following sleeve gastrectomy

Posted on January 18, 2016

M. Lauti1, S. Stevenson1, A. G. Hill1, A. D. MacCormick1 1University Of Auckland,Department Of Surgery,Auckland, -, New Zealand

Introduction:

Weight regain following sleeve gastrectomy is an increasingly recognised and important problem. Despite this, it is poorly reported and understood. Similar to other centres, we have noticed an association between discharge from the bariatric service and the onset of weight regain. We aimed to elucidate this further from the patient perspective.

Methods:

Patients at least two years from sleeve gastrectomy, who had experienced weight regain, were invited to participate in a focus group discussion. Participants were asked to complete a demographic survey and discussions were audio-recorded. Transcripts underwent content analysis using an inductive approach.

Results:

Thirty-eight participants participated in one of seven focus group discussions. The majority of participants were female, European and satisfied with their surgery and follow-up care. Participants described positive and negative aspects of the surgery, their follow-up care and causes of weight regain. Important emergent themes included the desire for more support delivered within the overarching principles of providing individualised and specialised care by providers that maintain good rapport and assist in maintaining motivation. Furthermore, this follow-up support may be delivered in non-traditional ways rather than traditional face-to-face consultations.

Conclusion:

We conclude that individualised, innovative and sustainable care pathways are needed for our bariatric patients.

65.14 Post-Operative Costs to the Elderly Following Emergency Surgery; a Prospective Cost Analysis

Posted on January 18, 2016

G. J. Eamer1, L. M. Warkentin1, T. Churchill1, F. Clement2, R. G. Khadaroo1 1University Of Alberta,Department Of Surgery,Edmonton, AB – ALBERTA, Canada 2University Of Calgary,O’Brien Institute For Public Health,Calgary, AB, Canada

Introduction:
Aging populations and improved medical technology have led to increased surgical interventions in the elderly. North Americans aged 65 or older make up 15% of the population in 2015; this is projected to rise to 22% by 2050. Post-operative complications are associated with longer hospital stays, increased cost and lost independence. There is no data examining patients’ accrued personal expenses and lost working days following emergency surgery discharge. This study will estimate the financial and social costs incurred by elderly post-operative patients following acute abdominal surgery.

Methods:
A prospective cohort of 73 patients 65 or older was enrolled in a study of post-surgical interventions to improve outcomes. The patients underwent acute abdominal surgery at either of the two level 1 trauma centers in Alberta, Canada, and completed a 6-month follow-up. Exclusion criteria were elective or palliative surgery, trauma, previous admission, or dependence for 3 or more activities of daily living. A detailed chart review gathered clinical and biochemical data. A validated health resource utilization inventory (HRU) was performed at a 6-month follow-up, which included questions on employment and medical products use. Participants were compared between sites to ensure demographic homogeneity using Fischer’s exact tests or ANOVA. The cost of healthcare products used or purchased in the 6 months following discharge was estimated using government and commercial sources and our HRU. Multivariate linear regression assessed the association of age, preadmission care requirements, post-operative complications and readmission with post-discharge costs.

Results:
Mean age was 79.3 (SD 7.9). More than 98% were Caucasian (n=72); 68% were married; 67% were 3 or less on the Clinical Frailty Scale; and 77% were living independently without care. 62% were classified ASA 3 or 4 (n=45). Following discharge 35% required assistance with cleaning, 30% with shopping, 24% with laundry and meal preparation, 14% with finances and 8% lost employment hours. The mean health care expenditure was 797 Canadian dollars (SD $932, inter-quartiles $157, $1,142, max $4,547) in the 6 months following surgery. Post-discharge cost was associated with needing preadmission care (β 0.313, CI 350-2330, p = 0.009,) as was age (β 0.061, CI 3.7-9.6, p < 0.001). Increased discharge costs were also associated with postoperative complication ($617, β 0.356, CI $283-951, p < 0.001), as was being readmitted ($524, β 0.253, CI $44-1004, p = 0.03).

Conclusion:
Our data demonstrates the significant financial and social costs to patients upon discharge, with an estimated mean cost of $797 in the 6 months post-discharge. Complications pre- and post-discharge also increase out-of-pocket costs to the patient. Reducing complications will not only reduce costs during admission, but also reduce patients’ costs following discharge.

65.10 Central Pain Processing and Treatment Response in Anterior Cutaneous Nerve Entrapment Syndrome

Posted on January 18, 2016

D. Van Rijckevorsel1, O. Boelens2, R. Roumen3,6, O. Wilder-Smith4,5, H. Van Goor1 1Radboud University Medical Center,Department Of Surgery,Nijmegen, , Netherlands 2Maasziekenhuis Pantein,Department Of Surgery,Boxmeer, , Netherlands 3Máxima Medical Center,Department Of Surgery,Veldhoven, , Netherlands 4Radboud University Medical Center,Department Of Anesthesiology, Pain And Palliative Medicine,Nijmegen, , Netherlands 5Aalborg University,Center For Sensory-Motor Interaction,Aalborg, , Denmark

Introduction:

Anterior Cutaneous Nerve Entrapment Syndrome (ACNES) is a common cause of chronic abdominal pain, refractory to local treatment in about 25% of cases for yet unknown reasons. We aimed to assess central pain processing after ACNES treatment and possible relationships between central pain processing and treatment outcomes by performing Quantitative Sensory Testing (QST).

Methods:
50 patients treated for ACNES with locally oriented treatment were tested. They were allocated to a responsive or refractory group based on response to treatment. Patients showing an improvement of the Visual Analogue Scale (VAS) pain score combined with an absolute VAS of < 40 were scored as responsive.
Thresholds to pressure and electric skin stimulation were determined in the ACNES dermatomes and four control areas. Conditioned pain modulation (CPM) response to a cold pressor task was determined. Patients filled in three pain-related psychological questionnaires.

Results:
Patients refractory to treatment showed significantly lower pressure pain thresholds in multiple dermatomes. No differences were found between groups for electric thresholds or CPM response. Duration of complaints before diagnosis and treatment was significantly longer in the refractory compared to the responsive group, and scores on pain-related questionnaires were higher.

Conclusion:
ACNES patients refractory to treatment have more signs of sensitized central pain processing and a longer duration of complaints before diagnosis and treatment. It appears that the presence of sensitized central pain processing is associated with less effective locally-orientated treatment.

65.07 The Impact of Index Hospital Costs on Readmission Among Patients Undergoing Major Abdominal Surgery

Posted on January 18, 2016

A. Ejaz1, A. A. Gonzalez1, F. Gani2, T. M. Pawlik2 1University Of Illinois At Chicago,Surgery,Chicago, IL, USA 2Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA

Introduction:
Reducing postoperative readmissions have been identified as an opportunity for healthcare cost containment. We sought to identify the impact of index admission costs on readmission rates and quantify any potential variation in costs and readmission attributable to the patient, procedure, and provider.

Methods:
Patients who underwent a colorectal, pancreas, or liver resection between 2009 and 2013 were identified at a tertiary care hospital. Variations in the index hospital costs among providers were compared using coefficient of variation (CV).

Results:
Among 4,114 patients, the overall unadjusted 30-day readmission rate was 17.2% varying by procedure (colorectal: 18.6% vs. pancreas: 18.6% vs. liver: 10.1%, P<0.001). The mean cost of surgery during the index hospitalization was $33,809±34,663 and varied by procedure (colorectal: $32,957 vs. pancreas: $37,360 vs. liver: $27,476, P<0.001). Median index length of stay (LOS) was 7 days (IQR: 5, 11) and was higher among patients who were eventually readmitted (readmitted: 8 days [IQR 6, 13] vs. not readmitted: 7 days [IQR 5, 11], P<0.001). Patients readmitted had a higher incidence of index hospitalization perioperative morbidity (readmitted: 20.3% vs. not readmitted: 16.4%; P=0.007). On adjusted analysis, pancreas (OR 1.88) or colorectal (OR 1.94) resection and an observed: expected index LOS >1 (OR 1.44) were independently associated with a higher risk of readmission (all P<0.001). Total index hospitalization costs were higher among patients who were readmitted (readmitted: $36,607±26,718 vs. not readmitted: $33,229±36,069; P<0.001). Further, among patients without an index hospitalization complication, total costs remained higher among patients who were eventually readmitted (readmitted: $31,138±19,528 vs. not readmitted: $25,964±13,999; P<0.001). At the provider level, readmission rates varied among surgeons performing the same procedure (colorectal: 0%-33.3% vs. pancreas: 0%-37.5%vs. liver: 0%-25%). Similarly, substantial variation in index hospitalization costs was also observed among surgeons performing the same procedure for readmitted (Colorectal: 87.6% vs. Pancreas: 72.7% vs. Liver: 58.6%) and non-readmitted (Colorectal: 120.7%% vs. Pancreas: 103.4% vs. Liver: 69.9%) patients.

Conclusion:
30-day readmission rates among patients undergoing major abdominal surgery vary significantly. Higher index hospitalization costs did not translate in to lower readmission rate.

65.08 Does bariatric surgery alter breast cancer treatment?

Posted on January 18, 2016

A. Ardestani1, E. Pranckevicius1, M. Golshan1, A. Tavakkoli1, E. Sheu1 1Brigham And Women’s Hospital,Department Of Surgery/ General/GI Division,Boston, MA, USA

Introduction: Obesity is an established risk factor for breast cancer and is thought to adversely affect outcomes. The impact of significant and sustained weight loss as achieved by bariatric surgery on breast cancer is not well understood.

Methods: We performed an institutional retrospective review of patients who underwent bariatric surgery and were diagnosed with malignant breast disease from 1989–2014. We compared patient demographics, tumor characteristics, and surgical and adjuvant treatments in patients diagnosed with breast cancer before (‘BEFORE’ group) or after (‘AFTER’ group) undergoing bariatric surgery.

Results: We included 101 patients, 62 and 39 patients in the BEFORE and AFTER groups, respectively. Patients in the BEFORE group were younger and more obese (Table 1). No significant differences were observed in tumor pathology in the BEFORE and AFTER groups including tumor size, hormone receptor status or lymphovascular invasion. Surgical outcomes were also similar between the groups including the rates of axillary dissection, positive margin, and peri-operative complications. However, a higher proportion of patients in the BEFORE were treated with chemotherapy and radiation therapy (Table 1). Of note, hormonal therapy was similar between the groups (63% vs. 47%, P=0.14). There was also a trend for higher recurrence in the BEFORE group.

Conclusions: This study represents one of the largest studies of breast cancer outcomes in bariatric surgery patients. Despite significant weight loss, bariatric surgery has no impact on tumor stage at diagnosis or hormone receptor status. Bariatric surgery appears to decrease the need for re-excisions, chemotherapy, and radiation therapy without a negative impact on breast cancer recurrence.

65.09 Outcomes After Discharge From The Surgical Intensive Care Unit to Long Term Acute Care Hospitals

Posted on January 18, 2016

T. S. Jones1, A. Bhakta1, E. L. Jones1, M. Nguyen1, M. Lyaker1, C. Byrd1, D. S. Eiferman1 1The Ohio State University,Columbus, OH, USA

Introduction:

Patients with prolonged hospitalizations in the Surgical Intensive Care Unity (SICU) often have ongoing medical needs that require further care at Long-Term Acute Care Hospitals (LTACHs) upon discharge. Setting expectations for patients and families after protracted SICU hospitalizations is challenging, and there is limited data to guide these conversations. The purpose of this study was to determine patient survival and readmission rates after discharge from the SICU to a LTACH.

Methods:

All patients admitted to the SICU at an academic tertiary care medical center from 2009 to 2014 were retrospectively reviewed. Patients represented all surgical subspecialties except cardiac and vascular surgery patients. Primary outcomes measured included complication rates defined by NSQIP, thirty day readmission rates to the SICU and mortality within one year of discharge.

Results:
296 patients were discharged directly from the SICU to a LTACH. The majority were male (64%) with a mean age of 61 ±16 years. Mean length of stay in the SICU prior to LTACH discharge was 27 ±15 days. The overall complication rate was 99% (293 of 296 patients); the most frequent complication was ventilator dependence greater than 48 hours (277 patients, 94%) followed by pneumonia (139 patients, 47%), sepsis (78 patients, 26%) and acute renal failure (32 patients, 11%). Two hundred and seventy-five patients (93%) required tracheostomy and enteral feeding access prior to discharge and 19 patients (6%) were newly dependent on hemodialysis. Mean GCS at time of discharge was 11. Overall thirty day readmission rate was 20%. There were 86 deaths within 1 year from discharge (29%) with an overall 3 year mortality of 35%

Conclusion:
Patients who are discharged to LTACHs have prolonged intesive care unit hospitalizations with high complication rates. After discharge, these patients have high readmission and one year mortality rates. Patients and families should be counseled about these outomces to allow for realistic expectations of survival following prolonged intensive care hospitalizations.

65.05 Overcoming the Weekend Effect: Impact of Electronic Medical Record System and Vendor Functionality

Posted on January 18, 2016

A. N. Kothari1,3, R. H. Blackwell3, R. M. Yau3, V. Chang2,3, M. A. Zapf2,3, T. Markossian2, G. N. Gupta3, P. C. Kuo1,3 1Loyola University Medical Center,Department Of Surgery,Maywood, IL, USA 2Loyola University Chicago Stritch School Of Medicine,Maywood, IL, USA 3Loyola Department Of Surgery,1:MAP Analytics Group,Maywood, IL, USA 4DePaul University,College Of Computing And Digital Media,Chicago, IL, USA

Introduction:
We previously demonstrated implementation of electronic medical record (EMR) systems as a mechanism to overcome the weekend effect (WE) in emergent/urgent surgery. We hypothesized this was related to EMR systems improving OR throughput and care transitions on the weekend. Our objective was to study how individual components of EMR systems contributed to overcoming the WE to test this hypothesis.

Methods:
This was a population-based cohort review using the 2011 Florida HCUP SID database and HIMSS Analytic database. We used prolonged weekend length of stay compared to the weekday at the hospital-level as a surrogate for the WE. Patients who underwent urgent/emergent surgical intervention at hospitals with the WE were propensity matched to patients at hospitals without the WE using patient (demographic, clinical) and hospital (case-mix, structural) characteristics.

Results:
2,841 patients comprised each matched group. EMR in the OR (O.R. 2.52, 95% C.I. [1.77, 3.60]) and electronic medication reconciliation (O.R. 2.43, 95% C.I. [2.10, 2.80]) were associated with overcoming the WE. Computerized physician order entry (O.R. 0.66, 95% C.I. [0.59, 0.75]), electronic bed management systems (O.R. 0.48, 95% C.I. [0.41, 0.55]), and electronic OR scheduling (O.R. 0.51, 95% C.I. [0.35, 0.75]) appeared to be risk factors for the WE. However, specific EMR vendor products within each of those cateogries could protect against the WE (see Table).

Conclusion:
EMR components that influence OR throughput and care transitions impact the ability for hospitals to overcome the WE. Additionally, these results are the first to demonstrate vendor-specific EMR functionality can significantly impact patient care.

65.06 As Safe as We Claim? A Population Based Analysis of Pyloromyotomy Outcomes in California

Posted on January 18, 2016

C. M. Kelleher1,2, P. T. Masiakos1,2, D. C. Chang2,3 1Massachusetts General Hospital,Pediatric Surgery,Boston, MA, USA 2Harvard School Of Medicine,Brookline, MA, USA 3Massachusetts General Hospital,Surgery,Boston, MA, USA

Introduction: Pyloromyotomy for hypertrophic pyloric stenosis is considered a safe pediatric surgical procedure with few complications or readmissions. Although the incidence of complications has been reported, the rate of readmissions on a population level is unknown.

Methods: Data was abstracted from the longitudinally linked Office of Statewide Health Planning and Development data from the State of California from 1995 to 2009, which allows patient tracking across all hospitals and across all years within California. Inclusion criteria were primary procedure code of pyloromyotomy, a diagnosis code of hypertrophic pyloric stenosis, and no prior record of any in-hospital admission.

Results: A total of 1900 patients were identified (16.8% girls, 31.7% whites, 5.1% blacks, and 58.2% Hispanics). 3.53% of the patients were found to have a significant congenital or comorbid condition; another 0.84% of patients were born prematurely. The median length of stay was 2 days (IQR 2-3 days). The in-hospital complication rate was 5.16%; There were no deaths. The rate of 30-day all-cause readmission was 4.01%, with a median of 0% across hospitals (IQR 0%-1.1%); and 13.2% of readmissions occurred at a different hospital. Surgically-related readmission rate was 2.16%. All-cause readmissions at 60 days, 90 days, 180 days, and 1 year were 5.8%, 7.3%, 10.4%, and 13.7%, respectively. The top three primary diagnoses on readmission were hypovolemia, upper respiratory infections, and post-operative infections.

Conclusion: Thirty day readmission for a surgical complication occurs in 1 of 50 patients undergoing a pyloromyotomy for hypertrophic pyloric stenosis and for all causes is 1 in 25 patients. This data can help inform physicians, families and policy makers about rates of hospital readmission in this common pediatric surgical procedure.

65.02 Trends of Inpatient Surgeries in Pediatric Inflammatory Bowel Disease Patients in the United States

Posted on January 18, 2016

A. L. Stokes1, C. Hollenbeak1, T. Falaiye1 1Penn State Hershey Medical Center,Hershey, PA, USA

Introduction: Pediatric inflammatory bowel disease is globally increasing in incidence. Advances in medical and surgical therapy have improved outcomes over the past two decades. While inpatient hospitalizations and rates of surgery are reportedly decreasing in other countries, trends in the rates of various types of inpatient surgeries in the United States have not been widely reported.

Methods: Pediatric patients ≤20 years of age with either Crohn’s disease (CD) or ulcerative colitis (UC) were identified in the HCUP KID database (2003, 2006, 2009, 2012). Surgeries including bowel resection, stoma creation, and perianal or percutaneous drainage procedures were identified using ICD-9 procedure codes. Logistic regression was used to identify factors associated with surgical intervention, while linear regression was used to identify factors associated with LOS and costs. Regression was also used to test the significance of trends in procedure rates over time. Survey weights were used to obtain estimates of national trends.

Results: Increasing numbers of hospitalizations for both CD and UC patients from ages 0 to 20 were found from 2003-2012 (up from 126 per 100,000 hospitalizations to 197 for CD; up from 68 per 100,000 to 115 for UC, both p<0.001). UC patients had higher LOS (6.4 vs. 5.4 days, p<0.001) and hospitalization costs ($15,011.20 vs. $12,356.80, p<0.001). CD had higher rates of intestinal resection (10.0% vs. 8.1%, p<0.001), but rates of stoma creation were higher in UC (8.6% vs. 2.2%, p<0.001). Factors associated with both intestinal resection and stoma creation (ileostomy or colostomy) include age between 10-20 years, male gender, Caucasian or Asian race, elective admission, and admission to an urban teaching hospital (all p<0.05). Whereas resection was associated with CD and fewer comorbidities, stoma creation was associated with UC and greater number of comorbidities (all p<0.01). Perianal drainage and percutaneous drainage procedures were both significantly associated with CD diagnosis. Rates of these procedures did not change significantly over time, except for increased stoma creation in CD (OR 1.06, 95% confidence interval [CI] 1.03-1.09) and increased percutaneous drainage in UC (OR 1.07, CI 1.00-1.14).

Conclusion: Despite increasing hospitalizations, the rates of common procedures in pediatric IBD patients have remained stable in the US over the last decade, with the exception of increasing stoma creation in Crohn’s patients. This plateau may indicate improved medical control of IBD obviating the need for surgery, or changing indications for surgical treatment. Further studies examining changes in the timing of surgery and the effects of biologic agents on surgical rates are warranted.

65.03 Extremes of Age Predict Readmission Following Elective Colorectal Surgery

Posted on January 18, 2016

L. Theiss1, L. Goss1, D. I. Chu1, M. Morris1 1University Of Alabama At Birmingham,Department Of Surgery,Birmingham, Alabama, USA

Introduction: Surgeons are operating on a growing population of elderly adults. Elderly patients are defined in most studies as anyone greater than 65 years. Few studies have characterized the elderly population by age groups. We hypothesize that increasing age is associated with worse post-operative outcomes including readmission.

Methods: We queried the 2011-2013 National Surgical Quality improvement Program (NSQIP) cohort for patients who underwent an elective colectomy and stratified them into age categories: 18-50, 51 to 60, 61 to 70, 71 to 80, and over 80. Univariate and bivariate comparisons analyses were performed. Using backwards logistic regression, we adjusted for difference in demographics, surgical characteristics, co-morbidities, and complications to identify independent predictors for readmission.

Results: Of the 70,843 patients who underwent elective colorectal surgery: 19.4% were under 50, 22.9% were 51 to 60, 25.5% were 61 to 70, 19.9% were 71 to 80, and 12.3% were over 80,.52.7% were women. Patients over 80 were primarily independent (90.2%) and had the longest length of stay (7 days, p<0.01) compared to all other age groups. The most frequent operation in this cohort was partial colectomy (40.4%), followed by LAR/DLI (34.6%), ileocecectomy (18.3%), and total colectomy (4.2%). Almost half of all colectomies were performed laparoscopically (46.5%). Post-operative outcomes differed significantly based on age (Table 1). Overall SSI rate was 8.4% and was the lowest in patients >80 years old (6.6%). Mortality rates increased with increasing age. Individuals under 50 had the highest readmission rate (12.3%) while individuals age 50-60 had the lowest (9.9%). In the fully adjusted model, patients under 50 years of age (OR 1.2 CI 1.1-1.3) and over 80 years of age (OR 1.14 CI 1.03-1.26) had a significantly higher chance of readmission.

Conclusion: Patients over 80 years and those under age 50 have the highest risk of readmission following elective colorectal surgery. Increasing age is also associated with increased mortality and increased hospital length of stay. As post-operative outcomes including readmission are being used as a quality metric, age of the patient undergoing the procedure should be considered.

65.04 Leucocyte Filtered Blood Transfusions are Associated with Decreased Postoperative Infections

Posted on January 18, 2016

S. Kwon3, R. S. Chamberlain1,2,3 1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2New Jersey Medical School,Surgery,Newark, NJ, USA 3St. George’s University School Of Medicine,St. George’s, St. George’s, Grenada

Introduction: Leucocyte filtered blood (LFB) has been shown to prevent cytomegalovirus reactivation, HLA immunization and recurrent febrile non-hemolytic reactions. LFB has been reported to decrease postoperative infections, however, prior reports are conflicting and contradictory. This meta-analysis examines the impact of LFB on the overall incidence of postoperative infections.

Methods: A comprehensive literature search of PubMed, Google Scholar, and the Cochrane Central Registry of Controlled Trials from January 1966 to July 2015 was conducted. Keywords included in the search were ‘leuk(c)oreduced’, ‘leuk(c)odepleted’, ‘filtered’, ‘white cell reduced’, ‘leuk(c)ocyte reduced’, ‘leuk(c)ocyte depleted’, and transfusions. Studies that compared LFB to non-leucocyte filtered blood and reporting postoperative infections were included. Outcomes analyzed included postoperative infections under ‘as per protocol’ (APP) and ‘intention-to-treat’ (ITT), as well as length of stay (LOS).

Results: 16 RCTs involving 6,776 randomized (ITT) patients (4,514 transfused (APP) patients) in various clinical settings (7 cardiac, 5 colorectal, and 4 other) were evaluated. The LFB group had an overall 25.6% reduction in postoperative infection risk when analyzed by APP (RR=0.744; 95% CI [0.593-0.934]; p=0.011) and 21.7% risk reduction when analyzed by ITT (RR=0.783; 95% CI [0.646-0.949]; p=0.013). When analyzed by APP, cardiac and colorectal surgeries derived the greatest infection reduction benefit (RR=0.748; 95% CI [0.623-0.897]; p=0.002 and RR=0.447; 95% CI [0.199-1.006]; p=0.052). LFB was also associated with a significant reduction in LOS (Standardized Difference of Mean (SDM) =-0.539; 95% CI [-1.038- -0.0040]; p=0.034).

Conclusion: LFB transfusions are associated with a significant decrease in postoperative infections for both APP and ITT populations, particularly in cardiac surgery patients. Additional adequately powered studies are needed to fully understand the benefits of LFB.

64.20 Safety of Prone Jackknife Position in Ambulatory Anorectal Surgery

Posted on January 18, 2016

F. Cheema1, S. Lee1, M. Zebrower2, J. L. Poggio1 1Drexel University College Of Medicine,Department Of Surgery,Philadelphia, PA, USA 2Drexel University College Of Medicine,Department Of Anesthesiology & Perioperative Medicine,Philadelphia, PA, USA

Introduction: Prone jackknife position allows for improved anatomical exposure during anorectal procedures. Debate exists regarding morbidity and anesthetic complications in this position. The primary objective of this study was to determine morbidity and mortality rates of ambulatory anorectal surgeries in prone jackknife position. The secondary objective was to determine which patient characteristics led to higher risk of morbidity and mortality.

Methods: Retrospective chart analysis was performed on 210 patients undergoing ambulatory anorectal surgery in the prone jackknife position in an academic hospital from 2012 to 2014. Factors analyzed were age, sex, clinical diagnosis, procedure, past medical history, ASA physical status classification, current smoking status, minimum intra-operative mean arterial pressure (MAP), minimum O2 saturation, estimated blood loss, fluids, anesthesia duration, antibiotic administration, days to discharge and 30-day readmissions. All patients underwent general anesthesia. Data was provided from history & physical forms, operative notes, anesthesia flowsheets and progress notes. Frequencies and means of the factors were calculated. Mortality was included only if it occurred within 30 days of surgery.

Results: Of 210 patients undergoing ambulatory anorectal surgery, there were no mortalities within 30 days of surgery. Mean age was 44.6 and 72.4% of patients were male. Complication rate was 3.3% with urinary retention taking up 42% of that. 30-day readmission rate from surgery was 1%. This encompassed two cases of rectal bleeding status-post excision & fulguration of anal condylomas and bright red blood per rectum status-post hemorrhoid surgery. 98.1% of patients were discharged same day of surgery. Mean minimum intra-operative MAP and O2 saturation was 70.6 and 98.7%, respectively. The most common clinical diagnoses were anal condylomas (37.6%), hemorrhoids (14.8%) and pilonidal cysts (11%). The most common procedures therefore were excision & fulguration, hemorrhoidal surgery and pilonidal cyst excision. Anal condyloma was the most common past medical history (40.4%), followed by HIV/AIDS (39%) and hypertension (32.3%). Current smoking rate was 45.7%. Mean ASA classification was 2.29, with mean blood loss of 6.22 cc, mean fluids given of 1015 cc, and mean anesthesia duration of 92 minutes. Antibiotics were not administered in 68.1% of cases.

Conclusion: Prone jackknife position in ambulatory anorectal surgeries under general anesthesia provides enhanced exposure and is a safe procedure with no mortality and minimal morbidity. Total complication rate was 3.3%, urinary retention being most common. Given the results, this study provides evidence that ambulatory anorectal surgery in prone jackknife position is relatively safe in terms of morbidity and mortality as well as anesthetic complications when considering the factors analyzed in this study.

64.21 Simulating the Operating Room as a Transition to Surgical Internship

Posted on January 18, 2016

Z. J. Ahola1, C. W. Lee1, S. Agarwal1, H. Jung1, A. O’Rourke1, A. Liepert1 1University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction: Nontechnical skills demonstrated by surgeons in the operating room are known to play an important role in ensuring patient safety and good surgical outcomes. Recognition of communication, leadership, and interpersonal skills as vital components of formal surgical training has resulted in ACGME-accredited skills training initiatives among residencies nationwide. However, early evaluation among medical students considering surgical careers has yet to be studied, and no specific training interventions have been initiated among graduating medical students to date. The purpose of this study was to examine and identify the influences of an early training intervention on teamwork and team performance among medical school graduates continuing onto surgical internship through the use of video recordings of an animal model operative simulation.

Methods: Video recordings of nine graduating medical student interactions were obtained during a full-day surgical case simulation utilizing porcine models. The animal model simulation was the final day of a two-week surgery intern preparatory curriculum for graduating medical students accepted into ACGME-accredited surgical internships. Two randomly assigned groups of students utilized two separate porcine models to perform common operative procedures, termed learning modules. Students received real-time instruction and feedback from residents and attending surgeons. The tasks were primarily performed by the students. All video recordings were reviewed for outcomes pertaining to teamwork knowledge, skills, and attitudes of the participants. The number of actions initiated and task, skill, and team activities were recorded for each individual. This study was qualitative and observational in nature.

Results: Nine medical students were de-identified and randomly divided into two groups, A and B. Team A consisted of 5 subjects, and Team B consisted of 4. The primary observations among participants included various dimensions of teamwork as follows: willingness to participate, encouragement of others, and self-appointed versus instructor-appointed leadership. Dominant individuals were identified as having the greatest hands-on participation and the greatest number of self-initiated actions within each learning module. The cumulative count of self-initiated actions was 55 in Team A and 41 in Team B. The cumulative count of instructor-initiated behaviors was 44 in Team A and 42 in Team B.

Conclusion: Dominant leadership was evident within each learning module. However, cumulative results of self and instructor-initiated behaviors were similar between groups. Common learning characteristics among early surgical trainees include shared learning, willingness for participation, and self and instructor-initiated leadership roles. This study demonstrates that video recordings of high-fidelity surgical scenarios in porcine operative models may be used to identify leadership and teamwork behaviors.

65.01 One-Sided Conversations: Prevalence of Communication Disabilities in the Adult Surgical Population

Posted on January 18, 2016

W. A. Davis1, B. Smalls1, A. Haider1, M. Morris1 1Brigham And Women’s Hospital,Center For Surgery And Public Health, Department Of Surgery,Boston, MA, USA

Introduction:
Communication disabilities, including hearing, speech, language, and voice problems, are a barrier to effective communication in the healthcare setting. The extent of communication disabilities in the surgical population has never been described. We aimed to describe the prevalence of communication disabilities in adult surgical patients from a nationally representative sample.

Methods:
We conducted a cross-sectional analysis using the 2012 National Health Interview Survey (NHIS). NHIS is a nationally representative, stratified, multistage survey that uses face-to-face interviews with non-institutionalized respondents to estimate health care utilization, access, and health-related behaviors for the U.S. population. In 2012, NHIS included a one-time supplemental section focused on communication disabilities. We utilized the 2012 NHIS Sample Adult Core questionnaire to examine the frequency of hearing, speech, language, and voice disabilities in a subpopulation of adult NHIS respondents who reported an inpatient or outpatient surgical procedure within the last twelve months. Additional surgical details were not available. We then conducted subgroup analyses by age, gender, race, ethnicity, and geographic region. To generalize observed results to the U.S. population, survey weights and variance estimations were applied to all statistics.

Results:
In 2012, 12.2% (95% CI: 11.7-12.7%) of the US adult population reported a surgical procedure within the last year, and 22.9% (95% CI: 22.3-23.5) experienced a communication disability. Subpopulation analysis limited to surgical patients (Table 1) revealed that approximately one third (33.8%, 95% CI: 32.1-35.5) reported a communication disability. The most commonly reported disability was hearing (23.5, 95% CI: 21.8-25.2) followed by voice (12.8, 95% CI: 11.6-14.0), speech (4.6, 95% CI: 3.7-5.5), and language (2.2, 95% CI: 1.7-2.8).

Conclusion:
Patients with communication disabilities comprise a major segment of the U.S. adult surgical population. This high prevalence, when combined with a lack of medical professional training and awareness, not only calls into question surgeons’ ability to provide patient-centered care to a significant percentage of their patient population, but also suggests an opportunity to address a source of preventable adverse events, inadequate informed consent, and poor patient satisfaction.

64.17 Post-operative Non-ICU Admission Following Robotic Pancreaticoduodenectomy is Safe and Reduces Cost

Posted on January 18, 2016

K. E. Cunningham2, M. S. Zenati2, J. Petrie3, J. Steve2, M. E. Hogg2, H. J. Zeh2, A. H. Zureikat2 2University Of Pittsburgh Medical Center,Surgical Oncology,Pittsburgh, PA, USA 3University Of Pittsburgh Medical Center,Finance,Pittsburgh, PA, USA

Introduction: Immediate post-operative admission to the ICU following pancreaticoduodenectomy (PD) has been standard of care for many institutions. Over the last decade, minimally invasive pancreaticoduodenectomy has emerged as safe and feasible. The aim of this project was to examine if omission of an immediate post-operative ICU admission would be safe and result in decreased length of stay (LOS) and reduced cost for patients undergoing robotic pancreaticoduodenectomy (RPD).

Methods: From December 2014 to June 2015, a non-ICU admission policy on post-operative day zero (POD0) was implemented for all patients undergoing RPD. Prior to this date, all RPDs were routinely admitted to the ICU on POD0. Using a prospectively maintained database, we compared the outcomes of the non-ICU RPD cohort to patients routinely admitted to the ICU post-operatively prior to implementation of this policy (January 2014-November 2014). All cases were analyzed on an intent-to-treat basis, thereby minimizing selection bias.

Results: The ICU cohort (n=49, average age 65.6 ±12, 51% females) and non-ICU cohort (n=34, average age 66.4 ± 9, 38% females) were comparable with no statistically significant differences with respect to age, sex, BMI, CCI and ASA score, pre-operative tumor size, diagnosis, receipt of neoadjuvant therapy, operative time, and estimated blood loss. Seven patients (21%) from the non-ICU group were directly admitted to the ICU post-operatively based on unpredicted changes in intra-operative clinical status necessitating ICU care. They were included in the non-ICU group and their outcomes were analyzed on an intent-to-treat basis. The rates of Clavien complications, pancreatic leak, reoperation, readmission and mortality demonstrated no statistically significant difference between both groups (Table 1). A statistically significant trend toward reduced total hospital LOS in the non-ICU group was noted (median 6.95 days versus 7.7 days, P=0.083). This reduced LOS and avoidance of routine post-operative ICU admission translated into a cost reduction from $25,812 (IQR $19,875 -$29,853) in the ICU group to $19,739 (IQR $17,964 -$25,521) in the non-ICU group, P=0.01. The reduction in cost remained statistically significant even after adjusting for all related demographics and perioperative characteristics.

Conclusion: A standard policy of omitting a post-operative ICU admission on POD0 following RPD is safe and can result in reduced length of stay and overall savings in total hospital cost.

64.18 Postoperative Functional Decline in Older Adults

Posted on January 18, 2016

J. R. Berian1,2, K. Y. Bilimoria1,3, C. Y. Ko1,5, T. N. Robinson4, R. A. Rosenthal6 1American College Of Surgeons,Division Of Research And Optimal Patient Care,Chicago, IL, USA 2University Of Chicago,Department Of Surgery,Chicago, IL, USA 3Northwestern University,Department Of Surgery,Chicago, IL, USA 4University Of Colorado Denver,Department Of Surgery,Denver, CO, USA 5University Of California – Los Angeles,Department Of Surgery,Los Angeles, CA, USA 6Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA

Introduction: Geriatric-specific outcomes such as functional decline are critically relevant for older adults as they consider whether to undergo an operation.

Methods: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) collects novel geriatric-specific data as part of the Geriatric Surgery Pilot Project. A retrospective analysis was conducted on a cohort of patients from 25 participating hospitals collected between January and September 2014. Functional status represents an individual’s ability to perform the activities of daily living. The main outcome of interest was decline in functional status from preoperative baseline compared to at the time of hospital discharge (independent preoperatively to partially or totally dependent postoperatively, or partially dependent preoperatively to totally dependent postoperatively). Excluded cases were orthopedic and spinal procedures, death within 30 days, and patients whose preoperative functional status was total dependence. Multivariable logistic regression was performed to identify significant predictors for functional decline.

Results: The study included 6,295 patients with the average age of 74±8 years. The rate of functional decline was 15% among patients <=65 years of age, 14% for ages 66-75 years, 23% for ages 76-85, and 39% for those over age 85 years. On multivariable regression, significant predictors for functional decline included age 76-85 or >85 (OR 1.6 and 2.6, respectively, 95% CI 1.1-2.3 and 1.7-4.0, respectively), female sex (OR 1.3, 95% CI 1.1-1.5), ASA class 3 or 4 (OR 2.7 and 3.3, respectively with 95% CI 1.1-7.2 and 1.3-9.0, respectively), history of COPD (OR 1.3, 95% CI 1.0-1.7), diabetes requiring insulin (OR 1.3, 95% CI 1.0-1.6), disseminated cancer (OR 1.6, 95% CI 1.2-2.1), having experienced a fall within 1 year prior to the operation (OR 1.6, 95% CI 1.3-2.0), or the use of a mobility aid preoperatively (OR 2.0, 95% CI 1.7-2.4). Additional factors associated with functional decline were an emergency operation (OR 2.3, 95% CI 1.8-2.9) or experiencing postoperative complication (OR 1.7, 95% CI 1.4-2.1). Factors found to be protective were overweight status (OR 0.8, 95% CI 0.7-0.9) and other race (non-white, non-Hispanic, non-black)(OR 0.4, 95% CI 0.3-0.5).

Conclusion: Functional decline occurs in older adults following surgery. This occurs in the ‘younger old’ as well as ‘oldest old’. Adjusted analysis finds that advancing age, female sex, high ASA class, certain comorbidities, prior falls and use of mobility aids are associated with functional decline. Counselling high-risk patients about the risk of losing independent functional status is an important component of preoperative decision-making for older adults.

64.14 Monitoring Surgery and Anesthesia: A Global Drive for Better Data

Posted on January 18, 2016

J. S. Ng-Kamstra1,2,3, N. P. Raykar1,2,4, S. Mukhopadhyay1,2,5, R. R. Yorlets2, G. Anderson1,2,6, S. Saluja1,2,7, G. Toma1,2, A. Silverstein1,2,8, B. B. Massenburg1,2,9, E. Bruno1,2,10, H. E. Jenny1,2,9, I. H. Marks1,2,11, L. Ilcisin1,2,12, R. Sood1,2,8, S. Sharma1,2, J. G. Meara1,2, M. G. Shrime1,2,13 1Harvard Medical School,Department Of Global Health And Social Medicine,Boston, MA, USA 2Boston Children’s Hospital,Department Of Plastic And Oral Surgery,Boston, MA, USA 3University Of Toronto,Division Of General Surgery,Toronto, ON, Canada 4Beth Israel Deaconess Medical Center,Department Of Surgery,Boston, MA, USA 5University Of Connecticut Integrated Residency Programs,Department Of Surgery,Storrs, CT, USA 6Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA 7Weill Cornell Medical College,Department Of Surgery,New York, NY, USA 8University Of Miami Miller School Of Medicine,Miami, FL, USA 9Icahn School Of Medicine At Mount Sinai,Department Of Medical Education,New York, NY, USA 10University Of Tennessee Health Science Center College Of Medicine,Memphis, TN, USA 11Barts And The London School Of Medicine And Dentistry,London, ENGLAND, United Kingdom 12Harvard Medical School,Department Of Medical Education,Boston, MA, USA 13Massachusetts Eye And Ear Infirmary,Department Of Otology And Laryngology And Office Of Global Surgery,Boston, MA, USA

Introduction:
Most of the world cannot access safe, affordable surgical and anesthesia care when needed. The global need for expanded access has been quantified, but surgical systems at a country level remain poorly described. The Lancet Commission on Global Surgery developed a set of six indicators that can point to opportunities to strengthen surgical systems, however, these are not yet uniformly collected. We aimed to collect country-level data on the proportion of the population within two hours of a surgical hospital (two-hour access), the number of surgical, anesthesia, and obstetric specialists per 100,000 population (SAO density), the number of surgical procedures per 100,000 population per year (surgical volume), the perioperative mortality rate (POMR), and the number of individuals who face impoverishing and catastrophic expenditures paying for surgery each year. Our goal is to collect robust data on at least 50% of countries for each indicator so that the World Bank can include these among the World Development Indicators.

Methods:
Collaborators contributed modelled estimates of surgical volume and SAO density, and a co-author provided modelled estimates of impoverishing and catastrophic expenditures. To collect primary data from Ministries of Health for the remaining indicators, we trained a team of eight research associates, developed an online data management system, assembled country contacts at Ministries of Health, and developed a strategy for outreach. With the support of our team, health leaders around the world reported data for their respective countries.

Results:
This work is ongoing, with anticipated completion in autumn 2015. To date, we have assembled modelled data on surgical volume, SAO density, and catastrophic and impoverishing expenditures for 194, 167, and 186 out of 215 countries, respectively. Two weeks after starting data collection, we have contacted 212 of 215 Ministries of Health. We have obtained at least partial data for 41 countries and have active communication with 44 more. Of these, 45 responses were from high-income countries (of 80 HIC total), 14 from upper-middle-income countries (of 53 UMIC), 14 from lower-middle-income countries (of 51 LMIC), and 12 from low-income countries (of 31 LIC).

Conclusion:
We have met WDI inclusion thresholds for four indicators using modelled data. New primary data will help to improve these estimates and to advance our understanding of the two remaining indicators: two-hour access and POMR. This effort will send a signal to the global health community that surgery is an "indivisible, indispensable part of health care" that requires investment and continual monitoring during the era of the Sustainable Development Goals.

64.15 Does Gender of Admitting Trauma Surgeon Impact Patient Outcomes?

Posted on January 18, 2016

P. P. Patel1, J. C. Kubasiak1, F. Bokari1, A. J. Dennis1, K. T. Joseph1, F. L. Starr1, D. E. Wiley1, K. K. Nagy1 1John H. Stroger, Jr. Hospital Of Cook County,Trauma,CHICAGO, IL, USA

Introduction:

Research has shown that gender differences in both leadership behavior and effectiveness exist in the boardroom. Many studies have demonstrated that female senior executives operate with a greater degree of energy and intensity, are more assertive and competitive in their approach to achieving goals, and obtain a better financial bottom line. The aim of this study is to evaluate if these female leadership advantages exist in a resuscitation room by examining if a team led by a female trauma surgeon has better patient outcomes.

Methods:

We preformed a retrospective cohort study involving all adult trauma patients who were admitted to our level 1 trauma center from July 1, 2012 to September 30, 2012. Our center is led by 6 full-time surgical attendings (male = 3, female = 3) with call distributed equally amongst all attendings. The goal was to evaluate the effect of the gender of the admitting trauma surgeon on patient disposition (home, observation, ICU or operating room) while controlling for patient sex, age, mechanism of injury and trauma severity as defined by the Injury Severity Score (ISS). Secondary outcomes included length of stay (LOS), readmissions, and mortality. Statistical analysis was performed using a χ 2 test to obtain likelihood ratios and Student’s t-test when appropriate.

Results:
654 patients were enrolled in the study of which 647 patients were analyzed. The study population was 80% male with a mean age of 35.1 years and mean ISS of 8. No difference was noted between patients seen by male and female attendings. When stratified by ISS, no statistically significant relationship was found between the gender of the admitting trauma surgeon and patient disposition after initial resuscitation. Mean LOS, readmissions, and mortality were also equal.

Conclusion:

Patients with equal ISS were given the same disposition after resuscitation, averaged the same LOS, and had no difference in readmission or mortality regardless of the gender of the admitting surgeon. Our results suggest that although males and females may have different leadership styles, in the setting of leading the resuscitation of an acutely injured patient, the gender of the trauma surgeon does not impact outcomes.

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