18.09 Measuring Burnout in Surgical Residents: Do Traditional Indices Accurately Represent The Issue?

Posted on January 18, 2018

C. R. Coverley1, J. Tieman1, M. Chang1, D. Cole1, O. Osuchukwu1, T. S. Riall1  1Banner University Medical Center – Tucson – Banner Health,Surgery,Tucson, AZ, USA

Introduction: Burnout poses a significant threat to the surgical workforce and has been shown to affect surgeons-in-training. In studies assessing burnout in residents, surgeons, and physicians, physicians are classified as “burned out” if they meet criteria on any one subscale of the Maslach Burnout Inventory (MBI) – Emotional Exhaustion (EE), Depersonalization (DP), or Personal Accomplishment (PA). These criteria have been criticized as potentially over representing true burnout. Our goal was to evaluate resident burnout based on these criteria and to correlate these with other measures of life satisfaction and wellbeing.

Methods: In 2016 we instituted the Energy Leadership Resiliency and Wellbeing Program as part of the formal training experience for our general surgery residents. We compared residents who met the criteria for burnout in one or more of three subscales of the MBI with resident-reported satisfaction in 14 different areas of life as measured by the validated Energy Leadership Index (ELI). These areas were: Financial Success, Leadership, Work Relationships, Family Relationships, Intimate Relationships, Engagement at Work, Personal Freedom, Communication, Productivity, Time Management, Work-Life Balance, Health and Wellness, Energy Level, and Spiritual Satisfaction. We then compared satisfaction in the 14 areas in residents who did or did not meet criteria on one, two, or all three subscales.  

Results: Forty-three surgical residents, 30.2% female and 69.8% male, completed the MBI and ELI. 53.5% of our residents met criteria for burnout on at least one subscale of the MBI; 41.9% met criteria on 2 subscales, and 7.0% met criteria on all 3 subscales. Our analysis demonstrated that residents who met the definition of burnout in one subscale had decreased satisfaction in almost all surveyed areas. They also had higher perceived stress levels, higher depression rates, and lower wellbeing overall as measured by the Physician Well Being Index (PWBI) (Table). The percent of residents Very Satisfied or Completely Satisfied in each area uniformly decreased as the number of burnout subscales that were positive increased.

Conclusion: Our hypothesis explored the possibility that traditional MBI measures may not take into account the multifaceted nature of a rigorous surgical training experience and may overestimate true burnout. The results of our analysis highlight the validity of the MBI as a measure for identifying residents who already are displaying symptoms of burnout and dissatisfaction in multiple areas of their lives. Identifying surgical residents at risk and reaching out through implementation of formal wellbeing programs will play a critical role in training a resilient, productive, and professionally satisfied surgical workforce.

18.10 Does Resident Competition Within Question Banks Affect ABSITE Scores?

Posted on January 18, 2018

K. Hudak1, J. Porterfield2, H. Chen2, J. White2  1University Of Alabama At Birmingham,School Of Medicine,Birmingham, AL, USA 2University Of Alabama At Birmingham,Department Of Surgery,Birmingham, AL, USA

Introduction: Technology-driven online educational tools have expanded educational opportunities for surgical residents beyond the traditional formats. We sought to evaluate changes in American Board of Surgery In-Training Exam (ABSITE) percentage scores with participation in a competitive software-based question bank.

Methods: We designed a novel software program at our institution, which utilizes a gamified web-based competition to encourage participation in general surgery question banks. Questions were designed and evaluated by surgical faculty members. General surgery residents at a large academic medical center who participated in the ABSITE exam during 2016 and 2017 were given the option to participate in question-based competition rounds. We analyzed the percent correct score increase in ABSITE scores for participants and non-participants.

Results: Thirty residents completed the ABSITE exam in both 2016 and 2017. Twenty-two residents participated in the question gaming platform.  Participants averaged 20.8 percent completion of the extensive question bank. The average ABSITE score percentage for participants was 73.4 percent correct, while non-participants averaged 71.6 percent correct. The average ABSITE score percent increase from 2016 to 2017 was calculated for both participants and non-participants (3.25% vs. -0.28%).

Conclusion: Surgical residents at our institution who participated in our gamified surgical knowledge competition, on average increased their ABSITE score relative to non-participants. This suggests that incorporation of this novel educational tool is a method for improving general surgery resident performance on the ABSITE.

 

18.07 Surgical Resident Use of Google™ and YouTube™ for OR Preparation

Posted on January 18, 2018

A. Khalifeh1, B. Buckingham1, R. Kantar1, E. Reardon1, S. Kidd-Romero2, K. Luumpkins2, S. M. Kavic2  1University Of Maryland Medical Center,Department Of Surgery,Baltimore, MD, USA 2University Of Maryland,School Of Medicine,Baltimore, MD, USA

Introduction:
Information in surgical training has expanded beyond print books to include various electronic and internet resources. We aimed to evaluate the use of online information in a surgical residency.

Methods:
A survey was distributed to 52 general surgery residents (preliminary and categorical) at an academic medical center in April 2017.  This study was deemed exempt from IRB review. The survey explored demographics, social media literacy, use of print and internet sources in preparation for the operating room (OR), use of smartphones in patient care in addition to residents’ perception of internet sources.  The survey questions were structured using a Likert-type scale and results were analyzed using Fischer’s t-test. 

Results:
Forty-two residents returned completed surveys, 81% response rate. The mean age was 31 years, and 50% of the respondents were female. Residents frequently used print books, electronic books (e-books), YouTube, Google, and other web sources in preparation for the OR. The majority frequently accessed information from their smartphones. When analyzed per academic year, senior residents were more likely to use print books; while juniors were more likely to use e-books, YouTube and Google. While most residents agreed that the digital era made access to information easier, they were skeptical about the reliability of some internet sources.

Conclusion:
The majority of modern surgical residents access e-books and other internet sources. Interestingly, as residents progress in their training there is a trend to prefer print books rather than internet resources when preparing for the OR. 
 

18.08 Innovative Teaching Strategies for Surgery Resident Education Sessions

Posted on January 18, 2018

A. Awe1, M. Burger1, A. C. Abrams1, G. Caldito1, Q. Chu1, N. Samra1  1Louisiana State University Health Sciences Center- Shreveport,General Surgery,Shreveport, LA, USA

Introduction:

Recently a direct effort has been made by faculty and residents to explore ideas that effectively help improve resident education in preparing for the ABSITE and ultimately surgical board exams. The idea that our resident education faculty adopted was instead of lecturing with PowerPoint presentations on SCORE curriculum topics a pre-lecture activity (PLA) with high-yield questions and concepts surrounding a topic was used as a tool to teach. This innovative teaching strategy used in the setting of resident protected didactic sessions was birthed from the principles of the cognitive load theory. The idea was created to foster a more enjoyable active learning environment during these weekly 30 minute sessions.

Methods:

This project was designed to analyze the preference of the residents about the new teaching approach with PLA in comparison to the previous teaching style with PowerPoint presentations during our weekly didactic session. Our null hypothesis states the residents would not prefer the PLA approach for our weekly didactic sessions and prefer being lectured using PowerPoint presentations alone. We conducted a four question Likert Scale survey among 27 surgical residents to determine their preference. To analyze the survey results, the one-sided Z-test for a proportion was used to test our research hypothesis. To reject our null hypothesis the proportion of residents who would either “Strongly Agree” or “Agree” to each of the questionnaire items would be greater than 50%.

Results:
All 27 residents completed the survey anonymously. The majority of residents (88.9%) agree or strongly agree that having a PLA was more useful in comparison to using online portal from SCORE to prepare for didactic session. (Z- 4.06, p value <0.001). Additionally, 66.67% of residents strongly agree or agree the discussion of high yield score topics from PLA is more beneficial than a lecture about topic via a PowerPoint presentation. (Z- 1.74, p value <0.041). More than half (55.56%) strongly agree or agree during their independent study using notes from discussion of PLA was more helpful than having a copy of a PowerPoint presentation with a third (33.33%) being undecided and (11.11%) disagreeing or strongly disagreeing (Z- 0.58, p value 0.281). Lastly, 78% of residents want to continue with PLA as opposed to being lectured with PowerPoint presentations alone (Z- 2.89, p value 0.002).

Conclusion:
Using Items 1 to 4 in the Likert Survey completed by the surgical residents we were able to measure a resident’s preference for the use of PLA over the use of lectures using PowerPoint during didactic sessions. Our survey results indicate preference for PLA by more than 50% for Items 1, 2 and 4 with statistically significant p values. We were able to reject our null hypothesis for all items except for Item 3. With these results we see a preference by the residents for PLA to be used to assist with preparing for weekly didactic sessions.

18.05 Residents Teaching Residents: An Innovative Curriculum with Demonstrated Durability in Learning

Posted on January 18, 2018

B. P. Kline1, K. A. Mirkin1, L. R. Myers1, S. R. Allen1  1Penn State University College Of Medicine,Hershey, PA, USA

Introduction:

Surgical residents are required to master a vast and ever-increasing amount of knowledge, making it necessary to create efficient and robust methods of resident education. Our group has previously reported on a novel program encouraging both resident self-directed learning and peer-to-peer teaching, which we call Residents Teaching Residents.  Our sessions are designed to focus on textbook and procedural knowledge that all surgical residents are expected to learn during their training.  After implementation of the program, we now present our findings showing how knowledge is improved after a session and is retained over an extended period of time. 

Methods:

Over the course of the year, we held 3 sessions of Residents Teaching Residents.  Each session contained a didactic lecture on adult education theory, followed by a week in which residents were expected to prepare to take a hypothetical patient to the OR for an upcoming case.  They received an H&P as well as a 10-question pre-test on the topic related to the upcoming surgery.  Topics included colorectal, vascular, and trauma surgery.  After the week elapsed, a faculty member led a discussion on the pre-operative work up, treatment options, and operative planning for the patient.  A flipped classroom model was employed, requiring residents to study the topic before the session and come prepared to actively participate in the discussion.  The residents then performed a simulated case, with emphasis placed on senior residents (PGY 3-5) leading junior residents through the procedure. After the case, a post-test was given.  The test included the 10 original questions from the current session as well as 10 questions from each of the preceding sessions. Results were compared using student’s t-tests.

Results:

The average scores on the pre-test, post-test, and long term follow up test for colorectal surgery were 47%, 56%, and 61%, respectively.  There was significant improvement between pre-test and post-test (p=0.0069) and between pre-test and follow up test (p=0.0478).  For vascular surgery, the average scores on pre-test, post-test, and follow up test were 49%, 70%, and 56% respectively.  There was significant improvement between pre-test and post-test (p<0.0001) and the improvement from pre-test to follow up test approached significance (p=0.0595).  The trauma surgery topic contained a pre-test and post-test, for which scores were 65% and 69% respectively.  These did not vary significantly (p=0.63).  There has not yet been a follow up test for trauma.

Conclusion:

The Residents Teaching Residents curriculum at our institution emphasizes education theory, self-directed learning, near-peer teaching, and simulation based training.  The data obtained from resident knowledge assessments suggest that knowledge improved with the session and was retained over a period of several months. 

18.06 Program Directors' Knowledge of Opioid Prescribing Regulations for Residents: A Survey Study

Posted on January 18, 2018

D. Raygor1, E. Bryant2, G. A. Brat3, D. S. Smink2, M. Crandall1, B. K. Yorkgitis1  1University Of Florida-Jacksonville,Division Of Acute Care Surgery,Jacksonville, FL, USA 2Brigham And Women’s Hospital,Surgery,Boston, MA, USA 3Beth Israel Deaconess Medical Center,Surgery,Boston, MA, USA

Introduction: Opioid misuse is a public health crisis that stems in part from over-prescribing by healthcare providers. Surgical residents are commonly responsible for prescribing opioids at patient discharge and residency program directors (PDs) are charged with their residents’ education. Because each hospital and state has different opioid prescribing policies, we sought to assess PDs’ knowledge about local controlled substance prescribing polices.

Methods: A survey was emailed to PDs that included questions regarding residency characteristics and knowledge of local regulations.

Results: A total of 247 PDs were emailed with 110 (44.5%) completed responses. 104 (94.5%) allow residents to prescribe outpatient opioids; 1 was unsure. 63 (57.3%) respondents correctly answered if their state required opioid prescribing education (OPE) for full licensure. 22 (20.0%) were unsure if their state required OPE for licensure. 64 (58.2%) respondents answered correctly if a prescription monitor programs (PMP) exists in their state; 36 (58.1%) stated their residents have access. 29 (26.4%) were unsure if a state PMP existed. 76 (69.1%) SRPD’s answered correctly about their state’s requirement for an additional registration to prescribe controlled substances; 10 (9.1%) did not know if this was required.  29 (27.9%) programs require residents to obtain individual DEA registration; 5 (4.8%) were unsure if this was required.

Conclusion:Most programs allow residents to prescribe outpatient opioids. However, this survey demonstrated a considerable gap in PDs’ knowledge about controlled substance regulations. Because they oversee surgical residents’ education, PDs should be versed about their local policies in this matter. 

 

18.02 Barriers to Reporting Needlestick Injuries Among Surgical Residents

Posted on January 18, 2018

K. Kapp1, M. Mendez1, A. Bors1, R. Corn1, F. Sharif1, F. Alemi1  1University Of Missouri Kansas City,Department Of Surgery,Kansas City, MO, USA

Introduction: The Centers for Disease Control estimate there are over 300,000 needlestick injuries in the US each year (with 23% occurring in the operating room) resulting in productivity loss of $82.2 million.  The Accreditation Council for Graduate Medical Education data demonstrated 99% of residents had at least one needlestick by their final year of training with over half going unreported and 16% involving patients with HIV, Hepatitis B, Hepatitis C, or history of IV drug use.  Morbidity from needlesticks has devastating effects on surgeons both personally and financially.  The purpose of this study is to evaluate barriers to residents disclosing injuries to their healthcare system so that efficient means of reporting can be proposed to improve processes since early reporting leads to post-exposure prophylaxis and treatment decreasing sero-conversion and chronic infection.

Methods: An anonymous survey was distributed in person among residents of surgical specialties during didactic sessions.  Survey items canvassed included post-graduate training year, number of past needlesticks, facility location of occurrence, activity during occurrence, number of needlesticks reported, who they reported to, barriers to reporting including knowledge of how to report, time of day, fear of repercussions, previous poor experience, severity of injury, fear of or lack of confidentiality, bother to the patient, perceived low risk of disease transmission, estimated time away from clinical activity for reporting, overall personal experience in reporting, and whether they would report a future injury based on prior experience.  Data was analyzed with comparisons made between specialties.

Results:Surveys yielded responses from 76 residents in 6 surgical subspecialties.  Most needlestick injuries occurred in the Operating Room or Emergency Department.  70% of residents had a needlestick with 14% of injuries never being reported.  Forty-five percent of residents reported needlesticks less than 75% of the time.  Top reasons residents didn't report include:  Process is too time consuming, Lack of time, and Patient appeared low risk.  The majority estimated time away from clinical activity was 30-120 minutes.

Conclusion:Needlestick injuries are underreported by surgical residents nationally and in our institution with the main barrier to reporting being time constraints. Despite measures to improve safety and decrease the occurrence, the CDC reports needlestick injuries in the OR have increased by 6.5%.  Delayed reporting causes significant morbidity resulting in personal and financial harm to surgical residents.  Streamlining the process particularly the paper work by giving resident Occupational Health education during orientation and providing surgeons with reporting packets at the beginning of each academic year with basic resident and facility information prefilled to save time may increase needlestick injury reporting by surgical residents.

 

18.03 Women in Surgical Academia: Is Underrepresentation due to Lack of Competitive Inflow?

Posted on January 18, 2018

M. D. Moore1, K. D. Gray1, J. Abelson1, D. Fehling1, T. J. Fahey1, T. Beninato1  1Weill Corenll Medicine,Surgery,New York, NY, USA

Introduction: One of the goals of academic general surgery (GS) residency programs is to train future academic surgeons.  Women representation in surgical academia remains low despite the near-equilibration of men and women entering medical school and the increase in woman applicants to GS residency.  A correlation between high rank position and pursuit of an academic career among applicants to an academic GS residency program has been previously shown.  We aimed to elucidate if underrepresentation of women in academic surgery is due to gender disparity in applicants to an academic GS residency program and their position on the rank list.

Methods: Rank lists at an academic GS program were used to determine proportion of female ranked candidates from 1992-2016. The lists were further examined to determine proportion of women ranked in the top 20 positions.  The proportion of women enrolled in GS programs nationwide during the same time period was determined using available JAMA GME annual reports.

Results: Twenty-five rank lists with 2231 candidates (621 females, 1610 males) were evaluated.  The proportion of women candidates ranked increased from 24% in 1992 to 46% in 2016 with a maximum of 46% in 2016. The percentage of women enrolled in GS residency nationwide increased during that time from 16% to the current high of 39%. In the years 1992-1994, 1997, and 2006, a significantly higher percentage of women were ranked by our program than the percentage of women who were enrolled in GS programs nationally.  In the remaining years, the proportion ranked by our program was similar to the national applicant pool. The proportion of women ranked in the top 20 was no different than the proportion of women on the entire rank list.

Conclusion: The proportion of female applicants to a single academic GS program has either exceeded or paralleled national trends in proportion of women enrolled in surgery programs.  Similar proportions of women were ranked competitively in the top 20 positions.  Underrepresentation of women in surgical leadership positions does not appear to be due to a lack of inflow of qualified, competitive female candidates.

 

18.04 Academic Surgery or Community Practice: What's Driving Decision Making and Career Choices?

Posted on January 18, 2018

B. J. Goudreau1, T. E. Hassinger1, A. Schroen1, T. L. Hedrick1, C. L. Slingluff1, L. T. Dengel1  1University Of Virginia,General Surgery,Charlottesville, VA, USA

Introduction: Identifying factors that impact progression of surgical trainees into academic versus non-academic (community, private) practices may permit selecting residency candidates and tailoring residency experiences to promote academic careers. 

Methods:  An anonymous survey was distributed directly to surgeons graduating from a single academic institution from 1965-2016, excluding those currently in fellowship training or with inactive email addresses. Questions pertaining to practice type, research productivity, work-life balance, mentorship, and overall sentiment toward research and academic surgery were included. A five-point Likert scale measured responses on career satisfaction and influence of factors in practice setting choice. Responses were analyzed by academic versus non-academic practice settings. 

Results:  Of 147 survey recipients, 54 responded, 8 were ineligible (overall response rate= 37%).  Of 46 with known current practice type, 29 are in academic (63%) and 17 in non-academic practice (37%). Compared to non-academic surgeons, academic surgeons are more likely to have participated in dedicated research time during training (86% vs 53%, p < 0.01), and reported more publications at the conclusion of training (58% with >10 publications vs.18%, p<0.01).  45% of academic surgeons reported >$100,00 in student debt at time of graduation compared to 29% of non-academic surgeons, though this difference was not noted to be statically significant.  Factors encouraging an academic career were similar for both types of surgeons, including involvement in education of trainees and access to mentorship (Table 1).  Both groups were discouraged from an academic practice by grant writing requirements and funding responsibilities.  When queried as to professional satisfaction, 94% of all respondents (93% in academic practice and 88% in non-academic practice) reported they were satisfied or very satisfied professionally, and 88% would recommend surgery as a career to a current medical student (100% in academic practice, 67% in non-academic practice).   

Conclusion: Surgeons, particularly those in academic practice, report high satisfaction rates with their career choices.  Supporting funding mechanisms and grant writing programs while encouraging mentorship and participation in trainee education may encourage current surgical trainees to participate in academic medicine. 
 

18.01 A Competency-Based Curriculum to Teach and Assess the Fundamental Skills of Open Surgery (FSS)

Posted on January 18, 2018

J. W. Menard1, F. Shariff1, W. Goering1, A. Deladisma1, R. Damewood2, D. S. Lind1  1University Of Florida-Jacksonville,General Surgery,Jacksonville, FL, USA 2Wellspan Health York Hospital,General Surgery,York, PA, USA

Introduction: While modular curricula exists to teach/assess the fundamentals of laparoscopic (FLS) and endoscopic (FES) surgery, no similar curriculum exists for the fundamental skills of open surgery (FSS). Therefore, we describe our efforts to create, validate and distribute a competency-based curriculum to teach/assess the basics skills of open surgery.

Methods: Using a modified Delphi approach, we created a 15-point binary checklist for the steps required to open and close an abdomen. Construct validity was then determined by videotaped assessment of novice and experts performing a laparotomy on a simulated model (Simulab Corporation, Seattle, WA). We then developed a comprehensive, competency-based curriculum regarding the knowledge/skills required for open surgery. Finally, to facilitate distribution, we employed an innovative, web-based platform (ApprenNet) to provide learners with on-line content, video-based evaluation and expert feedback (see Figure 1).

Results: Using a 15-point binary checklist, experts performed significantly better than novices on the simulated abdomen (0.88 vs. 0.27; p=0.06). The FSS curriculum has been successfully implemented in 7 general surgery residency programs at the PGY1/2 level (N=110). For distant learning, we effectively employed an app-based, educational platform (ApprenNet). Learners used the app to record/submit their simulated laparotomy using their personal smart-devices. 

Conclusion: We have successfully created, validated and distributed a competency-based curriculum to teach/assess the fundamental skills of open surgery (FSS). Similar to FLS/FES, general surgery training programs should require all residents to successfully complete the FSS curriculum.

 

17.20 Multidisciplinary Approach For Management Of Necrotizing Pancreatitis: A Case Series

Posted on January 18, 2018

P. SENTHIL-KUMAR1, W. Alswealmeen1, Q. Yan1, P. O’Moore1, T. Braun1, D. Ringold1, O. Kirton1, T. Vu1  1Abington Memorial Hospital,Surgery,Abington, PA, USA

Introduction:

 Necrotizing pancreatitis is often a devastating sequelae of acute pancreatitis. Historically several approaches have been described with variable outcome. Open necrosectomy is associated with higher morbidity (95%) and mortality (25%). Endoscopic necrosectomy often is tolerated well but associated with stent migration and multiple procedures. Video-assisted retroperitoneal debridement is tolerated well but associated with severe bleeding if adjacent blood vessels are injured during the procedure leading to severe complications

Methods:
In our series. We perform a step up approach by Involvement of a multidisciplinary group consisting of general surgeons, gastroenterologists, Infectious disease physicians, critical care internalist, interventional radiologist and nutritional services to formulate a management plan. The necrotized pancreas is initially drained with an IR guided drain, fluid cultures sent for microbiology and treatment with appropriate antibiotics if deemed necessary. The drain is gradually upsized to a 24 Fr sized drain to form a well-defined tract for surgical debridement; A pre-operative CT scan of the abdomen with IV contrast to access the location and proximity of the vasculature around the necrotized pancreas. A collaboration with the interventional radiologist to discuss possible IR embolization of splenic artery prior to surgical debridement. The patient would then undergo video assisted retroperitoneal pancreatic necrosectomy and a sump drain left in-situ at the pancreatic fossa. Post-operative management in the surgical ICU would be lead by the critical care internalist.

Results:
Three patients were managed by this multidisciplinary approach with excellent outcomes. One patient underwent preoperative IR embolization followed by surgical debridement; second patient underwent embolization immediately following debridement; one patient did not require any embolization but had IR on standby if needed to intervene. Post-operatively all three patients recovered well. They all were tolerating good oral intake and were discharged to rehabilitation facilities.

Conclusion:

As this series show an early plan and collaboration with various subspecialities will produce an optimal outcome. It will lead us to a pragmatic and successful approach to this potentially catastrophic condition.

 

17.17 Insurance Status Influences Cardiac Outcomes for Bariatric Surgery

Posted on January 18, 2018

N. Javadi1, L. Garcia1, D. Azagury1, H. Rivas1, J. M. Morton1  1Stanford University,Bariatric And Minimally Invasive Surgery,Palo Alto, CA, USA

Introduction: Medicaid status has been associated with increased risk-adjusted mortality for major surgical operations. While previous studies have documented that disparities in post-operative outcomes vary as a function of insurance status, the influence of insurance status on cardiac outcomes of patients after bariatric surgery remains unknown. We hypothesize that primary insurance status significantly affects the cardiac outcomes of patients after undergoing bariatric surgery.

Methods: Patient data were obtained retrospectively from a bariatric surgery database at a single academic institution in  California between 2009 and 2017. Patients who received either laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) were categorized into three categories based on insurance status: private insurance, Medicare, or Medi-Cal. Patient demographic characteristics, BMI, weight, percent excess weight loss (%EWL), waist circumference, systolic/diastolic blood pressure, total cholesterol, high-density lipoprotein (HDL), low density lipoprotein (LDL), triglycerides (TG), fasting insulin, hemoglobin A1C (HbA1C), glucose, high sensitivity C-reactive protein (CRP), Lipoprotein(a) (Lp(a)), total plasma homocysteine (HmC), B-type natriuretic peptide (B-type BNP) and N-terminal pro b-type natriuretic peptide (NT-BNP) levels were collected at 6 and 12 months post-operatively. One-way analysis of variance (ANOVA), Kruskal-Wallis, and chi-square tests of association were conducted. 

Results:A total of 2482 patients were studied; 1697 patients had private insurance, 490 had Medi-Cal, and 295 had Medicare. Patients were predominantly female in every insurance group. Regardless of insurance group, most patients underwent LRYGB. At 12 months postoperatively, 541 privately insured patients, 218 Medicare patients and 218 Medi-Cal patients were lost to follow up. Significant differences were ascertained between private insurance and Medi-Cal groups in BMI, total cholesterol, and LDL cholesterol. Significant differences between private insurance and Medicare groups were observed in BMI, %EWL, and serum concentrations of homocysteine. Significant differences between Medicare and Medi-Cal were observed for total and LDL cholesterol. NT-BNP levels were statistically different between all three groups. 

Conclusion: This study demonstrates that differences in patient insurance influence cardiometabolic outcomes following bariatric surgery. These results indicate not only that, on average, Medicare and Medi-Cal patients have higher post-operative BMIs, but also that a lower proportion of patients with these forms of insurance attain a BMI within normal range 12 months after surgery relative to patients who are privately insured.

 

17.18 Postoperative Outcomes after Esophagectomy for Cancer in Elderly Patients

Posted on January 18, 2018

F. Schlottmann1, P. D. Strassle1, B. A. Cairns1, M. G. Patti1  1University Of North Carolina,Surgery,Chapel Hill, NORTH CAROLINA, USA

Introduction:  The progressing aging of the population in conjunction with the higher incidence of esophageal cancer will dramatically increase the number of elderly patients with esophageal cancer. We aimed to determine the postoperative outcomes after esophagectomy for cancer in elderly patients. 

Methods:  A retrospective, population-based analysis was performed using the National Inpatient Sample for the period 2000-2014. Adult patients (≥18 years old) diagnosed with esophageal cancer and who underwent esophagectomy during their inpatient hospitalization were included. Patients were categorized into <70 years old (yo) and ≥70 yo. Multivariable linear and logistic regression, adjusting for admit year, gender, race, comorbidities, primary insurance, household income, hospital region, hospital teaching status, and hospital size, were used to assess the potential effect of age on length of stay, hospital charges, and patient complications. The predicted probability of inpatient mortality was also estimated using multivariable logistic regression, where age was treated as a restricted cubic spline.

Results: Overall, 5,243 patients were included, with 3,699 (70.6%) <70 yo and 1,544 (29.5%) ≥70 yo. Elderly patients were more likely to be female and have comorbidities. The yearly rate of esophagectomies among patients ≥70 yo did not significantly changed during the study period (28.4% in 2000 and 26.3% in 2014, p=0.76). No significant differences in the incidence of postoperative venous thromboembolism, wound complications, infection, bleeding, renal failure, respiratory failure, shock, or average length of stay were seen. Elderly patients were significantly more likely have postoperative cardiac failure (OR 1.59, 95% CI 1.21, 2.09, p=0.0009) and postoperative mortality (OR 1.84, 95% CI 1.39, 2.45, p< 0.0001). The predicted probability of mortality also exponentially increased with age (1.5% in 40 yo, 2.5% in 50 yo, 3.6% in 60 yo, 5.4% in 70 yo, and 7.0% in 80 yo), Figure 1. Among elderly patients, hospital charges were, on average, $16,320 greater (95% CI $3,110, $29,530) than patients <70 yo, p=0.02. 

Conclusion: Elderly patients undergoing esophagectomy for cancer have a high risk of postoperative mortality and have a higher expense burden on the health care system. Elderly patients with esophageal cancer should be carefully selected for surgery.

 

17.19 Double Percutaneous Transesophageal Gastrostomy for Pyloric Stenosis Due to Gastric cancer

Posted on January 18, 2018

R. Iwase1, Y. Suzuki2, E. Yamanouchi3, H. Odaira2, K. Yanaga1  1The Jikei University School Of Medicine,Department Of Surgery,Minato-ku, TOKYO, Japan 2International University Of Health And Welfare Hospital,Department Of Surgery,Nasushiobara, TOCHIGI, Japan 3International University Of Health And Welfare Hospital,Department Of Radiology,Nasushiobara, TOKYO, Japan

Introduction:

The management of gastric cancer causing pyloric stenosis and gastric dilatation must include decompression of the stomach and nutritional support. Percutaneous transesophageal gastrotubing (PTEG) is an effective technique for either gastric decompression or enteral nutrition. Here, we investigated the efficacy and safety of double PTEG, i.e., PTEG for both purposes for patients with gastric cancer.

Methods:
Eleven patients with pyloric stenosis due to gastric cancer were admitted to our hospital between January 2015 and March 2017 and enrolled in this study. Each patient underwent double PTEG as soon as possible. After double PTEG tubes were placed, gastric decompression was started immediately and enteral nutrition was started within one day. Feeding and decompression through the double tubes were continued until the day before operation. Using data from these patients, we investigated the efficacy and safety of double PTEG.

Results:
Double PTEG was performed successfully in all patients and no critical adverse effects were observed. Of the eleven patients, eight underwent radical or palliative resection. Decompression of the stomach was achieved and nutritional parameters improved significantly after the double PTEG in all patients.

Conclusion:
Double PTEG is a safe and effective management technique for patients with pyloric stenosis and gastric dilatation due to gastric cancer.

17.15 The Malnourished Obese Patient: A Unique Paradox in Bariatric Surgery

Posted on January 18, 2018

J. H. Fieber1, P. Dowzicky1, C. Wirtalla1, N. N. Williams1, D. T. Dempsey1, R. R. Kelz1  1University Of Pennsylvania,Department Of Surgery,Philadelphia, PA, USA

Introduction: Hypoalbuminemia is a known risk factor for poor outcomes after elective general surgery. Many obese patients concurrently suffer from modest to severe malnutrition. We seek to evaluate the impact of hypoalbuminemia on surgical outcomes in obese patients undergoing elective bariatric surgical procedures.

Methods: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program for 2015 was queried for adult patients with body mass index [BMI] ≥ 35 undergoing bariatric surgery. Revision procedures and patients missing albumin values were excluded. The analysis was controlled for 12 potentially significant confounders. Low albumin was defined as albumin <3.5, <3.0, and <2.5. Independent logistic models were developed to estimate the adjusted odds of death/serious morbidity (DSM) or readmissions associated with hypoalbuminemia. A test for the interaction between 10% weight loss, measured in kilograms, and hypoalbuminemia was performed. Bonferroni correction was used to correct for multiplicity using 0.006 as the threshold for significance.

 

Results: A total of 106,577 patients were included in the study with a mean age of 44 years-old (IQ: 36-53), 78.9% female, and 74.8% White. By procedure, sleeve gastrectomy was most common (65%), followed by gastric bypass procedure (30.3%), laparoscopic band procedure (3%), and other bariatric procedures (1%). The majority of patients had a BMI of 40-49.9 (52.1%).  Among patients with low albumin, 6.3% (n=6,647) had albumin <3.5, 0.3% (n=350) had albumin <3, and 0.1% (n=94) had albumin <2.5. Patients with albumin <3.5 were 45% (OR: 1.45, CI: 1.25-1.67, p<0.001) more likely to have DSM following bariatric surgery. There was increasing likelihood of DSM with albumin <3 and albumin <2.5 [Table 1]. Patients with albumin <3.5 were 21% (OR: 1.21, CI: 1.09-1.35) more likely to require readmission. There was a significant interaction between 10% weight loss and low albumin for DSM when albumin was <3.0 (OR: 5.10, CI: 1.71-15.22, p=0.003).

Conclusion: Obesity is not uniformly associated with a well-nourished state. More than 5% of patients undergoing bariatric surgery have hypoalbuminemia.  Preoperative albumin is an important and modifiable risk factor for postoperative complications following bariatric surgery. Weight loss of 10% combined with hypoalbuminemia is synergistic for high complication rates and should be investigated before proceeding with elective bariatric surgery.
 

17.16 Comparative Analysis of Black Males vs. Black Females after Bariatric Surgery

Posted on January 18, 2018

E. S. Bauer4, M. S. Pichardo3,5, G. Ortega4, M. F. Nunez4, M. A. Spencer3, M. Wooten3, D. D. Tran2, T. M. Fullum2,4  2Howard University College Of Medicine,Department Of Surgery, Center For Wellness And Weight Loss Surgery,Washington, DC, USA 3Howard University College Of Medicine,Washington, DC, USA 4Howard University College Of Medicine,Clive O. Callender Howard-Harvard Health Sciences Outcomes Research Center,Washington, DC, USA 5Yale University,Department Of Chronic Disease Epidemiology,New Haven, CT, USA

Introduction:
As obesity rates grow, bariatric surgery continues to demonstrate itself as an effective treatment for long-term weight loss, contributing to improvements in obesity related diseases. While females make up 80% of all bariatric surgeries, studies show that males have comparable outcomes. Few studies focus solely on the outcomes of Black males and Black females after bariatric surgery. Our aim is to evaluate and compare the effectiveness of bariatric surgery on weight loss and resolution of co-morbidities among Black males and Black females at an urban institution.

Methods:
Retrospective study of patients who underwent bariatric surgery at a single urban academic institution between 2008 to 2016. Data retrieved from medical records included demographic, pre- and post-operative weight, height and co-morbidities (diabetes mellitus type II [DM], hypertension [HTN], and hypercholesterolemia [HC]), and surgical procedures (laparoscopic roux-en y gastric bypass (LRYGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic adjustable gastric band (LAGB)). All analysis compared males to females and stratified by surgical procedure. Primary outcomes interested were mean, weight loss, and BMI points loss by 12 months. Secondary outcomes were resolution of co-morbidities by 12 months. Adjusted multivariable regression analysis was performed to assess the relation between gender and outcomes of interest.

Results:
In an analytical sample of 422 black patients, 18% were male (n=74). Mean weight was 349 lbs (standard deviation (SD=76.19) for males and 290 lbs (SD=60.91) for females, and mean BMI for males was 50 kg/m2 (SD=9.21) and 48 kg/m2 (SD=8.99) for females. Among these patients, 43% of males and 32% of females had DM, 69% of males and 47% of females had HTN, and 32% of males and 28% of females had HC. At one year postoperatively, the mean BMI was 39 kg/m2 (SD=9.37) for males and 40 kg/m2 (SD= 4.92) for females. Among these patients, 15% of males and 9% of females had DM, 47% of males and females had HTN, 15% of males and 25% females had HC. There was no statistical significance between male and female outcomes in EWL% (OR=1.89, 95% CI=-6.78-4.46), BMI point difference (OR=3.60, CI=-19.03-26.23), resolution of DM (OR=1.55, CI=0.67-3.57), HTN (OR=1.13, CI=0.62-2.05), and HC (OR=1.87, CI=0.69-5.06).

Conclusion:

Our study demonstrates that there were no differences between Black males and Black females after bariatric surgery with respect to weight loss and resolution of co-morbidities.
 

17.13 Ethnic Disparities in Diabetes Outcomes after Bariatric Surgery

Posted on January 18, 2018

A. Valencia1, L. Garcia1, D. Azagury1, H. Rivas1, J. M. Morton1  1Stanford University,Bariatric and Minimally Invasive Surgery,Palo Alto, CA, USA

Introduction: Previous studies have demonstrated that persons from lower socioeconomic and racial/ethnic minority backgrounds are more likely to qualify for bariatric surgery. Despite notable research regarding access to bariatric surgery, there remains a need to assess differences in metabolic outcomes among racial/ethnic groups and across time. This study assesses ethnic differences in diabetes outcomes following bariatric surgery. 

Methods: A retrospective analysis including 745 patients with type 2 diabetes (T2D) who underwent Roux-en-Y gastric bypass (RYGB) surgery was conducted to understand racial/ethnic disparities in metabolic outcomes over time. Data were collected from a bariatric database including patients treated at an academic medical center in  California. Non-Hispanic White (NHW), Hispanic, Black, Asian, and Pacific Islander racial/ethnic groups were identified using self-reported data. T2D was defined as having one of the following criteria: a fasting glucose concentration >125 mg/dL, HbA1c >6.5%, and taking one or more diabetic medications. Patients who had a fasting glucose <100 mg/dL, HbA1c <6.5%, and were not on diabetic oral medications were considered to have resolved T2D. Within-group comparisons were made using paired t-tests.

Results:Significant reductions in BMI, body weight, fasting glucose, and HbA1c were observed for all racial/ethnic groups six months after RYGB. However, whereas NHW, Hispanic, and Black patients benefited from an additional and statistically significant reduction in BMI 12 months after surgery, this effect was not observed among Asian or Pacific Islander patients. In addition, NHW and Hispanic cohorts experienced additional reductions in fasting glucose and HbA1c at 12 months of follow up, but there were no further improvements in glucose metabolism among the Black, Asian, or Pacific Islander groups. Significant improvements in triglycerides, total cholesterol, HDL-C, and LDL-C were observed for NHWs, Hispanics, and Blacks but not for Asians and Pacific Islanders. T2D was resolved in 94% of Hispanics, 94% of Asians, 89% of NHWs, 87% of Blacks, and 75% of Pacific Islanders. 

Conclusion: This study demonstrates that RYGB was an effective treatment for normalizing glucose metabolism among patients with type 2 diabetes, regardless of racial/ethnic group.  However, Asians and Pacific Islanders did not continue to benefit from improvements in BMI, fasting glucose concentrations, or HbA1c between 6 and 12 months after surgery. These results suggest the need to provide Asian and Pacific Islander patients with additional support for achieving similar longitudinal metabolic improvements as NHW and Hispanic counterparts.

 

17.14 National Trends in Gastrectomy for Cancer by Race: Insight into Changing Epidemiology

Posted on January 18, 2018

E. M. Groh1, N. Hyun2, D. Check2, H. Chinnasamy3, J. M. Hernandez1, B. I. Graubard2, J. L. Davis1  1National Cancer Institute,Thoracic And Gastrointestinal Oncology Branch,Bethesda, MD, USA 2National Cancer Institute,Division Of Cancer Epidemiology And Genetics,Bethesda, MD, USA 3National Cancer Institute,Surgery Branch,Bethesda, MD, USA

Introduction: The incidence of gastric cancer has declined in the United States over the last few decades, however race-specific trends in gastrectomy remain undefined. The goals of this study were to evaluate the annual rates and outcomes of gastrectomy for cancer stratified by race during a time of a changing US population. 

Methods: Data was queried from the Nationwide Inpatient Sample (NIS) from 1993 to 2013. All patients undergoing gastrectomy for cancer as defined by International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) procedure and diagnostic codes were identified. Multivariate analyses were performed on common covariates including sex, race, type of gastrectomy, comorbidity score and hospital characteristics. SAS® 9.4 Software was used for statistical analysis. 

Results: We identified a significant decline in the rates of gastrectomy for cancer between 1993 and 2013 (p<0.0001). In 1993, there were 9,879 gastric resections for cancer whereas in 2013, there were 7,270, representing a 26.4% decrease. Despite the decreasing frequency of operations undertaken for gastric cancer in the US, we identified a concomitant decrease  in the rates of in-hospital mortality during the study period (p=0.0002). Not surprisingly, in-hospital mortality was significantly lower at urban teaching hospitals as compared to rural or urban nonteaching hospitals (p=0.0217), where most resections were undertaken. In analyzing the rates of gastrectomy for cancer stratified by race, we identified a 32.5% decrease in operations undertaken in white patients, whereas a 39.5% increase in operations was observed in Hispanic patients. During this same time period the percent Hispanic U.S. population more than doubled. Multivariate analysis of patients undergoing gastrectomy for cancer revealed that Asian patients had significantly lower in-hospital mortality rates when compared to Whites (p=0.0041). However, there was no difference in in-hospital mortality when comparing African-American (AA) and Hispanic patients to White patients.

Conclusion: The annual rate of gastrectomy for cancer is declining in the U.S. in general, although race-specific changes may reflect changes in the population over the study period. Despite decreasing frequency of gastrectomy, mortality rates have also declined for patients undergoing gastrectomy for cancer. Rates of in-hospital mortality were worse in AA, Hispanic and White patients as compared to Asian patients for reasons that remained ill-defined. 

 

17.11 Esophageal Function and Obesity

Posted on January 18, 2018

J. U. Nguyen1, K. Feng1, J. P. Callaway2, B. L. Corey1, J. M. Grams1  1University Of Alabama at Birmingham,Division Of Gastrointestinal Surgery/Department Of Surgery,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,Department Of Medicine,Birmingham, Alabama, USA

Introduction: Patients with obesity have been shown to have an increased intra-abdominal pressure and dysfunction of the gastroesophageal junction. We hypothesized that obesity would be associated with increased mean basal and residual lower esophageal sphincter (LES) pressures but also increased GERD.

Methods:  Retrospective review was performed on all adult patients undergoing high resolution manometry (HRM) and 24-hour pH monitoring at a single academic institution from 2014 to 2016. Exclusion criteria included a diagnosis of achalasia or hiatal hernia, and active acid suppression medications during testing. Patients were stratified by BMI (kg/m2): normal weight <25; overweight 25 to 29.9; class I, II, class III obesity at 30 to 34.9, 35-39.9, and ≥ 40, respectively. Statistical analyses were performed using Chi-square test, Kruskal-Wallis one-way analysis of variance, linear regression, or multiple regression as appropriate. Statistical significance was determined as p-value <0.05.

Results: A total of 507 patients were included in the study. After stratification, there were 149 (29.4%) patients who had normal weight, 159 (31.4%) overweight, 121 (23.9%) with class I obesity, 46 (9.1%) with class II obesity, and 32 (6.3%) with class III obesity. Mean basal LES pressure was significantly increased in patients with class III obesity (p=0.004), while mean residual LES pressure only trended toward being increased (p=0.060). There was no statistical difference in esophageal contraction vigor (Distal Contractile Integral, DCI) (p=0.43). In unadjusted linear regression models, there was a positive linear correlation between mean basal LES pressure and BMI (p<0.001) as well as between mean residual LES pressure and BMI (p<0.001). There was no association between DCI and BMI (p=0.425). These results persisted after adjustment for age. In subset analyses, 24-h pH monitoring was performed in 201 of these patients: normal weight 54 (26.9%), overweight 67 (33.3%), obesity 80 (39.8%). There were no significant differences among the groups in any esophageal acid exposure parameters or between any of the parameters of esophageal acid exposure and BMI when examined as a continuous variable.

Conclusion: In conclusion, these data suggest that obesity augments the basal resting and relaxation pressures of the LES but is not associated with changes in esophageal contractility. However, mean DCI values in obesity still remained within normal limits and standard criteria should be adequate to determine disease states. Obesity did not result in increased esophageal acid exposure.

 

17.12 Laparoscopic Revision of Roux-En-Y Gastric Bypass to Distal Bypass for Weight Regain: Midterm Outcomes

Posted on January 18, 2018

N. R. Changoor1, G. Ortega1, J. Kendall2, C. M. Smith2, K. Hughes1, T. M. Fullum1, D. Tran1  1Howard University College Of Medicine,Department Of Surgery,Washington, DC, USA 2Howard University College Of Medicine,Washington, DC, USA

Introduction:
Roux-en-Y gastric bypass (RYGB) is well known to be effective for the morbidly obese population. However, weight regain continues to be a significant problem for many patients. We report the outcomes of revision of RYGB to distal RYGB (DRYGB) in patients suffering from weight regain following their original procedure.

Methods:
A review of prospectively collected data was performed at a tertiary urban teaching hospital. Over a four-year period between March 2012 and March 2017, 21 patients underwent laparoscopic revision of RYGB to DRYGB. At the time of the original RYGB, the mean weight and body mass index (BMI) were 324.4 ± 60.8 lbs. and 52.2 ± 8.2 kg/m2, respectively. The interval between the original procedure and the revision was 120.1 ± 61.2 months.  Patients regained on average 70.2 ± 41.8 lbs, or a BMI gain of 11.4 ± 6.7 kg/m2. The mean weight at the time of revision was 277.5 ± 54.8 lbs. (BMI of 44.7 ± 6.9 kg/m2). All patients suffered from one or more obesity-related comorbidities.

Results:
The mean operative time was 157.4 ± 30.8 minutes. All patients were discharged on post-operative day 1, except for two who were discharged on post-operative day 2. There were no complications or mortalities within 30 days of surgery. The average weight (BMI) were 229.4 ± 53.6 lbs. (37.0 ± 6.0 kg/m2) at six months, 215.5 ± 46.5 lbs. (34.4 ± 5.8 kg/m2) at one year, 205.2 ± 28.9 lbs., (34.3 ± 4.0 kg/m2) at two years, 184.5 ± 44.9 lbs. (29.1 ± 7.5 kg/m2) at three years, and 177.4 +-42.6 lbs (27.9 +- 6.2 kg m/m2) at 4 years. We used percent excess BMI loss (%EBMIL) calculated as follows: (BMI at revision – BMI at 4 years)/(BMI at revision – ideal BMI) x 100. The %EBMIL at four years was 74.7 ± 35.2%. Four patients (19%) suffered from protein calorie malnutrition following the procedure, of which two required reversal. One patient died at four years from severe protein calorie malnutrition because of failure to follow up. Another patient, who was not malnourished, required reversal due to ischemic bowel secondary to adhesive bowel obstruction. Using paired t-test, significant difference was found between the BMI at revision and the BMI at four years post revision (p = .02).

Conclusion:
The options of surgical revision are limited for patients who regained weight after RYGB. In spite of higher risks of long term malnutrition, laparoscopic revision to DRYGB remains an effective procedure for these patients.
 

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