50.13 The Early Impact of Medicaid Expansion on Insurance Coverage for General Surgery

Posted on January 18, 2018

A. S. Chiu1, R. A. Jean1, J. Ross2, K. Y. Pei1  1Yale University School Of Medicine,Surgery,New Haven, CT, USA 2Yale University School Of Medicine,Internal Medicine,New Haven, CT, USA

Introduction:
In 2014, the expansion of Medicaid under the Affordable Care Act allowed states to extend Medicaid benefits to adults with incomes less than 138% of the federal poverty level. Although the Supreme Court ruled that states could opt out of Medicaid expansion, 26 states and the District of Columbia expanded Medicaid eligibility in 2014, with five more states subsequently doing the same. Medicaid expansion has contributed to a decrease in the number of uninsured patients and an increase in the utilization of primary care services; however, it remains unclear whether this has translated into increased insurance coverage for surgical patients.  

Methods:
The National Inpatient Sample (NIS) is the largest all-payer, nationally representative database in the United States. Discharges for the 10 most burdensome emergency general surgery operations (defined as a combination of frequency, cost, and morbidity), were identified in the NIS between 2010-2014. Weighted averages were used to produce nationally-representative estimates. The primary outcome studied was the distribution of insurance type for surgical patients before and after Medicaid expansion in 2014.

Results:
After Medicaid expansion, the proportion of operative admissions covered under Medicaid rose from 15.5% to 18.5% (p<.001), or by approximately 20%. Over the same time, the proportion of uninsured surgical patients decreased from 8.9% to 6.6% (p<.001). In total this translated into an increase of 32,185 general surgery patients who were covered under Medicaid, and 34,305 fewer uninsured general surgery patients. The percentage of privately insured patients decreased from 40.9% in 2010 to 36.2% in 2014 (p<.001), while the percent of Medicare patients rose from 30.4% to 35.4% (p<.001) over the same period. 

Conclusion:
In the first year of Medicaid expansion alone, data from a nationally representative sample shows that the number of general surgery patients covered by Medicaid increased by more than 30,000, while the number of uninsured general surgery patients fell by nearly 35,000. The proportion of private insurance has also gone down over this period, with a reciprocal rise in Medicare coverage, likely explained by demographic shifts towards an aging population. Continued study is needed to evaluate the ongoing impact Medicaid expansion is having on coverage for surgical patients.
 

50.14 POSTOPERATIVE RESPIRATORY FAILURE: Safer Surgery IMPROVES OUTCOMES

Posted on January 18, 2018

A. L. Lubitz1, J. A. Shinefeld1, T. A. Santora1, A. Pathak1, E. E. Craig1, A. J. Goldberg1, H. A. Pitt1  1Temple University,Philadelpha, PA, USA

Introduction: Postoperative respiratory failure is an uncommon, but deadly and costly complication. Approximately 30% of patients who suffer this complication die, and the excess cost is estimated to be $50,000.00 per patient. The aim of this analysis is to document that a multidisciplinary Safer Surgery approach can reduce the incidence of postoperative respiratory failure.

Methods: Postoperative respiratory failure was monitored in both the Vizient (University HealthSystem Consortium) and the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) databases. In Vizient the Patient Safety Indicator (PSI)-11 documents the observed (O) rate per 1,000 cases, the expected (E) rate per 1,000 cases, and the O/E ratio for postoperative respiratory failure. PSI-11 data were monitored from Fiscal Years (FY) 2014-2017. In the ACS-NSQIP database both unplanned intubation and ventilation greater than 48 hours are reported as odds ratios and deciles. Data in the 10th decile are classified as “Need Improvement” while 2nd to 9th decile outcomes are “As Expected.” Safer Surgery is a multidisciplinary initiative whose aim is to optimize the preoperative, intraoperative and postoperative phases of care. Patient education and preparation are key elements in this program, as are surgeon, anesthesiologist and nursing interventions. The RECOVER mnemonic was developed to emphasize: R-review materials, E-expand your lungs, C-cough and deep breath, O-oral care, V-vary activity, E-eat safely and R-rest with the head of the bed up. Educational materials are distributed to patients in surgery clinics, Preanesthesia Testing (PAT) and via the patient portal of our electronic medical record system. Multimedia educational materials were produced for patients, residents and nursing staff.

Results:Patient Safety Indicator (PSI)-11 O/E Ratio decreased from 1.36 in FY 14, to 0.77 in FY 15, to 0.48 in FY 16 to 0.43 in FY 17 (Table 1). The Observed PSI-11 mortality was 30% in the first 18 months of the analysis and decreased to 15% in the most recent 18 months. These improvements represent a savings of 11 lives and $1.5 million dollars. Both the ACS-NSQIP unplanned intubation and ventilator greater than 48 hours needed improvement in FY 15 (Table 1). Both of these metrics have improved to “As Expected” in FY 16 (Table 1).

Conclusion:A multidisciplinary Safer Surgery program improved postoperative respiratory failure outcomes at an academic medical center. A bundle of preoperative, intraoperative and postoperative best practices resulted in improved respiratory outcomes.

 

50.12 Preoperative Antibiotic Timing and Postoperative Duration in Ruptured Appendicitis

Posted on January 18, 2018

R. Amin1, S. Walker1, K. Somers1, M. Arca1  1Medical College Of Wisconsin,Milwaukee, WI, USA

Background: Our practice for ruptured appendicitis has evolved from administering intravenous (IV) and oral antibiotics for a predetermined number of days postoperatively, to only giving inpatient IV antibiotics until the following criteria is met: afebrile for 24 hours, tolerating oral diet, and pain control without IV medications. We aimed to determine whether the timing of preoperative antibiotics relative to incision, and duration of immediate postoperative antibiotics impact the development of surgical site infection (SSI).

Methods: We performed an IRB-approved single institution retrospective review of all patients with ruptured appendicitis based on a prospectively collected registry from January 1, 2013 until October 31, 2016. Univariate and multivariate analyses were performed with CI >95%.

Results: There were 406 patients; 62% were male. Median age was 10.3 years (IQR, 7.3, 13.2). The majority of our patients had an American Society of Anesthesiologists (ASA) classification of 1 or 2 (78.5%), while 21% were ASA 3, and 0.5% classified as ASA 4.  Laparoscopic surgery was performed in 89.9% of cases, 5.7% of these cases were converted to open, and 4.4% were performed in an open fashion. Sixty-three patients (15.5%) developed SSI: 5 (1.2%) superficial, 2 (0.5%) deep, and 54 (13.3%) organ space. There were two wound dehiscence’s. There was no statistically significant difference in sex, age at operation, or ASA in terms of SSI development.

Pre-operative antibiotics: All patients received IV antibiotics at time of diagnosis, leading to an average interval of 96+90 minutes between preoperative antibiotic administration and incision. When comparing patients who received preoperative antibiotics <60 minutes or >60 minutes before incision, we found no statistical significance in SSI development (p=0.64).

Post-operative antibiotics: We grouped patients using the number of antibiotic days they received immediately following surgery. There was no difference in SSI based upon timing of the immediate postoperative antibiotic dose (p=0.707). Predictably, patients with SSI had longer median antibiotic treatment (9 days [IQR 5,13]) than those without (5 days [IQR 3,6], p<0.001).

Antibiotics and complications: Patients that developed SSI were grouped by the total number of postoperative antibiotic days received. The distribution was as follows: 1 day (n=10, 3 SSI), 2 days (n=31, 1 SSI), 3 days (n=62, 6 SSI), 4 days (n=76, 3 SSI), 5 days (n=74, 3 SSI) and >5 days (n=153, 47 SSI).

For each additional hour of case length, the odds of complication roughly double (OR= 2.08 [95% CI 1.27, 3.39], p=0.0034

Conclusion: Timing of preoperative antibiotics relative to incision did not affect SSI rates. Duration of immediate postoperative antibiotics does not affect SSI development, provided clinical criteria are used to guide antibiotic management.  Longer operative time is associated with higher complications.

50.10 Can the Laparoscopic Approach Be Employed in Octogenarians with SBO?

Posted on January 18, 2018

E. H. Chang1, P. Chung3, M. J. Lee1, M. Smith5, K. Barrera1, V. Roudnitsky2, A. Alfonso4, G. Sugiyama4  1State University Of New York Downstate Medical Center,General Surgery,Brooklyn, NY, USA 2Kings County Hospital Center,Division Of Trauma And Acute Care Surgery,Brooklyn, NY, USA 3Coney Island Hospital,Department Of General Surgery,Brooklyn, NY, USA 4Hofstra Northwell School Of Medicine,Department Of Surgery,Hempstead, NY, USA 5Vanderbilt University Medical Center,Department Of Trauma Surgery,Nashville, TN, USA

Introduction: The number of octogenarians is projected to increase four-fold by the year 2050. Laparoscopic surgery (LAP) has been associated with decreased length of stay and pain, however the open approach is often employed for small bowel obstruction (SBO). Our aim was to compare laparoscopic surgery (LAP) in the octogenarian population in patients presenting with SBO from adhesive disease with the traditional open exploratory approach. 

Methods:

An observational study utilizing ACS NSQIP from 2006-2014 was performed. Patients ≥80 years of age, who underwent emergency surgery within one day of admission with a postoperative diagnosis of intestinal/peritoneal adhesion with obstruction (ICD9 560.81) were included in the study. Risk variables of interest included: age, sex, race, BMI, preoperative sepsis, ASA classification, length of stay (LOS), postoperative mortality, and postoperative pneumonia. Univariable analysis was performed using Student’s t-test and Wilcoxon Rank Sum Test for continuous variables while Fisher’s Exact Test and Chi-square Test for categorical variables. Multivariable analysis was performed using Logistic Regression. 

Results:

A total of 103 LAP and 692 open cases were identified. There were no significant differences in age (p=0.1518), sex (p=0.7994), BMI (p=0.1151), or race (p=0.3722) between the groups. However, the open group tended to have higher ASA class (p=0.0225) and incidence of preoperative sepsis (p=0.01597). Unadjusted outcomes showed longer LOS in open vs LAP (median 4.0 vs 8.0 days, p<0.0001), higher incidence of postoperative mortality in open vs LAP (p=0.0071), and higher incidence of postoperative pneumonia in open vs LAP (p=0.0032). Logistic regression with postoperative mortality and pneumonia ad dependent variables were performed adjusting for preoperative risk variables and LAP vs Open. Age (OR 1.11, 95%CI 1.01-1.22, p=0.0311) and preoperative sepsis (OR 3.77, 95%CI 1.06-12.02, p=0.0287) were associated with mortality. Male sex (OR 2.68, 95%CI 1.58-4.60, p=0.0003) and open procedure (OR 5.03, 95%CI 1.50-31.34, p=0.0282) were associated with postoperative pneumonia. 

Conclusion:

We compared outcomes after LAP vs open adhesiolysis for adhesive SBO in the octogenarian population. Adjusting for multiple preoperative variables and LAP vs open approach, we found that age and presence of preoperative sepsis, but not procedure type, was associated with mortality. Therefore, octogenarians who present with SBO due to adhesive disease may benefit from an initial laparoscopic approach. Further prospective studies are warranted.
 

50.11 Gastrografin Challenge Protocol Decreases Length of Stay in Patients with Small Bowel Obstruction

Posted on January 18, 2018

W. Huett1, N. J. Bruce1, W. C. Beck1, M. K. Kimbrough1, J. Jensen1, M. Sutherland1, R. Robertson1, K. W. Sexton1  1University Of Arkansas For Medical Science,Little Rock, AR, USA

Introduction:  The gastrografin challenge (GGC) is a diagnostic tool used to predict the need for surgery in patients with small bowel obstruction (SBO) due to adhesive disease.  The GGC was recently implemented into the management of SBO protocol for surgical services at our institution in the 3rd quarter of 2015. We hypothesized that the length of hospital stay would subsequently decrease for patients receiving our updated protocol utilizing the GGC.

Methods:  In this retrospective analysis of prospectively collected data, the length of stay for patients admitted to surgery services for SBO before and after implementation of the GGC protocol were measured. The GGC clinical protocol could be found on the division website and was implemented using morning report. If contrast reached the colon at 24 hours, nasogastric tube was removed and diet advanced.  If contrast failed to reach the colon at the 24 hour film, operative therapy was recommended. As an additional, temporal control, patients admitted to the medicine service with SBO before and after the surgical services implemented the GGC protocol were examined as well.

Results: A total of 1,468 patients admitted to the surgical services were included in our analysis, as well as 1,026 patients admitted to the medicine service. Implementation of the GGC protocol in the management of adhesive small bowel disease on surgical services reduced the average length of stay by 2 days (7.3± 11.5 days, n=993; vs 5.3 ±  9.6, n=475, p=0.0002).  There were 993 patients in the control group, and 475 patients in the intervention arm.  There was no difference in mean length of stay for patients admitted to the medicine service with SBO in the time before and after implementation of GGC protocol by surgical services (6.3 ±  11.7 days, n=649 control; 7.0 ±  11.8 days, n=377, p=0.8).  In the patients admitted to the surgical services before the protocol, 24% underwent an operation compared to 5% after implementation of the protocol (p<0.0001).

Conclusion: Use of the GGC in the initial, protocol-driven management of adhesive SBO decreases length of stay likely due to a decreased need for operative intervention. 

 

50.07 Neutrophil Lymphocyte Ratio (NLR) Predicts Hospital Length Of Stay In Acute Appendicitis

Posted on January 18, 2018

E. B. Rodas1,2, M. Guillén2, E. Granda2, F. Martínez2, E. B. Rodas1,2  1Virginia Commonwealth University,Acute Care Surgical Services/ Surgery,Richmond, VA, USA 2Universidad Del Azuay,Cuenca, AZUAY, Ecuador

Introduction:
Neutrophil to lymphocyte ratio (NLR) has demonstrated to be a marker of inflammatory response in many conditions including acute appendicitis. We hypothesize that admission NLR could predict hospital length of stay (HLOS) in acute appendicitis.

Methods:
A retrospective cohort study was conducted during 2013 in a tertiary hospital and included all patients admitted through the emergency department with the diagnosis of acute appendicitis treated surgically. A database utilizing SPSS-V19 was created. To evaluate sensitivity of the test we constructed ROC curves; association between variables and risk was evaluated with chi-square and odds ratio.

Results:
During the 12-month period 338 patients were admitted with acute appendicitis. There were 203 (60.05%) male and 135 (39.94%) female patients. Mean age 34.67 ± 11.65 years. When chi-square was applied to increased NLR and HLOS a value of 21.36 (p <0,05), odds ratio 3.019 (CI 1.874-4.864). Also chi-square was applied to NLR and ICU admission, a value of 3.64 (p <0.05) and an odds ratio of 6,18 (CI 0.736 – 51.931). Moreover, the NLR for the different phases of appendicitis was: inflammatory phase (n=87), 7.98 (± 10.40), suppurative (n=142) 11.27 (± 23.54), gangrenous (n=67) 8.15 (± 4.78) and perforated (n=42) 18.44 (± 23.78).

Conclusion:
In acute appendicitis, a higher NLR is associated with an increased in HLOS. The utilization of this simple parameter could potentially be used to allocate resources at the time of admission. Furthermore, NLR trended upward as the disease severity progresses. Additional studies are warranted to validate these findings.
 

50.08 Risk Factors of Mortality in Patients with Necrotizing Soft Tissue Infections in Rwanda

Posted on January 18, 2018

M. CHRISTOPHE1, J. Rickard2,4, F. Charles1,3, N. Faustin1,2  1University Of Rwanda,College Of Medicine And Health Sciences,Kigali, KIGALI, Rwanda 2University Teaching Hospital Of Kigali,Surgery,Kigali, , Rwanda 3Rwanda Military Hospital,Plastic And Reconstructive Surgery,Kigali, KIGALI, Rwanda 4University Of Minnesota,Surgery And Critical Care,Minneapolis, MN, USA

Introduction: Necrotizing soft tissue infections (NSTI) is an emergency surgical condition with severe physiologic and metabolic derangement that predisposes the patient to increased mortality and morbidity worldwide, particularly in developing countries if not diagnosed and treated early.

Methods: This prospective observational cohort study includes all patients aged12 and above who presented at Department of Surgery, University Teaching Hospital of Kigali from April 2016 to January 2017 with NSTI. We describe epidemiology, operative management, and outcomes of care. We evaluated the risk factors for mortality using bivariate and multivariate logistic regression.

Results:We identified 175 patients with confirmed diagnosis of NSTI. The majority of patients (53%) were male and the mean age was 44 years. The median duration of symptoms was 8 days (Interquartile range (IQR): 5-14) .The overall mortality was 26%. The median length of hospital stay was 23days (IQR: 8-41). Multivariate regression analysis revealed four independent predictors of mortality: presence of shock at admission (odds ratio (OR) 14.15, 95% confidence interval (CI):0.96-208.01, P=0.05), chronic kidney disease (OR 8.92, 95% CI:1.55-51.29, P=0.01) infection located to the trunk (OR: 5.60 , 95% CI:0.99-31.62, P=0.05), and presence of skin gangrene (OR 4.04, 95% CI: 1.18-13.76, P=0.02).

Conclusion:NSTI mortality is high. Patients present in late stage, which carries increased mortality and morbidity. It is imperative that increased efforts need to be done in regards to early consultation, diagnosis and surgical management to prevent bad outcomes

 

50.09 Incidence and Histopathologic Variations in Appendiceal Neoplasm Presenting as Acute Appendicitis

Posted on January 18, 2018

R. F. Brown1, K. Cools1, M. Shah1, W. Stepp1, T. Reid1, A. Charles1  1University Of North Carolina At Chapel Hill,Chapel Hill, NC, USA

Introduction: Patients with a primary appendiceal neoplasm (PAN) often present with variable symptoms, including those of acute appendicitis (AA).  However, with the incidence of PAN increasing nearly two-fold over the past ten years, it is vital to evaluate the effect this has on patients who present with AA, but ultimately have PAN.  The purpose of this study is to identify variations in PAN incidentally diagnosed after treatment for AA.

Methods:  A retrospective review of a pathology database was performed identifying all patients who underwent surgical management of AA between January 2000 and December 2015. Pathology reports were reviewed and patients with PAN were identified. Pearson chi-squared test was performed to compare the difference in incidence of PAN after treatment for AA.

Results: Of the 4336 patients surgically treated for AA between 2000-2015, 1.2% (n=51) had PAM.  Between 2000-2005, incidence of PAN in those presenting with AA was 0.5% compared to 1.3% between 2006-2010 and 1.6% between 2011-2015 (p<0.001 for all).  Table 1 demonstrates patient demographic and histopathological variation over these time periods.  This indicates an increase in the proportion of carcinoid, adenocarcinomas, mixed adenoneuroendocrine carcinomas, and other malignant tumors over time.

Conclusions: Our data suggest that the incidence of PAN presenting as AA is significantly increasing over time.  Additionally, there appears to be a shift in the pathologic variation of PAM, with a decrease in mucinous cystadenomas and an increase in adenocarcinoma and mixed adenoneuroendocrine carcinomas. These findings suggest that acute care surgeons must be increasingly aware that every appendectomy is potentially an oncologic procedure.

50.05 Perioperative Factors Influencing Urinary Retention After Laparoscopic Inguinal Hernia Repair

Posted on January 18, 2018

D. F. Roadman1, M. Helm1, M. Goldblatt1, A. Kastenmeier1, T. Kindel1, J. Gould1, R. Higgins1  1Medical College Of Wisconsin,Milwaukee, WI, USA

Introduction:  Post-operative urinary retention (POUR) after laparoscopic inguinal hernia repair has an incidence of 2-30%. POUR can lead to urinary tract infections, longer lengths of stay, and decreased patient satisfaction. The primary objective of this study was to determine the incidence of and perioperative factors contributing to POUR at our institution in patients who underwent a laparoscopic total extraperitoneal (TEP) inguinal hernia repair. 

Methods:  A retrospective chart review was performed of patients who underwent a laparoscopic TEP inguinal hernia repair at our institution from 2009 to 2016. POUR was defined as patients who required indwelling or straight urinary catheterization postoperatively due to an inability to void spontaneously. Univariate analyses were performed on perioperative variables and their correlation with POUR. 

Results: In total, 578 laparoscopic TEP inguinal hernia repair patients were included in the study: 277 (48%) indirect, 144 (25%) direct, 6 (1%) femoral, and 151 (26%) combination of direct, indirect and/or femoral hernias. Of these, 292 (51%) were bilateral and 286 (49%) were unilateral. Overall, 64 (11.1%) of the 578 patients developed POUR, requiring urinary catherization post-operatively. POUR was significantly associated with benign prostatic hyperplasia (BPH), age 60 years or older, urinary tract infection (UTI) within 30 days, and lower body mass index (BMI) (Table 1). Additional pre-operative, intra-operative, and post-operative variables that were not statistically significant determinants of POUR are also listed in Table 1.

Conclusion: Patients greater than 60 years old, with BPH, and a lower BMI were more likely to develop POUR after laparoscopic TEP inguinal hernia repair. Additionally, these patients were also more likely to develop a UTI within 30 days. Identifying patients at higher risk for the development of POUR can help with patient education and expectations. Additionally, future quality initiatives can be explored to minimize the incidence of POUR in high risk patient populations.

 

50.06 Outcomes of Acute Appendicitis in Veteran Patients

Posted on January 18, 2018

O. Renteria1, S. Huerta1,2  1University Of Texas Southwestern Medical Center,Surgery,Dallas, TX, USA 2VA North Texas Health Care System,Surgery,Dallas, TX, USA

Introduction: Some studies indicate that non-complicated acute appendicitis might be treated exclusively with antibiotics instead of an appendectomy.  We hypothesize that conservative treatment might not be appropriate for veteran patients.    

Methods: This a retrospective, single institution analysis at the VA North Texas Health Care system between 7/05 to 6/17 for all patients who underwent an appendectomy (n=345).  Patients who had an appendectomy for cancer, or incidentally for other reasons were excluded (n=35) as were patients with interval appendectomies (n=16) as well as patients with perforated appendicitis (n=14).  Using postoperative complications as a dependent variable, univariate analysis was performed using Fisher’s Exact Test for categorical and Student’s T-Test for continuous variables.  Significant variables were included in a multiple logistic regression model with postoperative complications as the dependent variable. Data are expressed as means ± SD and significance was established at a p≤0.05 (two-sided).

Results: Of patients who underwent an appendectomy for acute appendicitis (n=280; male=90%; age=46.0±15.7 y.o.; BMI=31.2±18.3 Kg/m2), seven had a malignancy in the specimen (2.5%), one had endometriosis and five had been previously treated conservatively.  Without major complications, minor complications occurred in 20 patients (7.1%) and 30-day mortality was zero. LOS was 3.7±4.3 days. On presentation, 91% of patients had a CT scan and 92% underwent a laparoscopic appendectomy.  Conversion rate was 5%.  Age (57.4±13.1 vs. 45.4±15.6 y.o); blood loss (75.6±95.1 vs. 18.4±27.7 cc); ASA (2.6±0.9 vs. 2.2±0.8); tachycardia on initial presentation (95.2±20.6 vs.  85.8±17.1 bpm); and leukocytosis (16.1±4.8 vs. 13.2±4.4 cc/U) [all p’s <0.05] were associated with complications.  Patients with a gangrenous appendix and history of cardiovascular disease were also more likely to have complications.  Blood loss (OR=1.1; 95% CI 1.0 to 1.1) and a history of cardiovascular disease (OR=4.8; 95% CI 1.2 to 19.9) were independent predictors of complications.

Conclusion:  In Veteran patients, the low rate of complications, the risk of harboring malignancy and failure to conservative management argue against managing acute appendicitis with antibiotics compared to an appendectomy.

50.03 Do Ventriculoperitoneal Shunts Increase Complications after Laparoscopic Gastrostomy in Children?

Posted on January 18, 2018

E. Rosenfeld, MD1, K. Mazzolini, BS1, A. S. DeMello1, A. Karediya1, Y. Yu1, J. G. Nuchtern1, S. R. Shah1  1Baylor College Of Medicine & Texas Children’s Hospital,DeBakey Department Of Surgery,Houston, TX, USA

Introduction: In patients requiring gastrostomies, ventriculoperitoneal (VP) shunts are a frequently encountered comorbidity. The objective of this study is to evaluate the postoperative management of children with VP shunts that undergo laparoscopic gastrostomy placement, and determine their incidence of complications. We hypothesized that the presence of a VP shunt wound not increase the rate of immediate complications in children undergoing laparoscopic gastrostomy placement.  

 

Methods: Children 18-years-old or younger who underwent laparoscopic gastrostomy placement at a freestanding academic children's hospital between 1/1/2014 and 9/30/2016 were reviewed. Data collected included demographics, postoperative feeding regimen, and clinical outcomes (including complications within 90 days of gastrostomy placement). We compared patients based on their presence of a VP shunt prior to laparoscopic gastrostomy. Statistical analysis was performed using Chi-square, Fisher's exact and Wilcoxon Rank-Sum tests.

 

Results: We reviewed the medical records of 270 children that underwent laparoscopic gastrostomy placement by 15 pediatric surgeons. Of these, 9% (25) had a previously placed VP shunt. In comparing patients with a VP shunt to those without a VP shunt there was no significant difference in median age (4 vs 3 years, p=0.92), gender (48% vs 51% males, p=0.80), body mass index (15 vs 16, p=0.69), or preoperative diet (48% vs 47% nasogastric tube dependent, p=0.60). In addition, there was no significant difference in intraoperative or postoperative management in those with or without a VP shunt: procedure time (43 vs 42 minutes, p=0.37), type of gastrostomy placed (96% vs 97% MIC-KEY button, p=0.37), postoperative gastrostomy contrast study (9% vs 7%, p=0.68), day of initiation of postoperative feeds (84% vs 73% on postoperative day #1, p=0.70), method of initiation of feeds (60% vs 55% continuous, p=0.25), and type of initial feeds (83% vs 71% Pedialyte, p=0.24).  Similarly, there was no significant difference in clinical outcomes between the two cohorts, including hospital length of stay, return to the emergency department, or postoperative complications within 90 days (Table 1). 

 

Conclusion: Children with ventriculoperitoneal shunts do not have a higher rate of immediate complications after laparoscopic gastrostomy placement, and may be managed similar to other children in the postoperative period.    

50.04 Robotic Port Site Hernias After General and Oncologic Surgical Procedures

Posted on January 18, 2018

R. Diez-Barroso1, C. H. Palacio1, J. A. Martinez1, A. Artinyan1, K. Makris1,2, D. S. Lee1,2, N. N. Massarweh1,2, C. Chai1,2, S. Awad1,2, H. S. Tran Cao1,2  1Baylor College Of Medicine,Houston, TX, USA 2Michael E. DeBakey Veterans Affairs Medical Center,Houston, TX, USA

Introduction:
Robotic surgery has evolved as a platform for various general and oncologic surgical procedures.  With increasing use of this technology, whether 8-mm ports should be closed comes into question.  We sought to characterize the incidence of port site hernias (PSH) and outcomes of patients who underwent general and oncologic robotic-assisted surgical procedures.

Methods:
A retrospective chart review of a single institutional database identified patients who underwent robotic-assisted general and oncologic surgeries from July 2010 to December 2016.  For each patient, the number, location, and size of all robotic ports were collected.  PSH was detected either clinically or radiographically, in which case it was defined as a disruption of the fascia with eventration of fat or bowel at a site of prior port placement on imaging.

Results:

178 patients underwent robotic general and oncologic surgical procedures, with 725 total ports, including 433 8-mm working ports, 72 12-mm working ports, 178 camera ports, and 42 assistant ports.  94% of the patients were male, the mean age was 63±12, BMI was 29±7 kg/m^2, and median ASA score was 3.

Types of cases included rectal (38.2%), colon (20.2%), hepatopancreatobiliary (14.0%), inguinal hernia (12.4%), and other hernias (14.6%).  8-mm robotic port sites were not closed, whereas all larger port sites were.

At a median follow-up – defined by date of most recent surgery clinic visit or most recent abdominal cross-sectional imaging study available – of 193 days, there were 3 PSH through 8-mm port sites (1.7% of patients and 0.7% of 8-mm port sites).  2 of the 3 required emergent reoperation for small bowel incarceration, and both were through lateral-most port sites, above the iliac crest.  BMIs of these two patients were 33 and 34, and operative times for their index operation were 598 minutes and 366 minutes.  The third 8-mm PSH contained fat and was through a port site at the linea semilunaris.

Conclusion:
PSH through 8-mm robotic ports occur infrequently, but can cause significant morbidity.  Closure of 8-mm port sites might be considered at sites of relative fixation where abdominal wall layers have limited ability to slide over one another, and in the setting of long operative times, significant torque at the port site, and patient factors such as obesity.

50.02 BMI as an Independent Risk Factor for Complications after Laparoscopic Ventral Hernia Repair

Posted on January 18, 2018

L. Owei1, R. Swendiman1, S. Torres Landa1, D. Dempsey1, K. Dumon1  1Hospital Of The University Of Pennsylvania,Gastrointestinal Surgery,Philadelphia, PA, USA

Introduction:
A body mass index (BMI) greater than 30kg/m2 is a known independent risk factor for surgical and medical complications following open ventral hernia repair (VHR). This study aims to examine the relationship between BMI and laparoscopic VHR.

Methods:
Data was obtained from the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2015. Patients were stratified into 7 BMI classes, as well as by hernia type (reducible vs. strangulated) and time of repair (initial vs. recurrent). Univariate analyses, namely the Chi-square test for categorical variables and ANOVA or Kruskal-Wallis for continuous variables, were employed to examine the association between BMI class and patient characteristics, comorbidities, recurrent hernia repair, strangulated hernias, and risk of perioperative complication. Logistic regression was used to assess the risk of complication by BMI class with adjustment for potential confounders.

Results:
Of the 57,957 patients who underwent laparoscopic VHR between 2005 and 2015, 61.4% were obese. Patients were stratified into 7 body mass index (BMI) classes: underweight (BMI < 18.5 kg/m2), normal weight (BMI 18.5 – 24.9), overweight (25 – 29.9), obese (30 – 34.5), severely obese (35 – 39.9), morbidly obese (40 – 49.9), and super obese (BMI ≥ 50). When stratified by BMI class, we found significant differences in age, gender, race, comorbidities, and pre-operative characteristics. The overall complication rate was 4.0%, ranging from a low of 3.0% for normal BMI patients, to 6.9% for patients with a BMI ≥ 50 kg/m2. Recurrent repair and strangulated hernias both demonstrated higher complication rates. All complications (surgical and medical) were significantly associated with BMI class (p < 0.0001). This association remained even after adjusting for age, sex, race, comorbidities, recurrent repair, and strangulated hernias. Patients with a BMI ≥ 40 kg/m2 were found to be significantly more likely to have a complication compared to patients with BMIs ≤ 25kg/m2 (Table 1). This risk of complications further increased with increasing BMI class.

Conclusion:
Obesity, especially those in a higher BMI class, is an independent risk factor for surgical and medical complications after laparoscopic VHR. Patients with BMIs ≥ 40kg/m2 are at 1.3 times greater risk for complications. While this group is different from the patients undergoing open VHR, the higher threshold at which BMI becomes a significant risk factor in laparoscopic VHR suggests that a laparoscopic approach should be considered for patients with BMIs ≥ 30kg/m2 to reduce their risk of post-operative complications.
 

50.01 Impact of Acute Care Surgery Service on Diverticulitis Patients Managed with Operative Intervention

Posted on January 18, 2018

M. N. Khan1, M. Hamidi1, A. Jain1, E. Zakaria1, N. Kulvatunyou1, T. O’Keeffe1, A. Tang1, L. Gries1, B. Joseph1  1University Of Arizona,Tucson, AZ, USA

Introduction:
Trauma services are increasingly providing emergency surgery (ES) care by developing “acute care surgery service (ACS)” which is a combination of trauma surgery, broad-based ES, and surgical critical care. ACS implementation has been shown to provide timely care with improved patients outcomes. The aim of our study was to evaluate the impact of ACS on outcomes in patients who underwent ES for acute diverticulitis

Methods:
We reviewed all patients who were admitted with the diagnosis of acute diverticulitis from 2009-2014. Patients who underwent ES (within 24 hours of hospital admission) were included while those who were admitted during ACS implementation year (2011) were excluded. Patients were divided into two groups: (Pre-ACS [2009-2010] and Post-ACS [2012-2014] and were matched in a 1:2 ratio using propensity score matching for demographics, comorbidities and admission vitals and labs. Outcome measures were time to evaluation by the surgeon, time to operating room (OR) from emergency department (ED), hospital length of stay (LOS), complications, mortality and adjusted hospital charges.

Results:
A total of 1216 patients were analyzed. 284 patients underwent operative intervention within 24 hours of admission, of which 207 patients (Pre-ACS, 69; Post-ACS, 138) were matched. Patients in ACS group had lower median time to evaluation by the surgeon (150 minutes vs 313 minutes, p<0.001), less median time to OR from ED (8.3 hours vs 12.4 hours, p<0.001), less median hospital LOS (6.3 days vs 8.1 days, p=0.02) and a less median hospital charges ($52,252 vs $59,543, p<0.001) as compared to the pre-ACS group. However, there was no difference in complications rate (35% vs 37%, p=0.12) and mortality rate (5% vs 6.6%, p=0.18) between the two cohorts.

Conclusion:
Acute care surgery model implementation at our institution lead to earlier time to evaluation by surgeon, less time to OR from ED, a shorter length of hospital stay, and reduction in hospital charges. Acute care surgery model results in better patient outcomes and improved utilization of hospital resources in patients undergoing operative intervention for acute diverticulitis.
 

49.19 Resident Implementation of an Enhanced Recovery Pathway for Colorectal Surgery in a Rural Community

Posted on January 18, 2018

D. S. Urias1, J. Di Como1, M. Marley1, T. Tersine1, W. Fritz1, R. Dumire1  1Conemaugh Memorial Medical Center,Johnstown, PA, USA

Introduction:  The evidence on the success of enhanced recovery pathways (ERP) at small and large medical facilities is robust. ERP addresses the surgical stress and postoperative physiology of patients undergoing surgery and has resulted in faster recovery, shorter hospital stay, decreased costs, and improved quality of life. The implementation of these types of protocols can be lengthy, complex, and costly. Therefore small private community hospitals with limited resources and limited experience with these methods find implementation a challenge. Through a quality improvement process, a resident run team established an ERP for elective colorectal surgeries with the goal of mirroring the outcomes reported in the literature. 

Methods:  We conducted an observational analysis of patients who underwent elective colon resection surgery from May 2016 through July 2017 and were placed on an ERP at our 453 bed private, rural, community hospital. This group was compared to patients that underwent this surgery prior to ERP implementation from January 2015 through April 2016. Implementing the ERP included shifting the paradigms of private practicing surgeons and anesthesiologists, anesthetists, nursing staff and pharmacists, thus convincing them to adopt the new pathway. Administrators, physicians, residents and nurses were educated on the ERP through a series of board committee meetings, group lectures, and countless direct encounters which led to its execution. Outcomes and complications that were compared included length of stay, readmission rate, time to ambulation, flatus, and first bowel movement, surgical site infections (SSI), and cost. 

Results: Sixty-nine pre-ERP patients (54% male) were compared with sixty ERP patients (57% male). The ratio of open to laparoscopic procedures was 61:8 pre versus 31:29 for the ERP group. The median length of stay was decreased from 5 to 3 days (P = .0005) with a readmission rate of 15.9% vs 8.3% (P = .190). The median time to ambulation decreased from 2 days to 1 (P = 0005). Patients reported flatus sooner, the median was reduced from 3 to 2 days (P = .0005). The median time to first bowel movement also decreased from 3 days to 1 (P = .0005). SSI rate was decreased from 8.7% in the pre ERP (6 SSI – 5 intra-abdominal (IAB) and 1 superficial (SIP)) to 3.3% (2 SSI – 1 IAB and 1 SIP) in the ERP group (P = .208). Based on preliminary cost data, the mean direct cost of stay per patient is expected to hold at a decrease of approximately $2,000. 

Conclusion: Despite the strong evidence of ERP, considerable time and effort was required to overcome organizational inertia and individual bias due to long-standing beliefs of the healthcare team. Adoption of ERP was achieved through persistent education of all team members; the excellent results confirm its acceptance and has stamped its placement in perioperative management of colorectal surgery patients. 

49.20 Successful Outcomes after Bariatric Surgery in Black Patients

Posted on January 18, 2018

M. S. Pichardo2,4, G. Ortega3, E. S. Bauer3, S. Timberline2, M. F. Nunes3, E. Smith2, D. Tran5, T. M. Fullum5  2Howard University College Of Medicine,Washington, DC, USA 3Howard University College Of Medicine,Clive O. Callender Howard-Harvard Health Sciences Outcomes Research Center,Washington, DC, USA 4Yale School Of Public Health,Department Of Chronic Disease Epidemiology,New Haven, CT, USA 5Howard University Hospital,Center For Wellness And Weight Loss Surgery, Department Of Surgery,Washington, DC, USA

Introduction:

Bariatric surgery remains the standard treatment for long-term weight loss and resolution of co-morbidities. Data on post-operative outcomes in Black patients are sparse. This study aims to evaluate the impact of bariatric surgery on weight loss and resolution of co-morbidities in a Black patient population.

Methods:

This is a retrospective review of 592 patients whom underwent weight loss surgery between August 2008 to June 2013. Outcomes of interest included mean weight loss, percent excess weight loss (%EWL), BMI point difference, and resolution of co-morbidities. Unadjusted analysis was performed to compare pre- and post-operative characteristics between laparoscopic roux-en-y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). Adjusted multivariable regression analysis estimated the association between outcomes of interest comparing the two surgical procedures.

Results:

Of 413 Black patients included in the final analysis, most were female (82%) and had a mean age of 43 (standard deviation (SD)=10.7). More than half of patients underwent LRYGB (67%). In unadjusted analysis, at baseline, patients undergoing LRYGB had a greater body weight (308.65 (SD=63.67) vs 289.78 (SD=69.53), p=.006) and BMI (50.05 (SD=9.32) vs 46.77 (SD=8.91), p<.001) and a greater proportion of diabetes (38.99% vs 25.00%, p=.005) and hypertension (77.26% vs 66.18, p=.016) compared to patients who underwent LSG. At 12 months, there were no statistical significant differences between LRYGB and LSG in weight loss (219.61 (SD=55.25) vs 228.59 (SD=63.85), p=.282), BMI points loss (-8.89 (SD=75.97) vs. -9.23 (SD=4.65), p=.473), nor resolution of diabetes (52.78% vs 35.29%, p=.075), hypertension (37.38% vs 27.78%, p=.108) or hypercholesterolemia (58.33% vs 43.75%, p=.159). Percent excess weight loss was significantly higher among LRYGB (mean=29.36, SD=6.66) when compared to LSG (mean=20.07, SD=9.65, p<.001). In multivariable regression analysis, no statistical significant differences were observed between LRYGB and LSG in BMI points loss (β=3.01, 95%CI=-15.79 – 21.82) nor resolution of diabetes (OR=2.11, 95%CI=.92 – 2.86), hypertension (OR=1.54, 95%CI=.88 – 2.70) or hypercholesterolemia (OR=1.97, 95%CI=.81- 4.79). Percent excess weight loss was found to be higher with LRYGB (β=9.76, 95%CI=7.55 – 11.98) compared to LSG.

Conclusion:

Black patients who underwent bariatric surgery experienced successful excess weight loss and resolution of co-morbidities at 12 months. Patients undergoing LRYGB demonstrated greater percent excess weight loss than their LSG counterparts. Both LRYGB and LSG had similar effects in achieving the resolution of co-morbidities.

49.17 Decline in Katz Scores Is Associated with Longer Postoperative Lengths of Stay in Older Adults

Posted on January 18, 2018

A. Lucy1, E. Malone1, J. Richman1, C. Balentine1, D. Chu1, K. Flood2, M. Morris1  1University Of Alabama at Birmingham,Gastrointestinal Sugery,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,Gerontology, Geriatrics, Palliative Care,Birmingham, Alabama, USA

Introduction:  Studies show preoperative functional status is associated with postoperative outcomes. Katz Activity of Daily Living Scores provide a simple, validated evaluation of functional capabilities of elderly patients. Currently, most surgical outcomes research uses National Surgical Quality Improvement Project (NSQIP) data which does not prospectively collect functional status.  Instead, it retrospectively estimates functional status as independent, partially, or fully dependent by chart abstraction. Little is known about the change of functional status during the postoperative period and its relationship to postoperative outcomes. We hypothesize Katz scores are associated with postoperative outcomes in older adults.

Methods: We queried NSQIP data for patients ≥65 years who underwent colectomy, proctectomy, hepatectomy, or pancreatectomy between 1/1/2014-1/8/2017 at a single institution. Katz scores were collected from electronic medical records. Inclusion criteria were patients who had surgery within 2 days of admission, postoperative length of stay (poLOS) ≥3 days, a baseline Katz score documented any time during hospitalization and ≥1 current Katz score documented within 3 days postop. We examined NSQIP-assessed outcomes and Katz scores and stratified patients into those with a decline in Katz score ≥3 or stable scores. Chi-square or Fisher's Exact Tests and t-tests were used to examine differences in categorical and continuous variables. A negative binomial model was used to examine the change in poLOS for Katz decline ≥3 with adjustment for covariates.

Results: Of 170 surgical patients, 87 (51%) had a decline in Katz scores ≥3 and 83 (49%) did not. The 2 groups did not differ significantly in age, race, gender, or comorbidities (all p>0.05). Patients with a decline in Katz score were more likely to have undergone open procedures (93%; p<0.01). The majority of patients with a decline in Katz score underwent pancreatectomy (55%), followed by colectomy or proctectomy (23%) and hepatectomy (22%). The majority of patients with no decline in Katz underwent colectomy or proctectomy (50%), followed by pancreatectomy (40%) and hepatectomy (10%; p<0.01). The Katz decline group was more likely to experience any NSQIP measured postoperative complication (38% vs 14%; p<0.01). Patients with a ≥3-point decline in Katz score had significantly longer poLOS (mean: 9.2 vs 6.2 days; p<0.01). NSQIP functional status was independent for 99% of patients in our cohort.  The predicted mean LOS is 9.3 days for Katz decline ≥3 compared to 6.7 days for no decline.

Conclusion: Decline in Katz scores is associated with increased poLOS in older surgical patients. Katz scores or other prospective measures of functional status or frailty should be collected and monitored in surgical patients to improve assessment of postoperative risk both preoperatively and during the postoperative hospital course.

49.18 Treating Inguinodynia after Laparoscopic or Open Inguinal Hernia Repair

Posted on January 18, 2018

M. Landry1, L. Grimsely1, M. Mancini1, B. Forman1, N. Shokur3, V. Vetrano2, B. Ramshaw1  1University Of Tennessee Medical Center,Division Of Surgery,Knoxville, TENNESSEE, USA 2University Of Tennessee Health Sciences Center,College Of Medicine,Memphis, TENNESSEE, USA 3East Tennessee State Univeristy,Quillen College Of Medicine,Johnson City, TENNESSEE, USA

Introduction:
Traditional methods of clinical research may not be adequate to improve the value of care for patients with complex medical problems such as chronic pain after inguinal hernia repair. This problem is very complex with many potential factors contributing to the development of this complication.

Methods:
We have implemented a clinical quality improvement (CQI) effort in an attempt to better measure and improve outcomes for patients suffering with chronic groin pain (inguinodynia) after inguinal hernia repair.  Between April 2011–January 2017, 104 patients underwent 105 operations in an attempt to relieve pain. Patients who had prior laparoscopic inguinal hernia repair (28) had their procedure completed laparoscopically only (mesh removal and neurolysis).  Patients who had open inguinal hernia repair (77) had a combination of a laparoscopic and open procedure (mesh removal, neurectomy and primary reconstruction of the groin) in an attempt to relieve pain.  This evaluation of outcomes was intended to investigate whether there are differences in outcomes depending on if the initial hernia repair was done open or laparoscopic.  

Results:
Of the laparoscopic only procedure, nine patients (32.14%) reported significant improvement, thirteen patients (46.42%) reported moderate improvement and six patients (21.42%) reported little or no improvement.  Of the laparoscopic-open procedure group, forty-two patients (54.54%) reported significant improvement, twenty-six patients (33.76%) reported moderate improvement and nine patients (11.68%) reported little or no improvement. There was a 17.85% hernia recurrence rate for the laparoscopic only group (5/28) and a 10.38% hernia recurrence rate for the combined laparoscopic-open group (8/77). 

Conclusion:
These results suggest the laparoscopic only patients did not have as much improvement as the patients who had prior open inguinal hernia repair.  Based on these results, additional process improvement ideas will be implemented in an attempt to improve outcomes, especially for the group of patients who have prior laparoscopic inguinal hernia repair.
 

49.15 A Practical Approach to Locating the Corona Mortis

Posted on January 18, 2018

B. Hoerdeman1, T. P. Sprenkle1, M. D. Gothard2, M. L. McCarroll1, D. Rhodes1  1Pacific Northwest University Of Health Sciences,College Of Medicine,Yakima, WA, USA 2Biostats, Inc.,East Canton, OH, USA

Introduction: The corona mortis (CM) or “crown of death” is a clinically important common pelvic vascular variant. Its name is derived from its association with unexpected hemorrhage and possible exsanguination during surgical operations and trauma in the anterior pelvic and inguinal region. The CM is defined as any vascular anastomosis (arterial or venous) between the obturator and external iliac arterial systems. The incidence and location of the CM in relation to the pubic symphysis is well documented. However, the location of the CM in relation to the anterior superior iliac spine (ASIS) and pubic tubercle (PT), both palpable anatomic landmarks, have not been described previously. Our objective, was to analyze the arterial CM using measurements from these two anatomic reference points as a guide for determining the location of a possible CM. This could be useful in many clinical settings, giving physicians a quick and practical method to roughly estimate where this potential vessel could lie.

 

Methods:  Seventy hemi-pelvises from embalmed cadavers were dissected. Any arterial anastomosis between the obturator and external iliac systems greater than 2 mm was identified and distances to the ASIS and PT were measured several times by two researchers, using both an electronic caliper and a ruler. Statistical analyses of measurements were conducted including: mean (with 95% confidence interval (CI)), median, Min – Max, a Shapiro-Wilks Test of Normality, a two-tailed t-tests. Data were analyzed both collectively and stratified by gender.

 

Results: Of the 35 cadavers (70 hemi-pelvises) dissected, 24 arterial corona mortis’ >2 mm were identified (34.3%), 17 in males and 7 in females. The mean distance from the PT to the CM for all specimens was 51.5 ± 8.1 mm (95% CI 48.0 – 54.9 mm), the median distance was 50.5 mm, and the range was 39.8 to 68.3 mm. The mean male PT to CM distance was significantly different from this measurement in females (p=0.028) indicating a gender difference in this distance. The ASIS to CM distance, as a proportion of the ASIS to ASIS distance had a mean percentage ratio of 43.5% ± 4.0% (95% CI 41.8% – 45.3%), a median of 43.2%, and a range of 39.9% to 51.1%, with no significant gender differences detected (p>0.05).

 

Conclusion: The ASIS and PT both can be used as anatomic landmarks to help determine the location of an arterial CM, if present. The clinical need to map the corona mortis is evident both by its high incidence in the general population (19% for arterial CM) and by the scarcity of the topic in the current literature. Our study gives clinicians measurements based off of two palpable anatomic landmarks (ASIS and PT) upon which to roughly estimate the location of a potential CM, assisting in the mapping of this important and complex anatomical area. We believe that our study lays the foundation upon which future studies can further fill this gap in the medical literature.

 

49.16 Postoperative Infection: Trends in Distribution, Risk Factors, and Clinical and Economic Burden

Posted on January 18, 2018

M. E. Garstka1, Z. Al-Qurayshi1, S. M. Baker1, C. Ducoin1, M. Killackey1, E. Kandil1  1Tulane University School Of Medicine,Department Of Surgery,New Orleans, LA, USA

Introduction:
Postoperative infection (POI) represents a serious complication in all surgical disciplines and can undermine a patient’s treatment and recovery course. In this analysis, we aim to examine recent national trends in distribution, risk factors, and clinical burden of disease due to POI.

Methods:
We performed a cross-sectional study utilizing the Nationwide Inpatient Sample, 2003-2010. The study population consisted of adult (≥18 years) inpatients with POI. Controls were randomly selected from patients who underwent the same procedures.  As the NIS represents 20% of US hospital admissions and includes costs, excess cost and excess stay was calculated based on the average difference between cases and controls and multiplied by five to estimate national burden.  Cost was adjusted for inflation rate to reflect 2015 dollar value.

Results:
139,652 cases of POI and 941,670 controls were included. POIs were most common in procedures that involved the digestive tract (46.5%), cardiovascular system (16.3%), and musculoskeletal system (11.2%). In the sample, there was no significant change in the POI annual incidence (average: 17,456.5 case/year) (p=0.10). Older age, male, overweight, elective admission, and teaching or urban or large size hospitals all were independent risk factors of POI in the multivariate model (p<0.05). There was no significant risk difference based on trauma status (p=0.88). POI was associated with a higher mortality risk [OR: 2.93, 95%CI: (2.82, 3.04), p<0.001]. Nationally, it is estimated that POI resulted in an annual average of 1.04 million days of excess hospital stay and $2.72 billion excess cost.

Conclusion:
Demographic and clinical factors influence the risk of POI.  These factors may suggest areas for clinical quality improvement initiatives, given such independent risk factors as elective admission and teaching, urban, or large size hospitals. POI poses substantial clinical and financial burden in the United States, and further analysis of the associated costs is also needed to identify areas for intervention to reduce this burden. 
 

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