73.05 Predicting the Need for Operative Management of Small Bowel Obstruction with Machine Learning

Posted on January 31, 2019

J. D. Bozzay1,19, P. F. Walker1,19, V. Khatri1,17,19, M. Zielinski2, S. Wydo3, D. Cullinane4, J. Dunn5, T. Duane6, D. Turay7, K. Inaba8, R. Lesperance9, M. Rosenthal10, J. Watras11, A. Pakula12, K. A. Widom13, J. Cull14, E. Toschlog15, T. Z. Hayward16, S. Schobel-Mchugh1,17,19, E. A. Elster1,17,19, C. J. Rodriguez1,19, M. J. Bradley1,17,18,19  1Walter Reed National Military Medical Center,Department Of Surgery,Bethesda, MD, USA 2Mayo Clinic,Department Of Surgery,Rochester, MN, USA 3Cooper University Hospital,Department Of Surgery,Camden, NJ, USA 4Marshfield Clinic,Department Of Surgery,Marshfield, WI, USA 5UC Health Northern Colorado,Department Of Surgery,Loveland, CO, USA 6John Peter Smith,Department Of Surgery,Forth Worth, TX, USA 7Loma Linda University Health,Department Of Surgery,Loma LInda, CA, USA 8Keck School of Medicine of USC,Department Of Surgery,Los Angeles, CA, USA 9San Antonio Military Medical Center,Department Of Surgery,Fort Sam Houston, TX, USA 10Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA 11Inova Fairfax Hospital,Department Of Surgery,Falls Church, VA, USA 12Kern Medical Center,Department Of Surgery,Bakersfield, CA, USA 13Geisinger Medical Center,Department Of Surgery,Danville, PA, USA 14Greenville Memorial Hospital,Department Of Surgery,Greenville, SC, USA 15East Carolina University,Department Of Surgery,Greenville, NC, USA 16Indiana University School Of Medicine,Department Of Surgery,Indianapolis, IN, USA 17Surgical Critical Care Initiative,Bethesda, MD, USA 18Naval Medical Research Center,Department Of Regenerative Medicine,Bethesda, MD, USA 19Uniformed Services University Of The Health Sciences,Bethesda, MD, USA

Introduction: Identifying candidates who will require therapeutic surgery (TS) for non-emergent small bowel obstruction (SBO) remains challenging.  Machine learning models can elicit complex dependencies and may perform better than traditional regression models. The objective of this study was to compare both strategies to best identify patients who would require TS for the management of SBO.

Methods: A prospectively maintained multi-institutional database from the Eastern Association for the Surgery of Trauma was reviewed. Presence of peritonitis, closed loop obstruction on imaging, virgin abdomen, or patients with data paucity were excluded, leaving 566 patients for analysis. Random Forest (RF) and logistic regression (LR) models were generated separately for both gastrografin challenge (GC) and non-GC patients.

Results: 156 (27.6%) patients underwent TS. The non-GC RF model produced an area under the curve (AUC) of 0.68, sensitivity of 0.64, and specificity of 0.70. The non-GC LR model produced an AUC of 0.62, sensitivity of 0.59, and specificity of 0.65. The GC RF model produced an AUC of 0.89, sensitivity of 0.86, and specificity of 0.89. The GC LR model produced an AUC of 0.89, sensitivity of 0.87, and specificity of 0.87. Predictive variables for therapeutic surgical intervention for the GC RF and LR models included GC test result,  systolic blood pressure, presence of intraperitoneal fluid, presence of CT transition point, and previous occurrence of at least of 1 of the following: Crohn’s disease, enterocutaneous fistula, gastric bypass, metastatic cancer, small bowel obstruction, or ventral hernia. In the GC RF and LR models, removal of the GC test result as a predictor, substantially lessened performance metrics for both the RF (AUC of 0.59, sensitivity of 0.57, specificity of 0.64) and LR models (AUC of 0.61, sensitivity of 0.62, specificity of 0.65). The GC test result alone had a sensitivity of 0.7 and specificity of 0.93.

Conclusion: An accurate model for predicting the need for SBO TS was developed using a combination of clinical and radiographic data. Furthermore, incorporation of the GC significantly improves model performance and is an important clinical test during the workup of non-emergent SBO. The improved performance for GC patients is critically dependent on the inclusion of GC result as a predictor. This type of predictive modeling may be a useful adjunct to support future clinical decision-making. Evaluation with an external validation dataset is required to assess the generalizability of model performance.

73.04 Treatment Goal Concordance Among Patients and Health Surrogates in the Perioperative Setting

Posted on January 31, 2019

B. V. Udelsman1, N. Govea3, Z. Cooper4, A. Bader5, M. Meyer2  1Massachusetts General Hospital,Surgery,Boston, MA, USA 2Massachusetts General Hospital,Anesthesiology,Boston, MA, USA 3Harvard Medical School,Boston, MA, USA 4Brigham And Women’s Hospital,Surgery,Boston, MA, USA 5Brigham And Women’s Hospital,Anesthesiology,Boston, MA, USA

Introduction:

            Under sedation patients temporarily surrender decisional capacity. Thus, the health decision surrogate can have an especially important role in the perioperative period.   Prior studies of general medical and intensive care unit patients have demonstrated poor concordance between patients and their surrogates in regards to treatment priorities.  The aim of this study was to determine the degree of concordance in the perioperative setting and to identify areas for improvement.

 

Methods:   

Prospective cohort study set in the preoperative clinic.  Patients (>55 years) and their surrogates (dyads) who presented to the preoperative clinic were eligible for participation.  Patients who presented without a surrogate were excluded. Dyads were asked multiple choice questions about the patient’s care preferences using domains typically included in advance directives: resuscitation, intubation, hemodialysis, artificial nutrition, physical disability, cognitive disability, and chronic pain.  Concordance was defined as the surrogate correctly predicting patient treatment preferences. Dyads were also surveyed on socio-demographics and quality of life.  

            

Results:

            36 pairs completed the survey.  The median patient age was 68 (IQR 60, 77).  Most patients were white (91%), had graduated high-school (94%), and had an ASA score of 3 or greater (86%).  Surrogates were either a spouse (81%), an adult son/daughter (14%), or a sibling of the patient (5%).  The majority of patients (78%) and surrogates (83%) reported having prior conversations regarding the patients’ goals of care.  Most patients (86%) reported being “very confident” in their surrogates understanding of their health care preferences, while most surrogates (86%) reported similar confidence in their knowledge of the patient’s preferences.  Concordance regarding major treatment domains ranged from 86% for resuscitation to 39% for artificial nutrition.  Prior conversations regarding treatment preferences did not significantly effect concordance between patients and surrogates in any domain (Table 1).

 

Conclusions:

            Concordance between patients and surrogates regarding major treatment preferences is highly variable the perioperative setting.  This discordance may limit patient autonomy and result in non-beneficial treatment that is not concordant with patient goals. Conversations regarding treatment preferences did not significantly improve concordance, signifying the need for targeted conversations potentially facilitated by a health care professional.

73.03 Differential Responses of Operating Room Personnel to Behaviors of Male and Female Surgeons

Posted on January 31, 2019

E. M. Corsini1, J. G. Luc2, K. G. Mitchell1, N. S. Turner1, A. A. Vaporciyan1, M. B. Antonoff1  1University Of Texas MD Anderson Cancer Center,Thoracic And Cardiovascular Surgery,Houston, TX, USA 2University of British Columbia,Cardiovascular Surgery,Vancouver, BRITISH COLUMBIA, Canada

Introduction:
To date, several qualitative studies have been conducted assessing the relationships between physicians and registered nurses (RN), with special attention paid to the dynamics between females working together. However, while surgeon demographics have shifted in recent decades to include more women, the female-to-female relationship in the operating room (OR) remains largely unstudied. Furthermore, stereotypical surgeon-specific behavior may stand at odds with societal expectations for appropriate behavior of women. Therefore, we sought to examine biases related to surgeon sex within the environment of the operating room, paying special attention to views of female allied health professionals.

Methods:
We performed a prospective, randomized study in which OR support staff, including RN, surgical technologists (ST), and surgical assistants (SA), were asked to assess questionable surgeon behaviors across a standardized set of five scenarios via online survey. Respondents were randomized to surveys that either described a female or male surgeon, with all other aspects of the survey identical. For each scenario, respondents were asked to identify the behavior as Acceptable; Unacceptable but would ignore; Unacceptable and would confront surgeon directly; or Unacceptable and would report to OR management. Analyses included comparisons of respondents’ assessments of surgeon behaviors with the sexes of both the surgeon and respondents; χ2 was used to identify associations among these variables.

Results:

There were 3,186 responses (response rate=4.5%). 81% of respondents were female, 54% were RN, 55% reported working in the OR for greater than 15 years, 41% were Baby Boomers, and 94% worked in the United States. When evaluating across all scenarios and both surgeon sexes, female respondents were more likely to find the surgeon’s behaviors inappropriate than male respondents (p=0.001), (Figure). Sex of the surgeon did not appear to play a role in the assessment of appropriateness of the surgeon’s behaviors when evaluated across all respondents (p=0.322), male respondents (p=0.980), or female respondents (p=0.265). Similarly, sex of the respondent did not impact the likelihood to report the surgeon, regardless of surgeon sex (p=0.499).

Conclusion:
Our results suggest that ancillary OR staff of either sex do not have an inherent bias towards male or female surgeons when assessing behaviors via survey. However, female OR support staff appear to be more critical in their evaluation of surgeons across both sexes. Future investigations should aim to capture more subtle differences in responses and behaviors in the OR, such as body language, tone of voice, and type of language used.

73.02 Disparities in Outcomes of Emergency General Surgery for Children Stratified by Socioeconomic Status

Posted on January 31, 2019

G. J. Lee1, C. Ezeibe2, C. Zogg2, A. H. Haider2, G. Ortega2  1Harvard School Of Public Health,Health Policy,Boston, MA, USA 2Center for Surgery and Public Health,Department Of Surgery,Boston, MA, USA

Introduction:  Socioeconomic status plays a direct factor in accessibility to consistent health services and various studies have examined its outcomes on surgical care in adults. Our study aims to evaluate the impact of socioeconomic status on mortality among children in a national database.

Methods: We utilized the Kids' Inpatient Database for the year 2012 and selected children who underwent a surgical procedure and were admitted with a primary emergency general surgery (EGS) diagnosis. Patients without insurance or median household income (MHI) data were excluded. Patients were stratified by insurance status (Private, Medicaid, Uninsured) and MHI quartile. Multivariable logistic regression was performed with moratility as the outcome for each insurance and MHI group while adjusting for patient and hospital charactersitics.  

Results:

137,013 met our inclusion criteria, with mean age 11.1 years (SD=6.7), 74,868 (54.6%) males and 62,145 (45.4%) females. The most common races were White (50.7%) followed by Hispanic (27.4%) and followed by Blacks (12.7%). With respect to insurance rates, patients were privately insured (48.7%), had Medicaid (46.0%), or were uninsured (5.4%). Median household income ranges were from lowest at $1 to $38,999 (29.6%), low-medium at $39,000 to $47,999 (24.1%), medium-high at $48,000 to $62,999 (23.9%), and highest at $63,000 and more (22.4%). Mortality rates during hospitalization according to insurance status demonstrated the lowest for private insurance (0.75%), followed by uninsured (0.88%), with the highest rate in those with Medicaid (1.30%). Mortality rates during hospitalization according to insurance status demonstrated increasing mortality rates indirectly proportional to income status. Those with the lowest income quartile had a mortality rate of 1.2%, followed by low-medium (1.2%), followed by medium-high (0.9%), and highest (0.7%). On adjusted analysis, the odds ratio for privately insured patients was 1.29 (p = 0.00, 95% CI 1.15 to 1.45), compared to Medicaid patients was 1.93 (p = 0.00, 95% CI 1.48 to 2.51). Separately, on adjusted analysis, the odds ratio for low-medium household income was 0.94 (p = 0.401, 95% CI 0.82 to 1.08), for medium-high household income was 0.76 (p = 0.00, 95% CI 0.65 to 0.87), and highest household income was 0.65 (p = 0.00, 95% CI 0.55 to 0.76).

Conclusion:

Insurance status and MHI have an impact on children undergoing EGS. More studies are necessary to elucidate these disparities. 

73.01 Early Transition to Comfort Measures After Emergency General Surgery: An Opportunity for Improvement

Posted on January 31, 2019

A. Briggs1,2, V. Anto1, R. Handzel1, A. Peitzman1, R. Forsythe1  1University of Pittsburgh Medical Center,Pittsburgh, PA, USA 2Dartmouth Hitchcock Medical Center,Lebanon, NH, USA

Introduction:

Critically ill patients undergoing emergency general surgery procedures have significant risk of mortality. Perioperative patient and family conversations in this population can be difficult, as they can require not only discussion of the clinical situation, but also quality of life prior to the acute illness, assessment of patient goals for future quality of life and end of life care. The aim of this study was to analyze goals of care discussions in EGS patients in the intensive care unit (ICU).

 

Methods:
Emergency general surgery patients originating in or admitted to the medical and surgical intensive care units from 2010 to 2016 who underwent abdominal surgery were identified from a prospective, electronic record based registry. Postoperative deaths during admission were identified. Charts were reviewed to determine code status at the time of admission, changes in during the hospital stay, and at the time of death. Involvement of palliative care or ethics services was recorded. 

 

Results:

During this time period, 799 patients underwent abdominal procedures. The unadjusted mortality rate was 24.2% (193/799). Of those patients who died, 97.4% (188/193) were full code at the time of admission, although in 33.7% of cases (65/193) there was no documentation of a detailed discussion of code status prior to the index procedure. At the time of death, 79.3% (153/193) had been transitioned to ‘comfort measures only’ (CMO). Palliative care or ethics services were involved in 14.5% of cases. During admission, 25.4% of patients had multiple changes in code status, with the majority transitioning from full code to ‘do not resuscitate’ (DNR) and then ultimately to CMO prior to death. In 6 patients, code status was decided at the time of arrest. Within the first 48 hours, 26.9% of deaths occurred, with 73.1% of these as patients transitioned to CMO, 11.5% as DNR and 15.4% with full code. In this early mortality population, 36.5% of patients did not have a documented preoperative discussion of code status.

 

Conclusions:

The majority of ICU patients who died after EGS procedures had been transitioned to CMO status prior to death. In patients who died within 48 hours, one-third had no documented preoperative discussion of code status. An understanding of patient goals of care is vital in the perioperative management of critically ill EGS patients. Further study is required to determine whether an increase in the preoperative discussion of code status would yield different decisions regarding pursuit of emergency procedures in this high-risk population.  

72.10 Trends of Anticoagulant Use Among Surgical Patients in the Era of Direct Oral Anticoagulants

Posted on January 31, 2019

N. Thalji1, D. Kor2, M. Warner2, M. Zielinski1  2Mayo Clinic,Department Of Anesthesiology And Perioperative Medicine,Rochester, MN, USA 1Mayo Clinic,Department Of Surgery,Rochester, MN, USA

Introduction:  Patterns of anticoagulant use in surgical patients are poorly characterized. Contrasting warfarin, direct oral anticoagulants (DOACs) offer rapid onset and obviate monitoring needs, but cannot be rapidly reversed. We aimed to define the prevalence, indications and temporal trends of anticoagulant use in surgical patients, with a focus on DOACs.

Methods:  We studied adult non-cardiac surgical cases at our institution from 2007-2017. Cases on preoperative anticoagulation including DOACs (i.e. apixaban, dabigatran, edoxaban, rivaroxaban) were identified. Anticoagulated vs non-anticoagulated patients were compared using t-test/chi-square. We analyzed temporal trends in anticoagulation use by the Cochran Armitage trend test (significance p<0.05).

Results: A total of 361,360 cases were studied. Median (IQR) age was 59yrs (47–70) and 48% (172,355) were male. Overall, 8% (29,220) of cases received anticoagulation, representing 21,303 unique patients. Compared to 224,928 non-anticoagulated patients (332,140 cases), anticoagulated subjects were older (69 vs 59yrs), more frequently male (56% vs 47%), and had more comorbidities (Median [IQR] Charlson Index 5 [4–7] vs 3 [1–5]) (all p<0.001). Of anticoagulated subjects, AFib was present in 38%, DVT in 30%, PE in 10%, and prosthetic heart valves in 9%. From 2007-2017, the proportion of anticoagulated cases increased 32% (2007=6.7%, 2017=8.9%; p<0.001) (Fig1A). Of anticoagulated cases, 10% (2,865) were on DOACs, with most on apixaban (48%) or rivaroxaban (42%). In 2017, 31% of anticoagulated cases were on DOACs (Fig1B).

Conclusion: Operative cases for patients on home anticoagulation represent a significantly comorbid and increasing proportion of surgical volume. Widespread adoption of novel anticoagulants has culminated in DOAC use in 1/3 of contemporarily anticoagulated cases. Studies delineating perioperative risks for patients on DOAC therapy are increasingly relevant.

 

72.09 Surgeon Specific Outcomes Do Not Reliably Assess Quality

Posted on January 31, 2019

B. T. Fry1,2, S. P. Shubeck2,3, J. R. Thumma2, J. B. Dimick2,3  1University Of Michigan,Medical School,Ann Arbor, MI, USA 2University of Michigan,Center For Healthcare Outcomes & Policy,Ann Arbor, MI, USA 3Michigan Medicine,Department Of Surgery,Ann Arbor, MI, USA

Introduction: Individual surgeon performance data has become increasingly available to patients and providers alike. Additionally, there is a push at many institutions for internal reporting of surgeon outcomes to promote quality improvement. However, major concerns exist over the reliability of using surgeon specific data to detect differences in performance. No study has comprehensively evaluated the effect of low surgeon volume on multiple surgical outcomes across a wide variety of procedures.

Methods:  Using 2014 data from the State Inpatient Database, we calculated population level average mortality and complication rates across five surgical procedures: coronary artery bypass grafting, colectomy, pancreatectomy, total hip replacement, and bariatric procedures. We then calculated the minimum surgeon volume necessary to detect a doubling of each outcome rate at an alpha level of 0.05 and power level of 80%. Finally, we used annual individual surgeon caseloads to determine the proportion of surgeons who met or exceeded these minimum volumes. We then performed a sensitivity analysis to examine the proportion of surgeons who met the minimum volume threshold when aggregating caseloads over 3 years. 

Results: Surgeon specific data was available for 13,708 surgeons who performed a total of 236,413 cases in 8 states. Average mortality rates ranged from 0.05% for bariatric procedures to 4.1% for colectomy. Average complication rates ranged from 2.2% for bariatric procedures to 31.3% for pancreatectomy. Virtually 0% (1 of 13,708) of all surgeons performed an adequate number of cases annually to detect a doubling of the average mortality rate, while 9% (1,280) of surgeons performed enough annual cases to detect a doubling of the average complication rate. When examining estimated 3-year aggregate caseloads, 0.3% (48) of surgeons would perform enough cases to detect a doubling in mortality, while 25% (3,414) of surgeons would perform enough cases to detect a doubling in complication rates.

Conclusion: The majority of surgeons do not perform an adequate number of procedures to detect differences in individual mortality and complication rates. These results suggest that surgeon level outcome data cannot reliably assess performance and quality.

 

72.08 Resource Utilization and Predictors of Readmission in Medically-Managed Diverticulitis

Posted on January 31, 2019

A. L. Mardock1, Y. Sanaiha1, S. E. Rudasill1, H. Khoury1, H. Xing1, P. Benharash1  1David Geffen School Of Medicine, University Of California At Los Angeles,Cardiothoracic Surgery,Los Angeles, CA, USA

Introduction: Acute diverticulitis is increasingly treated with medical management, reserving resection for complicated or recurrent cases. However, previous reports have shown that nearly one third of medically managed patients with diverticulitis recur within a year of discharge from initial presentation. The present study utilized a national database to assess the incidence and resource utilization of ninety-day readmission following medical management of diverticulitis in the United States.

Methods: This retrospective review of the 2010-2015 National Readmissions Database included all adults admitted for acute colonic diverticulitis and discharged without surgical intervention. Chi-squared univariate analysis was performed to identify differences in demographics and comorbidities between patients with and without 90-day readmission. Causes of readmission were identified using diagnosis related group codes.  Multivariable regression analysis was performed to assess independent predictors of readmission.

Results: Of the estimated 746,053 patients, 3,906 (0.5%) expired at index hospitalization, while 176,390 (23.6%) were readmitted within ninety days of discharge. Among those readmitted, 53.8% had a primary diagnosis at readmission related to small or large bowel procedure, digestive disorder, or gastrointestinal hemorrhage, all commonly associated with recurrent diverticulitis. Readmitted patients were older (62.8 vs. 60.5 years, p<0.01) and more likely to be female (59.4 vs. 58.5%, p<0.01) and insured by Medicare (49.6 vs. 42.4%. p<0.01). Readmitted patients also had higher adjusted costs ($8,488 vs. 6,667, p<0.01) and longer lengths of stay (4.9 vs. 3.7 days, p<0.01) at their index hospitalization. During the first readmission, 2,938 (1.7%) patients expired, and the mean length of stay was 5.9 days (95% CI 5.85-5.97), leading to a mean cost of $13,341 (95% CI $13,150-13,531). Independent predictors of 90-day readmission included intestinal or colovesical fistula, abscess, and concurrent malignancy, among others (see Table).

Conclusion: Readmissions following medical management of colonic diverticulitis represent a significant cause of resource utilization and are associated with increased mortality. Many such readmissions are related to recurrent gastrointestinal complications and procedures. It merits discussion as to whether surgical treatment at index hospitalization could conserve resources by preventing unnecessary readmission. A stronger understanding of factors that predispose these patients to readmission could guide decisions regarding medical versus surgical treatment of acute diverticulitis.

72.07 Surgical Therapy for Small Bowel Obstruction Decreases Readmissions and Increases Cost?

Posted on January 31, 2019

M. B. Richardson1, R. J. Reif1, S. Haruna1, H. Jensen1, S. Karim1, W. C. Beck1, J. R. Taylor1, K. W. Sexton1  1University of Arkansas for Medical Sciences,Little Rock, AR, USA

Introduction:  Small bowel obstruction (SBO) is common in patients hospitalized for acute abdominal pain. However, data on long-term follow-up of patients is lacking and no superior management strategy has been identified. We hypothesized that surgical management would decrease readmissions compared to medical management in the treatment of SBO.?

Methods:  This was a retrospective study of the 2010 – 2014 National Readmissions Database. Patients diagnosed with SBO were categorized into two groups: patients that were operatively treated (surgical), and patients managed conservatively (medical). We compared the in-hospital outcomes and readmission rates between the two groups (α=0.05). ?

Results: Within the study period, 778,599 patients diagnosed with SBO were identified. A total of 68,400 (8.8%) patients were treated surgically, compared to 710,199 (91.2%) patients in the medical group. Overall mortality (7.7% vs 4.4%, p<0.01) and length of stay (15.7 vs 7.3 days, p<0.01) were higher in surgically treated patients. However, while 83,007 (11.7%) of the patients treated medically were readmitted, only 4,795 (7.0%) of the patients treated surgically necessitated readmission to the hospital. Cost of care was higher for surgically treated patients both during initial hospital stay ($155,293 vs $67,918, p<0.01) and at readmission ($269,105 vs $123,334, p<0.01).?

Conclusion: Surgical treatment of SBO was associated with higher in-hospital mortality and longer length of stay. Patients who were treated medically for SBO had significantly higher readmission rates. Despite a higher rate of readmission, conservative treatment was associated with lower cost of care both at initial hospital admission and readmission. Non-operative management of SBO is a viable and cost-effective treatment strategy.?

 

 

 

 

 

72.06 The Longer It Takes The Longer They Stay: Outcomes Following Laparoscopic Ventral Hernia Repair

Posted on January 31, 2019

A. Y. Lee1, G. Sugiyama1, M. G. Sfakianos1, J. M. Nicastro1, G. F. Coppa1, P. Chung2,3  1Zucker School of Medicine, Hofstra Northwell,Department Of Surgery,Manhasset, NY, USA 2State University of New York Downstate Medical Center,Department Of Surgery,Brooklyn, NY, USA 3Coney Island Hospital,Department Of Surgery,Brooklyn, NY, USA

Introduction:
Laparoscopic ventral hernia repair is widely employed and associated with decreased postoperative pain and reduced length of stay (LOS). We sought to investigate factors that might influence LOS following laparoscopic ventral hernia repair, such as operative time.

Methods:
We used the 2010-2015 ACS NSQIP Participant Use Files (PUF) and identified cases with laparoscopic repair (CPT code 49652) for ventral hernia without mention of obstruction or gangrene (ICD9 codes 553.2, 553.20, 553.21, 553.29). We included only adult (≥18 years) patients that underwent elective surgery, admitted from home, performed by a General Surgeon. We excluded cases with small bowel resection (CPT code 44120), disseminated cancer, wound class III or IV, and missing data. Operative times <5 minutes and LOS >30 days were also excluded. Operative time was divided into quartiles (1st: <61 minutes; 2nd: 61-90 minutes; 3rd: 90-135 minutes; 4th: ≥135 minutes). Age was also divided into quartiles (1st: <47 years; 2nd: 47-58 years; 3rd: 58-67 years; 4th: >67 years). Risk variables included age, sex, race, morbid obesity status, history of diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), dyspnea, bleeding disorder, ascites, hypertension, renal failure, dialysis dependent, functional status, smoking status, steroid use, weight loss, preoperative transfusion within 72 hours of surgery, ASA class, and operative time. Primary outcome was LOS. Multivariable analysis was performed using negative binomial regression adjusting for all risk variables.

Results:
We found 1,791 patients with mean age 56.2 years. Majority were women (n=1,082, 60.4%), and White (n=1,534, 85.7%). Median LOS was 1.0 (SD 2.35) days. Negative binomial regression showed that ASA class IV vs I (IRR 2.90, p<0.0001), ASA class III vs I (IRR 2.92, p<0.0001), class II vs I (IRR 1.98, p=0.00013), partially dependent vs independent functional status (IRR 2.15, p=0.024), history of COPD (IRR 1.60, p=0.00047), insulin dependent diabetes (IRR 1.43, p=0.0037), and 4th vs 1st quartile of age (IRR 1.39, p=0.0011) were associated with increased LOS. Additionally, Black vs White race (IRR 1.32, p=0.0015), 4th vs 1st quartile (IRR 4.35, p<0.0001), 3rd vs 1st quartile (IRR 2.79, p<0.0001), 2nd vs 1st quartile (IRR 1.91, p<0.0001) operative times were highly associated with increased LOS. Dialysis dependent (IRR 0.59, p=0.040), male vs female sex (IRR 0.84, p=0.0035), and morbid obesity (IRR 0.87, p=0.036) were associated with decreased LOS.

Conclusion:
In this large observational study using a national clinical database, operative time in patients undergoing elective laparoscopic ventral hernia repair is independently associated with increased LOS in patients. Additionally, Black vs White race was also found to be independently associated with increased LOS. Prospective studies are warranted to determine ways to decrease disparities in care.
 

72.05 Minimizing Opioid Prescribing in Surgery (MOPiS) Initiative: An Analysis of Implementation Barriers

Posted on January 31, 2019

J. M. Coughlin1,2, M. Shallcross1, W. Schäfer1, R. Khorfan1, J. Stulberg1,3,4, K. Y. Bilimoria1,3,4, J. K. Johnson1,3  1Feinberg School Of Medicine – Northwestern University,Surgical Outcomes And Quality Improvement Center, Department Of Surgery And Center For Healthcare Studies,Chicago, IL, USA 2Rush University Medical Center,Department Of Surgery,Chicago, IL, USA 3Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA 4Northwestern Memorial Hospital,Chicago, IL, USA

Introduction: The United States is amidst an opioid epidemic. To reduce our reliance on opioids for pain management, our institution developed the Minimizing Opioid Prescribing in Surgery (MOPiS) initiative at five different hospitals. MOPiS is a multi-component intervention including (1) preoperative expectation setting on appropriate pain management (2) screening patients for addictive behavior and substance abuse risk, (3) optimizing perioperative non-opioid pain management, and (4) minimizing opioid prescribing at discharge. We conducted a pre-intervention formative evaluation to identify barriers to implementation, as well as solutions to address them.

Methods: Prior to implementation of the MOPiS initiative, we conducted semi-structured interviews at each hospital (n=5) with 23 key stakeholders (surgeons, nurses, pharmacists and administrators). The four components of the intervention were explained and interviewees were asked about perceived barriers and solutions for implementation. Interviews were audio recorded and transcribed. Responses were analyzed to identify common themes using the Theoretical Domains Framework (TDF), an integrative framework that applies theoretical approaches to interventions aimed at behavior change.

Results: Common themes of potential implementation barriers were identified and classified under five TDF domains: knowledge, social/professional role and identity, environmental context and resources, belief about consequences, and behavioral regulation (Table 1). Clinician knowledge of appropriate opioid stewardship is often lacking, and patients do not consistently receive comprehensive pain management education (knowledge). Providers of all levels cited time as the greatest barrier (environmental and context resources) to providing patient education. Pharmacists are not routinely incorporated into the treatment team, although they consistently express an interest in educating and advising (social/professional role and identity). Patients have varying expectations of post-operative pain management and physicians fear patient dissatisfaction if these expectations are not met (belief about consequences). Physicians who over-prescribe are not being held accountable for their prescribing practices (behavioral regulation).

Conclusions: Implementation barriers have the potential to derail any improvement initiative, and successful implementation of an opioid reduction initiative will require specific strategies to overcome barriers. In our MOPiS initiative, utilizing a pre-intervention formative evaluation process enabled the design of strategies to facilitate implementation of the components of the initiative.

72.04 A Nationwide View on Recent Trends in Partial Cholecystectomy

Posted on January 31, 2019

A. F. Sabour2, K. Matsushima1, E. Alicuben1, M. Schellenberg1, K. Inaba1, D. Demetriades1  1LAC+USC Medical Center,Acute Trauma Surgery,Los Angeles, CALIFORNIA, USA 2Keck School of Medicine of USC,Medicine,Los Angeles, CALIFORNIA, USA

Introduction:
Partial cholecystectomy provides a viable alternative to the proverbial “difficult” gallbladder. To date, few studies have observed the establishment of partial cholecystectomy as an increasingly common surgical practice. The purpose of this study was to assess nationwide trends of partial cholecystectomy through evaluation of operative variables, patient- and institution-level characteristics, and yearly rates in procedure preference.

Methods:
Data was obtained from the Nationwide Inpatient Sample (NIS) between 2003 to 2014. Patients with an ICD-9-CM diagnostic code for acute cholecystitis were categorized based on procedures for either open total, laparoscopic total, open partial, or laparoscopic partial cholecystectomy. Any patients younger than 18 years of age or with a preoperative stay longer than 1 week were excluded. Logistic regression analysis was performed to evaluate significant patient- and institution-level characteristics associated with the use of partial cholecystectomy.

Results:
A total of 298,009 patients were evaluated over 12 years. During our study period, the rate of partial cholecystectomy sharply increased from 0.22% of all cholecystectomy procedures to 0.80% (p<0.001). Conversion from a general laparoscopic to open partial cholecystectomy increased significantly from 0% in 2003 to 4.76% in 2014 (p=0.049). Partial cholecystectomies were performed at significantly higher rates in males (OR: 1.96, p<0.001), Asian Americans (OR: 2.15, p=0.037), and patients with alcohol abuse (OR: 2.23, p=0.024). Teaching hospitals (OR: 2.28, p<0.001) and those in rural areas (OR: 2.27, p=0.001) were also found with significantly higher numbers of partial cholecystectomies.

Conclusion:
Growing trends in the use of partial cholecystectomy suggest evolving surgical practices for acute cholecystitis. Current data suggests that gender, ethnicity, and hospital characteristics may already play a deciding role in procedure preference. Future studies are warranted to determine the indications for partial cholecystectomy and its outcome benefit.
 

72.03 Recurrence Rate and Healthcare Expenditures following Component Separation for Abdominal Wall Hernias

Posted on January 31, 2019

J. R. Montgomery2,3, J. Henderson1, J. B. Dimick2,3, D. A. Telem2,3  1University Of Michigan,Statistics,Ann Arbor, MI, USA 2University Of Michigan,General Surgery,Ann Arbor, MI, USA 3University Of Michigan,Center For Healthcare Outcomes & Policy,Ann Arbor, MI, USA

Introduction: Performance of component separation (CS) as part of an open hernia repair has doubled over the past 6 years. The impact of CS as part of open hernia repair (OHR) on hernia recurrence and healthcare expenditures when compared to OHR alone remains unknown. We aim to characterize the comparative risk of hernia recurrence after CS and associated difference in overall healthcare expenditures.

Methods: Using Truven Marketscan Data, patients aged 18 to 65 who underwent an abdominal wall hernia repair from 2009 to 2015 were identified. Recurrence was defined as any hernia repair within two years of index operation. Multivariate logistic regression models and time-to-event analyses were used to determine factors associated with hernia recurrence. Healthcare expenditures were defined by total inpatient payments and both price-standardized and inflation-adjusted.

Results: A total of 22,157 patients underwent hernia repair during the study period. For those patients who completed two years of follow-up (n=7,547), CS (n=1,074) was associated with a decreased incidence of hernia recurrence when compared to OHR (n=6,473) alone for both recurrent (7.5% vs 11.8%, p=0.028) and nonrecurrent (5.2% vs 9.6%, p<0.001) hernias. In a two-factor logistic regression, CS was protective for hernia recurrence (OR 0.55, 95%CI 0.42-0.72, p<0.001), whereas recurrent hernias were more likely to recur again (OR 1.29, 95%CI 1.07-1.56, p=0.008). In a proportional hazard models using all index repairs regardless of follow-up and adjusting for baseline recurrent hernia, CS remained associated with decreased chance of subsequent hernia recurrence (HR 0.51, 95%CI 0.42-0.61, p<0.001) [Figure 1]. Compared to OHR, CS was associated with an increased initial cost of $8,406 ($24,484 vs $16,078). However, given its lower postoperative recurrence rate, it is subsequently associated with a decreased cost of $131 per year, per patient.

Conclusion: Our analysis reveals that CS as part of an OHR is associated with decreased recurrence rates at 2-years as compared to OHR alone. Although initially more expensive, its decreased postoperative recurrence rate is associated with a subsequent savings of $131 per year, per patient. Utilization of CS for patients with highest risk of postoperative hernia recurrence may result in decreased overall healthcare expenditures.

 

72.02 Watchful Waiting for Ventral Hernias: A Large Single-Institution Descriptive Analysis

Posted on January 31, 2019

E. R. Dadashzadeh1,2, D. Van Der Windt1, R. Handzel1,2, J. Moses1, P. Bou-Samra1, V. P. Anto1, M. Hossain1, A. Tsung1, M. R. Rosengart1  1University Of Pittsburgh,Department Of Surgery,Pittsburgh, PA, USA 2University Of Pittsburgh,Department Of Biomedical Informatics,Pittsburgh, PA, USA

Introduction:

Ventral hernias remain a frequent complication of abdominal surgery. To avoid incarceration, operative repair is the current accepted treatment. While the morbidity and mortality of ventral hernia elective repair (ER) are well-documented, the same cannot be said for watchful waiting (WW) as we lack knowledge of the natural history of untreated ventral hernias, including the true incidence of incarceration events. To date, no prospective randomized trials comparing ER to WW have been completed, and the largest retrospective cohort analysis was a 2016 European single-center study consisting of 569 patients. The purpose of this study was to leverage our institution’s large patient population by performing a descriptive analysis of the ventral hernia experience in Western Pennsylvania.

Methods:

This retrospective cohort study was conducted by utilizing linked quality improvement health administrative databases from the University of Pittsburgh Medical Center spanning from January 1, 2010 to December 31, 2017. ICD-9 and ICD-10 coding was used to identify patients with a diagnosis of ventral hernia. Additionally, surgical CPT coding and admission data were used to classify patients into one of the following 3 groups: Elective Repair (ER), Watchful Waiting (WW), and Failure of Watchful Waiting (FWW). Manual audits of randomly selected patients were performed to confirm accurate classification. All-cause mortality was determined using our inpatient database linked with the Social Security Death Index.

Results:

After excluding patients under the age of 18 and those who presented with an incarceration event as their initial encounter within our system, 24240 unique patients were identified with a diagnosis of ventral hernia. 4447 patients underwent ER, 79% of them within 3 months from their initial ventral hernia diagnosis. 19793 patients underwent WW, of whom 264 suffered an acute incarceration event (FWW). The incidence of incarceration events in our population was 3.7 per 1000 patient-years. The all-cause mortality for the FWW cohort was significantly higher than both the ER and WW cohorts (12.1% vs 3.0% and 3.8%, P<0.0001). The median follow-up duration for the entire study was 51 months.

Conclusion:

While watchful waiting appears to be a safe strategy for the majority of patients presenting with a ventral hernia, the mortality associated with its failure is fourfold that of those who underwent elective repair. Instead of awaiting the results of randomized prospective trials in the hope of a single, collective approach for all patients presenting with a ventral hernia, future studies can evaluate leveraging both clinical and imaging data to identify and select those patients with the highest risk of incarceration for elective repair.

72.01 Cost-effectiveness of Index Treatment Strategies for Gallstone Pancreatitis

Posted on January 31, 2019

S. W. Knight1, S. Scaife2, J. D. Mellinger1, S. Ganai1,3  1Southern Illinois University School Of Medicine,Surgery,Springfield, IL, USA 2Southern Illinois University School Of Medicine,Center For Clinical Research,Springfield, IL, USA 3Southern Illinois University School Of Medicine,Population Science And Policy,Springfield, IL, USA

Introduction: Guidelines for management of gallstone pancreatitis (GSP) recommend cholecystectomy at the index admission to limit risk of readmission from recurrent pancreatitis, cholangitis or acute cholecystitis. It is uncertain whether endoscopic retrograde cholangiopancreatography (ERCP) with or without sphincterotomy or stenting is sufficient management for this patient population. We hypothesized that index cholecystectomy (chole) for GSP would be the more cost-effective strategy using a time horizon of a single quality-adjusted life-year.

Methods:  A retrospective cohort analysis was performed using the National Readmission Database (NRD) from 2013-2015 across 1st-3rd quarters to obtain full 90-day readmission data for all analyzed patients. Inclusion criteria identified adults admitted with pancreatitis and various cholelithiasis ICD-9 codes. Exposures were procedures (ERCP, cholecystectomy, none, or both) coded during the index hospitalization. Outcomes included cost, likelihood of 90-day readmission, and risk of death. A societal perspective framework for cost-effectiveness was used based on likelihood of readmission, median cost of each admission, mortality with intervention or readmission, and negative utility of a readmission (NUR), factoring the perceived impact of a 90-day readmission in respect to quality of life (QOL)..

Results: In total, 396,978 index admissions with a diagnosis of GSP were studied. Readmissions were noted in 32.8% of patients receiving no procedure (n=336393), 12.6% receiving chole (n=54917), 13.5% of patients receiving chole and ERCP (n=2260), and 38.6% of patients receiving ERCP (n=3408).  Median cost for those who were not readmitted was $21k for no  procedure, $55k for chole, $59k for chole/ERCP, and $41k for ERCP.  Median cost for those who were readmitted was $72k for no procedure, $83k for chole, $149k for chole/ERCP, and $108k for ERCP. Readmission mortality was 1.45% for no procedure, nil for chole and chole/ERCP, and 0.85% for ERCP.  Figure 1 models cost-benefit ratio using the above data controlling to the cost of a no procedure strategy across varying NUR.

Conclusion: Our cost-effectiveness analysis supports the hypothesis that cholecystectomy performed at the index admission for gallstone pancreatitis is superior to ERCP alone. ERCP is more favorable than ERCP/chole only when the expected surgical mortality is high or the NUR is less than 0.2 (<10 weeks of impaired QOL with readmission), primarily because of higher readmission rates and index+readmission mortality risk. ERCP alone prior to discharge is not an optimal strategy for an average-risk patient.

71.10 Overtreatment: A Qualitative Analysis of Surgeons, Endocrinologists, and Patients with Thyroid Cancer

Posted on January 31, 2019

C. B. Jensen1, M. C. Saucke1, J. L. Jennings1, H. J. Khokhar1, C. I. Voils1, S. C. Pitt1  1University Of Wisconsin,Endocrine Surgery Division – Surgery Department,Madison, WI, USA

Introduction: Overtreatment is a significant problem in the United States, particularly in patients with low-risk thyroid cancer. In order to reduce the harms of unnecessary care, it is essential to understand stakeholders’ attitudes and beliefs about overtreatment. 

Methods: We conducted 34 semi-structured interviews with surgeons, endocrinologists, and patients with low-risk thyroid cancer. Interviews probed about decision-making for thyroid cancer, including less extensive and non-surgical management options. We used content analysis to identify themes related to overtreatment and created concept diagrams to map observed relationships between these themes.

Results: Surgeons and endocrinologists discussed overtreatment of low-risk thyroid cancer as resulting directly from overdiagnosis. They believed the process commonly starts with incidental discovery of a thyroid nodule on imaging and viewed biopsy as a habitual action driving overdiagnosis. Providers ascribed the reflexive biopsy to lack of adherence to or knowledge of guidelines, radiology recommendations, and the desire of patients and physicians to minimize diagnostic uncertainty. Providers described the subsequent diagnosis as an event that lets “the cat out of the bag” or “opens Pandora’s box.” Providers acknowledged that the resulting cancer diagnosis provokes a strong instinctive and culturally rooted need to proceed with surgery. As a consequence, most providers believed it is easier to prevent overdiagnosis than overtreatment. They suggested overdiagnosis can be addressed with provider-focused educational interventions, resetting patients’ expectations, and engaging the media. In contrast, patients did not discuss overdiagnosis or overtreatment. Some patients described the linear process from an incidental finding to surgery. Their statements confirmed the “need to know” was a major motivation for biopsying their nodule. Most patients felt that once they had a cancer diagnosis, surgery was a foregone conclusion. Patients admitted their knowledge about thyroid nodules and cancer was low, leaving room for education about the need for biopsy and less extensive treatments. They expressed significant trust in their surgeon and willingness to consider less extensive management options if recommended.

Conclusion: Surgeons’ and endocrinologists’ attitudes and beliefs about overtreatment focus on the automaticity of overdiagnosis. Both patients and providers acknowledge the established pathway that propels patients from incidental discovery of a thyroid nodule to surgery. Research is needed to determine if this seemingly inevitable progression can be interrupted with educational and behavioral interventions. 

71.09 Effects of Mentorship Using Surgical Simulation For Economically Disadvantaged High School Students

Posted on January 31, 2019

T. P. Williams1, A. R. Wenholz1, T. S. Reynolds1, I. C. Okereke2  1University Of Texas Medical Branch,Department Of Surgery,Galveston, TX, USA 2University Of Texas Medical Branch,Division Of Cardiothoracic Surgery,Galveston, TX, USA

Introduction:
Economically disadvantaged (ED) high school students are less likely to graduate from high school and enroll at a college or university.  Our institution recently began a mentorship program, in which students participated in a structured career coaching program and then attended sessions in a surgical simulation laboratory.  Our goal was to determine whether the mentorship program affected the likelihood that these students would pursue formal education after high school.

Methods:
Students enrolled in an urban, ED high school who accepted an invitation to the program were given multiple lectures by one attending surgeon about college admission requirements, strategies to overcome potential socioeconomic and cultural obstacles and sources of funding for college tuition.  Thereafter the students were brought to the surgical simulation laboratory and participated in basic surgical skills such as knot-tying and laparoscopic simulation exercises.  The students were asked to complete an anonymous survey both before and after the program gauging their level of self-confidence and likelihood of attending a college or university after high school (Figure 1).  All participation was voluntary.

Results:
Twenty students participated in the program.  Eighty percent (16/20) were female.  Seventy percent (14/20) of students resided in a household with an income under $25,000.  Sixty-five percent (13/20) were Black/African American, and 35 percent (7/20) were Latino/Hispanic.  Upon completion of the program the average survey score increased significantly for having a major chosen for college (p = 0.04), feeling more prepared for the academic obligations of college (p = 0.02) and being interested in pursuing a career as a surgeon (p < 0.01).

Conclusion:
In-person mentorship can make high-risk students more likely to pursue education at a college or university.  Exposure to surgical simulation can raise students’ interests in a surgical career.  Further longitudinal studies are needed to see the effects that mentorship using surgical simulation can have on graduation rates and the probability of obtaining a degree at a college or university.
 

71.08 Impact of a Patient Navigator on a Free Surgery Program for the Uninsured

Posted on January 31, 2019

J. Heimroth1, S. Edwards1, J. Matzke3, S. Walling2, E. SUTTON1  1University of Louisville School of Medicine,Hiram C. Polk, Jr, MD Department Of Surgery,LOUISVILLE, KY, USA 2University of Kentucky School of Medicine,Department Of Surgery,Lexington, KY, USA 3Medical College of Wisconsin,Milwaukee, WI, USA

Introduction: Surgery on Sunday Louisville, Inc. (SOSL) is a nonprofit organization whose mission is to provide free endoscopy and outpatient surgery to people who are uninsured or underinsured.  Two years ago, SOSL began to collect patient outcomes such as wait time from referral to consultation and wait time from referral to surgery.  Seeing lengthy wait times, SOSL hired a patient navigator to attempt to improve these initial two outcomes.  Our hypothesis was that a patient navigator would improve wait times by aiding patient throughout in our referral system.

Methods: Patient outcome data such as date of referral, days from referral to consultation, days from referral to surgical procedure, and dates of follow up were prospectively collected for 278 patients referred to SOSL from February 1, 2016 to June 1, 2018.  The patient navigator, who spoke the primary language of the patient majority (Spanish), was hired on March 1, 2017.  Data were retrospectively analyzed for the 13 months prior to her hiring (Group A) and compared to the 15 months after her hiring (Group B).  Patients were excluded if they did not show up for their clinic appointment and thus had no values for inclusion.  Mean days from referral to consultation and referral to surgical procedure were calculated for each group and compared using a student’s t test for normally distributed data.

Results: Patients referred before the hiring of a patient navigator (Group A, n=99)) experienced a mean wait time of 49 ± 52 days until consultation and 126 ± 98 days from referral to surgical procedure.  Patients referred after the hiring of a patient navigator (Group B, n=160) experienced a mean wait time of 49 ± 51 days until consultation and 149 ± 57 days from referral to surgical procedure.  Thus, there was no significant difference between days to consultation (p=1.0, 95% CI -12.94 to 12.94) between Groups A and B.  There was however a significant difference in days to surgery (p=0.02, 95% CI -41.96 to -4.04) in favor of Group A.

Conclusion: Hiring a patient navigator maintained the wait time from referral to consultation, yet a navigator was not able to impact the wait time from referral to surgery in a model that attempts to delivery surgery free of charge to the patients.  The impact of increased referral volume cannot be determined from this study.  These results suggest another solution to lengthening surgical wait times should be sought.

 

71.07 Do Surgeons and Patients Value Shared Decision Making in Surgery?

Posted on January 31, 2019

E. M. Carlisle1, L. A. Shinkunas2, C. J. Klipowicz3, L. C. Kaldjian2  1University Of Iowa,Division Of Pediatric Surgery/Department Of Surgery,Iowa City, IA, USA 2University Of Iowa,Program In Bioethics And Humanities,Iowa City, IA, USA 3University Of Iowa,Department Of Anthropology,Iowa City, IA, USA

Introduction: Shared decision making (SDM) is presumed to be the preferred approach to patient counseling.  However, few data exist regarding whether patients prefer SDM over a surgeon-guided approach during complex surgical decision making. Even less data exist regarding surgeon preferences toward SDM. In this systematic review we identified studies that address patient and surgeon preferences toward SDM in surgery.

Methods: We conducted a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) based systematic review of articles published in Medline, EMBASE, and Cochrane databases that evaluated surgeon/patient preferences toward SDM in adult surgery. Two investigators independently reviewed all identified articles.  Articles were included if they specifically investigated preferences of surgeons/patients toward SDM in adult surgery.

Results:The search yielded 20359 articles. 4988 duplicate articles were removed yielding 15371 articles for title/abstract review. 86 articles addressed preferences toward SDM in surgery.  Complete analysis of the articles is currently underway. Preliminary results from the first 35 articles demonstrate the following: 13 subspecialties were represented: Surgical Oncology (34%), General Surgery (20%), Cardiac Surgery (11%), Orthopedic Surgery (11%), Plastic Surgery (11%), Gynecology (9%), Urology (9%), Vascular Surgery (9%), Neurosurgery (6%), Thoracic Surgery (6%), Transplantation (6%), Colorectal (3%), and Otolaryngology (3%).  43% of articles discussed decision making for patients with cancer. Of those, 80% focused on breast cancer. 60% were from non-US institutions, and 71% focused on outpatient decision making. 83% concentrated on patient preferences, and 20% focused on surgeon preferences.  51% discussed decisions between operative or nonoperative management, 34% discussed decisions among different surgical procedures, and 11% discussed decisions regarding the timing of surgery. No articles addressed decision making for emergency surgery.  In the 7 articles addressing surgeon preferences, most surgeons favored SDM. For patients, 46% favored SDM, 23% surgeon-guided decision making, and 14% independent decision making.

Conclusion:Despite recommendations that SDM is the best approach to clinical counseling, our systematic review identified very few articles that evaluate patient and surgeon preferences toward SDM in surgery. The majority of articles focused on non-emergent, outpatient decision making related to oncologic diagnoses. Additionally, most studies were preformed outside of the US where different health care systems or attitudes toward physicians may impact decision making preferences. Further research is needed to understand whether patients and surgeons may prefer a more surgeon-guided approach to decision making in emergent, inpatient decision making. Additionally, more work is needed to assess decision making preferences for patients and surgeons focused on non-oncologic diagnoses.

 

71.06 Prevalence of Thymic Parathyroids in Primary Hyperparathyroidism during Radioguided Parathyroidectomy

Posted on January 31, 2019

S. Dream1, B. Lindeman1, H. Chen1  1University Of Alabama at Birmingham,Birmingham, Alabama, USA

Introduction:

Radioguided surgery has been an effective tool for identifying hyperfunctioning parathyroid glands, including both adenomas and hyperplastic glands during routine parathyroidectomy for hyperparathyroidism.  The purpose of this study was to examine the role of radioguided surgery for the identification of intrathymic adenomatous and hyperplastic parathyroid glands.

Methods:
Between March 2001 to February 2018, 2291 patients underwent parathyroidectomy by one surgeon for primary hyperparathyroidism.  Of these patients 158 (7%) were identified to have an ectopic intrathymic parathyroid gland. All patients underwent radioguided parathyroidectomy with preoperative injection of 10 mci of TC-99m sestamibi.  Ex vivo radionuclide counts were used to confirm parathyroid excision with specimen radioactivity of >20% of the background level.

Results:
The mean age was 56 ±1 years with 74% of the patients being female.  Preoperatively, 122 patients underwent sestamibi scan with the scan correctly identifying the the affected gland 61% of the time.  Mean preoperative calcium was 10.7± 0.1 mg/dL and the mean preoperative parathyroid hormone(PTH) was 112 ± 6 pg/mL. Mean background radionuclide count was 208 +/-7, mean ex vivo radionuclide count was 127 ± 9, with ex vivo counts of removed glands were >20% in all patients.  Thymectomy was performed in 140 of the patients. Mean postoperative calcium was 9.3 ± 0.1 mg/dL and the mean postoperative PTH was 46 ± 3 pg/mL.

All ectopic parathyroid glands were successfully identified using gamma probe.  Ex vivo counts found to be significantly higher in patients with adenomas. Patients with parathyroid adenomas also were older in age and had higher preoperative calcium levels (see table).  While 10% of patients with primary hyperparathyroidism have hyperplasia, 42% of patients with thymic parathyroids had hyperplasia.

Conclusion:
Radioguided parathyroidectomy is useful in detecting ectopic parathyroid glands in the thymus.  Patients with hyperplasia disproportionately have thymic parathyroid glands.
 

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