35.09 Factors Predicting Failure to Rescue in Hospitalized Patients Requiring Emergency General Surgery

Posted on January 31, 2019

B. Zangbar1, D. Gross1, L. Boudourakis1  1SUNY Downstate Medical Center,Surgery,Brooklyn, NY, USA

Introduction: Patients requiring emergency general surgery (EGS) consultation while admitted as inpatient comprise a large part of patients requiring surgical intervention with often complicated decision-making process. However, majority of research related to emergency general surgery is focused on the patients operated after presenting with acute symptoms to emergency department. Failure to rescue (FTR) of the inpatients who require emergency general surgery has never been studied. Aim of our study was to assess factors predicting FTR of inpatients who had EGS two days or more after admission.

Methods: We performed a review of ACS NSQIP database (2015) and included patients older than 18 who underwent EGS on second hospital admission day or later. We excluded outpatient status, and elective surgeries. EGS operations included were appendectomy, partial and total colectomy, small bowel resection, surgical management for peptic ulcer perforation, cholecystectomy, lysis of adhesions, and exploratory laparotomy. Complications were identified and FTR was defined as mortality after a complication. Multivariable logistic regression was used to identify predictors of FTR.

Results: A total of 6,003 EGS patients who met our criteria were included. The majority of patients were white (62.9%), the median age was 64 (IQR: 51-76) years, they were functionally independent (90.0%), and admitted from home (80.5%). Overall complication rate was 38.1% (n=2,285) with most common complication being bleeding requiring transfusion (19.3%) followed by prolonged intubation (7.8%) unplanned intubation (5.1%) and pneumonia (4.8%). Median postoperative LOS was 7d (IQR 2-12d) and overall mortality was 10% of which 9.2% died within 30 days of operation (median time to death: 5d IQR 1-11d). FTR was 21.3% (n=486) with bleeding requiring transfusion the most common complication among the expired patients (60.9%). On multivariate logistic regression analysis for FTR, Age (OR 1.025), Ascites (OR 1.54), being currently on dialysis (OR 1.67), having disseminated cancer (OR 1.71), being on steroids (OR 1.67), Septic Shock (OR 3.79), Sepsis (OR 3.26), and total operative time (OR 0.997) and ASA classification were independent predictors of mortality after adjusting for gender, body mass index, functional status, days from admission to operation, and all other comorbidities.

Conclusion: Hospitalized patients requiring EGS are a unique subset of patients with high risk for complications and mortality. FTR rate is high among these patients with most common complication being bleeding requiring transfusion. These patients present with several comorbidities despite being functionally independent on admission and these comorbidities seem to contribute in FTR of these patients.

35.08 Patients Who Report Feeling Downhearted at Discharge are More Likely to be Readmitted

Posted on January 31, 2019

S. J. Baker1,2, J. Richman1,2, E. Dasinger1,2, T. Wahl1,2, L. Graham3,4, K. Itani5, H. Mary3,4, M. Morris1,2  1University Of Alabama at Birmingham,General Surgery,Birmingham, Alabama, USA 2Birmingham Veterans Affairs Medical Center,General Surgery,Birmingham, ALABAMA, USA 3Stanford University,General Surgery,Palo Alto, CA, USA 4VA Palo Alto Healthcare Systems,Palo Alto, CA, USA 5VA Boston Healthcare System,General Surgery,West Roxbury, MA, USA

Introduction: The Veterans RAND-12 Health Survey (VR-12) is used within Veterans Affairs’ hospitals to measure health related quality of life.  In this study we explored if specific VR-12 questions could predict post-operative readmissions. We hypothesized that patients who reported lower overall health or depressive symptoms would have higher readmission rates. 

Methods:  Patients undergoing general, vascular, or thoracic surgery at 4 Veterans Affairs (VA) Medical Centers, August 2015-June 2017 with a post-operative hospital stay over 48 hours were prospectively enrolled. Trained interviewers assessed patient’s health status on the day of discharge using the VR-12 survey consisting of 12 questions corresponding to eight principal physical and mental health domains: general health perceptions, physical functioning, role limitations due to physical and emotional problems, bodily pain, energy-fatigue, social functioning, and mental health. Each item is scored on a 5 point Likert scale. Unplanned readmissions within 30 days post-discharge were identified using VA records with a telephone interview at day 30 to identify readmissions to non-VA hospitals. Relationships between individual VR-12 responses and readmission were evaluated using bivariate tests and logistic regression models with and without adjustment for clinical and demographic covariates.

Results: We recruited 736 patients with a median age of 67 (IQR: 61-71), 96% (n=692) were male, and the majority were Caucasian (84%, n=607). Patients with and without readmission were similar in age (65 vs. 67, p=0.11), need for emergent procedure (3.6% vs. 2.8%, p=0.79), operative time (hours 4.01 vs. 4.45, p=0.28), and surgical procedures (p=0.51) but differed in Charlson comorbidy index (CCI) and functional status. Readmitted patients had higher CCI (5.4 vs 3.9, p<0.001) and were more often classified as dependent functional status (13% vs. 5%, p=0.004).  A model that included the two VR12 questions which approached significance [(self-reported general health (ANOVA p<0.01) and ‘How much of the time in the past 4 weeks have you felt downhearted and blue?’ (ANOVA p=0.06)] was adjusted for specialty, age, operative time, CCI, dependent status, and emergency procedure. In this model, self-reported health approached significance (ANOVA p=0.06) driven by those reporting ‘poor’ health trending towards more frequent readmission (OR  3.80, 95% CI 0.97-14.88); feeling blue was associated with readmission (ANOVA p=0.01), in particular, patients who reported feeling blue ‘a good bit of the time’ were more likely to be readmitted (OR 3.47, 95%CI 1.45-8.31). 

Conclusion: Patients who report feeling ‘downhearted and blue’ at the time of discharge are more likely to be readmitted and could be identified with a single question. This information can be used to efficiently identify patients at risk for readmission and should be validated through other studies. 

 

35.07 Understanding Communication Gaps in the Hospital Consultation Process

Posted on January 31, 2019

C. Fischer2, V. Rendell3, E. Winslow3  2University Of Wisconsin,School Of Medicine And Public Health,Madison, WI, USA 3University Of Wisconsin,Department Of Surgery/School Of Medicine And Public Health,Madison, WI, USA

Introduction: Communication gaps have been tied to medical errors, treatment delays, and patient dissatisfaction. The hospital consultation process is particularly vulnerable to communication gaps, but these gaps have not been well studied. We aimed to evaluate which specific communication issues lend weaknesses to the consult process from the perspective of providers and patients.

Methods: As part of an existing quality improvement project at our institution, we evaluated inpatient communication event reports from clinicians and staff from February 2017 to January 2018. We also performed semi-structured interviews of inpatients who had received either a medical oncology (MO) or general surgery (GS) consult. Interviews were transcribed. A qualitative content analysis was performed on the event reports and interviews to uncover themes illustrating consult communication challenges. Themes were enumerated, and percentages determined out of total event reports or total interviews as appropriate.

Results: Of the 782 event reports reviewed, 59 (9%) were directly related to physician-physician communication during consultations and were categorized into six main groups: 1) inadequate verbal communication between providers (73%); 2) inadequate verbal communication between the provider(s) and the patient and/or their family (10%); 3) inadequate chart documentation from providers (10%); 4) delays in communication (3%); 5) inappropriate communication (2%); and 6) not accepting a consult (2%). Inadequate verbal communication was further categorized by environment: ED (23%), inpatient (47%), and inpatient involving an operation/procedure (30%).

Interviews of 33 inpatients with GS consults and 17 with MO consults were conducted between June and August 2018. Five major patient-perceived issues with provider communication were identified with sub-themes detailed in Table 1: 1) inadequate verbal communication between provider(s) and the patient/family; 2) poor communication between physicians; 3) communication with the patient before consensus on a plan has been reached; 4) use of excessive medical terminology; and 5) inadequate non-verbal communication. Only patients with GS consults reported use of excessive medical terminology.

Conclusion: Inadequate verbal communication between providers is frequently identified as problematic in the inpatient setting by both clinicians and patients. The periprocedural setting represents a significant portion of these verbal communication issues. In order to improve communication within the hospital consultation process, strategies that target the quality of provider-to-provider and provider-to-patient communication, particularly in the peri-procedural setting, are likely to be most productive.
 

35.06 Quality Assessment of the Surgical Quality Improvement Literature

Posted on January 31, 2019

O. A. Sacks1, A. J. Lambour2, S. Nammalwar1, S. L. Wong1,2  1Dartmouth Medical School,Lebanon, NH, USA 2Dartmouth-Hitchcock Medical Center,Department Of Surgery,Lebanon, NH, USA

Introduction:

In recent years there has been a proliferation of surgical quality improvement (QI) work and a commensurate increase in the number of reports in the surgical literature. The Standards of Quality Improvement Reporting Excellence (SQUIRE) guidelines were developed and disseminated (version 2.0 was released in 2015) to systematize and improve QI study design and reporting. We performed a systematic review of the surgical QI literature to assess the quality of QI reporting.

Methods:

We completed a systematic review of the surgical QI literature between 2008-2018, limited to publications in the top 30 surgical journals and the top 20 general interest journals based on impact factor. Inclusion criteria included English language studies, an identifiable surgical QI intervention, and measurement of quality. Papers were reviewed for concordance with the SQUIRE statements using a dichotomous (y/n) scale. Evaluation was organized both by the 18 main SQUIRE statements and their 40 subheadings.

Results:

1480 abstracts were identified in the initial literature search and 58 articles met the inclusion criteria. No articles were completely adherent to the SQUIRE guidelines. On average, QI publications met just 10/18 (56%) of the main statements and 24/40 (60%) of the subheading topics. Generally, the articles were concordant with components such as “Problem Description” (58/58, 100%), “Rationale” (56/58, 97%), and “Specific Aims” (55/58, 95%). Publications lacked a general description of methodology: only 41 publications adequately described the “Intervention” and only 26 described the measures chosen to assess the processes and outcomes of that intervention (“Study of the Intervention”) (71% and 45%, respectively). Very few articles (22/58, 38%) satisfactorily reported the “Results” and only 29 (29/58, 50%) articles listed the key findings and strengths of the project (“Summary”) (Figure). In total, only 7 articles cited the SQUIRE guidelines (7/58, 12%). Papers that cited SQUIRE were compliant with a mean of 26/40 (65%) statements, compared to 24/40 (60%) statements for those that did not cite SQUIRE (p=0.82). Most of the papers that cited SQUIRE (5/7, 71%) were published after the release of SQUIRE 2.0.

Conclusion:

The quality of surgical QI reporting is relatively poor. Our analysis demonstrates that the SQUIRE guidelines have not been widely adopted as a framework for the reporting of surgical QI studies. Increased adherence to the SQUIRE guidelines has the potential to meaningfully improve the development and dissemination of surgical QI projects.

35.05 Enhanced Recovery After Surgery (ERAS) Pathway for Patients Undergoing Abdominal Wall Reconstruction

Posted on January 31, 2019

J. S. Colvin1, M. Rosen1, S. Rosenblatt1, A. Prabhu1, D. Krpata1  1Cleveland Clinic,General Sugery,Cleveland, OH, USA

Introduction: Enhanced Recovery After Surgery (ERAS) pathways represent a multi-modal approach to post-operative care, with the goal of improved recovery, outcomes, and value. Patients undergoing abdominal wall reconstruction have lengths of stay of six days on average. We hypothesized that implementation of an ERAS pathway for abdominal wall reconstruction would result in faster recovery and decreased length of stay (LOS).

 

Methods: A universal ERAS protocol for patients undergoing elective abdominal wall reconstruction at the Cleveland Clinic was implemented. The protocol consisted of multi-modal analgesia with transversus abdominis plane (TAP) blocks in addition to both narcotic and non-narcotic oral pain medications. Early feeding and diet advancement as well as goal-directed intravenous fluids were implemented. Bowel regimen, routine labs, and use of drains were also standardized. One hundred consecutive patients undergoing abdominal wall reconstruction with use of our ERAS pathway were compared to a historical cohort. Groups were compared on demographics and clinical characteristics using chi-square, Fisher’s exact, and two sample t-tests.

 

Results: The average LOS was not significantly different after implementation of the ERAS protocol (6.0 ± 8.3 vs 6.0 ± 11.5 days, p=0.96). Time to regular diet was also not significantly different (3.43 ± 2.2 vs 3.6 ± 7.9 days, p=0.57). There was decrease in time to discontinuation of intravenous or epidural patient-controlled analgesia (3.8 ± 6.0 days vs 3.2 ± 4.7 days, p=0.05). There was no increase in readmission rates. In a sub-group analysis, factors associated with a LOS<4 days were hernia width ≤9.5 ± 7.2 cm (p=0.009), operative time ≤2.5 ± 0.85 hours (p=0.001), and pre-operative quality-of-life (HerQles) score ≥59.5 ± 11.7 (p=0.008). 

 

Conclusion: Our study is one of the largest to investigate ERAS protocols for complex ventral hernia repairs.  In this cohort, ERAS failed to reduce LOS.  We were able to identify predictors of a shorter LOS, which included smaller hernia defects, shorter operative times, and higher baseline quality of life scores. This demonstrates which subset of patients may have greater benefit from an ERAS pathway within our practice. 

35.03 Inter-rater Agreement of the CLASSification of Intra-operative Complications (CLASSIC)

Posted on January 31, 2019

P. Krielen1, L. Gawria1,2, M. Stommel1, S. Dell-Kuster2,3, R. Rosenthal4, R. Ten Broek1, H. Van Goor1  1Radboud University Medical Center,Departement Of Surgery,Nijmegen, GELDERLAND, Netherlands 2University of Basel,Basel Institute Of Clinical Epidemiology And Biostatistics,Basel, Switzerland 3University Hospital Basel,Departement Of Anaesthesiology,Basel, Switzerland 4University of Basel,Basel, Switzerland

Introduction:

Surgical outcomes depend on the quality of preoperative, intraoperative and postoperative care. Prospectively validated classification systems for evaluation of intraoperative adverse events (iAEs) are not available. Recently, a classification of intraoperative complications (CLASSIC) to grade iAEs has been developed, retrospectively validated (Rosenthal 2015), and extended to 5 grades of severity. The aim of this retrospective analysis of prospectively collected data is to assess the inter-rater agreement  of CLASSIC and its predictive value for severe postoperative complications using data from a cohort study of elective abdominal surgeries (LAPAD study (ten Broek 2013), NCT01236625).

Methods:

In the LAPAD study, detailed data on iAEs and their treatment were collected by an independent researcher present in the operating room. For the current research questions, two independent teams, each consisting of a dedicated researcher and a surgeon, retrospectively graded all previously recorded iAEs according to CLASSIC. The two teams were blinded for each other's grading. Discrepancies between the teams in the grading of iAEs were resolved through discussion. Cohen’s Kappa coefficient was calculated to determine the inter-rater agreement. Uni- and multivariable logistic regression were used to estimate the predictive value of the highest CLASSIC grade (categorized as 0, I-II, and III-V) on the occurrence of the most severe post-operative complication according to Clavien-Dindo (dichotomized as grade III-V versus 0-II). Multivariable analysis was adjusted for all variables, which were significant in univariate analysis.

Results:

Seven hundred fifty-five abdominal surgeries were reviewed for the occurrence of iAEs. iAEs were observed in 333 surgeries (44.1%) by team 1, and 324 (42.9%) by team 2. The raw agreement between both teams was 86.9% for the classifications of iAEs according to CLASSIC. The Cohen’s Kappa coefficient across all 5 CLASSIC grades was 0.87 (95% CI 0.84-0.90). A severe iAE (CLASSIC III – V) was observed in 86 (11.4%) of surgeries. Any post-operative complication was observed in 278 (36.8%) surgeries, of which 129 (46.4%) severe postoperative complications (Clavien-Dindo grade 3 or higher). In 27 (31.4%) patients with a severe iAE, a severe post-operative complication was observed, compared to 52 (20.9%) of patients with a minor iAE, and 50 (11.9%) with no iAE (p<0.001). An iAE was a significant independent risk factor for severe post-operative complications in multivariable analysis, with OR 3.07 (95% CI 1.76 – 5.34) for severe iAEs and OR 1.97 (95% CI 1.28 – 3.04) for minor iAEs as compared to no iAEs.

Conclusion:

The newly proposed CLASSIC is a reliable tool for the classification of iAEs, with a good inter-rater agreement. A higher severity grade of iAEs according to CLASSIC was associated with a higher risk of severe post-operative complications.

35.02 Diverting High-Risk Patients from the Lowest-Quality Hospitals for Complex Surgical Procedures

Posted on January 31, 2019

M. E. Smith1,2, U. Nuliyalu2, J. B. Dimick1,2, H. Nathan1,2  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA

Introduction: Surgery at low-quality hospitals is associated with increased morbidity and mortality. High-risk patients have disproportionately worse outcomes and achieve the greatest benefit when referred to high-quality hospitals. However, referral to high-quality hospitals may impose unreasonable travel burdens and lead to discontinuity of care. A more selective referral strategy focused on diverting high-risk patients from the lowest-quality hospitals may be practical and beneficial. We sought to quantify the impact and feasibility of a local referral strategy focused on high-risk patients.

Methods: We identified patients age >65 years undergoing elective lung resection (Lung), proctectomy (Rectal), coronary artery bypass graft (CABG), esophagectomy (Esoph), and pancreatectomy (Panc) in 2012-2014 Medicare claims data. Hospitals were stratified into 5 grades of quality, A-F, by risk- and reliability- adjusted serious complication rates. Patients were risk-stratified by clinical factors. Travel burden was calculated by comparing the distance between a patient’s home zip code and Grade F hospital’s zip code versus the distance between a patient’s zip code and that of the nearest higher-quality hospital (Grade A or Grade A-C).

Results: One quarter of high-risk patients were treated at Grade F hospitals (24% Lung, 28% Rectal, 18% CABG, 23% Esoph, 19% Panc). Shifting these patients to Grade A hospitals would decrease serious complications from 54% to 13% (Absolute Difference: Lung 31%, Rectal 47%, CABG 27%, Esoph 58%, Panc 43%) and mortality from 13% to 7% (Lung 5%, Rectal 3%, CABG 4%, Esoph 11%, Panc 7%) (Table). High-risk patients at Grade F hospitals could travel a median of 4 additional miles to reach a Grade A hospital. Expanding the definition of high-quality to include Grade A, B, and C hospitals results in comparable benefits. Diverting high-risk patients from Grade F to Grade A-C hospitals would decrease serious complications from 54% to 16% (Lung 28%, Rectal 43%, CABG 23%, Esoph 55%, Panc 41%) and mortality from 13% to 8% (Lung 5%, Rectal 2%, CABG 3%, Esoph 9%, Panc 7%) (Table). Notably, patients could travel shorter distances to reach the nearest A, B, or C hospital than the F hospital they were treated at.

Conclusion: Shifting the highest-risk patients out of the worst hospitals for complex surgical procedures would require selectively referring only 5% of patients. Triaging patients from Grade F to the nearest A-C hospital would optimize surgical value while requiring the majority of patients to travel acceptable distances. This suggests that local referral of high-risk patients out of the lowest quality hospitals is a necessary and practical strategy for improving the value of surgical care.

35.01 Targeted Checklist Compliance with Oral and Mechanical Prep Improves Surgical Site Infection Rates

Posted on January 31, 2019

C. L. Antonacci1, D. Armellino2, K. Cifu-Tursellino2, M. E. Schilling2, S. Dechario2, G. Husk2, M. Jarrett2, A. Antonacci2  1Tulane University School Of Medicine,New Orleans, LA, USA 2North Shore University And Long Island Jewish Medical Center,Manhasset, NY, USA

Introduction:

In addition to increased patient morbidity and mortality, National Surgical Quality Improvement Program data suggest that surgical site infection (SSI) accounts for a 9.2% increase in hospital costs above uncomplicated colectomy cases.  This project, which included 12 acute care facilities, was designed to reduce the incidence of post-colectomy SSI by implementing a system-wide standardized surgical bundle checklist, monthly communication of outcome data to practitioners and analysis of factors contributing to organ space infection, as defined by the National Healthcare Safety Network (NHSN). 

Methods:

A colectomy bundle checklist was utilized to gather information on clinical practice from 761 colectomy cases within our system from 1/1/2016 to 12/31/2017.  Data was entered into a relational database analyzing over 50 patient, procedure, SSI and bundle compliance elements at the system, hospital and surgeon level.   Documentation compliance with the checklist items was compared to surgeon specific NHSN infection rates (< 2.5% and > 2.5%) by paired Student’s t-test.

Results:

Compared to 2016, elective post-colectomy SSIs for our health system in 2017 were reduced by 33% with a 45.3% reduction in intrabdominal infections, a 71.4% reduction in deep space infections and a 6.1% reduction in superficial site infections.  Bundle checklist compliance was analyzed with respect to pre-operative use of oral antibiotics, mechanical bowel prep, and intra-operative re-dosing of IV antibiotics. Of 540 elective colectomy cases, 420 (77.78%) were in compliance with regard to oral antibiotics, 468 (86.67%) with mechanical bowel prep, and 441 (81.67%) with re-dosing IV antibiotics. Of 39 surgeons with checklist data and NHSN reported infections, 4 (10.26%) had infection rates less than 2.5%, while 35 (89.74%) had infection rates greater than 2.5%.  Statistically significant differences were observed in checklist compliance between surgeons with infection rates <2.5% and >2.5%, respectively, for: (1) oral antibiotics 186/217 (85.7%) v. 87/134 (64.9%), p < 0.002; and (2) mechanical bowel prep 194/217 (89.4%) v. 36/65 (55.5%), p<0.006.  The use of intra-operative re-dosing of IV antibiotics 171/217 (78.8%) v. 113/130 (86.9%) was not significantly different.

Conclusion:

These data suggest that implementing a system-wide standardized surgical bundle checklist  and  relational database system can significantly reduce the incidence of elective colectomy SSIs. Analysis of bundle checklist compliance between low infection rate surgeons (<2.5%) and high infection rate surgeons (>2.5%) demonstrates significantly lower utilization of pre-operative oral antibiotic and mechanical bowel preps in high infection rate surgeons. These data further suggest that target compliance rates may need to be set in the 85% to 90% range for these bundle items to achieve optimal reductions in elective colectomy SSIs. 

 

34.10 Narrow- vs. Broad-Spectrum Antibiotics for Simple Acute Appendicitis Treated by Appendectomy

Posted on January 31, 2019

S. Qian1, G. Vasileiou1, G. D. Pust1, A. I. Eid4, C. Dodgion2, T. Zakrison1, M. D. Ray-Zack3, R. Rattan1, N. Namias1, D. D. Yeh1  1University Of Miami,Division Of Trauma And Surgical Critical Care,Miami, FL, USA 2Medical College Of Wisconsin,Division Of Trauma And Critical Care,Milwaukee, WI, USA 3Mayo Clinic,Department Of Surgery,Rochester, MN, USA 4Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA

Introduction: We sought to compare the effectiveness of narrow- vs broad-spectrum antibiotics for adults with simple acute appendicitis.

Methods:  In this post hoc analysis of a prospective multicenter observational study of appendicitis in adults (≥18 yrs) conducted from 01/17-05/18, we included patients with simple appendicitis (non-perforated) as diagnosed intra-operatively. Subjects were grouped based on receipt of broad-spectrum antibiotics (3rd or 4th generation cephalosporin, carbapenem, fluoroquinolone, vancomycin, piperacillin/tazobactam, or ampicillin/sulbactam) or narrow-spectrum antibiotics (penicillin, 1st or 2nd generation cephalosporin, beta-lactam, clindamycin, macrolide, aminoglycoside, tetracycline, sulfonamide, amoxicillin/clavulanate, metronidazole, or aztreonam) before and/or after appendectomy. Outcomes compared were surgical site infection (SSI), intra-abdominal abscess (IAI), secondary interventions (percutaneous drainage or operation), Emergency Department (ED) visits, and 30-day readmission.

Results: A total of 1,796 subjects were included for analysis. In comparing Narrow (n=665) vs. Broad (n=1,131) groups, there was no difference in age (39±16 vs. 40 ±16 yrs, p=.266), male sex (49% vs. 52%, p=.186), weight (82.6±21.5 vs. 83.6 ±21.2 kg, p=.352), current tobacco use (18% vs. 17%, p=.125), immunosuppression (4% vs. 4%, p=.763), WBC count (13.2±4.0 vs. 13.6±4.6, p=.053), Alvarado score (6±1 vs. 6±2, p=.636), or Charlson Comorbidity Index (0[0-1] vs. 0[0-1], p=.478). A total of 636 (35%) received post-operative antibiotics, (219 (33%) in the Narrow and 417 (37%) in the Broad group, p=0.092). Of those receiving post-operative antibiotics, 349 (55%) received post-operative antibiotics for ≥ 24 h for a median duration of 4 [2,8] days (88 (40%) in the Narrow and 261(63%) in the Broad group, p<0.001). Cumulative incidence of SSI, IAI, secondary interventions, ED visit, and hospital readmissions are displayed in the Table. Only secondary interventions were significantly more common in the Broad group.

Conclusion: Significant practice variation in duration and spectrum of antibiotic adjunct for surgical treatment of simple acute appendicitis treatment is evident and broad-spectrum antibiotics did not offer clinical advantages over narrow-spectrum antibiotics. Restriction of antibiotic spectrum should be considered, though randomized trials are required to overcome selection bias.

 

34.09 Surgical Management during Non-elective Admission for Incisional Hernia Decreases Readmission Rate

Posted on January 31, 2019

G. T. Rives1, W. C. Beck1, J. R. Taylor1, B. Davis1, A. Bhavaraju1, M. K. Kimbrough1, R. D. Robertson1, S. Karim2, R. J. Reif2, K. W. Sexton1  1University of Arkansas for Medical Sciences,Department Of Surgery,Little Rock, AR, USA 2University of Arkansas for Medical Sciences,College Of Public Health,Little Rock, AR, USA

Introduction:
The management strategy for non-elective admissions for incisional hernia is variable.  Patients are either managed medically or surgically, a decision which is physician dependent with morbidity and symptomatology most often guiding treatment. While surgery is the more definitive treatment, there is no widely accepted guideline in the approach to treating incisional hernias. Although readmission data is lacking, it was our goal using the data available to evaluate the rate of readmission when comparing the two modalities.  We hypothesized that while increasing cost, surgical management would decrease readmissions.

Methods:
The national readmission database was queried for all patients admitted with the diagnosis of incisional hernia from 2010 through Q3 2015 using ICD-9 diagnosis codes.  There were 208,239 patients with non-elective admissions. Univariate and bivariate statistics were performed with JMP PRO (Cary, NC) comparing retrospective data available on the length of stay, readmission rate, Elixhauser Readmission Score, Elixhauser Mortality Score, and total costs amongst the two modes of treatment.

Results:

When comparing medical to surgical therapy, 162,473 patients were managed medically whereas 45,766 underwent surgical treatment.  The average length of stay was 6.1 days and 8.5 days for medical and surgical therapy, respectively. The readmission rate was 19.3% for medical management compared to 6.6% for those managed surgically. The Elixhauser Readmission and Mortality Scores were 19.4/6.35 for medical therapy and 12.2/3.8 for surgical therapy. In regard to costs, the total cost all admissions was $68,175 for patients managed medically and $98,464 for those managed surgically. These results are summarized in Table 1. Of patients with initial medical therapy that were readmitted (31,355), 1018 (3.25%) underwent operative therapy on first readmission.  An additional 4,690 eventually underwent an operation for 18.2% of the total readmitted population. Of patients with initial surgical therapy that were readmitted (n= 3,028), 52% (n=1567) underwent an operation on their first readmission.

Conclusion:
Operative management of patients admitted non-electively with incisional hernia decreases readmission rate and increases cost.  Furthermore, up to 18% of patients in the medical therapy group eventually underwent operative therapy. Those patients managed medically had an average length of stay 2.4 days shorter than those managed surgically. Patients medically managed also had a higher Elixhauser Mortality Score indicating a greater degree of morbidity amongst the group. Further work needs to be done to determine the optimal management strategy of non-elective admissions for incisional hernia.

34.08 A Qualitative Study of Surgical Coaching as a Mechanism to Challenge the Surgical “Personality"

Posted on January 31, 2019

M. E. Byrnes1, T. A. Engler1, C. C. Greenberg2, B. T. Fry1, J. B. Dimick1  1University Of Michigan,Department Of Surgery & Center For Health Care Outcomes And Policy (CHOP),Ann Arbor, MI, USA 2University Of Wisconsin,Department Of Surgery & Wisconsin Surgical Outcomes Research Program (WiSOR),Madison, WI, USA

Introduction:

The “surgical personality” is a mostly negative academic and cultural image of the surgeon as egotistical, paternalistic, and inflexible.  Because of this image, surgeons have been viewed as resistant to change and some behaviors, vulnerability for example, are viewed as “suspect” because they seemingly threaten professional competency.  We report on exit interviews of surgeons who participated in a coaching program and demonstrate how their narratives challenge the surgical “personality” and forge an evolving and more open professional surgical identity suggesting a shift in surgeon identity and culture. 

Methods:

We interviewed n = 34 bariatric surgeons at the end of a two-year surgical coaching program.  Transcribed interviews were analyzed in NVivo, computer-assisted qualitative data analysis software.  Coding of transcripts were approached through iterative steps.  We utilized an exploratory method; each member of our team independently examined three transcripts to evaluate emergent themes early in the investigation.  The team met to discuss our independent themes and develop the codebook collectively.  We created a descriptive framework for our first round of coding based on emerging themes.  We employed a second round of coding to further our analysis using an interpretive framework.

Results: 

Three major themes emerged from our data.  Participants in this study discussed the ways that participation in the coaching program initially conflicted with their identity as a competent professional.  Surgeons were acutely aware how participation might have destabilized their surgical identity because they might be viewed as vulnerable.  Despite these concerns about image, surgeons were open and committed to their own professional or personal improvement via coaching.  Surgeons largely reported that coaching allowed them to reflect on their practices and find spaces of vulnerability in a profession that does not always value reflection.  Finally, surgeons report that the safe spaces of intentional coaching contributed to their ideas about how surgeons, and ultimately surgery, can change. 

Conclusion:

The surgical “personality” did not exist in our data as it has been described in the literature.  Surgeons do report having recognition and concern for their image yet, this professional image is related to their success as a competent professional and not because of some psychological defect or “paranoia”.  Participation in a coaching program challenged how surgeons thought of themselves in relationship to social and peer expectations.  Our results indicate that surgeons do feel peer and social pressures related to identity but are much more complex and nuanced than what social scientists have imagined.  The safe space of intentional coaching allowed participants to practice vulnerability and commit to improvement without their commitment being viewed as suspect or incompetence. 

34.07 Excellent Pain Control and Patient Satisfaction Without Opioids After Laparoscopic Cholecystectomy

Posted on January 31, 2019

A. K. Hallway2, J. Santos-Parker1, J. Lee1,2, J. Vu1,2, W. Palazzolo2, J. Waljee1,2, C. Brummett1, M. Englesbe1,2, R. Howard1,2  1University Of Michigan,Medical School,Ann Arbor, MI, USA 2University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction: Excessive opioid prescribing after surgery results in leftover medication being introduced into the community. Moreover, 5-20% of patients who receive an opioid prescription after surgery will become chronic opioid users. Minimizing post-operative opioid prescriptions may mitigate the risk of overdose, chronic opioid use, and reduce the number of opioids entering the community.

Methods: A pilot study was conducted in adult patients undergoing laparoscopic cholecystectomy at a single academic health system. A novel, opioid-sparing pathway (Pain-control Optimization Pathway [POP]) was utilized in which patients elect to receive education about managing their post-operative pain without opioids. Patients receive instructions for staggered non-opioid (ibuprofen and acetaminophen) pain management along with a “rescue dose” of 4 oxycodone tablets. These patients were then surveyed 30-90 days after surgery and compared to a statewide cohort of similar patients undergoing traditional laparoscopic cholecystectomy (non-POP) to assess medication use, satisfaction, regret, and pain.

Results: Of the 28 patients currently enrolled in POP, five have reached the 30-day post-operative time-point and responded to the survey. A statewide database of 100 non-POP patient responses were used for comparison. There were no significant differences in age or sex between groups. All POP patients received acetaminophen and ibuprofen and a rescue prescription of 4 oxycodone tablets (30 oral morphine equivalents [OMEs]). Non-POP patients received an average of 33±14 opioid tablets (200±138 OMEs; P<0.001). POP patients used an average of 0.8±1.8 tablets (6±13.5 OMEs) compared with 14±16 tablets (89±136 OMEs) in non-POP patients (P<0.001). 80% of POP patients did not use any opioids compared to 24% of non-POP patients. POP patients had 3.2±1.8 tablets (24±13.4 OMEs) remaining per patient while non-POP patients had 19±14 opioid tablets (111.0±90 OMEs) remaining per patient (P<0.001). 100% of POP patients indicated that their pain was manageable with the opioid-sparing model, with no significant differences in surgical site pain after surgery between groups. There were no significant differences in patient satisfaction or regret to undergo surgery between groups.

Conclusion: Opioid-sparing pain control resulted in lower opioid consumption, reduced leftover medication, and provided similar pain control and satisfaction compared to non-POP patients. These preliminary findings suggest that opioid-sparing pain management after surgery is a feasible strategy to eliminate excess pills from entering the community and possibly mitigate the risk of chronic opioid use.

34.06 Acute Cholecystitis at Safety-Net Hospitals: A Multi-factorial Approach Towards Improvement in Care

Posted on January 31, 2019

S. Singh1, S. Armenia1, A. Merchant1, D. H. Livingston1, N. E. Glass1  1New Jersey Medical School,Department Of Surgery,Newark, NJ, USA

Introduction:
Evidence supports index over interval cholecystectomy for patients admitted with acute cholecystitis. Though studies have shown poorer outcomes at safety-net hospitals (SNH), the effect of SNH has been considered as a single variable and not been stratified by other factors such as payer status and hospital characteristics. Our hypothesis was that for the underinsured, SNH will provide a higher level of care compared to non-SNH. We compared the treatment of patients with acute cholecystitis using index cholecystectomy and length of stay (LOS) as proxies for quality and cost of care between SNH and non-SNH controlling for insurance status, hospital region, size, and teaching status.

Methods:
National Inpatient Sample 2012-2014 was queried for all patients ≥18 years with acute cholecystitis. The primary and secondary outcomes of interest were index cholecystectomy and LOS, respectively. Proportion of Medicaid and uninsured discharges were used to define SNH (highest quartile) and non-SNH (lowest quartile). Multivariate logistic regression was used to calculate associations between outcomes and the effect of SNH designation, stratified by insurance status and hospital characteristics, while controlling for other factors such as demographics and comorbidities.

Results:
403,370 discharges with acute cholecystitis were identified (241,505 SNH; 161,865 non-SNH). SNH discharges were younger, more male, less white, and had fewer comorbid conditions than those at non-SNH (all p < 0.0001). SNH and non-SNH discharges had similar rates of index cholecystectomy, except at SNH in the northeast (OR: 0.74, p = 0.001). Patients at SNH had longer LOS for acute cholecystitis regardless of treatment; cholecystectomy or no surgery. When controlling for insurance status, patients at SNH had longer lengths of stay compared with non-SNH: Medicare (OR: 1.17, p = 0.0076), private insurance (OR 1.18, p = 0.0489), and uninsured discharges (OR: 1.47, p = 0.0159).  There was also increased LOS in SNH relative to non-SNH in the Midwest, in urban non-teaching and teaching hospitals, and in large hospitals (all as defined by NIS; 1.36, p = 0.0195; 1.28, p = 0.0111; 1.29, p = 0.0037; 1.25, p = 0.0202).

Conclusion:
Quality of care disparities cannot be explained by simply examining SNH status as a single independent variable. Instead the effect of SNH on outcomes is a complex relationship between other variables like insurance status, region, teaching status of hospital, etc. While our data did not demonstrate superiority of care for uninsured patients at SNH we did show general equivalence of care with respect to index cholecystectomy.  Regional differences in cholecystectomy in the northeast require further exploration. The variability and increased LOS at SNH highlight potential opportunities to further improve quality and decrease cost of care at our most vulnerable hospitals. 
 

34.05 The Impact of Diagnosis on Patient Satisfaction in a Large Sample of General Surgery Outpatients

Posted on January 31, 2019

N. Bandealy1, V. R. Rendell1, K. A. LeRette2, M. A. Leaf2, E. R. Winslow1  2UW Health,Enterprise Analytics,Madison, WI, USA 1University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction: Growing emphasis on Value Based Purchasing and patient-reported outcomes has increased interest in drivers of patient satisfaction. While demographic and other patient-related factors are known to impact satisfaction, the role of disease-related factors, specifically primary diagnosis, is not well studied. We aimed to determine if primary diagnosis affects satisfaction scores in the surgical outpatient setting.

Methods:  Primary diagnosis was examined in relation to patient experience scores as reported in Medical Practice Survey responses of general surgery patients seen in an outpatient setting from July 2016-2018. Diagnoses with similar presentations, treatments, and prognoses were merged into groups prior to viewing survey results to ensure unbiased sorting. Groups with fewer than 50 surveys were excluded. Chi squared univariate analyses compared the percentage of top box responses to three key survey questions regarding provider and overall clinic evaluation across patient, clinic, provider, and survey-related variables. Multivariate logistic regression was performed to determine factors associated with top box responses.

Results: Survey results were extracted for 1,262 patients across 6 clinical groups:  breast cancer (n=411), benign gallbladder disease (n=83), hernias (n=285), thyroid/parathyroid hormonal disorders (n=161), and hormonally inactive thyroid masses and cancer (n=225). On univariate analyses, female patients had higher percent top box scores for question 1 (Time spent with provider) and question 3 (Likelihood of recommending the clinic) (p<0.05). Female providers had higher percent top box scores for question 1 and question 2 (Likelihood of recommending provider) (p<0.05).  Responses to questions 2 and 3 differed by clinic location (p=0.01 and p=0.04, respectively) and by diagnosis group (p=0.001 and p=0.02, respectively). On multivariate analyses, only diagnosis group r­­­­­­­­­­­­­­­­­­­emained significant for all three questions (Table 1). Patients in the breast cancer group were more likely to recommend the clinic than patients in all but one diagnosis group. They were also more likely to recommend their provider than the thyroid/parathyroid hormonal disorders group. Clinic location was significant for the amount of time provider spent and likelihood of recommending clinic, but was not significant for the likelihood of recommending the provider.

Conclusion: For general surgery outpatients, breast cancer patients have higher satisfaction scores compared with patients with several other examined diagnoses on multivariate analyses. This suggests diagnosis alone may influence outpatient patient satisfaction survey results. Institutions should consider the role diagnosis plays when evaluating provider performance.

 

34.04 The Effect of Primary Language on Emergency General Surgery Outcomes: A Statewide Database Study.

Posted on January 31, 2019

T. Feeney2,3, S. Sanchez1,2, T. Brahmbhatt1,2, R. Schulze1,2, P. Burke1,2, G. Kasotakis1,2, T. Dechert1,2, F. T. Drake2,3  1Boston Medical Center,Section of Acute Care And Trauma Surgery,Boston, MA, USA 2Boston University School of Medicine,Department Of Surgery,Boston, MA, USA 3Boston Medical Center,Section Of Surgical Endocrinology,Boston, MA, USA

Introduction:  Emergency General Surgery (EGS) represents a diverse set of operations performed on acutely ill and injured patients. The EGS patient population is diverse and increasingly from less advantaged cohorts, who have a higher likelihood of not speaking English (ENG). However, the effect of primary language on EGS outcomes has not been studied. We aimed to evaluate the effect of non-English primary language on outcomes following EGS operations.

Methods:  The New Jersey Statewide Inpatient Database from 2009-2014 was used to evaluate cases identified as representing 80% of the national EGS case volume. Cases were restricted to ages >18, resulted from emergency department admissions, were noted to be emergent or urgent, and were performed between 0-2 days after admission. We evaluated outcomes for Spanish speakers (SPA) speakers and non-English/non-Spanish (NENS) speakers compared to ENG speakers. Outcomes were in-hospital mortality, 7-day readmission, and hospital length of stay (LOS). Generalized linear mixed models were used to account for hierarchy in the data, and logistic and negative binomial regression were used to estimate odds ratios and incident rate ratios respectively. Sensitivity analysis was performed to assess whether missing confounding variables could ablate effect estimates.

Results: 105,174 patients were included. A majority of ENG speakers were white and had private insurance; SPA speakers were younger and had fewer comorbidities. Where differences between SPA and NENS speakers existed, NENS speakers were more like the ENG speaking group. Readmission exhibited high between-hospital variability. Regression results are shown in the results table. After adjusting for operative risk, comorbid conditions, social determinants of health, and intra-hospital correlation, we found that non-English speakers had reduced LOS after appendectomy and lysis of adhesions. However, SPA speakers had an increased LOS following highest risk operations. There was no difference in mortality or short-term readmission in either language group compared to ENG. Sensitivity analysis indicated that the observed decreases in LOS were not robust to unmeasured confounding, while the increase in LOS among SPA speakers in the highest risk procedures was robust to additional confounding.

Conclusion: These data suggest SPA speakers are younger and healthier than ENG speakers, and that NENS speakers are more like ENG speakers than SPA speakers. Primary language does not have an independent impact on readmission or inpatient mortality following EGS operations. The effect of primary language on LOS after EGS depends on the type of operation. Future studies should focus on long term outcomes and generalizability to other regions of the United States.

34.03 Post-Discharge Opioid Utilization in Laparoscopic versus Open Inguinal Hernia Repair

Posted on January 31, 2019

A. W. Knight1, E. B. Habermann1, D. S. Ubl1, M. D. Zielinski1, C. A. Thiels1  1Mayo Clinic,Trauma, Critical Care, And General Surgery,Rochester, MN, USA

Introduction: Open inguinal hernia repair (IHR) is thought to cause worse postoperative pain than minimally invasive surgery (MIS). Accordingly, these patients are often prescribed more opioids at discharge. We aimed to evaluate opioid use in patients undergoing IHR to optimize discharge prescribing practices for this common procedure.

Methods: Opioid-naïve adults undergoing open or MIS IHR were prospectively identified from three centers (3/17-11/17) to complete a 29-question telephone interview on median day 26 (IQR 23-30) following discharge. Opioid prescription and consumption data were converted into Morphine Milligram Equivalents (MMEs) and compared between MIS and open IHR. Univariate Chi-square, Fisher’s exact test, univariate, and multivariable logistic regression were used.

Results: Of 279 patients, 202 (72%) completed the survey and were included (n=100 open, n=102 MIS). Patients undergoing open IHR were slightly older (71 vs 65, p<0.001) and less likely to be female (5% vs 17%, p=0.008) than MIS patients. There was no difference in BMI (p>0.05). MIS IHR patients were more likely to have a bilateral IHR (open 5% vs MIS 48%, p<0.001). Discharge pain scores were similar (open 2.3±1.7 vs MIS 2.4±1.6; p=0.63).

Open IHR patients were more likely to receive opioids at discharge than those undergoing MIS IHR (98% vs. 90% MIS; p=0.03) and were prescribed slighter greater amounts of opioids (open 153 MMEs vs 150 MIS; p=0.049). There was no difference in opioid use by approach (open 15 MMEs vs 8 MIS; p=0.35). Most patients used less than 50 MMEs (open 72% vs MIS 75%; p=0.54). Over one-third of patients used no opioids (open 39% vs MIS 44%; p=0.50). 75% of prescribed opioids remained unused at time of survey. 11% of patients disposed of unused opioids. Mean days from surgery to cessation of opioid use was 2.6±3.9.

Most patients were satisfied with postoperative pain control (open 86% vs MIS 95%; p=0.09). However, the open group was more likely to report not being prescribed enough opioids at discharge (open 10%, MIS 1%; p=0.02). Bilateral repair was not associated with increased opioid use (univariate OR 1.23, p=0.56). On multivariable analysis, low discharge pain and normal BMI were independently associated with needing no opioids at discharge (Figure).

Conclusion: Post-discharge opioid utilization is similar between patients undergoing open and MIS IHR. Depending on patient factors, 0 to 8 tabs of 5 mg oxycodone is sufficient for most opioid-naïve patients undergoing IHR.

34.02 Impaired Respiratory Mechanics and Repetitive Atelectasis during Laparoscopic Abdominal Surgery

Posted on January 31, 2019

S. Murphy1, C. Love4, M. W. Breidenstein2, M. Rafferty4, A. Friend2, J. Bates3, G. Tharp2, P. Bender2  4University Of Vermont College Of Medicine / Fletcher Allen Health Care,College Of Medicine,Burlington, VT, USA 3University Of Vermont College Of Medicine / Fletcher Allen Health Care,College Of Engineering And Mathematical Sciences,Burlington, VT, USA 1University Of Vermont College Of Medicine / Fletcher Allen Health Care,General Surgery,Burlington, VT, USA 2University Of Vermont College Of Medicine / Fletcher Allen Health Care,Department Of Anesthesia,Burlington, VT, USA

Introduction:

Laparoscopic abdominal surgery and general anesthesia alter respiratory mechanics, which can lead to postoperative pulmonary complications (PPC). PPC mechanisms are not understood but may partly depend on ventilation technique.  Lung protective ventilation strategies pioneered in the ICU have had some success in the OR but are not yet standardized.  One component of intraoperative ventilation that may reduce lung trauma is individualization of positive end expiratory pressures (PEEP) to maintain a positive transpulmonary pressure (TPP). The TPP is a summation of forces experienced by the alveoli and is the difference between airway pressure (Pao) and intrapleural pressure (Ppl). When TPP is positive, the alveoli open; when TPP is negative, the alveoli close.  TPP can be estimated using esophageal manometry, which approximates Ppl, by the equation PTPP=Pao–Pes, where Pes is the esophageal pressure. We hypothesized that subjects undergoing robotic abdominal laparoscopic surgery (RALS) would have negative TPP at end-expiration (TPPexp), positive TPP at end-inspiration (TPPins), and that TPP would decrease with insufflation and Trendelenberg positioning (Tberg).

Methods:

We conducted a cross-sectional study of pulmonary mechanics in subjects having RALS at the University of Vermont Medical Center. Using a flow meter and esophageal manometry we calculated TPPexp and TPPins after subjects were intubated and supine, then supine with abdominal insufflation, insufflated and in Tberg, and finally, supine and desufflated.  TPP data were extracted from 2–3 minutes of stable ventilation using a single compartment model of pulmonary mechanics. Data were analyzed using repeated measures ANOVA. A p <0.05 was considered significant. Data are presented as mean±s.d cmH2O.

Results:

We recruited 28 subjects undergoing RALS.  Not all positions had reliable data for 2–3 minutes.  We found mean TPPexp following intubation to be –3.9±5.2 with mean TPPins of 3.2±4.1 (n=28). Once insufflated with pressures ranging from 12–16mmHg, TPPexp fell to–6.9±6.1 with TPPins of 2.7±3.4 (n=27). With Tberg between 13–30?, mean TPPexp was –7.7±6.0 with TPPins of 3.3±3.4 (n=27). After returning to supine and desufflated, TPPexp averaged –3.8±5.1 with TPPins of 4.0±3.8 (n=20). Repeated measures ANOVA showed insufflation and Tberg significantly decreased TPPexp (p<0.001) compared to the initial supine position.

Conclusions:

Even without abdominal pressure from insufflation and Tberg, the changes in TPP show cycling of the alveolar units, concerning for atelectatic trauma. Abdominal insufflation and head-down positioning contributed significantly to atelectatic cycling. Our results suggest that PPC may be related to repeated atelectasis from ventilation parameters and imply individualized changes in PEEP could improve respiratory dynamics in the surgical patient.

34.01 Incidence and Trends of Acute Renal Failure following Emergency General Surgery Operations

Posted on January 31, 2019

B. Kavianpour1,2, Y. Sanaiha1, A. L. Mardock1, H. Xing1, S. Yazdani1, P. Benharash1  1David Geffen School Of Medicine, University Of California At Los Angeles,Cardiothoracic Surgery,Los Angeles, CA, USA 2Stony Brook University School of Medicine,Department of Medicine,Stony Brook, NY, USA

Introduction:

Acute renal failure (ARF) and progression to hemodialysis (HD) have been shown to significantly impact patient morbidity and mortality in various operations. The incidence of severe perioperative renal dysfunction in high acuity patients has not been well-explored at the national level.  Thus, the present study aimed to evaluate the trends of perioperative ARF and HD incidence and associated mortality amongst emergency general surgery patients (EGS).

Methods:

This was a retrospective cohort study using the National Inpatient Sample to identify all adult patients (>18 years) without a prior history of chronic kidney disease who underwent an EGS procedure from 2008-2015. EGS was defined as small and large bowel resection, cholecystectomy, appendectomy, lysis of adhesions, and surgical management of ulcer disease. The study cohort was stratified into three groups: without ARF, ARF, and ARF requiring HD. A multivariable logistic regression model was developed to predict the odds of mortality and composite complications with the occurrence of perioperative ARF and/or HD. Non-parametric trend analyses of incidence and associated mortality were performed on ARF and HD patient populations.

Results:

Of an estimated 6,781,918 patients who underwent EGS during the study period, 501,678 (7.4%) patients developed ARF and 30,334 (0.4%) patients required HD. Compared to patients without ARF, ARF and HD patients were significantly older (ARF: 67.6y vs 51.2y, P<0.0001; HD: 63.2y vs 51.2y, P<0.0001) and had higher Elixhauser comorbidity scores (ARF: 3.3 vs 1.7, P<0.0001; HD: 3.4 vs 1.7, P<0.0001). Over the eight-year study, the incidence of ARF (5.4 to 9.8%, P<0.0001) significantly increased while the incidence of HD remained unchanged at 0.4% (P=0.07) (Figure 1). The in-hospital mortality rates for ARF (20.8% to 14.0%, P<0.0001) and HD (44.7% to 40.6%, P=0.0181) significantly decreased from 2008 to 2015 (Figure 1). The occurrence of ARF increased the odds of complications by 162% (OR=2.62, P<0.0001) and mortality by 120% (OR=2.20, P<0.0001) while HD increased the odds of complications by 925% (OR=10.25, P<0.0001) and mortality by 287% (OR=3.87, P<0.0001).

Conclusion:

In this national study, we found that the incidence of perioperative ARF significantly increased for the EGS population without a concomitant increase in HD. Both ARF and HD were associated with significantly higher odds of morbidity and mortality. An ongoing investigation of novel methods of perioperative ARF prevention, early detection, and intervention is warranted to improve the value of care for EGS patients.

33.10 Technical Innovation in Transoral Endoscopic Endocrine Surgery: A Modified “Scarless” Technique

Posted on January 31, 2019

I. Suh1, C. Viscardi1, Y. Chen1, I. Nwaogu1, R. Sukpanich1, J. E. Gosnell1, W. T. Shen1, C. D. Seib1, Q. Duh1  1University Of California – San Francisco,Department Of Surgery, Endocrine Surgery Section,San Francisco, CA, USA

Introduction:  The transoral endoscopic approach for thyroid and parathyroid surgery is the latest remote-access endocrine surgical technique aiming to eliminate a visible anterior neck incision in selected patients. The early experience in North America has demonstrated promising safety and efficacy results, but as expected has uncovered unique challenges and drawbacks.  We present a case series of our institutional experience and evolution in the technique in response to our perceived challenges.

 

Methods:  We reviewed all patients who successfully underwent transoral endoscopic thyroid and parathyroid surgery at our institution from 4/2017-6/2018.  A technical innovation to the technique was introduced midway in the experience.  Demographics, surgical indications, technical details, and perioperative outcomes were recorded in a prospective database and analyzed retrospectively. 

 

Results: 13 patients underwent transoral endoscopic thyroid and parathyroid surgery, with mean follow-up of 23 weeks.  Mean age was 39 years, and all but one were female. Eleven patients underwent thyroidectomy and 2 patients underwent focused parathyroidectomy.  Of the ten patients who underwent thyroidectomy for nodular disease or papillary thyroid carcinoma, the FNA cytology and mean nodule size were as follows: 1) Bethesda II nodules: 3.1 cm (n=6); 2) indeterminate nodules: 3.3cm (n=1), and 3) papillary thyroid carcinoma: 1.2cm (n=3).  There were no injuries to the recurrent laryngeal or mental nerves.  One patient undergoing total thyroidectomy had transient hypocalcemia which resolved within 1 month.  

The first 5 cases were performed with the traditional transoral endoscopic technique with 3 incisions in the oral vestibule.  Amongst these cases, 3 patients complained of pain at the midline of the chin that lasted for 3 months.  The capsules of two specimens for benign or indeterminate nodules were disrupted in the specimen retrieval bag during extraction through the mouth.  In response, we developed a hybrid transoral and submental technique (TOaST) in which the 1cm middle incision is placed in a hidden submental location (Figure).  The subsequent 8 cases were performed with this hybrid approach.  There were no differences in technique-specific complications between the traditional and TOaST approaches.  The TOaST approach had no instances of significant chin pain or specimen disruption, and cosmetic outcomes remained excellent.

 

Conclusion: We present a pilot series of our institution’s evolution in the transoral endoscopic approach to thyroid and parathyroid surgery, incorporating a technical innovation that addresses unique challenges that we identified in this procedure and population.

 

33.09 Extent of Surgery for Low Risk Thyroid Cancer in Elderly: Equipoise in Survival, but Not in Short-Term Outcomes.

Posted on January 31, 2019

A. Zambeli-Ljepovic1, F. Wang1, M. Dinan1, T. Hyslop1, M. T. Stang1, S. Roman2, J. A. Sosa2, R. Scheri1  1Duke University Medical Center,Durham, NC, USA 2University Of California – San Francisco,San Francisco, CA, USA

Introduction:
Papillary thyroid cancer (PTC) is the fastest increasing cancer in the U.S. Despite an excellent prognosis for PTC overall, treatment has not been standardized for the elderly population, who are also more likely to suffer complications from thyroid surgery. This study aims to describe how extent of surgery (total thyroidectomy vs. lobectomy) and administration of radioactive iodine (RAI) affect complications, readmissions, and emergency department (ED) visits among elderly patients with low risk PTC. 

Methods:
The linked SEER-Medicare database was used to identify patients ≥66 years treated for clinical T1N0M0 PTC between 1996 and 2011. Multivariable logistic regression was used to evaluate the effect of extent of surgery, RAI administration, and other factors on endocrine and RAI-specific complications, 90-day readmissions, and ED visits that did not result in admission. Complications occurring ≤30 days after surgery were defined as short-term; those present ≥6 months after surgery were considered long-term.

Results:
3341 patients met inclusion criteria; 77.3% were women, mean age was 72.9 years, mean tumor size was 0.8 cm, and 56.1% of tumors were found incidentally. Overall, 67.6% underwent total thyroidectomy, 32.4% underwent lobectomy, and 31.8% received postoperative RAI. Among patients who were known preoperatively to harbor PTC, 78.5% were treated with total thyroidectomy. Lobectomies outnumbered total thyroidectomies in the outpatient setting (37.7% vs. 27.6% respectively, P < 0.01). On multivariable analysis, patients treated with total thyroidectomy were more likely to have short-term complications [odds ratio (OR) 1.99, P < 0.01] and to be readmitted after surgery (OR 1.59, P < 0.01). Short-term complications were also independently associated with female sex (OR 1.34), black race (vs. white, OR 1.65), and comorbidity index (≥2 vs. 0, OR 1.43); all P < 0.01. Long-term endocrine complications were more common in female patients (OR 1.37, P = 0.025). Black patients and those with ≥2 comorbid conditions were more likely to present to the ED (OR 1.50 and 1.92, respectively) and to be readmitted after surgery (OR 2.19 and 2.29); all P < 0.01. RAI ablation was independently associated with complications of the eyes and salivary glands (OR 2.19, P < 0.01); RAI was not associated with an increased risk of ED visits or readmissions.

Conclusion:
Most elderly patients with low risk PTC undergo total thyroidectomy and a third receive postoperative RAI, treatments that place patients at risk for potentially avoidable complications and readmissions, since evidence does not support a survival benefit. Black and female patients appear to have greater inequities in access to quality care. There remain opportunities to improve postoperative health and quality of life while preserving the excellent prognosis of PTC.

« Previous Page
Next Page »