67.02 Role Of Expertise In Nodal Dissection For Gastric Cancer

Posted on January 26, 2017

B. A. Borraez-Segura1,2, R. Oliveros1, O. Guevara1, M. E. Manrique1, I. D. Martin2, B. A. Borraez-Segura1,2  1Instituto Nacional De Cancerologia,Gastrointestinal Surgery And Digestive Endoscopy,Bogota, BOGOTA, Colombia 2Fundación Clinica Shaio,General Surgery,Bogota, BOGOTA, Colombia

Introduction:  Surgical expertise is the perfect match between theory and practice in surgery. For surgeons, nodal dissection improves survival in patients with diagnosis of gastric cancer, but the proper procedure requires the proper surgical and academic skills. Even being clear that D2 dissection is the standard of treatment, the number of nodes is a representation of the optimal treatment for gastric cancer and is directly associated with surgical expertise. The aims of this study were to determine: (a) the number of nodes dissected during a total and subtotal gastrectomy by general and by gastrointestinal surgeons; and  (b) how often a proper nodal dissection was performed by the two groups.

Methods:  Review of a prospectively set database. We compare the pathology report of 144 patients who underwent total or subtotal gastrectomy for gastric cancer in terms of nodal dissection for general (Group A) and gastrointestinal surgeons (Group B). 

Results: In 58 of the 144 patients (40,3 %) the gastrectomy was performed by general surgeons and in 86 patients (59,7 %) it was performed by gastrointestinal surgeons. The average of nodes resected in the group A and B were 22,7 ± 9,9 and 32,6 ± 15 respectively (p=0,0001).  A proper D2 Gastrectomy (more than 15 nodes) was performed in 77,6 % of the patients in group A, and 96,5% of the patients in group B. 

Conclusion: The results of this study show that in patients with gastric cancer: (a) the number of resected nodes during a gastrectomy was higher in procedures performed by gastrointestinal surgeons, and (b) a proper nodal dissection for gastric cancer was performed more frequently by the same group. The findings suggest that in patients who underwent surgery for gastric cancer, the technical and academic skills play an important role and may improve survival.

 

66.10 eCART Before the Hearse: Predicting Severe Adverse Events in Over 30,000 Surgical Inpatients

Posted on January 26, 2017

B. Bartkowiak1, A. M. Snyder1, A. Benjamin2, A. Schneider2, N. M. Twu1, M. M. Churpek1, D. P. Edelson1, K. K. Roggin2  1University Of Chicago,Department Of Medicine,Chicago, IL, USA 2University Of Chicago,Department Of Surgery,Chicago, IL, USA

Introduction:  Postoperative clinical deterioration on the wards is associated with increased morbidity, mortality, and cost.  Early warning scores (EWSs) have been developed to detect inpatient clinical deterioration and trigger rapid response activation more generally, but little is known about the specific application of EWSs to postoperative inpatients.

Methods:  We aimed to assess the accuracy of three general EWSs for predicting severe adverse events (SAE) in postoperative inpatients. We conducted a retrospective cohort study of adult patients hospitalized on the wards following operative procedures at an academic medical center in the United States from 11/2008 to 1/2016.  We compared the Modified Early Warning Score (MEWS), National Early Warning Score (NEWS), and the electronic Cardiac Arrest Risk Triage (eCART) score. The maximum scores from postoperative ward locations were used for analysis. SAE were defined as ICU transfer, ward cardiac arrest, or ward death in the postoperative period.  Accuracy was evaluated using the area under the receiver operating characteristic curve (AUC).  Patients with multiple operations were censored at the start of the second procedure.

Results: Of the 30,009 patient admissions included in the study, 4% (n=1,530) experienced a SAE a median of 2 days (IQR; 0.3-5.6) following the procedure.  Patients who experienced a SAE reached higher maximum scores during their postoperative stay with the following median (IQR) values: eCART, 58 (12-159) vs 12 (7-23); MEWS, 4 (3-6) vs 3 (2-3); and NEWS, 9 (7-11) vs 6 (4-7).  The accuracy for predicting the composite outcome was highest for eCART (AUC 0.80 [CI; 0.79-0.81]), followed by NEWS (AUC 0.77 [CI; 0.75-0.78]), and MEWS (AUC 0.75 [CI; 0.74-0.77]); see figure. Of the individual vital signs and labs, high respiratory rate was the most predictive (AUC 0.70) and high temperature the least (AUC 0.48).

Conclusion: EWSs are predictive of SAEs in postoperative surgical patients. eCART is significantly more accurate in this patient population than both NEWS and MEWS. Future work validating these findings multi-institutionally and determining whether the use of eCART improves the outcomes of high-risk post-operative patients is warranted.

66.09 Preoperative Depression is Associated With Adverse Post-Surgical Outcomes in General Surgery Patients

Posted on January 26, 2017

D. S. Lee1,2, L. Marsh3,4, M. Garcia-Altieri3,4, K. Makris1,2, L. Chiu1,2, N. Becker1,2, S. S. Awad1,2  3Baylor College Of Medicine,Psychiatry,Houston, TX, USA 4Michael E. DeBakey VA Medical Center,Psychiatry,Houston, TX, USA 1Baylor College Of Medicine,General Surgery,Houston, TX, USA 2Michael E. Debakey VAMC,General Surgery,Houston, TX, USA

Introduction:  Depression is a common comorbidity in surgical patients and is associated with adverse post-operative outcomes for a variety of surgical procedures.  However, this association is not well studied for general surgery procedures, and the use of retrospective data to identify patients with depression has been shown to be highly unreliable.  

Methods:  202 consecutive patients who were scheduled for a variety of elective general surgery procedures were prospectively screened for depression using the Patient Health Questionnaire – 8 item scale (PHQ-8) during their pre-operative visit.  The PHQ-8 defines major depression by a score of 10 or greater and severe major depression by a score of 20 or greater.  Demographics, comorbidities, body mass index (BMI), serum albumin, wound classification, and American Society of Anesthesiologists (ASA) score were collected.  Operative time was used as a surrogate marker of operative complexity.  Outcomes of interest were surgical site infection (SSI), readmission (RA), and emergency room visits that occurred within 30 days of the index operation, and these complications were considered as one composite outcome variable.  T-test and chi square test were used for comparisons of continuous and categorical variables.

Results: Of the 202 patients screened, 171 underwent surgery as scheduled (42 depressed, 129 not depressed).  No significant differences were found in age, comorbidities, serum albumin, wound class, ASA score, or operative time.   Patients with major depression (PHQ-8 score ≥ 10) had a higher composite complication rate than non- depressed patients (21.4% vs. 13.2%, p=0.195).  By adjusting the threshold for diagnosing depression to a PHQ-8 score of 20 (severe major depression), we found that these patients had a higher complication rate than patients with a PHQ-8 score less than 20 (44.4% vs. 14.2%, p=0.012)

Conclusion: Depression is an under-recognized comorbidity and is associated with adverse outcomes after general surgery procedures.  Patients with more severe depressive symptoms may need to be referred to a mental health professional prior to surgery in order to optimize management of depression and decrease the chances for an adverse event.

 

66.08 Variations in HIDA Scan-based Gallblader Ejection Fractions Over Time in Suspected Biliary Dyskinesia

Posted on January 26, 2017

E. Wiesner1,2, L. Martin1,2, W. Peche1,2, J. Langell1,2  1University Of Utah,Department Of Surgery,Salt Lake City, UT, USA 2VA Salt Lake City Health Care System,Center Of Innovation,Salt Lake City, UT, USA

Introduction:  The diagnosis of biliary dyskinesia (BD) remains somewhat controversial.  However, the Rome IV Criteria for Functional Gastrointestinal Disorders outlines the clinical diagnostic requirements for BD. Many authors also recommend supportive confirmation of the diagnosis with cholecystokinin (CCK)-stimulated cholescintigraphy (hepatobiliary iminodiacetic acid [HIDA] scan) and calculation of gallbladder ejection fraction (GBEF).  No prior studies have evaluated the consistency and utility of repeat HIDA-GBEF imaging in patients with suspected BD.  Here, we conducted a retrospective study to evaluate HIDA-GBEF consistency overtime among patients with suspected BD. 

Methods:  We queried the Veteran’s Healthcare Administration National Corporate Data Warehouse from January 2005 to July 2016 for patients who underwent more than one HIDA. Patients undergoing HIDA for a suspected diagnosis of BD were included. Radiology reports were reviewed and the GBEF for each study was abstracted. The data were analyzed for changes in GBEF over time, specifically evaluating differences between studies and cross over from abnormal-to-normal and normal-to-abnormal diagnostic criteria.

Results: We identified 546 patients who underwent more than one HIDA scan during the study period.  522 underwent two HIDA scans, 23 underwent three HIDA scans, and 1 underwent four HIDA scans.  The initial EF was reported as normal in 365 patients (mean GBEF 68% +/-19) and reduced in 181 patients (mean GBEF 17% +/-10).  Of the patients with an initially normal GBEF, 97 patients (27%) had a reduced EF on subsequent imaging (average GBEF 64+/-19% versus 19.7+/-14%) with a mean time between studies of 33.7 months.  Of the patients with an initially low GBEF, 81 patients (45%) had a normal EF on subsequent imaging (average GBEF 18+/-11% versus 73+/-44%) with a mean time of 26.53 months between studies.

Conclusion: We found substantial variation in repeat HIDA scan data over time with about one-third of patients demonstrating a change in diagnostic criteria.  These data suggest that HIDA scan GBEF may have a low precision, calling into question its clinical value in the evaluation of BD.  Additional studies are necessary to determine the utility of HIDA-GBEF in the evaluation of patients with suspected BD.

 

66.07 Does Practice Make Perfect: The Impact of Resident Participation in Cholecystectomy at VA Hospitals

Posted on January 26, 2017

L. Martin1,2, C. Zhang1, A. Presson1, R. Nirula1, W. Peche1,2, B. Brooke1,2  1University Of Utah,Salt Lake City, UT, USA 2VA Salt Lake City Health Care System,Salt Lake City, UT, USA

Introduction:  Resident participation in operative cases within Veterans Administrative (VA) hospitals is often assumed to be associated with worse surgical outcomes.  While recent studies have evaluated the association between resident post-graduate year (PGY) and perioperative morbidity, this metric fails to capture resident participation as a function of case-level involvement.  We designed this study to examine resident participation as a function of training and case-level involvement on cholecystectomy performed at all PGY levels.

Methods:  We identify all cholecystectomies performed at nationwide VA hospitals from 2005 to 2014 using surgical CPT codes and then requested the corresponding Veterans Affairs Surgical Quality Improvement Project (VASQIP) dataset.  Resident participation was categorized (Levels 0-3) as a function of involvement as well as year of training (Table).  We performed multivariate regression analyses to examine the effect of resident participation on operative time and composite metric of peri-operative complications (intra-op transfusion, return to OR, or organ space infection) after adjustment for surgical approach (laparoscopic vs. open), diagnosis (cholelithiasis vs. cholecystitis), patient comorbidities, perioperative physiology, and preoperative laboratory values.

Results: A total of 32,833 patients were identified as having undergone either laparoscopic (82%) or open (17%) cholecystectomy for either acute or chronic cholecystitis (74%) or symptomatic biliary disease (26%).  Mean operative time was 102 min, and was found to be significantly increased for residents at each participation level when compared to an attending operating alone in multivariate models (Table).  The peri-operative complication metric occurred in 1436 cases (4%), and was found to be significantly increased in univariate analysis for resident participation at levels 2 (OR 1.24; p<0.05) & level 3 (OR 1.35; p<0.05) as compared to an attending operating alone.  However after adjusting for patient-level confounders in the multivariate model, resident participation level was not found to be significantly associated with a higher likelihood of peri-operative complications (Table).

Conclusion: While resident participation in cholecystectomy within VA hospitals is associated with increased operative time, there is no adverse effect on the rate of perioperative complications.  These findings suggest that resident involvement achieves education and training objectives without sacrificing quality of care.

66.06 Population-Based Evaluation of Enhanced Recovery Protocol Implementation in Michigan

Posted on January 26, 2017

E. George1, G. Krapohl3, S. E. Regenbogen2,3  1University Of Michigan,Health Science Scholars Program,Ann Arbor, MI, USA 2University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 3University Of Michigan,Michigan Surgical Quality Collaborative,Ann Arbor, MI, USA

Introduction:  Enhanced Recovery Protocols (ERP) are widely demonstrated to improve perioperative outcomes after colectomy, yet it remains unknown to what extent ERPs have been successfully implemented outside the high-volume and highly specialized institutions that pioneered them. Thus, we sought to quantify the extent of ERP uptake within a representative, population-based, statewide hospital collaborative, and to understand obstacles to further dissemination.

Methods:  We conducted a statewide survey among 70 member hospitals of the Michigan Surgical Quality Collaborative. Through interviews with key stakeholders, we identified hospitals with full ERPs and those in the process of implementation, and described the time course of their development. Respondents named key obstacles to ERP implementation and detailed specific practices included in their protocols. Hospital characteristics were obtained from the American Hospital Association Annual Survey and compared using chi square tests for proportions.

Results: Interim results from 46 respondent hospitals (66% interim response) revealed that between 2010 and 2016, 13 (28%) hospitals fully implemented an ERP, while 22 hospitals (48%) did not. The time course of uptake is detailed in the Figure. At present, 11(24%) hospitals are still in development, but have not yet fully implemented their ERP. Hospitals with ERPs identified coordination of time and logistics of development and implementation (54%) as the most common obstacle, followed by disagreement on standard practices (15%), and nursing preferences (8%). For those without ERPs, the most common obstacles are surgeon engagement (52%), disagreement on standard practices (15%), coordination of time and logistics for development and implementation (15%), and anesthesiology preferences (12%). ERP hospitals were no more likely than non-ERP hospitals to be either teaching institutions (77% vs. 61%, p=0.50) or large hospitals with more than 300 beds (54% vs. 42%, p=0.53).

Conclusion: Despite increasing consensus around the value of ERPs for colectomy and years of emphasis among our statewide collaborative, implementation continues to be a challenge. Administrative support, logistical burden, and surgeon engagement are the most commonly reported challenges to more widespread ERP adoption. Interestingly, the likelihood of ERP implementation is no different in large academic hospitals than that of small non-academic ones. These findings suggest that broader implementation of ERP will require a three-pronged approach: improved dissemination of evidence-based standardized protocols to foster wider consensus, administrative support to incentivize the time and logistical burden of implementation, and opportunities to educate and engage surgeon leaders.

 

66.05 Utility of the 10 Hounsfield Unit Threshold for Identifying Adrenal Adenomas: Can We Improve?

Posted on January 26, 2017

M. Kohli1, R. Randle1, S. Pitt1, D. Schneider1, R. Sippel1  1University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction: Adrenal incidentalomas are identified on up to 5% of abdominal CT scans. Assessing such lesions for malignancy is essential for establishing appropriate patient follow up. A threshold of 10 Hounsfield units (HU) is currently recommended for differentiating benign adenomas from non-adenomas. Our study aims to evaluate the utility of the 10 HU threshold and to determine whether additional CT imaging features can be used to identify adenomas. 

Methods:  We performed a retrospective review of a single institution’s prospective endocrine surgery database. Our cohort included 192 patients who underwent an adrenalectomy between 2001 and 2015 due to a unilateral adrenal mass (excluding pheochromocytoma). All masses that were non-adenomatous via surgical histology (adrenal cortical carcinomas, ganglioneuromas, metastases, etc.) were in the non-adenoma group. Imaging characteristics of adenomas (n=128) and non-adenomas (n=64) were compared. Sensitivity and specificity for detection of adenomas were calculated over a range of unenhanced HU values and using absolute washout >60%. Multivariate analysis was performed to identify predictors of adenomas.  

Results: Unenhanced HU values <10 were more common in adenomas compared to non-adenomas (47.6% vs. 6.7%, p<0.001), but less than half of the adenomas resected met this criterion. Two non-adenomas (1 lymphangioma and 1 metastasis) measured <3 HU. Non-adenomas were more likely to measure ≥4cm (p=0.001), have irregular borders (p<0.001), have a non-homogeneous appearance (p=0.006), and contain calcifications (p=0.028). These suspicious imaging features were also present in 12-39% of benign adenomas. Multivariate analysis revealed that HU ≤16 (OR 15.9, 95% CI 3.1-81.7, p=0.001) and smooth borders (OR 6.4, 95% CI 2.1-20.0, p=0.001) were both independent predictors of adenomas. The 10 HU cutoff had a sensitivity of 47.6% and a specificity of 93.3% (AUC=0.71, p<0.001). Raising the cutoff to 16 HU improved the sensitivity to 65.9% without detriment to specificity, which remained 93.3% (AUC=0.79, p<0.001). Absolute contrast washout of >60% had a sensitivity and specificity of 53.8% and 100%, respectively (AUC=0.61, p=0.011). In the cohort of patients with washout values available (n=33), if a lesion was <16 HU and/or had >60% absolute washout, the sensitivity and specificity increased to 96% and 100% (AUC=0.98, p<0.001). 

Conclusion: The traditional 10 HU threshold has a high specificity for identifying adrenal adenomas, but is limited by a poor sensitivity. Increasing the threshold to 16 HU has the potential to improve sensitivity without sacrificing specificity. A combination criteria of <16 HU and/or >60% absolute washout yielded both a high sensitivity and specificity and can thus be used to accurately identify adrenal adenomas and allow for appropriate selection of patients for non-operative management.  

 

66.04 Impact of Complications after Pancreatectomy in the ACS NSQIP Procedure-Targeted Database

Posted on January 26, 2017

J. A. Mirrielees1, S. M. Weber1, C. C. Greenberg1, J. R. Schumacher1, J. E. Scarborough1  1University Of Wisconsin,Surgery,Madison, WI, USA

Introduction:  Existing federal quality initiatives primarily target a number of nonspecific postoperative complications that are easy to measure without regard for their relative value, such as surgical site infection, venous thromboembolism, adverse cardiac events, and respiratory complications.  The impact of these and other procedure-specific complications on the clinical and resource utilization of pancreatectomy patients is not currently known. We employ an empirical approach to examine the potential impact of a series of complications following pancreatectomy on mortality and resource utilization in order to identify the highest value targets for quality improvement interventions.

Methods:  Patients from the 2014 ACS-NSQIP Pancreatectomy-Targeted Participant Use File were included for analysis.  The frequency of 2 procedure-specific and 7 non-specific postoperative complications were determined.  Multivariable poisson regression with log link and robust error variance was used to determine the independent associations between individual complications and subsequent 30-day clinical (mortality, end-organ dysfunction) and resource utilization (prolonged hospitalization, hospital readmission) outcomes.  Adjusted relative risk estimates from these models were used to calculate adjusted population attributable fractions (PAFs) as a measure of complication impact.  The PAF describes the estimated reduction in the incidence of an adverse outcome that would be anticipated if exposure to a specific postoperative complication had been completely avoided in the study population. 

Results: There were 5,047 patients who underwent pancreatectomy in the study period. The most frequent complications included bleeding (18.3%), pancreatic fistula (18.1%), organ/space surgical site infection (11.4%), and delayed gastric emptying (11.3%). Bleeding and pneumonia were the complications with the largest overall impact on 30-day mortality in our study population (see Table).  Complete prevention of these complications would have resulted in reduction in mortality of 29.7% and 26.4%, respectively.  

Conclusion: 

Bleeding, pneumonia, pancreatic fistula, delayed gastric emptying, and organ/space surgical site infection have relatively large impacts on the clinical and resource utilization outcomes of patients who undergo pancreatectomy.  Most of the complications that are targeted by existing federal quality initiatives (urinary tract infection, venous thromboembolism, and surgical site infection) have comparatively small impacts on this patient population.  Redirecting initiatives towards the postoperative complications which matter the most would likely improve their effectiveness.

66.03 Increased Adoption of Bundled Measures Decreases Surgical Site Infection Rate for Colectomy

Posted on January 26, 2017

L. Ly1, J. Cedarbaum1, Y. Chen1, A. Hjelmaas1, R. Anand1, S. Collins2, S. Regenbogen2  1University Of Michigan,Medical School,Ann Arbor, MI, USA 2University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction:  With the advent of value-based purchasing for preventing healthcare-acquired infections, there is increasing interest in bundled interventions to reduce the rates of surgical site infections (SSI). In our statewide Michigan Surgical Quality Collaborative (MSQC), we previously found that compliance with six preventative measures was associated with decreased SSI rates for individual colectomy patients. We now seek to evaluate the effect of hospital-level implementation of these bundled preventative measures on overall SSI rates.

Methods:  This retrospective cohort study included all elective colectomies in 59 MSQC hospitals from 2012 to 2015. In accordance with our previously published method, a “bundle score” was assigned to each case, with one point given for each SSI preventative measure followed: 1) postoperative normothermia (temperature of >98.6°F); 2) SCIP-2-compliant IV prophylactic antibiotics; 3) postoperative glycemic control (day 1 glucose ≤140 mg/dL); 4) minimally-invasive surgery; 5) oral antibiotics with mechanical bowel preparation, if used; and 6) short operations (<100 minutes). We computed Pearson correlation coefficients to compare associations between trends in hospitals’ average “bundle score” over time and their risk- and reliability-adjusted incidence of postoperative SSI.

Results: Among the study population of 4,784 cases, 298 patients developed SSIs (6.2%). Overall, 91% of patients had postoperative normothermia; 87% had appropriate IV prophylactic antibiotics; 57% had postoperative glycemic control; 57% had minimally-invasive surgeries; 49% had oral antibiotics with mechanical bowel preparation, if used; and 28% had short operative duration. The year-to-year change in hospitals’ average bundle score ranged from -0.82 to +0.87, with an average of +0.07. The change in SSI incidence ranged from -9.0% to +5.3%, with an average of -0.1%. There was a small but statistically significant negative correlation between the change in “bundle score” and the change in SSI rate at the hospital level (Pearson’s r=-0.18, p=0.02, see Figure).

Conclusion: Among MSQC hospitals, there was a wide variability in the adoption of the six SSI preventative measures. Hospitals that increased compliance with this bundle of interventions for SSI prevention in colectomy were significantly more likely to experience a decrease in the incidence of postoperative SSI. These findings suggest that efforts to further increase adoption of these preventative measures are warranted. 

66.02 Decreased Inpatient Mortality after Hepatic Resection in a State Population

Posted on January 26, 2017

D. A. Hashimoto1, Y. J. Bababekov2, S. M. Stapleton2, I. H. Marks2, K. D. Lillemoe1, D. C. Chang2, P. A. Vagefi1  1Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA 2Massachusetts General Hospital,Codman Center For Clinical Effectiveness In Surgery,Boston, MA, USA

Introduction:  There have been considerable improvements in surgical technique and perioperative care in the last decade with respect to hepatic resection for hepatobiliary diseases.  As a result, decreased post-operative mortality has been described at the institutional level. However, inpatient mortality trends following hepatic resection have yet to be assessed on a population level.

Methods:
The New York (NY) Statewide Planning and Research Cooperative System (SPARCS) inpatient database was utilized. All patients over the age of 18 years who underwent wedge hepatectomy or lobectomy from 2000-2014 were included. Trauma and recipient hepatectomy were excluded. Adjusted analysis accounted for age, race, payer status, Charlson Comorbidity Index (CCI), cirrhosis, viral/alcoholic hepatitis, hepatic malignancy (primary vs. secondary tumor), need for biliary-enteric reconstruction, and hospital hepatectomy volume.

Results:

A total of 13,467 hepatectomies were performed from 2000-2014 in the state of NY with a mean inpatient mortality of 2.35% (± 15.1% SD). Of these, 86.6% of hepatectomies were performed at academic centers (hospitals with a surgical residency). Inpatient mortality decreased from a rate of 3.69% in 2000 to 1.98% in 2014 (p<0.0001). Adjusted analysis demonstrated a decreasing trend in mortality from 2000 to 2014 with sustained significance reached in 2009 (OR 0.29, p=0.001) (Figure 1).

Subset analysis revealed similar findings for patients in academic centers, with secondary tumors, or with CCI>3 (all p<0.001). Independent predictors of mortality included age>70 years, male gender, Medicare payer status, primary liver tumor, and need for biliary-enteric reconstruction. Hepatectomy at an academic center (OR 0.62, p=0.002) and female gender (OR 0.67, p=0.001) were protective against mortality.

Conclusion:
This study demonstrates at the state population level that inpatient mortality after hepatectomy has improved over the time period 2000-2014. Increased survival may be due to a combination of advancements in operative and perioperative care. In-depth analyses of surgical care at hospitals in NY may reveal state wide quality improvement practices that led to reduced inpatient mortality after hepatic resections. Such measures could serve as a model for other health systems.

66.01 Bariatric Surgery in the Land of the Long White Cloud (Aotearoa/New Zealand)

Posted on January 26, 2017

A. D. MacCormick1, A. D. MacCormick1  1University Of Auckland,Surgery,Auckland, AUCKLAND, New Zealand

Introduction:
New Zealand has some of the highest obesity rates in the world, with indigenous and Pacific populations most significantly affected.  Counties Manukau Health (CMH) provides government-funded healthcare to South Auckland, a young, ethnically diverse and deprived population. CMH Bariatric Service has performed approximately 150 bariatric procedures since 2007, the vast majority being sleeve gastrectomy, and prioritizes the optimization of patient care.

Methods:
We performed a systematic review of the literature to determine the components for a bariatric enhanced recovery after surgery (ERAS) program. Subsequently we performed one of the first randomized controlled trials of ERAS versus standard care in patients undergoing Laparoscopic Sleeve Gastrectomy. Review of our five year outcomes indicated a propensity for weight regain at 18 months. We therefore conducted a systematic review looking for reasons this may occur and to determine a standard definition for weight regain.

Results:

ERAS programs are well recognized as providing important improvements in post-operative outcomes in colorectal surgery. The effects of ERAS following bariatric surgery, however, were until recently unknown.  A randomized trial conducted at CMH compared ERAS to standard care and found a significant reduction in length of stay and cost in the ERAS group with no increase in complication or admission rates.

 

Medium and long term outcomes following sleeve gastrectomy have only been reported in recent years.  Review of the five-year outcomes at CMH revealed %EWL outcomes of 60% at 18 months and 40% at five years, indicating a significant trend towards weight regain.  Furthermore, the onset of the weight regain was noted to occur at the time patients were discharged from the CMH Bariatric Service suggesting that a lack of follow-up support may be associated with weight regain.

 

Systematic review of weight regain specifically following sleeve gastrectomy has identified a lack of follow-up support as a potential contributor to weight regain.  To investigate this further, focus group discussion with almost 40 CMH sleeve gastrectomy patients who had experienced weight regain were conducted.  They also identified a lack of follow-up support as a contributing factor to weight regain and expressed a desire for more long-term support.  Based on these findings, a one year text message support intervention was designed and is currently being evaluated by randomized trial.

Conclusion:
Although only a relatively small center at the bottom of the world, the CMH Bariatric Service is committed to optimizing post-operative outcomes.  From this body of work, contributions have been made to consensus guidelines for bariatric ERAS programs as well as to the topical issue of weight regain.

65.10 Statewide Assessment of Surgical Outcomes and the Acute Care Surgery Model

Posted on January 26, 2017

N. L. Bandy1, S. DeShields1, R. C. Britt1  1Eastern Virginia Medical School,Norfolk, VA, USA

Introduction:
While emergency general surgical services are needed across hospitals of all sizes, workforce issues, access disparities, lifestyle considerations and hospital availability all influence the availability of timely and quality care for those in need of urgent surgical intervention.  The Acute Care Surgery (ACS) model has emerged as a potential solution to improving care delivery.  Prior studies have demonstrated improvements in single centers in the delivery of quality and efficient care using the ACS model. This study examines the differences in outcomes for appendicitis and cholecystitis statewide between traditional and ACS models.

Methods:
The VHI administrative database was queried to obtain outcome data on patients admitted with appendicitis or acute cholecystitis in the state of Virginia between 2008 and 2014. Hospital administration was contacted to determine surgical care model status. Data regarding length of stay, costs, complications and mortality were obtained for 28, 948 encounters. Bivariate and multivariate analysis was used to compare the outcomes between the two models.

Results:
Overall, the patients cared for with by ACS were more likely to be uninsured and with higher rates of medical co-morbidities. In the appendicitis subgroup, the patients cared for in an ACS institution had an uninsured rate of nearly 29%, versus 19% in the traditional hospitals. The ACS group had statistically higher rates of cancer and diabetes as well as renal, cardiac, liver and pulmonary disease. In the ACS hospitals, there were higher costs ($30,060 vs $28,460, p= 0.013), longer lengths of stay (3.31 vs 2.92 days, p <0.001), complications (OR 1.2, p=0.016) and overall mortality (OR 2.4, p=0.029). On multivariate analysis the mortality difference was not significant. For patients in the acute cholecystitis group, those cared for in an Acute Care Surgical hospital were more likely to be uninsured (18 vs 12.2%, p < 0.001) with higher rates of cancer, cardiovascular, renal and hepatic disease. The ACS patients had a slightly longer length of stay (4.55 vs 4.13 days, p= .009) without significant differences in mortality, complications or cost. On multivariate analysis there were no significant differences in the groups.

Conclusion:
We have demonstrated that in Virginia ACS take care of sicker patients with a higher rate of medical co-morbidities and uninsured status. For appendicitis, the outcomes are slightly worse for the ACS programs. For cholecystitis, the outcomes are equivalent at both traditional and Acute Care programs despite the differences in patient populations. This study is discordant to previously published studies demonstrating improvements following adoption of the ACS model, however prior studies only included single institutions. Further studies will be useful to determine what patient population and disease processes benefit the most from being cared for under the Acute Care model.
 

65.09 Improving Efficacy of Postoperative Care for Laparoscopic Surgery Through Telemedicine.

Posted on January 26, 2017

C. Jenny1, K. Gardner1, C. Ziegler1, E. Sutton1  1University Of Louisville,School Of Medicine,Louisville, KY, USA

Introduction:
Telemedicine is increasingly being used to improve accessibility and efficiency of health care delivery. We performed a pilot study employing telemedicine for emergency general surgery patients who underwent laparoscopic appendectomy or cholecystectomy for uncomplicated acute appendicitis or cholecystitis to assess feasibility and patient acceptance of telemedicine for routine postoperative evaluation.

Methods:
Patients were eligible for the study if they were between 18-90 years old and had undergone an uncomplicated laparoscopic appendectomy or cholecystectomy. The experimental group was set at 20 participants and the control group set at 10 participants. If participants did not have access to visual communication technology, a webcam was offered to the patient at no charge. After informed consent, the 20 patients in the experimental group were given a link to a web based meeting platform (http://bluejeans.com) and instructions about how to use a smartphone or computer with a webcam to log in at their specified meeting time with a meeting ID and password. Follow-up visits were subsequently evaluated with a six question online survey to determine patient satisfaction with video and audio quality, timing, and the patient’s receptiveness to future telemedicine visits (Likert scale 1-5, 1- strongly disagree, 5- strongly agree). Questionnaire results from this group were then compared to a control group of patients who experienced a traditional in office follow-up visit.

Results:
Sixty-three patients were approached about participation, 20 of which entered the study as telemedicine participants (31.7%). The 43 patients who did not participate in the study were invited to serve as controls.  Of the telemedicine participants, 90% were satisfied with their telemedicine visit, and 85% of those patients would choose to use telemedicine again.  Of the telemedicine participants, 75% would suggest the use of telemedicine to another physician. Satisfaction with the post operative visit was not significantly different between the telemedicine group and office visit group (4.2 vs 4.5, p=0.124). Only one telemedicine study participant took time off from work and 19 participants reported that their telemedicine visit took less than 1 hour of their time in total.  In comparison, 90% of controls took greater than 1 hour including travel time to complete their in-office follow-up visit, with 2 participants (20%) taking greater than 4 hours.  Eighteen out of our 20 study participants (90%) were comfortable with the technology they were required to use to operate the web based meeting platform. 

Conclusion:
This study suggests that it is feasible to use telemedicine in the follow up of patients who have had uncomplicated laparoscopic appendectomies and cholecystectomies and that patient satisfaction is reasonably high.  Future studies should be conducted examining the use of telemedicine for more complex perioperative care of the surgical patient.

65.08 Epidural Utilization during Pancreatectomy: An ACS-NSQIP Assessment of Perioperative Outcomes

Posted on January 26, 2017

G. G. Kasumova1, O. Tabatabaie1, S. Logarajah1, A. Fadayomi1, S. Ng1, J. F. Tseng1  1Beth Israel Deaconess Medical Center,Surgical Outcomes Analysis & Research, Department Of Surgery,Boston, MA, USA

Introduction: Epidurals are frequently utilized during major abdominal surgery in attempt to improve postoperative analgesia and outcomes. Epidural analgesia is also an integral part of enhanced recovery regimens. However, results surrounding their use in pancreatectomy are conflicting. We evaluated a large modern cohort of patients undergoing pancreatectomy to assess the effect of epidural utilization on perioperative outcomes.

Methods: Retrospective review of patients undergoing pancreatectomy for any indication in 2014 using the targeted ACS-NSQIP database. Patients with disseminated cancer, non-elective or emergency procedures were excluded from analysis. Characteristics were compared via chi-square and Wilcoxon rank sum test. LOS and thirty day morbidity were evaluated.

Results: A total of 4398 patients underwent pancreatectomy with 846 (19.2%) undergoing epidural placement. Epidurals were more likely to be placed during open vs. laparoscopic procedures (22.2% vs. 10.1%, p<0.0001). Black patients were least likely to have an epidural placed (16.8% vs. 18.6% for white vs. 25.0% for other, p=0.0007). There were no differences in age, sex, ASA class or BMI. Patients with epidurals were more likely to have delayed gastric emptying (13.9% vs. 10.2%, p=0.007), UTI (4.7% vs. 3.2%, p=0.035), postoperative bleeding (19.7% vs. 15.6%, p=0.004), and pancreatic fistula (20.6% vs. 16.7%, p=0.014). There were no differences between groups of pneumonia, DVT, other major complication, and 30 day mortality. Operative time was significantly longer in those with additional epidural anesthesia, median of 339 minutes (IQR: 258, 439) vs. 305 minutes (IQR: 210.5, 401). Postoperative LOS was significantly longer in patients with epidural placement, median 8 (IQR: 6, 11) vs. 7 (IQR: 5, 10). On subset analysis, 1566 patients underwent proximal pancreatectomy with 337 (21.5%) receiving an epidural; there were no differences in postoperative major morbidity and LOS. Of 1287 patients who underwent distal pancreatectomy, 170 (13.2%) received an epidural; those with epidural had significantly longer LOS median 6 (IQR: 5, 8) vs. 5 (IQR: 4, 7).

Conclusion: Addition of epidural anesthesia did not affect major perioperative morbidity, but did demonstrate prolonged LOS. Patients receiving epidural analgesia may be less likely to receive adequate pain control postoperatively leading to delayed mobilization and prolonged admission. Surgeons may also select patients for epidural placement based on anticipated procedure complexity. Further evaluation will need to evaluate type of analgesic to determine its utility and potential role in enhanced recovery regimens following pancreatectomy, as well as potential implications for reimbursement.

65.07 Patient-Reported Quality of Life Outcomes after Bariatric Surgery: a Single Institution Review

Posted on January 26, 2017

A. J. Vegel1, N. Shah1, A. O. Lidor1, J. A. Greenberg1, Y. Shan1, X. Wang1, L. M. Funk1  1University Of Wisconsin-Madison,Department Of Surgery,Madison, WI, USA

Introduction:  Bariatric surgery is the most effective method for weight loss and comorbidity resolution among patients with severe obesity. However, there are limited data describing its impact on patient-reported quality of life (QoL). We sought to determine the impact of bariatric surgery on patient-reported QoL and identify variables associated with higher postoperative QoL.

Methods:  QoL data were collected from patients (n=209) who underwent bariatric surgery at a single institution from January 2010 through December 2012. QoL scores were obtained by administering the Moorehead-Ardelt Quality of Life Questionnaire II (MAQoLII) during clinical visits. The MAQoLII is a validated survey addressing self-esteem, physical activity, social life, work ability, sexual functioning and approach to food. Cumulative scores can range from +3.0 (“Very Good”) to -3.0 (“Very Poor”). Patient demographics, preoperative comorbidities and weight loss data were collected from a retrospective bariatric surgery database. A repeated measures ANOVA test was used to analyze the trend in QoL scores at the preoperative visit and consecutive postoperative visits. Multivariable logistic regression was used to generate odds ratios for variables hypothesized a priori to be associated with higher QoL postoperatively. A non-responder analysis was performed to identify potential sources of selection bias.

Results: Patients lost an average of 59.1% (±19.0) of their excess body weight one year after surgery. Mean body mass index(BMI) decreased by 13.3 kg/m2 (±12.4). 87 patients (41.6%) responded to the MAQoLII at one year.  Mean QoL scores doubled from 0.82 preoperatively to 1.66 one year postoperatively (p<0.001) (Figure). Patients scored higher in all individual areas of the MAQoLII one year after surgery: self-esteem (0.36 vs. 0.22; p=0.008), physical activity (0.31 vs. 0.11; p=0.003), social life (0.36 vs. 0.28; p=0.048), work ability (0.22 vs. 0.07; p<0.001), sexual functioning (0.16 vs. 0.04; p=0.019) and approach to food (0.26 vs. 0.11; p=0.004). On multivariable analysis, higher QoL was associated with private insurance/self-pay vs. Medicare (OR 3.87 [95% CI 1.36–11.0]). There was no association between QoL and gender, race, preoperative BMI and comorbidities or excess weight loss. The non-responder analysis indicated that survey responders were older (49.4 vs. 45.3; p=0.017) and more likely to be Caucasian (93.2% vs. 83.5%; p=0.036).

Conclusion: Bariatric surgery patients experienced significant improvements in quality of life one-year post surgery. Modifiable predictors of a high quality of life after bariatric surgery remain unclear and will require additional investigation.

 

65.06 Standardized Ultrasound Reports for Diagnosing Appendicitis Reduce Annual Imaging Costs

Posted on January 26, 2017

A. Nordin1, S. Sales1, J. Nielsen1, B. Adler2,3, D. Bates2,3, B. Kenney1,3  1Nationwide Children’s Hospital,Department Of Surgery,Columbus, OH, USA 2Nationwide Children’s Hospital,Department Of Radiology,Columbus, OH, USA 3The Ohio State University College Of Medicine,Columbus, OH, USA

Introduction:

Appendicitis is the most common abdominal surgical emergency in children, and imaging is an important diagnostic adjunct. While computed tomography (CT) scans are commonly used in adults, ultrasound is preferred in children to minimize radiation exposure. Furthermore, CT scans are more expensive than ultrasound. We have previously reported our experience in instituting a standardized ultrasound report for appendicitis, which decreased our CT rate by 67.3%. In this analysis, we seek to demonstrate the cost savings associated with using this ultrasound template.

Methods:

Retrospective chart review for the three month period immediately preceding template implementation (6/2012 to 9/2012) was combined with prospective review through the end of 12/2015 for all patients presenting to the emergency department who received diagnostic imaging for suspected appendicitis. The type of imaging and its results were recorded and percent compliance to the template, sensitivity and specificity, and CT rates were calculated. Cost information was obtained from the 2016 Ohio Medicaid Fee Schedule. Total estimated annual imaging costs using pre-template ultrasound and CT utilization rates were compared with post-template annual costs to calculate both the annual and cumulative savings of this new imaging strategy.

Results:

In our pre-template period, 304 ultrasounds and 168 CTs were performed for utilization rates of 80.2% and 44.3% respectively. Extrapolating these numbers over a year results in 1132 ultrasounds and 626 CTs, with a combined annual cost of $300,527.70. Similar calculations were performed for each succeeding year, in order to account for changes in patient volume (Figure 1). By the end of 2015, 1733 ultrasounds and 156 CTs were performed; the rate of ultrasound usage increased to 98.9% while the CT rate declined to 8.9%. At these rates, our total annual cost was $223,043.71, a savings of $149,458.86 from the estimated cost of $372,502.57 using pre-template imaging rates. Since implementation, annual savings have steadily increased for a projected cumulative cost savings of $339,273.74.

Conclusion:

Standardizing ultrasound reports for appendicitis not only reduces the rate of CT scans and the resultant radiation exposure but also decreases annual imaging costs, even in spite of increased numbers of patients evaluated for appendicitis. This change in imaging strategy has been maintained over several years. Continued cost reduction may be possible through the use of diagnostic algorithms to further decrease the number of imaging studies.

65.05 Implementing a Protocol to Prevent Dehydration Readmissions in Ileostomy Patients

Posted on January 26, 2017

P. D. Henry1, A. W. Trickey1, M. W. Laporta2, K. A. Matzie1, C. Allred1, L. Dougherty1  1Inova Fairfax Hospital,Department Of Surgery,Falls Church, VA, USA 2Thomas Jefferson University,Division Of Acute Care Surgery, Department Of Surgery,Philadelphia, PA, USA

Introduction:  Patients with new ileostomies face numerous physiological and psychological challenges ranging from dehydration that can cause acute renal failure to difficulties with stoma care. Despite resources to educate and support these patients, the hospital readmission rate for new ileostomies is high. This project aimed to study the impact of an integrated care delivery model for patients undergoing ileostomies at a large teaching hospital. We implemented a new ileostomy protocol to improve patient care outcomes and evaluated 30-day readmission rates due to dehydration before and after implementation.

Methods:  The ileostomy protocol, which provides comprehensive ileostomy care education to patients and the entire clinical care team, was a collaborative effort created by a multidisciplinary committee. Initial education began at the pre-operative visit with the surgeon and outpatient ostomy nurse. A standardized pain, fluid, and diet regimen was implemented post-operatively (per standard hospital Enhanced Recovery After Surgery protocol). Early patient participation in stoma management and patient’s comfort by discharge were ensured. Upon discharge, patients were given logs to record their daily weights, intake, and output, as well as education materials outlining when to call the office with concerns about dehydration. High-risk patients were identified and their instructions modified accordingly. Patients were set up with visiting nurses who had also been educated on the protocol. On home day 3, patients communicated by phone with an office nurse to review overall status and logs of weights, intake, and output. Dehydration-related readmissions within 30 days of hospital discharge were identified based on diagnosis codes and tracked from 24 months prior to implementation of the protocol. Spearman rank correlation was calculated to analyze trends in percentage of ileostomy patients with 30-day dehydration readmissions over 6 month intervals.

Results: A total of 153 ileostomy patients were included in the analysis (78 prior to initial protocol introduction, 75 following protocol introduction). The percentage of patients readmitted with dehydration significantly decreased over time (Spearman’s rho=-0.86, p=0.0137).

Conclusion: A multidisciplinary protocol for new ileostomy patients that includes pre-operative education, standardized pain, fluid, and diet regimens, active in-hospital patient participation, and post discharge tracking of intake and output with close follow up is effective in decreasing 30-day hospital readmission rates. Similar clinical protocols may be generalizable to other types of complex abdominal surgery.

 

 

 

65.04 Parathyroid histology plays a role in the localization sensitivity of Tc-99m sestamibi scans

Posted on January 26, 2017

V. Sant1, A. Kundel1, J. Ogilvie1, K. Patel1  1New York University School Of Medicine,Endocrine Surgery,New York, NY, USA

Introduction: Tc-99m sestamibi imaging is commonly used for preoperative localization of parathyroid adenomas, allowing for a focused minimally invasive procedure. However, a significant false-negative (FN) rate often necessitates four-gland exploration. Prior efforts in assessing predictive factors for FN imaging have demonstrated mixed results regarding significance of histology. We hypothesize that parathyroid histology influences the sensitivity of preoperative sestamibi localization of parathyroid disease. 

Methods: All parathyroid surgeries from 2007-2013 were analyzed. Cases with indeterminate pathology, absent preoperative sestamibi scan, prior neck surgery, and pathology consistent with hyperplasia were excluded. Failure of sestamibi localization but surgical finding of parathyroid adenoma was classified as false-negative (FN); concordance of sestamibi with surgical localization was deemed true-positive (TP), and discordance between sestamibi and surgical localization was deemed false-positive (FP). Results were stratified by TP, FN, and histology. Statistical significance was calculated using Pearson’s Chi-squared test. Parathyroid weight and preoperative calcium, PTH and vitamin D levels were compared using Student’s T-test.

Results:659 cases underwent analysis. 374 were TP, 31 FN and 254 FP. Of TP, 275 (73.5%) were chief cell predominant, 60 (16.0%) oxyphil, 27 (7.2%) mixed, and 12 (3.2%) clear. Of FN, 28 (90.3%) were chief cell predominant, 1 (3.2%) oxyphil, 0 mixed, and 2 (6.5%) clear. The difference in chief vs oxyphil predominance in TP vs FN was statistically significant (p=0.045). Overall sestamibi sensitivity was 92.3%, with 90.8% for chief predominance and 98.4% for oxyphil (p=0.045). Average parathyroid weight was 816 mg, TP 1012 mg and FN 405 mg (p=6.34×10-7). This difference persisted for chief cell predominance (TP 1068 mg, FN 350 mg, p=9.34×10-9), but differences for the remaining histological subtypes were not statistically significant. Preoperative levels of calcium, PTH and vitamin D were not significantly different (calcium: TP 11.3, FN 14.0; PTH: TP 122.0, FN 130.4; vitamin D: TP 26.4, FN 31.2).

Conclusion:Sestamibi imaging is significantly more sensitive in detecting parathyroid adenomas with oxyphil predominance, a cell type known to have high mitochondrial activity, which localizes sestamibi. As expected, sestamibi imaging detected TP adenomas, that were on average, over twice the mass of those in FN scans. This study represents the largest single-institution study to date on this topic. Further work to identify adenomas without oxyphil cell predominance may significantly improve preoperative localization and increase the success of a focused minimally invasive approach.
 

65.03 Disease and Treatment Factors Associated with Lower Quality of Life Scores in Adults with MEN-1

Posted on January 26, 2017

S. Goswami1, B. J. Peipert1, S. E. Yount3,4, C. Sturgeon1  1Feinberg School Of Medicine – Northwestern University,Department Of Surgery,Chicago, IL, USA 3Feinberg School Of Medicine – Northwestern University,Department Of Medical Social Sciences,Chicago, IL, USA 4Feinberg School Of Medicine – Northwestern University,Department Of Psychiatry And Behavioral Sciences,Chicago, IL, USA

Introduction: The physical and psychosocial morbidity of multiple endocrine neoplasia type 1 (MEN-1) is ill-defined. Due to lack of genotype-phenotype relationships, heterogeneity in clinical manifestations, and infrequent surgical cures, there is controversy regarding optimal management. Thus it is important to understand how disease and treatment-related factors relate to patient-reported outcomes (PROs) such as health-related quality of life (HRQOL). We hypothesized that disease and treatment burden negatively impacts HRQOL in adults with MEN-1.

Methods: Adults ≥18 years with MEN-1 (n=174) were recruited through an MEN-1 support group. An online survey on demographics, disease features, and treatment history was administered, and respondents were grouped and compared based on their answers. The PROMIS-29 instrument was used to evaluate HRQOL in 7 domains. T scores generated from MEN-1 survey responses were compared to United States (US) normative data using a 1-sample t-test. The Mann-Whitney U test was used for subgroup analysis of categorical variables and linear regression was performed on continuous variables. Holms-Bonferroni was used to correct for multiple comparisons. Data are reported as mean T scores ± standard deviation.

Results: Adults with MEN-1 reported scores reflecting poorer physical, mental, and social well-being than US normative data in all 7 domains (p<0.001): anxiety (61.1±10.2), depression (57.1±10.5), fatigue (60.7±11.7), pain interference (55.6±11.1), physical function (44.7±9.5), sleep disturbance (57.2±9.0), and social function (44.9±10.6). Respondents with recurrent hyperparathyroidism (42%) reported worse scores than those without recurrence in 5 of 7 domains: anxiety (63.2±8.6 vs 58.1±10.0, p<0.01), depression (58.5±8.9 vs 54.3±11.3, p<0.05), fatigue (63.2±10.8 vs 57.9±11.9, p<0.05), pain interference (58.8±9.8 vs 53.0±12.0, p<0.01) and social functioning (43.3±9.3 vs 48.2±11.4, p<0.01). Requirement of prescription medication for MEN-1 (73%) was associated with worse PRO scores across all 7 domains (p<0.05). Increased frequency of specialty doctor appointments was associated with higher levels of anxiety, depression and pain interference and lower levels of physical and social functioning (r = 0.19-0.28, p<0.05). Traveling > 50 miles for specialty care was associated with greater anxiety (p<0.01). Increased frequency of hospitalization was associated with higher anxiety (r=0.26, p=0.001). No significant association was found between presence of pancreatic tumors or extent of pancreatic surgery and HRQOL. PRO scores were independent of age, sex, and ethnicity.

Conclusion: This study is the first to explore PROs in MEN-1. Adults with MEN-1 report lower HRQOL than US normative data in all 7 PROMIS-29 domains. Factors associated with lower HRQOL include recurrent hyperparathyroidism, increased travel distance and frequency of specialty appointments, hospitalization frequency, and requirement of prescription medications.

65.02 Predicting The Difficulty Of Elective Laparoscopic Cholecystectomy – A Novel Scoring System

Posted on January 26, 2017

N. M. Hanna1, E. A. Villatoro1  1King’s Mill Hospital,General Surgery,Mansfield, NOTTINGHAMSHIRE, United Kingdom

Introduction:
Laparoscopic cholecystectomy is one of the most commonly performed operations by general surgeons, both trainees and consultants. Unfortunately, they all come in various shapes and sizes. The aim of this study is to create a scoring system to predict the difficulty of elective laparoscopic cholecystectomy.

Methods:
One consultant general surgeon’s laparoscopic cholecystectomies between May 2015 and May 2016 (101 patients) were evaluated using a scoring system that included gender, CRP on index admission, gall bladder wall thickness, BMI, previous abdominal surgery, and previous severe acute pancreatitis. Basic patient demographics, length of operation, conversion to open, subtotal cholecystectomy, drain insertion, and length of stay were obtained. 

Results:
82 patients were identified retrospectively and organised into three categories depending on the score (0-4, 5-9, and 10-22). Category 1 (n=53, mean age 46.9) had a mean operation time of 77.6 minutes, a 1.9% conversion rate, a 9.4% likelihood of becoming a subtotal cholecystectomy, an 11.3% chance of having a drain, and a mean length of stay of 0.45 days. Category 2 (n=22, mean age 51.9) had a mean operation time of 93.9 minutes, a 4.5% conversion rate, a 31.8% likelihood of becoming a subtotal cholecystectomy, a 36.3% chance of having a drain, and a mean length of stay of 1.59 days. Category 3 (n=7, mean age 33.4) had a mean operation time of 100.1 minutes, a 0% conversion rate, a 28.6% likelihood of becoming a subtotal cholecystectomy, a 42.9% chance of having a drain, and a mean length of stay of 2.00 days.

Conclusion:
Our study demonstrates that we were able to accurately predict those patients who would have a longer operative time, a higher likelihood of conversion to open, and a longer post-operative hospital stay, which were considered surrogate markers for the difficulty of the procedure. This scoring system may be beneficial in the pre-operative setting.
 

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