93.02 Teamwork in the Pediatric Operating Room – A New Target for Improving Patient Safety

Posted on January 26, 2017

C. K. Shoraka1,2,3, J. Wang1,2,3, J. E. Abraham1,2,3, K. M. Masada1,2,3, A. N. Minzenmayer1,2,3, K. T. Anderson1,2,3, K. Tsao1,2,3, K. P. Lally1,2,3, A. L. Kawaguchi1,2,3  1The University Of Texas Health Science Center At Houston,McGovern Medical School,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Pediatric Surgery,Houston, TX, USA 3Center For Surgical Trials And Evidence-based Practices (C-STEP),Houston, TX, USA

Introduction: Lapses in communication, cooperation, leadership, situational awareness, and other teamwork behaviors may result in avoidable patient harm. Thus far, teamwork in the operating room has been inadequately studied.  We evaluate teamwork behaviors in the pediatric operating room in order to identify areas for targeted improvement.

Methods: During 2015-2016, two 8-week observational study periods were conducted at a tertiary children’s teaching hospital with convenience sampling of elective pediatric surgery operations. Teamwork scores were assigned by trained observers using the Observational Teamwork Assessment for Surgery (OTAS) scale. The surgical, anesthetic, nursing, and scrub teams received a scaled composite score for each behavior – communication, coordination, cooperation/back-up behavior, leadership, and situational awareness – in the preoperative, intraoperative and postoperative phase. Descriptive statistics were used to assess variation in observed team behaviors. A p-value of < 0.05 was considered significant.

Results: A total of 496 cases were observed during 2015-2016. Across all teams, operative periods, and behaviors the mean OTAS score was 3.61 ± 0.74. Overall, surgical teams had the highest mean (± standard deviation) teamwork score, followed by nursing, anesthesia, and scrub teams, respectively (3.69 ± 0.81, 3.66 ± 0.73, 3.59 ± 0.71, and 3.49 ± 0.68; P < 0.001). Surgical teams exhibited the best communication (3.86 ± 0.88) and leadership (3.65 ± 0.83) with the poorest overall cooperation/back-up behavior (3.57 ± 0.76) (P < 0.001); nursing teams had the highest scores for cooperation/back-up behavior (3.83 ± 0.75) (P<0.001). Scrub technicians scored the lowest of all teams in leadership behavior (3.22 ± 0.46) (P<0.001). Nursing (3.84 ± 0.73, 3.61 ± 0.70) and anesthetic (3.78 ± 0.75, 3.51 ± 0.66) teams had the highest relative scores both pre-and postoperatively. Surgical teams the highest scores intraoperatively (3.95 ± 0.84) (P < 0.001).

Conclusion: This study revealed numerous areas for teamwork improvement in the pediatric surgical operating room – leadership roles for technicians, cooperation for surgeons, and intraoperative team involvement for nursing and anesthesia. Our patient safety efforts will focus on targeted teamwork improvements as well as correlation of these behaviors with patient outcomes.

 

93.01 Daily Enoxaparin Provides Inadequate VTE Prophylaxis For Most VATS Patients Based On Anti-Xa Levels

Posted on January 26, 2017

C. J. Pannucci1, K. I. Fleming1, L. Moulton2, A. Prazak3, T. K. Varghese2  1University Of Utah,Division Of Plastic Surgery,Salt Lake City, UTAH, USA 2University Of Utah,Division Of Cardiothoracic Surgery,Salt Lake City, UTAH, USA 3University Of Utah,Department Of Pharmacy,Salt Lake City, UTAH, USA

Introduction:

Thoracic surgery patients, particularly those with malignancy, are at elevated risk for perioperative venous thromboembolism (VTE).  Enoxaparin prophylaxis prevents VTE amongst surgical patients.  However, emerging literature demonstrates that enoxaparin is not a “one size fits all” intervention, and inadequate enoxaparin dosing has been associated with downstream VTE events in other surgical subspecialties.  We examined the pharmacodynamics of enoxaparin 40mg per day in VATS patients with an emphasis on 1) dose adequacy, measured by peak and trough anti-Factor Xa (aFXa) levels and 2) the association between gross weight and peak aFXa level.

Methods:

We prospectively enrolled patients after VATS procedures into this ongoing clinical trial (NCT02704052).  All patients received enoxaparin prophylaxis at 40mg once per day, initiated at 12-18 hours after their surgical procedure.  Steady-state peak and trough aFXa levels, which mark enoxaparin effectiveness and safety, were drawn.  Goal peak and trough aFXa levels were 0.3-0.5 IU/mL and 0.1-0.2 IU/mL, respectively.  Patients with out of range peak aFXa levels had real time enoxaparin dose adjustment based on a written protocol, followed by repeat aFXa levels.  Stratified analyses examined variation in peak aFXa by patient’s gross weight.

Results:

To date, 21 patients who received enoxaparin 40mg once daily after VATS surgery have been enrolled.  28.6% of patients had initial in range peak aFXa levels.  19.0% of patients had any detectable aFXa activity at 12 hours.  Real time enoxaparin dose adjustment was performed based on peak aFXa levels, and 100% of patients in whom repeat labs were drawn had in-range levels.  Gross weight was associated with peak steady state aFXa level in patients who received fixed dose prophylaxis (Figure 1).  Patients with gross weight over 150 pounds were significantly more likely to have inadequate aFXa levels when compared to patients ≤150 pounds (86.7% vs. 33.3%, p=0.031). 

Conclusion:

Enoxaparin 40mg once daily provides adequate prophylaxis for a minority of patients (28.6%) after VATS surgery. 19% of patients had any detectable aFXa activity at 12 hours.  Thus, for a medication administered daily, four out of five patients receive chemoprophylaxis for less than 12 hours per day.  Patients with gross weight >150 pounds were significantly more likely to have inadequate aFXa levels in response to fixed dosing.  These preliminary findings support an individualized and possibly weight based approach to post-VATS chemoprophylaxis. Further research from this ongoing study will 1) correlate aFXa levels with downstream VTE and bleeding events and 2) examine additional patient-level predictors of enoxaparin metabolism after VATS.

92.20 Early Outcomes of Fluorescence Angiography in the Setting of Endorectal Mucosa Advancement Flaps.

Posted on January 26, 2017

A. Okonkwo1, J. Turner1, A. Chase1, C. E. Clark1  1Morehouse School Of Medicine,Division Of Colon And Rectal Surgery/Department Of Surgery,Atlanta, GEORGIA, USA

Introduction: Fistulo-in-ano has a reported incidence of 31-34%. Non-cutting options for fistula repair are seton placement, endorectal or dermal advancement flaps, fibrin sealant, anal fistula plug, and ligation of the intersphincteric fistula tract (LIFT).  Endorectal advancement flap (ERAF) procedures are commonly performed in patients in whom traditional cutting procedures are relatively contraindicated such as high transphincteric fistulas, low transsphincteric fistulas in women and fistula associated with Crohn’s disease. Despite having a reported success rate as high as 75-98%, ERAF is not without complications including flap breakdown, recurrence and fecal incontinence. Traditionally, maintaining a broad base to maintain blood supply has been advocated to reduce flap failure. Here, we report our early experience and outcomes of adult patients who underwent ERAF for complex fistulo-in-ano with the use of intraoperative fluorescence angiography (FA) to reduce complications related to flap ischemia. 

Methods: We retrospectively reviewed a prospectively maintained dataset of patients with an age range of 18 to 99 at a single urban teaching hospital who underwent ERAF for complex fistulo-in-ano between July 2014 and June 2016 by board certified Colorectal Surgeons. All procedures that utilized FA were selected for review including 30 and 60 day outcomes. Patients without documented follow up were excluded. 

Results:Seven cases were identified with average age and BMI of 37.9 and 25.9, respectively. There were 6 males and 1 female. There were 85.7% of patients who had prior surgery for fistulo-in-ano. No recurrences or complications of any type were noted at 30 and 60 day follow-up. Five of the seven patients (71.4%) required revision of the flap based on intraoperative FA prior to flap fixation.

Conclusion:FA is safe and offers real-time assessment of flap profusion prior to fixation in fistula repair. The rate of flap ischemia may be under estimated and thus intraoperative FA should be considered in the surgical armamentarium to further improve outcomes in ERAF.

 

92.19 The Optical Trocar Access in Laparoscopic Gastrointestinal Surgery

Posted on January 26, 2017

C. Tanaka1, M. Fujiwara1, M. Kanda1, M. Hayashi1, D. Kobayashi1, S. Yamada1, H. Sugimoto1, T. Fujii1, Y. Kodera1  1Nagoya University Graduate School Of Medicine,Dept. Of Gastroenterological?Surgery,Nagoya, AICHI, Japan

Introduction: ~The optical trocar access is one of techniques for the first trocar placement in laparoscopic surgery. By the optical trocar access, each tissue layer can be visualized prior to penetration, leading to prevention of organ injury, and air leaks at the site of trocars can be minimized even in obese patients. The aim of this study is to report the comparison of the required time for a trocar insertion between the optical trocar access and open group in patients who underwent laparoscopic gastrointestinal surgery.

Methods: ~We reviewed our prospectively collected database and identified 384 patients who underwent the laparoscopic gastrointestinal surgery for whom the initial trocar was inserted nearby the umbilicus either by the optical trocar access or by the open method. Prior to comparison between the two methods, the propensity score matching was used to adjust for essential variables between the optical trocar access and open groups. After matching, we compared the influences of age, sex, BMI, comorbidity, history of abdominal surgery, type of diseases and surgeon’s experience of the optical trocar access on required time for an initial trocar insertion. BMI was categorized into not obesity (<25 kg/m2) or obesity (≥ 25 kg/m2).

Results:~Patients categorized either as optical trocar access or open group were matched one-to-one by the use of propensity score matching and 137 pairs of patients were generated. The required time for a trocar insertion was significantly shorter in the optical trocar access group in comparison with that of the open group (36.6 vs 209.8 seconds, respectively, P<0.01). The prolonged time for an initial trocar insertion of optical trocar access was significantly associated with younger age of the patient and surgeon’s experience of 30 cases or fewer in the univariable analysis. The multivariable analysis identified the small experience of the surgeon as the only independent risk factor for prolonged time for an initial trocar insertion (OR 3.45, 95% CI 1.49 – 8.33, P <0.01; Table 2). Notably, BMI and history of abdominal surgery did not significantly affect the required time for a trocar insertion in the optical trocar access group. On the other hand, the prolonged time for an initial trocar insertion of open group was significantly associated with body mass index (OR 3.22, 95% CI 1.22 – 8.90, P = 0.02) and history of abdominal surgery (OR 2.96, 95% CI 1.27 – 7.12, P = 0.01).

Conclusion:~This study indicated that optical trocar access may be recommended for insertion of initial trocar in laparoscopic gastrointestinal surgery.

 

92.18 Laparoscopic vs Robotic Transversus Abdominus Release Learning Curve: Is There a Difference?

Posted on January 26, 2017

A. S. Weltz1, N. Wu1, U. Sibia1, J. Chamu1, H. R. Zahiri1, I. Belyansky1  1Anne Arundel Medical Center,Minimally Invasive Surgery,Annapolis, MD, USA

Introduction:

We previously described a novel approach to transversus abdominus release (TAR) via laparoscopic technique.  Use of robotic platform to address TAR has also been previously reported.  Considering the complexity of anatomy and difficult technical aspects, both of these approaches are thought to be associated with a steep learning curve.  We evaluate a single surgeon’s operative outcomes and early learning curve with laparoscopic and robotic TARs.

Methods:

Review of prospectively collected data for a single surgeon was performed for a consecutive series of thirty-two patients that underwent laparoscopic TAR (n=24) and robotic TAR (n=10) from August 2015- August 2016. A board-certified fellowship trained MIS surgeon, completed 40+ hours of simulation training on the da Vinci Surgical System (Intuitive Surgical Inc, Sunnyvale CA) and additional cadaveric training prior to the start his robotic procedures. The learning curve was examined by averaging operating room (OR) times in intervals of 5 procedures.

Results:

Thirty-two patients (22 Lap TAR vs. 10 rTAR) with mean age (55.3 vs. 60.2 years, p=0.393), BMI (31.7 vs. 30.4 kg/m2, p=0.589) and ASA (2.4 vs. 2.4, p=0.930) were studied.  Estimated blood loss (60.2 vs. 63.5 ml, p=0.758) and length of stay (2.3 vs 1.9 days, p=0.647) were equivalent. In laparoscopic TAR, operating room times (ORT) decreased from an average of 335.0 mins for the first five cases to 249.4 mins for the 6-10th cases (p=0.008).  In robotic TAR cases ORT decrease from average 323.2 mins for first 5 cases to 220.4 mins for the 6th-10th cases (p=0.108).  There was no significant difference in ORT when comparing laparoscopic vs robotic 6th-10th cases, 249.4 vs 220.4 mins (p=0.49) respectively.  Significant decrease in ORT for laparoscopy was seen comparing 1st-5th vs 15th-20th cases, 335.0 vs 253.4 mins respectively (p=0.006), but no significant difference when comparing 6th-10th vs 15th-20th cases implying the saturation of the learning curve was achieved between 6th and 10th cases.  Wound and non-wound related complications were equivalent at a mean follow up of 6 months.

Conclusion:

Our review of laparoscopic and robotic TAR experience revealed no difference in the learning curves when comparing laparoscopy to robotics in the hands of an MIS expert surgeon. Operative time revealed a significant downward ORT trend with an increased number of cases in both groups, with low morbidity.

92.17 Outcomes of Inguinal Herniorrhaphy with Concomitant Robotic Prostatectomy

Posted on January 26, 2017

M. H. Zeb1, N. D. Naik1, T. K. Pandian1, A. Jyot1, H. Y. Saleem1, E. F. Abbott1, M. Monali1, E. H. Buckarma1, D. R. Farley1  1Mayo Clinic,Dept Of Surgery,Rochester, MN, USA

Introduction:
Robotically assisted radical prostatectomy (RARP) with concomitant robotic inguinal hernia repair is an alternative to performing either procedure in separate settings. The safety and outcome of performing these procedures concomitantly is not well documented. We aimed to assess our experience and identify risk of recurrent hernias and other postoperative complications specifically surgical 

Methods:
We retrospectively analyzed all adult patients (age >18 years) who underwent RARP with concurrent robotic inguinal hernia repair from 2008 to 2016 at our institution. Patient characteristics and operative details were extracted from the medical records. Descriptive statistics were calculated for all demographic and clinical variables and were reported as mean ± standard deviation (SD), median with interquartile ranges (IQR) or as a proportion.

Results:

65 male patients were identified who underwent the concurrent procedures [mean age=63 (SD ±6), range=50-75 years, mean BMI=27.9 kg/m2]. Median follow-up was 357 days (IQR 94-1560). Mean ASA score was 2. Mean estimated blood loss was 216 mL (SD±162). Twenty two (33%) patients underwent bilateral repair and 43 (67%) patients underwent unilateral repair. No patient had a surgical site infection. Hematomas due to arterial bleeding in the obturator fossa from lymph node dissection required surgical evacuation in two patients. One patient developed a seroma in the inguinal region. In addition, two patients developed hematuria and one patient developed a transient bowel obstruction. A total of four patients developed post-procedure hernias, two of which were port site hernias within 1 year of the procedure while two were ipsilateral recurrent inguinal hernias.

Conclusion:

Concomitant robotic hernia repair with RARP appears to be safe and effective with a low incidence of the port site and recurrent hernias. However, more studies need to be done with a longer follow-up to assess the long term risk of developing these complications.

 

92.16 Lack of Association Between Lymph Node Metastasis and Nodule Size in Differentiated Thyroid Cancer

Posted on January 26, 2017

D. Bu Ali1, K. Mohsin1, D. Monlezun1, E. Kandil1  1Tulane University School Of Medicine,Surgery,New Orleans, LA, USA

Introduction:

Several studies have reported the association between large thyroid nodules and the increased incidence of lymph node metastasis in differentiated thyroid cancer. We aim to investigate the use of thyroid nodule size  in predicting lymph node (LN) metastasis in differentiated thyroid cancer (DTC). 

 

Methods:

This is a retrospective review of all patients who underwent thyroidectomy for (DTC)  by a single surgeon in an academic institution over 5 years. Clinicodemographic data, histopathological data and preoperative ultrasound features including nodule size and presence of internal vascularity or calcification were analyzed. Patients were divided into two groups based on the presence of positive LN.

 

Results:

A total of 139 patients were included, 28 (20.9%) had positive LN metastasis and 106 (79.1%) were non metastatic. There was no significant difference in nodule size on ultrasound between the two groups. The mean nodule size for the group with metastatic LN was 2.7 ± 1.5 cm and 2.5 ± 1.4 cm, for the non-metastatic group (p=0.48).  In addition, there was no association between larger nodule size and presence of positive LN metastasis, even in the combination with other ultrasound features such as calcification and internal vascularity (p>0.05).  However, there was a significant association of positive LN metastasis with the presence of positive BRAF mutation (OR: 14.32, p<0.001, Sens.= 87.5%, Spec. = 67.2%, PPV= 48.8%, NPV= 93.8%, Acc.= 72.5%)

 

Conclusion:

Larger thyroid nodule size on ultrasound is not associated with increased risk of LN metastasis in DTC. However, the presence of positive BRAF mutation was predictive of increased risk of presence of metastatic LN. Further future larger studies are required to validate these findings.  

 

 

92.15 Laparoscopic vs. Open Inguinal Hernia Repair: A Single-Center Analysis of Long Term Quality of Life

Posted on January 26, 2017

N. J. Mier1, M. C. Helm1, Z. Helmen1, M. E. Bosler1, A. Nielsen1, A. Kastenmeier1, J. C. Gould1, M. I. Goldblatt1  1Medical College Of Wisconsin,Milwaukee, WI, USA

Introduction:  Inguinal hernias are among the most common surgical procedures done in the world.  For decades, open hernia repair was the only option. However since the 1990’s, laparoscopic repairs have given patients another surgical option.  Recent studies suggest that open approach to hernia repair is associated with a greater incidence of chronic pain and patient dissatisfaction.  We evaluated quality of life (QOL) in patients who underwent open or laparoscopic inguinal hernia repairs at Froedtert and the Medical College of Wisconsin.  We hypothesized that patients undergoing laparoscopic inguinal hernia repairs would have improved QOL scores at six months and one year.

Methods:  This study was a retrospective analysis of adult patients who underwent inguinal hernia repair at the Condon Hernia Institute at Froedtert and the Medical College of Wisconsin between September 2012 and July 2016. All patients were administered Short Form-12 (SF-12) surveys at standard intervals to assess patient quality of life.  Physical and Mental Composite Scores (PCS and MCS) scores were calculated pre-operatively and post-operatively up to one year. Statistical analysis was performed using a T-test and Mann-Whitney U test for continuous variables and Chi-square test for categorical variables. A statistical significance was defined as p < 0.05.

Results: See Table

Conclusion: 

When comparing laparoscopic versus open inguinal hernia repairs at Froedtert and the Medical College of Wisconsin, we found that:

1) Patients who underwent open repair were older and more likely to have hypertension.

2) Patients with a history of abdominal surgery were more likely to undergo an open repair.

3) There was no difference in long-term QOL scores between laparoscopic and open repair as measured by the mental composite scores and physical composite score

 

92.14 Feasibility of Using Real-time Location Systems in Monitoring Recovery after Major Abdominal Surgery

Posted on January 26, 2017

R. Dorrell3, F. Hsu1, S. Vermillion3, C. Clark2  1Wake Forest University School Of Medicine,Public Health Sciences,Winston Salem, NC, USA 2Wake Forest University School Of Medicine,Department Of Surgery,Winston Salem, NC, USA 3Wake Forest University School Of Medicine,Winston Salem, NC, USA

Introduction:

Early mobilization after major abdominal surgery decreases postoperative complications and length of stay and has become a key component of enhanced recovery pathways.  However, patients face substantial barriers to early mobilization and objective measures of patient movement after surgery are limited.  Real-time location systems (RTLS) that are typically used for asset tracking provide a novel approach to monitoring in-hospital patterns of movement.  Since existing systems were not implemented for tracking dynamic patient movement, the current study investigated the feasibility of using RTLS to objectively track postoperative patient mobilization.

Methods:  

The real-time location system used for this study employs a meshed network of infrared and radio frequency identification sensors and detectors that sample device locations nearly every 3s resulting in over 1 million data points per day throughout an academic medical center.  RTLS tracking was evaluated systematically in three phases: 1) sensitivity and specificity of the tracking system using simulated patient scenarios, 2) retrospective passive movement analysis of patient-linked equipment (patient IV poles), and 3) prospective observational analysis of patient-attached tracking devices. 

Results:  

RTLS tracking detected simulated movement in and out of a patient room with sensitivity of 91% and specificity 100%.  Specificity decreased to 75% if time out of room was less than 3 minutes.  Sensor badge position (chest or wrist) did not change sensitivity or specificity.  All tracked patient-linked equipment (bed, IV poles, pumps, etc) were identify for 18 patients following major abdominal operations.  Movement of this equipment was retrospectively reviewed and analyzed.  For any individual patient, an IV pole may contain 4 tracking badges; therefore, the analysis was limited to a single IV pole tracking badge during the postoperative hospitalization.  Median length of stay was 6.7 days with 3386 location data points recorded.  Devices remained in the patient's room for mean duration of 684 min (SD 1216 min) per day.   Measurable patient movement on the ward was detected for only 2 patients (11%) with 1-8 out-of-room walks per day.   10 patients were prospectively monitored using wrist worn RTLS badges following major abdominal surgery. Patient movement was also recorded using patient diary, direct observation, and pedometer.  Sensitivity and specificity of RTLS patient tracking were both 100% in detecting out-of-room ambulation and correlated well with direct observation and patient-reported ambulation. 

Conclusion:

Real-time location systems are a novel technology capable of objectively and accurately monitoring patient movement and provides for an innovated approach to promoting early mobilization after major abdominal surgery.

92.13 In-Hospital Text-Paging Communication as a Surgical Quality Improvement Initiative

Posted on January 26, 2017

M. Janko1, M. G. Noujaim2, K. F. Angell1, J. Hill1, J. Kalil1, S. Steele3  3Case Western Reserve University School Of Medicine,Colorectal Surgery,Cleveland, OH, USA 1Case Western Reserve University School Of Medicine,Vascular Surgery,Cleveland, OH, USA 2University Of Massachusetts Medical School,School Of Medicine,Worcester, MA, USA

Introduction:  Medical staffs rely on paging to communicate patient safety concerns and updates in the hospital. Studies on medical wards have shown that numeric callback pages can be both disruptive and cryptic. In contrast, alphanumeric text paging using a hospital-issued pager on medicine wards has been shown to reduce disruptive pages and raise satisfaction scores among healthcare professionals. Here we report a quality improvement initiative among nurses and surgical interns involving text paging to communicate urgent and non-urgent issues on a surgical ward.

Methods:  Surgery residents recorded pre-intervention data for 1 month including average patient census, number of urgent and non-urgent pages received from surgical floors, number of text and traditional call-back pages from surgical floors, total number of pages received and major adverse events. Surgical nurses and residents completed surveys to assess pre-intervention satisfaction, responsiveness and workflow. Surgical nurses were then instructed to utilize text-paging to communicate with residents for non-urgent issues. Urgent communications continued to be communicated with traditional numeric callback pages. Paging data was again recorded for 1 month and surveys were repeated. Statistical analysis using Chi-squared and student’s t-tests were used to compare pre- and post-intervention results.

Results: After text paging implementation 40.2% of non-urgent pages sent from nurses to resident physicians were alphanumeric texts vs. only 17.9% before implementation (P < 0.0001), and there was a 19.5% reduction in the number of non-urgent numeric callback pages sent from nurses to physicians (P < 0.0001). 70% of nurses surveyed post-implementation responded alphanumeric text paging was the preferred method of contacting a physician. 70% of nurses thought text paging initiative improved efficiency in triaging and responding to pages. After implementation, 62% of nurses thought that overall communication with responding clinicians improved. Furthermore, residents reported increased satisfaction, improved workflow, and decreased educational interruptions with text paging. 

Conclusion: We successfully implemented a free web-based text paging initiative for all non-urgent pages from nurses to residents that has improved physician-nurse workflow and communication on the surgical wards without an increase in adverse events.

 

92.12 Trends in Parastomal Hernia Repair in the United States

Posted on January 26, 2017

T. Gavigan1, B. Matthews1, N. Rozario1, C. E. Reinke1  1Carolinas Medical Center,Department Of Surgery,Charlotte, NC, USA 2Carolinas Medical Center,Dickson Advanced Analytics,Charlotte, NC, USA

Introduction:  Parastomal hernia is the most common complication after stoma creation. An estimated 120,000 new stomas are created each year. Recent studies report an parastomal hernia incidence approaching 80%, with more than half requiring surgical repair. Parastomal hernias create significant morbidity, including patient discomfort, small bowel obstruction, and need for emergent surgery. Little is known about the rates of parastomal hernia repair over the last 10 years in the United States. We examined national trends in parastomal hernia repair (PHR) in this study, including annual frequency of procedure, patient characteristics, and same-admission complications.  

 

Methods: The 1998-2011 Nationwide Inpatient Sample was used to identify patients who underwent a PHR (ICD-9 PR 4642).   PHRs were classified as PHR with concurrent resiting (ICD-9 PR 4643), PHR with concurrent ostomy reversal (ICD-9 4652 or 4651), or primary PHR. Patient age, race, sex, comorbidities and type of insurance were identified. Complications, length of stay (LOS), and mortality were identified. The frequencies of patient characteristics and outcomes were calculated by year and by type of PHR and analyzed to identify trends.   

 

Results: The estimated number of annual parastomal hernia repairs increased from 4,161 to 7,646 (p=<0.01, R2=0.85) for a total of 73,659 repairs. 30% underwent a concurrent stoma reversal and 10% underwent a resiting.  The proportion of females undergoing PSHR remained steady (58%). There was an upwards trend in the proportion of privately insured patients (26%-31%, p<0.01) and the number of patients with 3 or more Elixhauser comorbidities (17%-44%, p<0.01). The frequency of reversal increased while the frequency of resiting decreased. LOS remained steady (median 6.3 days) and in-hospital mortality ranged from 1.8-3.9% annually. Mortality and emergency admission status were highest for patients who underwent primary PHR, while the distribution of number of comorbidities was not significantly different between the three groups.

 

Conclusions: The incidence of parastomal hernia repair nationwide is increasing and more than half of patients undergo primary repair.  Although the surgical focus has moved towards prevention, parastomal hernia is a persistent complication of stoma creation. Further exploration is warranted to determine if the observed increase in parastomal hernia repair is related to perceived improved techniques and outcomes, an increasing incidence of parastomal hernia, patient characteristics or other factors.  

92.11 Genitourinary Paraganglioma: An Analysis of the SEER Database (2000-2012)

Posted on January 26, 2017

S. Purnell1, A. Sidana1, M. Maruf1, C. Grant2, S. Brancato1, P. Agarwal1  1National Cancer Institute,Urologic Oncolocy Branch,Bethesda, MD, USA 2George Washington University Hospital,Urology,Washington, DC, USA

Introduction: Extra-adrenal paragangliomas (PGL) are infrequent, benign, neuroendocrine tumors arising from chromaffin cells of the autonomic nervous system. While most develop above the umbilicus, they have been reported in the genitourinary (GU) tract. Due to the paucity of literature on the rates of GU paraganglioma, our study aims to describe demographic, pathologic, and clinical characteristics of GU PGL, and compare them to non-GU sites of PGL.

Methods: Data was collected from the SEER 18 Database to compare GU and non-GU PGL diagnosed between 2000 and 2012. Chi-square and unpaired t-tests were used. Kaplan-Meier analysis and a log rank test were used to determine overall survival and statistical significance, defined as p<0.05.

Results:299 cases of PGL were retrieved and only 20 (6.7%) arose from the GU tract. 83.3% GU PGLs developed in the bladder, subsequently the kidneys/renal pelvis (16.7%), and spermatic cord (2%). Non-GU PGL developed most frequently within the endocrine system (43%). Overall, PGL was more common in men than women. The mean age at diagnosis in years was higher in non-GU than GU PGL (50.4±17.2 vs 40.8±15.6, p=0.026). GU PGL was less common in whites compared to PGL at other sites (p=0.033). The majority (50%) of GU PGL was organ confined while 5.7% of non-GU PGL was localized at diagnosis. All cases of PGL were treated with surgery. 30% of patients with GU PGL underwent LN dissection and none had radiation. There were 2 (10%) cause-specific deaths in the GU PGL groups between 2000 and 2012. 5-year overall survival was 93.3% for GU PGL versus 65.5% in non-GU PGL (p=0.062).

Conclusion:Genitourinary PGL remains rare, with low incidence (6.7% of all PGL cases) in the US population between 2000 and 2012. Also, it had high 5-year overall survival compared to PGL developing outside of the GU tract. The bladder represents the most common site of involvement and surgery is the mainstay of treatment for GU PGL. Clearer prognostic factors are needed to better elucidate PGL management in the future thus pooled studies from various institutions with detailed clinical information are needed to delineate these prognostic factors.

 

92.10 Wound Selfie: an App to Reduce Surgical Site Complications and Improve Patient-Provider Communication

Posted on January 26, 2017

G. M. Taylor1, A. L. Guzman4, J. Wilder6, A. Nakhmani5, R. T. Russell2, J. A. White3, J. H. Willig4  1University Of Alabama at Birmingham,Department Of Surgery,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,Div. Of Pediatric Surgery,Birmingham, Alabama, USA 3University Of Alabama at Birmingham,Div. Of Transplantation,Birmingham, Alabama, USA 4University Of Alabama at Birmingham,Div. Of Infectious Disease,Birmingham, Alabama, USA 5University Of Alabama at Birmingham,Department Of Electrical And Computer Engineering,Birmingham, Alabama, USA 6Datascription,New York, NY, USA

Introduction: Surgical site complications (wound infection, dehiscence, and evisceration) can prolong hospital stays, contribute to readmissions, and necessitate subsequent operations.  Early identification of complications improves patient outcomes and reduces healthcare expenditures.  In our current practice, providers lack a consistent channel to monitor wound sites and communicate with patients after hospital discharge prior to scheduled follow-up.  Phone reports from patients are often insufficient, and photos are difficult to send securely.  Our goal was to create a safe and efficient platform for patients to transmit wound site photos and other clinical information to their providers. 

Methods: A multidisciplinary team including advanced practitioners, software engineers, surgeons, and infectious disease physicians was convened to leverage health informatics technology and develop a platform for communication with patients after post-operative discharge. In addition, we intend to train image recognition software and machine learning algorithms to independently identify patients with concerning wounds who needed earlier follow-up based on their wound images and supplemental patient questions.

Results:  The resulting “Wound Selfie” app for Android and iPhone iOS smartphone platforms provides a secure, HIPAA-compliant tool for providers to evaluate surgical wounds and communicate with patients. At hospital discharge, providers introduce the smartphone app to the patient and help them take an initial wound photo.  Patients submit pictures of wound sites regularly for review by the surgical team. In addition, patients answer a series of questions about symptoms related to wound problems and systemic symptoms that help providers provide timely follow-up. Providers can review patients’ wound images in the app or a desktop software interface. Digital analysis of these images will train algorithms that incorporate symptoms and risk factors for wound complications. Ultimately, the app will independently identify patients who need early post-operative intervention.

Conclusions: This app adds a new dimension to patient-provider communication.  Surgeons with limited staff and patients who may live far from providers can communicate more efficiently about their postoperative care. This app will serve as a tool to facilitate population health. For example, transplant patients, a regional population with higher rates of wound complications, can instantly send wound-site images and subjective history to their tertiary care center for review.  While further study is warranted, we are excited about the potential of new technological and interdisciplinary approaches to improve clinical outcomes for patients.

92.09 Laparotomy Trends Observed in 9,950,759 Patients Using 2009-2013 National Inpatient Sample (NIS)

Posted on January 26, 2017

M. J. Carney1, J. P. Fox1, J. M. Weissler1, J. P. Fischer1  1University Of Pennsylvania,Division Of Plastic Surgery,Philadelphia, PA, USA

Introduction:  There are between 4 to 5 million laparotomies performed annually in the United States (US) despite a distinct trend towards minimally invasive surgery. Laparoscopic surgical approaches have resulted in decreased length of stay, with no changes in short term complications, while still possessing similar oncologic outcomes to more traditional open surgery. Up to 30% of patients undergoing laparotomy will develop incisional hernia (IH), amounting a cost burden of $3.2 billion annually. Despite the paradigm shifts towards minimally invasive techniques, persistent hernia morbidity poses an equivocal disconnect warranting critical review. We aim to address these trends through analysis of the largest all-payer inpatient care database. 

Methods:  Using the 2009-2013 Nationwide Inpatient Sample, we conducted a cross-sectional review of hospital discharges of open abdominal surgery. For each event the database offered diagnostic and procedural coding (i.e., ICD-9-CM and CPT-4), as well as other socio-demographic and clinical variables. We sub-grouped the resultant discharges into the following categories: endocrine, vascular, hematologic and lymphatic, esophagus and stomach, intestine (small and large), hepatobiliary and pancreas, hernia, urology, other abdominal, gynecology, obstetrics, and transplant. To assess comorbidities, enhanced-Elixhauser algorithm was used. 

Results: Between 2009 and 2013, there were nearly 10 million discharges associated with an open abdominal surgery based on our collection of ICD-9 procedural code identifiers. Overall, there were 2,140,616 patients receiving open surgery in 2009, decreasing to 1,760,549 in 2013 (0.82% change, p<0.001). Each subgroup demonstrated a congruent decrease in open procedures except for hernia. These procedures increased from 37,325 patients in 2009 to 41,845 in 2013 (1.12% change, p=0.001). The most prevalent comorbidities within this population included uncomplicated hypertension (25.26%), chronic pulmonary diseases (13.52%), obesity (10.24%), uncomplicated diabetes (11.06%), and depression (10.72%).

Conclusion: Our large volume analysis allowed for a unique view of surgical trends, health care population dynamics, and an opportunity to use evidence-driven analytics in the understanding of IH. Previous studies have primarily focused on categorizing IH repair techniques, occurrence risk factors, and recurrence within a specific surgical field. Public health initiatives in a preventative model are paramount and encourage health care providers to implement best practice techniques at point of care. 

 

92.08 Impact of Hospital Volume on Outcomes for Laparoscopic Lysis of Adhesions for Small Bowel Obstruction

Posted on January 26, 2017

R. A. Jean1, K. M. O’Neill1, K. Pei2, K. A. Davis2  1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA 2Yale University School Of Medicine,Department Of Surgery, Division Of General Surgery, Trauma And Surgical Critical Care,New Haven, CT, USA

Introduction:  Volume to outcome data has been studied in several complex surgical procedures, demonstrating improved outcomes at higher volume centers. Laparoscopic lysis of adhesions (LLOA) for small bowel obstruction (SBO) may result in better outcomes, but there is no information on the learning curve for this potentially complex case. This study evaluates the effect of procedural volume on length of stay, outcomes, and costs in laparoscopic lysis of adhesions for small bowel obstructions.

Methods: The Nationwide Inpatient Sample (NIS) dataset between 2000 and 2013 was queried for discharges for a diagnosis of SBO involving LLOA in adult patients. Patients with intra-abdominal malignancy and evidence of any other major surgical procedure during hospitalization were excluded. The procedural volume per hospital was calculated over the time period, and high volume hospitals were designated as those performing greater than 25 weighted LLOA per year. Patient characteristics were described by hospital volume status using stratified cluster sampling tabulation and linear regression methods. Length of stay (LOS), cost, and total charges were reported as means with standard deviation and median values. P<0.05 was considered significant.

Results:A total of 9,111 discharges were selected, which was representative of 43,567 weighted discharges nationally between 2000 and 2013. Over the study period, there has been a 450% increase in the number of LLOA performed. High volume hospitals had significantly shorter LOS (mean 4.92 days (SE 0.13); median 3.6) compared to low volume hospitals (mean 5.68 (SE 0.06); median 4.5). In multivariate analysis, high volume status was associated with a decreased LOS of 0.72 days (p <0.0001) as compared to low volume status. Other significant predictors for decreased LOS included decreased age, decreased comorbidity, and the absence of small bowel resection. There was no significant association between volume status and total charges in multivariate or univariate models but, high volume hospitals were associated with lower costs in multivariate models by approximately $984 (p=0.017). 

Conclusion:This study demonstrates that high hospital volume was associated with decreased length of stay for LLOA in SBO. Although volume was not associated with differences in total charges, there was a small decrease in hospital costs.

 

92.07 Mobile Application Design and Human Factors for Global Health Innovation

Posted on January 26, 2017

T. Schwab1,2, J. Langell1,2  1University Of Utah,Center for Medical Innovation,Salt Lake City, UT, USA 2University Of Utah,Department Of Surgery,Salt Lake City, UT, USA

Introduction:  The use of mobile technologies and software applications offers the opportunity for improvements in global healthcare delivery.  If the potential for these technologies are to be realized, human factors must be considered when designing applications, devices, and other mobile interfaces. The goal of human factors in the design process is to decrease patient safety risks and improve clinical outcomes.  The objective of this study was to determine the effectiveness and value of human factors-based application design for global health innovation.

Methods: We implemented a 4-stage development process (Figure 1) for global health mobile application design by 12 teams to develop a medical application prototype for use by developing world populations. The stepwise development process involves design specifications and market requirements identification, app software optimization, app implementation testing and user feedback, and establishing a system to promote continual improvement during the life of the application. Teams provided feedback through formal surveys and interviews to highlight key aspects of the development process which directly contributed to successful app design. Teams scored all components of the design process based on clinical outcome value.  “Significant outcome value” was defined as an overall 90 out of 100-point score, or higher.

Results: 

Five elements of the design process were identified as having significant outcome value in the medical app development process. 1) User observation: Outcomes score of 119/120.  Defined as “Understand the clinical problem and the correlated patient characteristics though user observation and validation.”  2) Safety: Outcomes score of 117/120.  Defined as “Address and ensure safety in every stage of the mobile medical application process, including development of a risk assessment model.”  3) Ease of navigation: Outcomes score of 110/120.  Defined as “A functional and well-designed navigational menu, intuitive interface, and simple multitasking functions.” 4) Anatomy: Outcomes score of 108/120.  Defined as “Human hand anatomy and capabilities consideration in the interface design process for optimal flow, function and performance.” 5) Environment: Outcomes score of 104/120.  Defined as “Identification of unique environmental factors early in the design and development process resulting in overcoming potential challenges.”

 

Conclusion: To encourage adoption of medical mobile applications in developing regions, developers must create safe, accurate and layman-friendly applications. This can be effectively accomplished through an iterative human factors–based design process involving the targeted end user.
 

92.06 Machine Learning to Identify Multigland Disease in Primary Hyperparathyroidism

Posted on January 26, 2017

J. Imbus1, R. W. Randle1, S. C. Pitt1, R. S. Sippel1, D. F. Schneider1  1University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction:  Most patients with primary hyperparathyroidism (PHPT) have a single adenoma (SA), but 20-25% of cases will have multigland disease (MGD). Preoperatative localization of SAs allows for a minimally invasive surgical approach, but these studies are less accurate or unnecessary in MGD. Therefore, pre-operative identification of MGD could direct the need for imaging as well as the operative approach, and potentially referral to experienced surgeons. Machine learning (ML) uses computer algorithms to build predictive models from labeled datasets. The purpose of this study is to use ML methods to predict MGD.

 

Methods:  We reviewed a prospectively managed database of patients undergoing parathyroidectomy from 2001 to 2016. Patients (age ≥ 18 years) with PHPT who underwent initial, curative resection were included. MGD was defined as > 1 gland removed. Patients with genetic syndromes, a history of lithium use, prior neck surgery, or parathyroid carcinoma were excluded. The ML platform WEKA was utilized to compare different classifiers for predicting SA vs MGD from demographic, clinical, and laboratory features. The meta-algorithm, bagging, which reduces variance by averaging probability estimates, was applied. We selected the model with the best overall accuracy and separately used cost-sensitive classifier to maximize sensitivity for MGD.  10-fold cross validation was used to evaluate accuracy.

 

Results: 2035 patients met inclusion criteria: 1522 patients had SA (75%) and 513 had MGD (25%). After testing many algorithms, we selected the rule-based algorithm, PART, for its accuracy and potential integration in a clinical decision-support tool.  Sample rules are shown in the figure.  Using PART with bagging achieved 78% accuracy; 78% recall (sensitivity), 45% specificity, 76% precision (PPV), 0.710 Area Under the Receiver Operating Characteristics curve (AUC). To maximize sensitivity of detecting MGD, the cost-sensitive classifier achieved 89% sensitivity, 0.697 AUC for MGD.  To validate the algorithm’s impact on practice, we reviewed imaging from a separate test set of 50 patients with MGD. The algorithm correctly identified 49 of these 50 patients (98%). Among these, 43 sestamibi scans and 14 ultrasounds were performed.  However, only 14 sestamibi scans and 4 ultrasounds were correct.  Eliminating the incorrect or non-localizing studies would have provided a potential cost savings of over $1200/patient.

Conclusion: Rule based ML methods can help distinguish SA from MGD early in the clinical evaluation to guide further workup including localization studies. ML can potentially save money spent on unnecessary imaging studies or guide referral to high volume surgeons who are comfortable with bilateral exploration for MGD.

92.05 Limitations of Comparing NSQIP Outcomes Over Time

Posted on January 26, 2017

E. M. Gleeson1, A. P. Johnson2, M. E. Kilbane3, H. A. Pitt4  1Drexel University College Of Medicine,Philadelphia, Pa, USA 2Thomas Jefferson University,Philadelphia, PA, USA 3Indiana University School Of Medicine,Indianapolis, IN, USA 4Temple University,Philadelpha, PA, USA

Introduction:  The National Surgical Quality Improvement Program (NSQIP) provides a unique resource to researchers at participating institutions through the de-identified national Participant Use Files (PUF).  In an effort to improve data collection, some definitions for the outcome variables have changed over time. Despite these changes, researchers often combine the PUFs across years to increase the power of their studies.  This analysis aims to determine if these definition changes have affected the rates of the outcomes recorded.

Methods:  We reviewed cases collected by NSQIP from 2005-2014.  Control charts were utilized to evaluate the association between variable definition changes and special cause variation in the occurrence rates of surgical outcomes over each admission quarter.  Mortality, known to have decreased since the institution of NSQIP without any variable changes, was used as a negative control variable.  We particularly focused on postoperative occurrences with the most dramatic variable changes: myocardial infarction (2009), bleeding requiring transfusion (2010), , and sepsis (2013).

Results: We found that the majority of postoperative occurrences decreased over time, consistent with mortality.  However, special cause variation was noted for myocardial infarction (2009), bleeding requiring transfusion (2010),  and sepsis (2013) with violation of control chart rules at the time of significant variable definition changes (Figure).

Conclusion: This study demonstrates that special cause variation in postoperative occurrences may correlate with significant variable definition changes.  This issue severely limits conclusions drawn by comparing these outcomes over time periods with significant definition changes.  Authors and readers should remain vigilant to the limitations of NSQIP data and be aware of definition changes when comparing outcomes across years.

 

92.04 Predictors of ED Visits and Readmissions Within One Year of Bariatric Surgery: A Statewide Analysis

Posted on January 26, 2017

M. C. Mora Pinzon1, D. Henkel6, R. E. Miller2, P. L. Remington1, S. N. Kothari4, J. Gould3, L. M. Funk5,6  1University Of Wisconsin,School Of Medicine And Public Health,Madison, WI, USA 2Wisconsin Department Of Health Services,Madison, WI, USA 3Medical College Of Wisconsin,Department Of Surgery,Milwaukee, WI, USA 4Gundersen Health System,Department Of Surgery,Milwaukee, WI, USA 5William S. Middleton VA Hospital,Madison, WI, USA 6University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction:  30-day complication and readmission rates following bariatric surgery are well reported. However, there are limited data regarding bariatric surgery readmissions and Emergency Department (ED) utilization beyond 30 days. In this study, we identified all ED visits and readmissions to any facility in Wisconsin within one year of bariatric surgery, and we examined patient and hospital characteristics associated with these visits.

Methods: Statewide hospital patient data collected by the Wisconsin Hospital Association were used to identify all obese patients >20 years old who underwent laparoscopic Roux-en-Y gastric bypass (RYGB) or laparoscopic sleeve gastrectomy (LSG) from 2011-2014. Patient demographics, complications during bariatric surgery hospitalization, and primary and secondary diagnoses were identified using the International Classification of Diseases, Ninth Revision (ICD-9). Iterative deterministic linkage was used to track individuals who subsequently received hospital care over the next year. Bivariate associations between patient/hospital factors and ED visit or readmission were examined. Factors significant at a p<0.1 were included in a multivariable logistic regression model.

Results: 5,701 procedures were identified: 70% RYGB (n=3,988), 30% LSG (n=1,713). 79% of the patients were female. The mean age was 45.7 years old (SD: 11.5). 39% of patients presented to the ED or were readmitted within one year of bariatric surgery. The frequency of ED visits during the first year ranged from 10.7% in the first 30 days to 5.7% during postoperative days 181-270. Readmission rates ranged from 4.4% in the first 30 days to 2.7% during postoperative days 91-180 (Figure). On multivariable analysis, an ED visit within 1 year of bariatric surgery was associated with younger age, female gender, RYGB (vs. sleeve), having ≥4 comorbidities, Medicare or Medicaid insurance, teaching hospital for index procedure, and experiencing a complication during the initial bariatric surgery hospitalization (all p <0.05). Readmission within one year was associated with male gender, RYGB, ≥4 comorbidities, Medicare insurance, teaching hospital, and complication during the initial bariatric surgery hospitalization (all p <0.05).

Conclusion: ED visits and hospital readmissions are more common within the first 30 days after bariatric surgery, but persist steadily throughout the first postoperative year. Quality improvement efforts focused on patients who are most likely to visit the ED or be readmitted – such as those who undergo a gastric bypass or experience a complication during their bariatric surgery admission – may improve outcomes and decrease hospital resource utilization.

92.03 Use of Mobile Health Technologies to Monitor Postoperative Recovery: Barriers and Advantages

Posted on January 26, 2017

J. S. Abelson1, E. J. Kaufman1, M. E. Charlson2, H. Yeo1,3  1Weill Cornell Medical College,Surgery,New York, NY, USA 2Weill Cornell Medical College,Integrative Medicine,New York, NY, USA 3Weill Cornell Medical College,Healthcare Policy And Research,New York, NY, USA

Introduction:  Using smartphone and mobile health (mHealth) technology to monitor recovery after surgery has the potential to improve postoperative care, prevent complications, and reduce cost. We evaluated individuals’ perception of barriers and advantages to using mHealth after surgery. 

Methods:  Data were collected by Cornell University’s Survey Research Institute. Interviews were performed across New York State. Respondents were asked the following open-ended questions: 1. What are barriers or issues you might see to using a free mobile health app after surgery to improve your care? 2. What are benefits you might see to using a free mobile health app after surgery to improve your care? Of the 800 responses, 200 responses were coded independently by 3 reviewers to develop a preliminary codebook. The subsequent 600 responses were coded independently by 2 reviewers. The codebook was refined iteratively with all changes independently verified by the 3rd reviewer; all disagreements were resolved by consensus. We used modified grounded theory to allow themes to arise from the data. 

Results: The average age of our cohort was 47 yrs (+17yrs) with an equal distribution of male and female participants. Most respondents were White (67%) while 13% identified as having Hispanic ethnicity. The most common barrier identified was protecting privacy and security of personal health data. Although less common, other areas of concern included: uncertainty about accessibility and usefulness of mHealth; preference for face-to-face interaction wtih surgeon; and high effort required by patients. There were several advantages noted by respondents; the most commonly cited advantages were the potential for mHealth to improve recovery and prevent complications as well as to strengthen communication and the relationship with surgeon. Other advantages included: increased patient knowledge and self-engagement in recovery; and saving time and money by reducing doctor visits. Several respondents identified no barriers, and a few identified no advantages. 

Conclusion: This is the first large-scale qualitative analysis to evaluate perceptions of barriers and advantages in using mHealth after surgery to monitoring recovery. The majority of participants identified a narrow range of barriers, primarily focusing on confidentiality and data security.  Nearly all participants identified a wide variety of potential advantages, ranging from improved communication with surgeons to preventing complications and saving time and money. These results indicate that while participants were in general willing to use mHealth and perceived many benefits, design and promotion of these apps should address patient concerns about data security and technology accessibility.

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