53.08 Have sphincter-sparing anal fistula repair outcomes improved over time?

Posted on January 26, 2017

J. Sugrue1, S. Eftaiha1, C. Warner1, S. Thomas1, V. Chaudhry1, H. Abcarian1, A. Mellgren1, J. Nordenstam1  1University Of Illinois At Chicago,Colon & Rectal Surgery,Chicago, IL, USA

Introduction:
Sphincter-sparing repairs are commonly used to treat patients with complex cryptoglandular anal fistulas. Despite suboptimal efficacy relative to fistulotomy, they remain appealing because they minimize the risk of postoperative fecal incontinence. The aims of the current study were to evaluate the trends and long-term efficacy of sphincter-sparing fistula operations and determine the risk factors for recurrence.

Methods:
A retrospective review of all patients with cryptoglandular anal fistulas who underwent a sphincter-sparing repair between 2005 and 2015 at a single academic institution was performed. Patients with inflammatory bowel disease were excluded. Patient demographics, comorbidities, fistula characteristics, and type of operation performed were recorded. The primary outcome was the rate of fistula healing without recurrence. The relationship between fistula healing rates and clinical factors reported in this study were analyzed.

Results:
160 patients underwent 223 sphincter-sparing repairs with a median follow-up of 10 months (range 0-120). Overall, 31% healed, 59% recurred, and 10% were lost to follow-up. The median time to fistula recurrence was 3 months (range 0-75). Comparing operations performed between 2005 and 2009 to those performed between 2010 and 2015, there was a significant increase in utilization of the ligation of the intersphincteric fistula tract (LIFT) procedure (p<0.001) and a significant decrease in the utilization of fistula plugs and fibrin glue (p<0.001) though the healing rates were similar: 28% and 34%, respectively (NS) (Figure 1). Patients undergoing a dermal advancement flap (DAF), rectal advancement flap (RAF), or LIFT procedure were less likely to recur compared to patients treated with a fistula plug or fibrin glue (p=0.01).  There were no significant differences in healing rates with respect to patient age, gender, BMI, smoking status, comorbidities, use of a draining seton, fistula duration, or history of prior attempts at repair.

Conclusion:
Long-term healing rates following sphincter-sparing repairs of cryptoglandular anal fistulas remain suboptimal despite an increased use of the relatively novel LIFT procedure and decreasing use of fistula plugs and fibrin glue. Patients treated with a RAF, DAF, or LIFT were less likely to recur compared to patients treated with fistula plugs or fibrin glue. No other significant predictors of fistula recurrence were found in this study. Continued studies are needed to discover better techniques in performing sphincter-sparing fistula repairs in order to decrease the rates of recurrence while preserving continence.

53.07 Incidence of Metastatic Micropapillary Thyroid Carcinoma

Posted on January 26, 2017

M. Bosley1, C. Cox1, M. Jones1, D. Carneiro-Pla1  1MUSC,Oncologic And Endocrine Surgery/Department Of Surgery,Charleston, SC, USA

Introduction: Thyroid cancer is the most common endocrine cancer in the United States and accounts for 3.8% of all new cancer diagnosis. The rate for new thyroid cancer diagnosis has been rising on average 5% each year over the last 10 years. It has been suggested that over diagnosis of micropapillary carcinomas (<1 cm) is the main contributor to the increase in thyroid cancer incidence.  These tumors are believed to rarely result in symptoms or death, only occasionally growing or spreading beyond the thyroid gland, so much that specialists have been urged not to work up or treat these “indolent” small tumors. Ultrasonography is limited in diagnosing central neck node metastasis which is the most sensitive method of evaluation available for these patients who now more often are recommended active surveillance rather than surgery.  The goal of this study is to report the incidence of metastatic disease from micropapillary thyroid cancers.

Methods: Medical records of 213 consecutive patients with thyroid cancers measuring on final pathology 1 cm or less were retrospectively reviewed. All patients were evaluated with preoperative US and operated on by a single endocrine surgeon between January 2007 and December 2015. Pathology reports were reviewed for tumor size, presence or absence of metastases in the central and lateral node basins and multifocality.

Results: Of the 213 patients, 188(88%) were females, 164(77%) caucasian, average age 56(19-89) years old. Thirty-one of 213 (14%) were found to have node metastases.  Four out the 31 patients also had positive lateral neck node metastases.  Thus, approximately 13% of patients with node metastasis also required selective lateral neck dissections. Furthermore, 34% of these patients had multifocal disease at the time of the diagnosis.

Conclusion: Although recent studies have shown that only 1.5% of the patients with micropapillary thyroid cancer will develop metastatic disease during surveillance, this report demonstrates that 14% of these small cancers are metastatic at the time of the diagnosis, not only to the central neck but also to lateral neck node basins.

 

53.06 The ACS-NSQIP Risk Calculator Is Less Accurate For Emergent Than Elective Colorectal Operations

Posted on January 26, 2017

A. L. Lubitz1, E. Chan1, D. Zarif1, M. Philp1, H. Ross1, A. Goldberg1, H. Pitt1  1Temple University,Philadelpha, PA, USA

Introduction:  The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) has developed a Risk Calculator to assist patients and surgeons with difficult shared operative decisions. However, limited data are available to validate the Risk Calculator in elective surgery, and studies to evaluate its utility in emergent situations are not available. The aim of this analysis was to determine the accuracy of the ACS-NSQIP Risk Calculator in patients undergoing elective and emergent colorectal operations. 

Methods: From January 2013 through December 2015, 75 patients undergoing emergent colorectal surgery at a safety-net hospital were identified. These patients were matched with 75 patients having elective colorectal operations within four days before or after the urgent cases. Charts were reviewed to obtain preoperative risk factors to populate the Risk Calculator (RC). Actual postoperative outcomes, derived from National Surgical Quality Improvement (NSQIP) data, were compared to those predicted by the RC. Serious complications were defined as previously described within NSQIP. Student’s t-tests were used to compare means for categorical variables and Chi-Squared test for goodness of fit were used to analyze ordinal variables. Statistical analyses were performed with SPSS version 22. 

Results: Emergent and elective patients differed (p<0.01) with respect to age, functional status, ASA class, steroid use, wound class, chronic obstructive pulmonary disease and chronic renal insufficiency. The RC accurately predicted outcomes in elective patients. Outcomes were worse in the emergent than in the elective operations (Table). In emergent cases the RC underestimated serious complications (Comp) and length of stay (LOS) and overestimated discharge to a Skilled Nursing Facility (SNF) (Table). 

Conclusions: The ACS-NSQIP Risk Calculator accurately predicts outcomes for elective colorectal surgery. Predicted and actual outcomes are dramatically increased in patients undergoing emergent colon operations. In patients requiring emergent colectomy the Risk Calculator underestimates serious complications and length of stay and overestimates the ability of safety-net patients to be discharged to a Skilled Nursing Facility.

 

53.05 Laparoscopic Surgery for Emergency Colorectal Surgery: Less Morbidity and Shorter Length of Stay

Posted on January 26, 2017

M. Sanghvi1, A. A. Maung1, K. A. Davis1, K. M. Schuster1  1Yale University School Of Medicine,Surgery,New Haven, CT, USA

Introduction: Fewer complications and shorter lengths of stay have been demonstrated for laparoscopic as compared to open approaches in elective colorectal operations. This experience has been expanded to include the use of laparoscopy for urgent or emergent colorectal conditions, despite a paucity of supporting evidence. We hypothesized that post-operative outcomes would be improved with a laparoscopic approach in emergency colorectal operations.

Methods: All NSQIP urgent or emergent targeted colectomy cases from 2012 to 2014 were reviewed. Outcomes included 30-day mortality and morbidity including: surgical site infection, anastomotic leak, other infectious complications, cardiovascular complications, renal failure, venous thromboembolism prolonged ileus, reoperation and length of hospital stay. Demographics, comorbidities, pre-operative lab results, wound class, ASA class and pre-operative functional status were assessed for risk adjustment. To assess the effect of attempting laparoscopy compared to an initial laparotomy, laparoscopy and laparoscopy converted to laparotomy were included in the laparoscopy group. Logistic and log-linear models were constructed to assess outcomes.

Results: There were 4877 patients in the laparotomy group and 809 in the laparoscopy group, 435 of which were laparoscopies converted to laparotomy. Unadjusted mortality was lower in the laparoscopic group (4.6% vs 14.2%; p<0.001), however after adjustment for confounders, a laparoscopic approach was no longer significantly associated with mortality (OR 0.698; 95% CI 0.45-1.09; p=0.115). After adjustment overall thirty day morbidity was lower although anastomotic leak was higher (table). Hospital stay was approximately 1 day shorter with laparoscopy. The type of surgical approach chosen did not impact the incidence of surgical site infection, prolonged post-operative ileus and reoperation rates.

Conclusion: Laparoscopic surgery in emergency colorectal operations appears to have comparable outcomes compared to laparotomy with shorter length of hospital stay. Laparoscopy may be associated with a higher leak rate, but lower overall morbidity when considering all cardiovascular, pulmonary and renal complications. Additional studies should investigate the impact of laparoscopy on anastomotic leak in emergency colorectal surgery.

 

53.04 Standardized Negative Pressure Wound Therapy Decreases Days of Vac Use in Acute Care Surgery

Posted on January 26, 2017

M. J. Forestiere1, R. C. Frazee1, C. L. Isbell1, T. S. Isbell1, R. W. Smith1, S. W. Abernathy1, Y. Munoz-Maldonado1, J. L. Regner1  1Scott & White Healthcare,General Surgery,Temple, Texas, USA

Introduction:
Surgical site occurrences (SSO) are prevalent in acute care surgery. The increased focus on quality has resulted in more in-patient and out-patient use of Negative Pressure Wound Therapy (NPWT) for surgical wounds. We created a NPWT protocol using Hydrofera Blue® bacteriostatic foam wicks, primary skin staples, and silver impregnated foam overlay to facilitate early wound closure. Our hypothesis is that a standardized NPWT protocol will decrease SSO and days of NPWT use.

Methods:
Retrospective cohort study assessed consecutive emergency celiotomies at our institution from July 1, 2013 – June 30, 2014. Patients under age of 18 were excluded. Included variables were demographics, surgical indication, vasopressor use, wound classification, NPWT days, and SSO. Primary outcomes were SSO [superficial & deep surgical site infection, fascial dehiscence, and return to OR], days of NPWT, and discharged with NPWT. Analysis used exact Chi-square tests between categorical variables, Monte Carlo Kruskal-Wallis tests for analysis of variance for ordinal and categorical variables, and Wilcoxon-Sum-Rank test for total days of NPWT.

Results:
212 patients underwent emergency celiotomy. After excluding clean wounds (n=54), the remaining patients were divided into primary closure only (n=51), traditional NPWT (n=63), and our NPWT protocol (n=43). There was no difference in ASA, BMI, surgical indication, wound classification, or SSO among the three groups. Total NPWT days were reduced in protocol versus traditional NPWT (median=3 vs 20.5 days, range = (3-51) vs (3-405) days, p=0.003). Fewer patients were discharged home with NPWT in the protocol vs traditional NWPT (14 vs 63.5%, p<0.0001, OR=10.7, 95% CI [3.7–35.1]).

Conclusion:
Protocol driven NPWT decreases NPWT usage days and maintains low surgical site occurrences. National adoption of this protocol has the potential to reduce healthcare costs and improve quality outcomes.
 

53.03 Biologic Versus Synthetic Absorbable Mesh in Complex Ventral Hernia Repair

Posted on January 26, 2017

K. Yuen1, S. Millikan1, J. Smolevitz1, M. Thaqi2, R. A. Jacobson1, K. W. Millikan1  1Rush University Medical Center,Department Of General Surgery,Chicago, IL, USA 2University Of Missouri,Department Of Surgery,Columbia, MO, USA

Introduction:
The separation of components (SOC) technique has improved outcomes in complex ventral hernia repair (VHR) since its inception. As the technique is relatively novel, unrealized gains in both outcomes and value likely exist. A recent consensus statement identified investigation into choice of mesh material as a needed future study. Our group recently reported low recurrence rates utilizing a biologic mesh onlay technique in VHR with SOC. While effective, the use of biologic mesh adds significant cost to patients and providers. In theory, synthetic absorbable mesh offers similar biological activity and repair strength at a lower cost than biologic mesh. We designed the current study to test the hypothesis that similar recurrence rates and safety could be achieved in VHR with SOC utilizing a synthetic absorbable mesh onlay compared to the same procedure performed with biologic mesh. 

Methods:
Retrospective cohort study of patients undergoing VHR with SOC utilizing a mesh onlay with biologic (Bio) vs synthetic absorbable (SA) mesh performed by two surgeons at one institution over eight years. Standard anterior component separation with midline fascial closure and mesh onlay was used in all patients. Biologic mesh were allomax type (Bard Davol, Murray Hill, NJ) and synthetic absorbable mesh were phasix (Bard Davol). Cohorts were staggered temporally – the allomax cohort operations took placed between 2008 and 2013, while the phasix cohort operations took place between 2013 and 2015. The primary endpoint was hernia recurrence; secondary endpoints were wound complications including infection, seroma and skin necrosis. Follow up took place in the clinical setting and recurrence was determined on history and physical exam. Statistical significance was determined using student’s t-test and two proportion z-test where applicable.

Results:
188 patients were identified (103 Bio, 75 SA). Average BMI was 36.2 Bio vs 37.2 SA, p=0.45. Percent female was 60.2% Bio vs 60.0% SA, p=1. Average age was 56.1 Bio vs 53.5 SA, p=0.11. 16.0% of Bio patients underwent concomitant panniculecomy versus 59.1% of SA patients, p<.001. Mean follow up was 65.1 months Bio vs 22.4 months SA. 

Overall recurrence at the end of the study period was 6.91% (13/188); recurrence using Bio was 6.80% (7/103) versus 8.00% (6/75) using SA, p=0.63. Overall rate of wound complications was 43.7% (45/103) Bio vs 46.7% (35/75) SA, p=0.67. 

Conclusion:
Recurrence rates and wound complications were similar between patients receiving biologic and non-biologic synthetic mesh repairs. Our results show relatively low recurrence in each group compared to prior studies, particularly in obese individuals. In light of potential cost savings and equivalent safety and efficacy, non-biologic synthetic absorbable mesh should be considered for regular use in VHR with SOC. 
 

53.02 Continuous Local Anaesthetic Wound Infusion for midline Laparotomy: A Systematic review

Posted on January 26, 2017

B. Kakala1,2, Z. Y. Yeh2  1University Of Sydney,General Surgery,Sydney, NSW, Australia 2Blacktown Hospital,General Surgery,Sydney, NSW, Australia

Introduction:  

Post-operative pain following an open midline laparotomy is associated with significant morbidity and mortality. Multimodal analgesia aims to achieve more effective pain relief and reduce some of these adverse effects such as signficant ongoing pain, ileus, nausea and vomiting. Continuous local anaesthetic wound infusions (CLAWI) into the laparotomy wound via an indwelling wound catheter is a promising addition to a multimodal postoperative analgesic regimen. This systematic review aims to appraise and synthesise evidence from randomised controlled trials evaluating CLAWI for controlling acute postoperative pain within 24 hours following surgery.

Methods:

Medline, Embase and Central databases were searched to March 2015. References were screened by title and abstract. Full texts of trials for potential inclusion were examined. Reference lists of included trials were hand-searched for additional trials. Two authors indepedently identified trials for inclusion, assessed the quality and risk of bias of included trials, and extracted data. Any unclear or missing inforamtion was sought by contacting the corresponding authors. Where necessary, missing data was imputed according to insturctions given in the Cochrane Handbook. Meta-analysis based on a fixed effects model was performed using RevMan 5.

Results:

A total of 3537 references werwe identified. After exluding 1282 duplicates, 379 non-English references and 1847 references based on screening, 29 full texts were further examined to identify 6 trials that fulfilled the inclusion criteria. 608 participants were included for review. All except one trial had moderate to high risk of bias. Two trials compared CLAWI (n=79) to epidural analgesia (n=77). Within 24 hours, there was no significant difference between the two groups in pain (mean difference [MD] 0.13 on a 10-point scale, p=0.55). four trials compared CLAWI with local anaesthetic (LA) (n=225) versus saline (n=227). Within 24 hours, the LA group had a statistically significant reduction in both pain (MD -0.43 on a 10-point scale, p=0.05) and opioid consumption (MD -5.02mg morphine equivalent, p=0.04).

Conclusion:

CLAWI was associated with a small but statistically significant reduction in both pain and opioid consumption within 24 hours following midline laparotomy. It was non-inferior to epidural analgesia in terms of acute postoperative pain control, and is a promising alternative in situations where epidural analgesia is contraindicated, impractical, technically difficult or poorly tolerated.
 

53.01 Moderately Severe Acute Pancreatitis: Value and Impact of Revised Atlanta Criteria 2012

Posted on January 26, 2017

A. K. Gulla1, Z. Dambrauskas2, Z. Dambrauskas2  1Georgetown University Medical Center,Department Of Surgery,Washington, DC, USA 2Lithuanian University Of Health Sciences,Department Of Surgery,Kaunas, KAUNAS, Lithuania

Introduction:

Acute pancreatitis (AP) is a severe and frequently life-threatening disease, which can lead to pancreatic necrosis, ALI, SIRS and MODS. This study explores whether or not patients categorized as "moderately severe" under Atlanta 2012 criteria should be treated as severe cases according to Atlanta 1992 due to occurrence of MODS, pancreatic necrosis, infectious complications.

Methods:

103 retrospective AP patients chart review who were admitted to Lithuanian Health Sciences University hospital, Department of Surgery (2008-2013). All patients were confirmed to have diagnosis of AP during the first 24 hours since admission (Atlanta classification, 2012).  In addition, the severity of pancreatitis was assessed by MODS and APACHEII scale with reevaluation after 48h and 72 h. All patients were categorized into 3 groups based on severity: mild, moderately severe, severe (Atlanta, 2012). Then, "moderately severe" cases were compared to mild and severe cases according to Atlanta 1992 classification. Outcomes and management were reassessed. 

Results:

There were 54 (52.4%) males and 49 (47.6%) females enrolled in the analysis. 53.4% of patients had edematous while 46,6 % had necrotic AP. The most common cause of AP was alcohol  (42.7%) followed by alimentary (26,2%), biliary (26,2%), idiopathic (4.9%). Using Revised Atlanta Classification (2012) and Atlanta Classification (1992) there were 49 (47,6%) mild vs 56 (54,4%), 27 (26,2%) moderately severe and 27 (26,2 %) vs 47 (45,6%) severe AP cases accordingly; Therefor, there was no statistical significance difference in ICU stay, use of interventional treatment, infected pancreatic necrosis and mortality rates between the “severe” groups (Atlanta 1992 and Revised Atlanta 2012).

However, "moderately severe" group 27 (103) patients (Atlanta, 2012) compared to severe form 27 of AP (Atlanta, 1992) had significantly better outcomes that those of severe form: necrosis -94,3%, sepsis -22,2%, longer ICU stay -24%) FNA (37%), US guided drainage- 14.8%, surgery -22,2%., APACHE II 13,2 ( p=0.002), MODS ( p=0,001).

This data shows that patients categorized as “moderately severe” (Atlanta, 2012) have similar clinical outcomes, mortality rates and need for intervention compared to “mild” and “self-limiting AP ( Atlanta, 1992) (Table 1).

Conclusion:

Patients who met the new criteria of “moderately severe” acute pancreatitis had more self-limited disease course, fewer complications, lower incidence of SIRS, lower MODS and APACHEII scores, no reported deaths and lower rates of interventions. This study shows that the new Atlanta 2012 criteria reduce unnecessary treatments and should result in better patient outcomes.

52.19 Predictors Of Emergent Operation For Diverticulitis

Posted on January 26, 2017

B. L. Corey1,2, L. Goss1,2, A. Gullick1,2, M. Morris1,2, D. Chu1,2, J. Grams1,2  1University Of Alabama At Birmingham,Surgery,Birmingham, ALABAMA, USA 2Birmingham Veteran’s Affairs Medical Center,Surgery,Birmingham, ALABAMA, USA

Introduction:  Emergent operations for diverticular disease are associated with worse clinical outcomes. Understanding predictors of emergency surgery may help guide recommendations for elective operations.  We hypothesized that patient-specific factors, such as co-morbid conditions, would predict emergent operation in the surgical treatment of diverticulitis. 

Methods:  The 2012-2013 national surgical quality improvement (NSQIP) patient database was queried for patients undergoing surgical management for diverticulitis. Patients were stratified by emergent versus non-emergent operations.  Univariate analyses were used to determine predictors of emergent versus non-emergent operations. Multivariate adjustments were made using logistic regression utilizing stepwise selection of all possible covariates. Significance was determined as p-value ≤0.05. 

Results: Of 8,070 patients who underwent surgery for diverticulitis, median age was 59 years and patients were more commonly female (54.2%), white (93%), and non-smoking (78.5%). Of these, 84.2% of cases were non-emergent and 15.8% were emergent. When compared to non-emergent patients, emergent patients were older (64 vs 59 years, p=<0.001) and had a higher incidence of diabetes (13.1 vs 10.2%, p=0.003), COPD (9.9 vs 3.8%, p<0.001), hypertension (54.3 vs 46.9%, <0.001), steroid use (14.1 vs 4.5%, p=<0.001), and severe or life-threatening ASA class (71.4 vs 37.4%, p<0.001). On multivariate analysis, independent predictors of emergency operation included male sex (odds ratio [OR]1.3), steroid use (OR 1.75), and higher ASA Class (ASA class 3, OR 2.7; ASA class 4-5, OR 17.7) (p<0.05). 

Conclusion: Patients of male sex, with steroid use, and higher ASA class were at increased risk of an emergency operation.  These factors should be considered when recommending surgery for patients with diverticulitis.

 

52.18 Implementation and Outcomes of an ERAS Protocol for Abdominal Wall Reconstruction

Posted on January 26, 2017

E. Stearns1, M. A. Plymale1, D. L. Davenport2, C. Totten1, S. Carmichael1, C. Tancula1, J. S. Roth1  1University Of Kentucky,General Surgery/Surgery/Medicine,Lexington, KY, USA 2University Of Kentucky,Surgery/Medicine,Lexington, KY, USA

Introduction: Enhanced Recovery after Surgery (ERAS) protocols are evidence-based quality improvement pathways reported to be associated with improved patient outcomes.  Building on the previously-reported protocol for abdominal wall reconstruction (AWR) that addresses optimal pain control and acceleration of intestinal recovery, a 17-element ERAS protocol for AWR was developed. The purpose of this study was to compare short-term outcomes for patients cared for after protocol implementation to a cohort of historical controls. Process evaluation was conducted to pinpoint level of adherence to protocol details in order to identify opportunities for improvement.

Methods: After obtaining IRB approval, surgical databases were searched for AWR cases for two-years prior and eleven months after protocol implementation. The two groups were compared on characteristics including age, body mass index, comorbidities, operative details, and clinical outcomes using chi square, Fisher’s exact test or Mann Whitney U test, as appropriate. Process evaluation consisted of determining the level of adherence to protocol details at the patient, health care provider and system levels.

Results: 173 patients underwent AWR by one surgeon during the time period described (46 patients with ERAS protocol in place and 127 controls).  Preoperative characteristics of age, gender, ASA Class, comorbidities, and smoking status were similar between the two groups.  Body mass index was slightly lower among ERAS patients (p = .042). Just over three-fourths of the cases in each group were CDC Wound Class 1; ERAS patients were more likely than controls to have had synthetic mesh implanted as opposed to other mesh types. In terms of clinical outcomes, ERAS patients had earlier return of bowel function (median 3 days vs. 4 days) (p = .002) and decreased incidence of superficial surgical site infection (SSI) (7% vs. 25%) (p = .004) than controls. Hospital length of stay was similar between the two groups. Protocol adherence by ERAS component ranged from a low of 54% (acceleration of intestinal recovery) to 100 % (postoperative glucose control). Protocol adherence by case varied from 55% (1 patient) to 94% (4 patients).

Conclusion: A comprehensive ERAS protocol for AWR demonstrates evidence for hastened return of bowel function and decreased incidence of SSI. Process evaluation identified specific areas of less than optimal adherence to protocol details, providing substantiation for increased education at all levels. A system-wide culture focused on enhanced recovery is needed to improve protocol adherence and subsequent patient outcomes.

52.17 Preoperative Opioid Abuse: Implications for Outcomes Following Low Risk Elective Surgery

Posted on January 26, 2017

A. N. Cobb1,2, A. Kothari1,2, S. Brownlee2, P. Kuo1,2  1Loyola University Medical Center,Department Of Surgery,Maywood, IL, USA 2Loyola University Medical Center,One:MAP Division Of Clinical Informatics And Analytics,Maywood, IL, USA

Introduction: Increasing numbers of patients are using opioids for pain management. While there is growing recognition of the potentially negative implications of postoperative opioid use, little is known about the effect of opioid abuse in the preoperative setting. The objective of this study was to determine the prevalence of opioid abuse in patients undergoing low risk elective procedures and to assess its impact on postoperative morbidity, mortality, and resource utilization. 

Methods: Patients with a preoperative diagnosis of opioid use disorder or dependence who underwent one of five low risk elective procedures (laparoscopic cholecystectomy, mastectomy, total knee replacement, gastric bypass, prostatectomy) were extracted using the Healthcare Cost and Utilization Project (HCUP) State Inpatient Database (SID) for California, New York, and Florida during the years 2009-2011. Descriptive statistics of the study population were calculated using arithmetic means with standard deviations for continuous variables and proportions for categorical variables. Risk-adjusted odds of mortality, morbidity, length of stay, and discharge disposition were calculated using mixed-effects regression models with fixed effects for age, race, sex, socioeconomic status, insurance type, and comorbid disease

Results: This study included 541,637 adult patients that underwent one of five elective surgical procedures. Of these, 403 patients (0.07%) were found to carry a preoperative diagnosis of opioid dependence. The largest proportion of patients with opioid dependence were Caucasian, female, privately insured, and of low socioeconomic status. The most common procedure in patients with opioid dependence was total knee replacement (322 patients). Patients with opioid use disorder were younger than those without (57 years vs 64 years p<0.001). Opioid use was not associated with inpatient mortality (OR=5.01, 95% C.I: 0.69 – 36.2), however it was associated with increased aggregate morbidity (OR=2.0, 95% C.I:1.19-3.39), the odds of having a non-routine discharge disposition (OR=0.38, 95% C.I: 0.30 – 0.48), and prolonged length of stay (OR=2.67, 95% C.I: .2.08 – 3.41).

Conclusion: Preoperative opioid use has a negative impact on postoperative outcomes and leads to increased resource utilization following low risk elective procedures. This presents an opportunity to create a preoperative screening tool to assess patients for opioid abuse or dependence. If patients are found to exhibit opioid abuse, a concerted effort should be made by surgeons to have these patients treated prior to elective surgical intervention, or decline to perform elective surgery on patients that misuse opioids and defer treatment.
 

52.16 Minimally Invasive Surgery For HCC: Comparison Of Laparoscopic And Robotic Approach

Posted on January 26, 2017

P. Magistri1,2, G. Tarantino1, G. Assirati1, T. Olivieri1, V. Serra1, N. De Ruvo1, R. Ballarin1, F. Di Benedetto1  1University Of Modena And Reggio Emilia,Hepato-Pancreato-Biliary Surgery And Liver Transplantation Unit,Modena, MO, Italy 2Sapienza – University Of Rome,Medical And Surgical Sciences And Translational Medicine,Rome, RM, Italy

Introduction:  Hepatocellular carcinoma (HCC) has a growing incidence worldwide, and represents a leading cause of death in patients with cirrhosis. Nowadays minimally invasive approaches are spreading worldwide in every field of surgery and in liver surgery as well.

Methods:  We retrospectively reviewed demographics, clinical and pathological characteristics and short-term outcomes of patients underwent minimally invasive resections for HCC at our Institution between June 2012 and May 2016.

Results: No significant differences in demographics and comorbidities were found between patients underwent laparoscopic (n=24) and robotic (n=22) liver resections, except for the rates of cirrhotic patients (91.7% and 68.2%, respectively, p=0.046). Peri-operative data analysis showed that the operative time (mean, 211 min and 318 min, respectively, p<0.001) was the only parameter in favor of laparoscopy. In fact, robotic approach allowed us to resect larger tumors (mean, 22.96 mm and 31.85 mm, respectively, p=0.02) with a statistically significant lower rate of conversions (16.7% vs. 0%, respectively, p=0.046). Moreover, robotic assisted resections were related to less Clavien I-II post-operative complications (22 vs. 14 cases, respectively, p=0.02). About resection margins, the two groups had similar rates of disease-free resection margins without any statistically significant difference.

Conclusion: A modern hepatobiliary center should offer both open and minimally invasive approaches to the liver disease, in order to provide the best care for each patient, according to the individual comorbidities, risk factors, and personal quality of life expectations. Our results show that the robotic approach is a reliable tool for an accurate oncologic surgery, comparable to the laparoscopic approach. Also, robotic surgery allows the surgeon to perform larger resections and to safely approach liver segments that are hardly resectable in laparoscopy, namely segment I-VII-VIII.  
 

52.15 Is there a Gender Disparity for Diabetes Remission after Bariatric Surgery?

Posted on January 26, 2017

K. Shpanskaya1, H. Khoury1, H. Rivas1, J. Morton1  1Stanford University,Palo Alto, CA, USA

Introduction:  Bariatric surgery is profoundly effective in improving and resolving type 2 diabetes mellitus (T2DM) in the severely obese. Our study aims to investigate the role of gender differences in T2DM remission and its related serum markers 12 months after bariatric surgery.

Methods: We performed a retrospective study of 817 severely obese T2DM patients that underwent laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy. T2DM remission was defined as complete or partial with a glycated hemoglobin (HbA1c) of less than 6.0% or 6.5%, respectively, with no diabetes medication use for 12 months after surgery. HbA1c, fasting glucose, and insulin were measured preoperatively and 12 months postoperatively. Data were analyzed using student’s t-test and multivariate regression analysis, controlling for age, change in BMI, type of surgery, and number of preoperative comorbidities.

Results: 213 males and 604 females with a mean age of 50.42 (SD 9.76) and 48.55 (SD 10.57), respectively, and an average preoperative BMI of 46.26 (SD 8.35) and 46.83 (SD 7.85) were included in this study. Preoperatively, HbA1c levels from males (N=184; 7.81, SD 1.80) and females (N=530; 7.01, SD 1.40) significantly differed (P=0.000). Initial fasting glucose was significantly higher (P=0.010) in males (N = 136; 151.44, SD 59.74) than in females (N=349; 137.08, SD 53.05). Females (N = 226; -15.35, SD 9.25) showed significantly greater BMI reduction at 12 months post-surgery than males (N= 76; -12.7, SD 10.43) (P=0.037). Males and females showed significant one-year improvement in HbA1c (P = 0.000; males from 8.1% to 5.4%, females from 7.1% to 5.5%), fasting glucose (P = 0.000; males from 149.97 to 101.76 mmol/L, females from 136.17 to 96.32 mmol/L), and insulin (P =0.000; males from 29.5 to 5.38 UI/L, females from 34.07 to 7.63 UI/L). One year after surgery, males (N=41; -2.67, SD 1.87) had a greater decrease in HbA1c levels (P=0.001) than females (N=153; -1.60, SD 1.48) after controlling for age, 12 month weight loss, and preoperative comorbidities. Change in fasting glucose (P=0.511) and insulin (P=0.728) at 12 months after surgery did not significantly differ. Postoperatively, no significant difference in HbA1c, in fasting glucose, or in insulin levels was seen. Neither complete nor partial T2DM remission one year after surgery was significant between genders (P=0.372, P=0.514). 

Conclusion: Our study is one of the first to explore gender differences in T2DM remission and diabetes serum markers at one year after bariatric surgery. Males show higher preoperative HbA1c levels and greater benefit of surgery for HbA1c levels at 12 months. Diabetes remission and reduction in fasting glucose and insulin levels at one year after surgery were not significantly different between males and females. Despite a worsened glycemic profile preoperatively, male bariatric surgery patients demonstrated significant improvement in diabetes markers similar to female bariatric surgery patients.

 

52.14 Quality of Life Assessment Before and After Ventral and Umbilical Hernia Repairs, a Prospective Study

Posted on January 26, 2017

S. L. Whitney1, M. Simhon1, C. Divino1  1Mount Sinai School Of Medicine,Surgery,New York, NY, USA

Introduction: Ventral and umbilical hernias are a common pathology in our population given increasing obesity rates and increasing rates of abdominal surgeries. We aimed to assess quality of life (QOL) improvement following repair of these hernias using a validated, the Carolina Comfort Scale (CCS), and compare these QOL outcomes between patients.

 

Methods: The CCS was tailored to assess symptoms and quality of life related to hernia repair. Patients undergoing repair were consented and completed three CCS surveys: pre-operatively, within 1 month after surgery, and greater than 1 month after. Questions on the CCS survey assessed severity of symptoms related to the hernia on a scale of 1-5 by asking if various positions and activities could result in worsening of pain, movement limitations and sensation of mesh post-procedure. Secondary outcomes measured were re-admission, complications, and blood loss.

 

Results: 43 patients consented to participate and filled out the 3 required surveys. The average age was 49.2 years with an average BMI of 29.7. 24 patients had a history of previous abdominal surgery with 13 of these being classified as incisional ventral hernias. 42 of 43 were reported to be symptomatic, with pain and movement limitations being present. All 43 cases were performed electively. 24 surgeries were performed laparoscopically, 13 were performed open, and 6 were performed robotically. Mesh was used in all laparoscopic cases and all robotic cases, and 3 of the 13 open cases. The average length of hernia duration was 38.5 months. On the CCS survey, all patients who underwent repair showed significant symptomatic improvement (p ≤ 0.05) between the pre-op symptoms and 2nd post-op visit symptoms in all 9 categories regarding pain and movement limitations. All patients who received mesh reported mild sensation of mesh that did mildly diminished by the second post-operative visit, but this change was not significant in any of the categories (p < 0.05). Of all patients who underwent repair, the mean rating of satisfaction on a scale of 1-5 was 3.93 at the second post-operative visit. The mean number of days to return to work was 25.7 days as reported at the second post-operative visit. The mean surgery time was similar in both laparoscopic and open cases (p 0.11). There were no recurrences during the follow-up period.

 

Conclusion: Patients reported significant improvement in pain and functional status following ventral and umbilical hernia repair surgery, with improved pain and diminished movement limitations.  Sensation of mesh did not significantly diminish as time progressed post-operatively. 

 

52.13 Outcomes of Neoadjuvant Therapy in Stage III Rectal Cancer

Posted on January 26, 2017

A. M. Dinaux1,2, R. Amri1,2, L. Bordeianou1,2, H. Kunitake1,2, D. L. Berger1,2  1Massachusetts General Hospital,Surgery,Boston, MA, USA 2Harvard School Of Medicine,Surgery,Brookline, MA, USA

Introduction:
Neoadjuvant therapy for patients with advanced stage rectal cancer remains the gold standard. Patients with either T3 or greater disease and/or suspected lymphadenopathy presently receive neoadjuvant chemoradiation. These patients have 3 possible outcomes to treatment. They can have a complete pathologic response. They can have a partial response and be pathologically node negative at surgery or they can have persistent disease with positive nodes. This abstract addresses outcomes in these groups. 

Methods:
All patients with clinically AJCC-stage III who received neoadjuvant treatment were selected from an IRB-approved, retrospective, prospectively maintained database, which contains all surgically treated rectal cancer patients who received their surgery between 2004-2014 at a single center. 

Results:
A total of 207 patients were clinically stage III based on preoperative imaging and received neoadjuvant treatment. Seventy-six of those still had nodal disease on pathology after treatment, compared to 131 nodal responders, of which 33 had a pathologic complete response. Compared to nodal responders with residual tumor, patients with positive nodes on pathology had higher rates of high-grade tumors (17.1% vs .4.1%; P=0.016), extramural vascular invasion (30.3% vs. 7.1%; P<0.001), perineural invasion (31.6% vs. 11.2%; P=0.001), large vessel invasion (27.6% vs. 7.1%; P<0.001) and small vessel invasion (27.6% vs. 10.2%; P=0.003). Distant metastatic recurrence percentage was also higher in the pN+ group (26.3% vs. 9.9%), with a shorter median disease free survival (18.5 months, IQR [8.7-32.3] vs. 32.3 [16.8-59.3]). Disease specific survival analysis showed a significant difference between clinically stage III patients with pathologic complete response, with residual tumor but no more nodal disease on pathology, and with persistent nodal disease. Previous mentioned groups are listed in order from best to worst survival in a Kaplan Meier-curve.

Conclusion:
Persistent nodal disease after neoadjuvant therapy is a very poor prognostic sign. Patients with residual nodal disease had significantly worse short and long-term oncological outcomes compared to those who had residual tumor but no positive lymph nodes. Considering that pathologically node positive patients showed higher rates of specific pathologic features, these features may be indicators of a poor response to neoadjuvant therapy. These prognostic factors may be detectable on preoperative assessments, biopsy and MRI. It is possible that these patients may benefit from receiving a full course of chemotherapy prior to surgical resection as they clearly have systemic disease.

52.12 Pre-Admission Frailty Predicts Post-Discharge Adverse Events in Acute Care Surgery Patients

Posted on January 26, 2017

Y. Li1, J. L. Pederson1, T. A. Churchill1, A. S. Wagg2,5, J. S. Holroyd-Leduc3,5, K. Alagiakrishnan2,5, R. S. Padwal2,6, R. G. Khadaroo1,4  1University Of Alberta,Department Of Surgery,Edmonton, AB, Canada 2University Of Alberta,Department Of Medicine,Edmonton, AB, Canada 3University Of Calgary,Department Of Medicine And Community Health Sciences,Calgary, AB, Canada 4University Of Alberta,Department Of Critical Care Medicine,Edmonton, AB, Canada 5Alberta Seniors Health Strategic Clinical Network,Calgary, AB, Canada 6Alberta Diabetes Institute,Edmonton, AB, Canada

Introduction:
Frailty is a subjective measure of decreased physiological reserve across multiple organ systems. Hospital readmissions are costly and may reflect quality of care, yet the importance of frailty for prognosis after discharge following emergency surgery is not well established. We evaluated the association of frailty and risk of readmission or post-discharge death in older surgical patients.

Methods:
We prospectively followed patients aged ≥ 65 years admitted to Acute Care Surgery at two tertiary care centres in Alberta, Canada who preoperatively required assistance with <3 activities of daily living. Severity of frailty prior to admission was defined as well (score ≤ 2), managing-vulnerable (3-4), and mildly-moderately frail (≥ 5) on the CSHA Clinical Frailty Scale (CFS). Primary endpoints were composites 30-day and 6-month all-cause readmission or death. We assessed endpoints using multivariable logistic regression that adjusted for confounders (Table 1).

Results:
Of 308 patients included, the mean age was 76±7.6 years, 55% were female, and the median CFS was 3 (range 1-6); 168 patients were managing-vulnerable and 68 were mildly-moderately frail. Most surgeries performed were cholecystectomies/appendectomies (28% closed, 8% open), small intestine (28%) or colon surgery (14%), and hernia repairs (14%). At 30 days, 42 (13.6%) and at 6 months, 104 (33.8%) patients were readmitted or died. Frail patients were more likely to be readmitted or have died within 30 days: 16% of managing-vulnerable (adjusted odds ratio [aOR] 4.60, 95% CI 1.29-16.45, p=0.019) and 18% of mildly-moderately frail (aOR 4.51, 95% CI 1.13-17.94, p=0.033) compared to 4% of well patients. At 6 months, an independent dose-response relationship was observed for increasing frailty severity: 33% of patients managing-vulnerable (aOR 2.15, 95% CI 1.01-4.55, p=0.046) and 54% of those mildly-moderately frail (aOR 3.27, 95% CI 1.31-8.12, p=0.011) were readmitted or died compared to 15% of well patients.

Conclusion:
Patients undergoing emergency abdominal surgery who were more frail were also more likely to be readmitted to hospital at 30 days and 6 months. To our knowledge, this is the first study to assess the impact of frailty on adverse events after discharge in this population. These findings can assist in developing targeted interventions to prevent readmissions in this vulnerable population.
 

52.11 A Comparitive Study Of Two Parathyroid Hormone Assays In Primary Hyperparathyroidism Patients

Posted on January 26, 2017

S. Joglekar1, J. C. Lee1,2, J. Serpell1,2, H. Schneider3  1The Alfred Hospital,Department Of General Surgery,Melbourne, VICTORIA, Australia 2Monash University,Endocrine Surgery Unit,Melbourne, VICTORIA, Australia 3The Alfred Hospital,Department Of Pathology (Clinical Biochemistry),Melbourne, VICTORIA, Australia

Introduction:
Inappropriately high serum parathyroid hormone (PTH) is a diagnostic criterion for primary hyperparathyroidism (pHPT). Recently hospital administrative records showed an increase in the diagnosis of pHPT during a 2-year (approx.) period when the Abbott assay was used instead of the usual Roche assay for our institution due to product unavailability. Therefore, we aimed to compare the clinical performance of these 2 2nd generation assays in patients undergoing parathyroidectomy for pHPT.

Methods:
All study patients underwent parathyroidectomy for pHPT at The Alfred Hospital. Those who were treated during the 20-month period (May 2012 to Feb 2014 inclusive) when the Abbott assay was in use were designated “Group A”; and those treated during the subsequent 20-month period (Mar 2014 to Dec 2015 inclusive) when the Roche assay was again in use were designated “Group R”. Comparisons were made of their biochemistry (serum calcium, PTH, vit D levels), as well as clinical outcomes (diagnostic accuracy and recurrence prognostication), using the Student’s t-test and Fisher’s exact test. Deviation of PTH from normal ranges are expressed as multiples of the upper limit of normal (xULN), as the 2 assays have different normal ranges. A biochemical diagnosis was classified as false positive (FP) when associated with a negative neck exploration. Post-operative PTH reduction was calculated from pre-operative and recovery room PTH levels. In this study, curative treatment was defined as normo-calcaemia lasting over 3 months. 

Results:
There were 79 patients in Group A and 64 in Group R. Mean ages and gender distribution were similar between the groups (63.3 ± 15.6 years vs 62 ± 12.9 years; 75% vs 70% female). The mean pre-operative PTH in Group A (2.25 ± 0.28 xULN) was significantly higher than in Group R (1.84 ± 0.25 xULN; p < 0.05); this was despite similar levels of hypercalcaemia (2.78 ± 0.17 mM vs 2.77 ± 0.18 mM respectively; p = 0.72). The FP rates were similar (p = 0.65), with each group only having 2 patients with a negative 4-gland exploration. Operative PTH reduction of > 50% was seen in the majority in both groups (Group A 92% vs Group R 93%), as was normo-calcaemia at 3 months (Group A 90% vs Group R 93%).

Conclusion:
This study confirmed that although the Abbott assay measured higher PTH levels in patients with pHPT compared to the Roche assay, this does not seem to affect the ability of these assays to make an accurate diagnosis. Furthermore, the comparable kinetics of post-operative PTH conferred similar medium term normo-calcaemia rates. 
 

52.10 A Prospective Study on Quality of Life after Laparoscopic and Open Inguinal Hernia Repairs

Posted on January 26, 2017

J. Horwitz1, F. Burbano1, R. Lingnurkar2, C. M. Divino1  1Icahn School Of Medicine At Mount Sinai,Department Of Surgery,New York, NEW YORK, USA 2Central Michigan University College Of Medicine,Mount Pleasant, MICHIGAN, USA

Introduction: Patient-reported quality-of-life (QOL) data is becoming an important component of modern surgical quality improvement initiatives. Using the Carolinas Comfort Scale (CCS), a validated QOL survey specific to patients undergoing hernia repairs with mesh, the aim of our study was to prospectively compare QOL outcomes for patients undergoing both laparoscopic and open inguinal hernia repairs.

Methods: Patients undergoing inguinal hernia repairs by a four surgeon group at The Mount Sinai Hospital from 2015-2016 were identified prospectively. The CCS survey was administered at the pre-operative visit, post-operative visit (<1 month from surgery), and follow-up visit (>1 month from surgery). These patients were stratified into operation specific groups: unilateral laparoscopic, bilateral laparoscopic, open with mesh plug-and-patch, open with mesh patch only. The primary outcomes were the CCS survey’s 1-5 point scale for mesh sensation, pain, and movement limitation in the pre-operative, post-operative, and follow-up settings. Secondary outcomes analyzed were blood loss, operative time, admission, re-admission, and recurrence.

Results: 92 patients, at this time, have completed the CCS surveys at all three visits. Mean follow-up time was 4.4 months. Within this group, 40 underwent laparoscopic repairs (31 bilateral and 9 unilateral) and 52 underwent open repairs (35 plug-and-patch, 17 patch only). Each operative group experienced a significant decrease in pain between the pre-operative and follow-up setting. There were no significant QOL differences between the laparoscopic and open groups, nor were QOL differences observed between the unilateral and bilateral laparoscopic groups. The open plug-and-patch group had a significantly higher pain and movement limitation score at follow-up compared to the open patch only group (p = 0.016 and p = 0.031, respectively); of note, no differences were observed at the baseline pre-operative visit. The unilateral laparoscopic group’s operative time was significantly longer than the unilateral open group, 74 vs 59 minutes (p <  0.001). There were no recurrences during the follow-up period.

Conclusion: Using prospective, patient-reported, QOL data with the CCS survey, we have demonstrated that all patients experienced lower pain scores after inguinal hernia repairs, regardless of operation type. There we no QOL differences between laparoscopic or open repairs; however, the open plug-and-patch repair group did experience increased pain and movement limitation at follow-up as compared to the open patch only repair group.

 

52.09 Risk Factor and Outcome Analysis of Patients with Bethesda Category III (AUS/FLUS) Thyroid Nodules

Posted on January 26, 2017

W. Ouyang1, O. Picado Roque1, S. Liu1, R. Teo1, A. Franco1, M. Gunder1, P. P. Parikh1, J. C. Farrá1, J. I. Lew1  1University Of Miami,Division Of Endocrine Surgery,Miami, FL, USA

Introduction:  With the Bethesda System for Reporting Thyroid Cytopathology (BSRTC), thyroid nodules designated as Bethesda Category III or atypia or follicular lesion of undetermined significance (AUS/FLUS) by fine needle aspiration (FNA) have an estimated risk of malignancy (ROM) ranging from 5% to 15%. Previous reports performed at other institutions suggest that the ROM for AUS/FLUS is highly variable. This surgical series determines the ROM and those clinical factors that may predict underlying malignancy in patients with thyroid nodules categorized as AUS/FLUS at a single institution.

Methods:  A retrospective review of prospectively collected data of 665 patients with index thyroid nodules who underwent FNA and thyroidectomy from April 2010 to June 2016 was performed. Patients with thyroid nodules classified as AUS/FLUS by FNA were divided into malignant or benign groups based on final pathology, noting whether malignancy was found in the index thyroid nodule or as an incidental lesion. Incidental cancers were defined as malignancy discovered outside the index nodule within the ipsilateral thyroid lobe or contralateral lobe. Such patients underwent initial thyroid lobectomy for definitive diagnosis unless there was a history of radiation exposure, familial thyroid cancer, obstructive symptoms, bilateral nodules and/or patient preference for which total thyroidectomy was performed. Groups were compared in terms of demographics, clinicopathologic factors, and surgeon performed ultrasound (SUS) features for malignancy.

Results: Among the 171 patients with AUS/FLUS nodules who underwent thyroidectomy, final pathology confirmed malignancy in 60% (103/171) of the patients compared to benign disease in 40% (68/171). Malignancy in the index thyroid nodule alone was found in 37% (64/171) of patients whereas incidental cancers were found in 9% (16/171) on final pathology. Twenty-three (14%, 23/171) patients were found to have both index nodule and incidental malignancy. The ROM for index thyroid nodule with AUS/FLUS overall is 51% (87/171). Papillary thyroid cancer (PTC) was the most common cancer, found in 86% (89/103) of patients with malignancy. The most common subtype among patients with PTC was the follicular variant in 71% (63/89), followed by the classic variant in 12% (11/89). Analysis of nodule features by SUS revealed solid texture more likely to be present in patients with a malignancy when compared to benign tumors (88.1% vs 73.5%, p<0.05).

Conclusion: In this surgical series, the malignancy rate of 51% in thyroid nodules with AUS/FLUS cytology is higher than the estimated ROM, but within range of other surgical reports in the literature. Furthermore, during SUS evaluation, solid features may help determine underlying malignancy in AUS/FLUS thyroid nodules. For appropriate treatment recommendations, surgeons should assess their ROM for AUS/FLUS nodules, which may vary in their everyday clinic practice and local institutional experience. 
 

52.08 Practical Adherence to the Step-Up Approach for Pancreatic Necrosis: An Institutional Review

Posted on January 26, 2017

V. Tam1, C. Umapathy4, M. Zenati3, S. Downs-Canner3, B. A. Boone1, J. Steve1, A. Zureikat1, K. K. Lee1, H. Zeh1, D. Yadav2, M. E. Hogg1  1University Of Pittsburgh,Surgical Oncology,Pittsburgh, PA, USA 2University Of Pittsburgh,Gastroenterology, Hepatology And Nutrition,Pittsburgh, PA, USA 3University Of Pittsburgh,Department Of Surgery,Pittsburgh, PA, USA 4University Of Pittsburgh,General Internal Medicine,Pittsburgh, PA, USA

Introduction:
Infected pancreatic necrosis is a highly morbid disease that was traditionally approached with an open necrosectomy. This approach was associated with rates of morbidity and mortality up to 95% and 39%, respectively. The multicenter randomized controlled PANTER trial published in 2010 in the New England Journal of Medicine proposed a “Step-Up” approach which demonstrated fewer major complications than conventional treatment, with comparable rates of mortality, and spared a major operation in one-third of patients. We sought to evaluate the practical adherence to the Step-Up approach at a single tertiary care institution, its temporal adoption into clinical practice, and impact on outcomes.

Methods:
This is a retrospective review of all patients treated at a tertiary care center with infected pancreatic necrosis between 2006 and 2014. Diagnosis was based on positive culture on pancreatic fine needle aspiration, or presence of an air filled necroma on computed tomography. “Modified Step-Up” (MSU) was defined as percutaneous or endoscopic drainage followed by additional percutaneous or endoscopic drainage, followed by any surgical intervention, including video-assisted retroperitoneal debridement and open necrosectomy. Patients were stratified into the “early” pre-PANTER (2006-2010) or ”late” post-PANTER (2010-2014) period. Rates of adherence to the MSU approach were compared as well as clinical outcomes. 

Results:
There were 130 patients with infected necrotizing pancreatitis in the overall cohort; 75(58%) and 55(42%) were treated in the early and late period. At baseline, patients admitted in the late period were more likely to have higher ASA scores (3-5 vs 1-2, 92% vs 39%, p<0.001). In the late period, adherence to MSU was 46%(n=25) vs. 27%(n=27) in the early period (p<0.05). Late period patients had a greater likelihood of percutaneous drainage (65% vs. 43%, p=0.012) and greater number of total median interventions (3 vs. 2, p<0.001), however had comparable rates of surgery (73% vs. 79%, p=0.432), including 34(85%) open necrosectomies in the late period vs. 55(93%) in the early period. There were no differences in length of hospital stay, rates of in-hospital mortality, long-term complications, or survival at 2-years following discharge. Patients in the late period were less likely to have a pancreatitis-related readmission (47% vs. 71%, p=0.007) or multiple readmissions (31% vs. 51%, p=0.024). 

Conclusion:
Overall, adherence to the MSU approach was 46% between 2010 and 2014. Patients treated during this period had lower rates of pancreatitis-related readmission and total readmissions, with similar rates of long-term complications and mortality compared to patients between 2006-2010. This study demonstrates that adoption of clinical guidelines can result in improved clinical outcomes. Barriers to implementation of the Step-Up approach should be identified to improve adherence rates. 

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