52.07 The role of simultaneous cystgastrostomy and necrosectomy for walled off pancreatic necrosis

Posted on January 26, 2017

M. R. Driedger1, F. R. Sutherland1, E. Dixon1, S. Gregg1, N. Zyromski2, C. G. Ball1  1University Of Calgary,General Surgery,Calgary, AB, Canada 2Indiana University School Of Medicine,Indianapolis, IN, USA

Introduction:  

Severe acute pancreatitis (SAP) occurs in 15% of patients with generalized pancreatitis. Walled off pancreatic necrosis (WOPN) is the most common end result of SAP.  When symptomatic, WOPN requires intervention. The aim of this study was to evaluate the role of simultaneous cystgastostomy and necrosectomy (CG/N) for WOPN.

Methods:

A retrospective review of patients with WOPN undergoing surgical management on a high volume pancreatic service over 11 years (2005-2016) was performed.  Outcomes included mortality, morbidity, intervention timing and symptom resolution. Statistics were descriptive.

Results:

Seventy-seven patients were analyzed (mean WOPN diameter=14.5 cm, 67.5% male, mean age=47 years). The majority were acutely ill, with an average preoperative length of stay of 28.7 days and 26% requiring preoperative support in the Intensive Care Unit (ICU). Preoperative complications were prevalent (42.9%), and included mesenteric vein thrombosis (37%), gastric outlet obstruction (19.2%), respiratory complications (19.2%), bacteremia (13.7%) and acute kidney injury (9.6%). Nearly all (93.5%) patients underwent an open trans-gastric CG/N while 6.5% received a cystjejunostomy. The median duration of time between the onset of SAP and operative intervention was 45.1 days. Forty-two percent of the cultured necrosum was infected with bacteria. Postoperative morbidity included infection (10.4%), bleeding (5.2%), fistula (5.2%) and re-operation (3.9%). Postoperative median hospital length of stay was 10 days (range 4-228) with 96.1% of patients discharged home. Mortality was 2.6% with 10.4% requiring postoperative ICU care. The mean length of follow up was 12 months with 87.7% of patients having complete clinical resolution of symptoms at an average of 7.3 weeks. Recurrent WOPN occurred in only 5.5% of patients at an average of 19 months after the index operation.

Conclusion:

Despite acutely ill and comorbid patients with large WOPN volumes, simultaneous CG/N offers a definitive single-stage solution in the vast majority of patients with minimal postoperative morbidity and rapid return to an asymptomatic state. Upon consideration of the minimal laparotomy required, this procedure represents the preferred approach for WOPN.

 

52.06 Prophylactic Antibiotic Use in Outpatient Anorectal Surgery for HIV Patients

Posted on January 26, 2017

S. A. Patel1, R. J. Kucejko1, J. L. Poggio1  1Drexel University College Of Medicine,Philadelphia, Pa, USA

Introduction:  Human immunodeficiency virus (HIV) has been a vexing challenge to healthcare providers since its discovery. As medical therapy increases survival among people with an HIV infection, surgeons have been seeing an increasing number of HIV-infected patients with anorectal pathologies, including anal dysplasia and cancer. There is, however, no data on the incidence and risk factors for postoperative complications, such as surgical site infections (SSIs), in HIV patients undergoing elective anorectal procedures, nor is there data to suggest the administration of prophylactic antibiotics. Regular antibiotics are costly and have side effects that urge for accurate targeting of use; the purpose of this study was to review a HIV-positive patient population that has undergone anorectal surgery for dysplasia and assess the need for antibiotic prophylaxis. 

Methods:  A retrospective chart review was performed of all HIV positive patients seen as an outpatient in the Colorectal Surgery Division from 2007 to 2014. Basic demographics and clinical data such as date(s) of surgery, follow-up visit(s), and antibiotic prophylaxis, as well as preoperative CD4 count and HIV viral load, were recorded for 229 patients and 362 procedures. Postoperative exam notes were reviewed to determine the presence of an SSI. To analyze the data, patients were stratified according to CD4 count and viral load. The proportion of patients who received prophylactic antibiotics was assessed and the SSI rate was calculated. A chi-squared analysis was performed to assess whether SSI risk was elevated in this population.

Results: SSIs occurred in two of 193 (1.04%) cases for which antibiotic prophylaxis was not administered and in none of the 36 cases with antibiotic prophylaxis and available post-operative reports. One SSI occurred in a 51-year-old male with a preoperative CD4 count of 612/μL and viral load of zero. The other SSI occurred in 57-year-old female with an unknown CD4 count and viral load. A chi squared analysis showed the incidence of SSIs in the groups with and without antibiotic prophylaxis was not significantly different (p=0.540). 

Conclusion: Our study found an SSI incidence of 1.04% in HIV-infected patients with CD4 counts above 50/μL, which does not suggest an elevated risk compared to the general population reported incidence of 3-11% for clean-contaminated wounds. Antibiotics are costly and have many side effects; based on our study, prophylactic antibiotics are not indicated for outpatient anorectal procedures in HIV patients with CD4 counts above 50/μL. 
 

52.05 Age is not associated with Readmission in Patients Undergoing Pancreatectomy or Colectomy Procedures

Posted on January 26, 2017

M. N. Mustian1, L. E. Goss1, D. Chu1, L. Theiss1, J. Christein1, C. Balentine1, M. S. Morris1  1University Of Alabama At Birmingham,Surgery,Birmingham, AL, USA

Introduction: More than one third of operations in the United States are performed on individuals aged 65 years or older. These patients are at high risk for unplanned readmission, prolonged hospitalization, and postoperative complications. This study analyzes the relationship between aging and perioperative outcomes for patients undergoing pancreatectomy and colectomy at a major academic medical center. We hypothesize that elderly patients would have higher rates of readmission and worse postoperative outcomes.

Methods: We used National Surgical Quality Improvement Project data from our institution to evaluate 1964 patients having colectomy or pancreatectomy between 2010 and 2016. We stratified by age: < 50, 50-59, 60-69, 70-79, and ≥80 years old. The primary endpoint was 30 day unplanned postoperative readmission.  Secondary endpoints included length of stay, mortality, postoperative readmission rates and NSQIP complications. Univariate and multivariate analysis were performed. We used stepwise backwards logistic regression analyses to identify risk factors for readmission.

Results: In our cohort of 1964 patients, 692 (35%) patients had pancreatectomies and 1272 (65%) colectomies.  The age distribution included:  23% age <50, 26% age 50-59, 28% age 60-69, 17% age 70-79 and 6% age 80 and older.  Median postoperative length of stay was 6 days and was similar across all age groups.  Median readmission rate was 13.6% and similar across age groups.  Major complications were observed in 216 patients and resulted in different rates of readmission based on age (<65 years 40% vs ≥65 years 27% p=0.03).  The risk of mortality increased steadily with age from <1% in the youngest group to 4.2% in the oldest group.  On multivariable analysis, there was no significant relationship between age and risk of readmission, but both minor (OR 1.76 CI 1.15-2.68) and major (OR 4.6 CI 3.2-6.5) complications were associated with increased odds of readmission.

Conclusion: Our data did not reveal an association between age and risk of readmission.  Postoperative complications are associated with readmission.  However, younger patients experiencing major complications were more likely to be readmitted when compared to older patients.  Reasons for readmission in elderly patients may differ from those of younger patients.  Further work is needed to understand the relationship between age and readmission to design programs to address the unique discharge needs of elderly patients.

52.04 Laparoscopic Partial Colectomy Reduces Length of Stay and Mortality in Patients with Ascites

Posted on January 26, 2017

D. T. Asuzu1, K. Y. Pei1  1Yale University School Of Medicine,Surgery,New Haven, CT, USA

Introduction:
Ascites increases perioperative complications and risk of death, but is not an absolute contra-indication for subtotal colectomy. It remains unclear whether this risk can be minimized using a laparoscopic versus open approach. We hypothesize that laparoscopic surgery reduces risk of complications and death in patients with ascites.

Methods:
Data was retrospectively analyzed from 2,419 patients with ascites who underwent laparoscopic or open colectomy from 2005 to 2013 using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Post-operative outcomes were compared using two-sample tests of proportions, or using two-sample T-tests after checking for variance equality with Welch’s approximation for degrees of freedom. Odds ratios (OR) and incidence rate ratios (IRR) for complications and death were calculated using univariable logistic regression or linear regression respectively. P values < 0.05 two-tailed were considered statistically significant. 

Results:
218 patients (9%) with ascites underwent laparoscopic colectomy. Laparoscopic surgery was associated with lower 30-day mortality (15.6% versus 24.3%, OR 0.58, 95% CI 0.39 – 0.84, P = 0.004) and shorter hospital length of stay (9 days versus 15 days, IRR 0.0046, 95% CI 6E-4 – 0.034, P < 0.001). There was no significant difference in operative time (145 minutes versus 146 minutes, P = 0.69) or superficial surgical site infections (7.3% versus 7.7%) between laparoscopic versus open surgery.

Conclusion:
Laparoscopic colectomy reduces 30-day mortality and hospital length of stay in patients with ascites. This surgical modality may help mitigate the additional risk associated with ascites in patients undergoing subtotal colectomy.
 

52.03 Trends in Utilizing Laparoscopic Colorectal Surgery Over Time in 2005-2014 Using the NSQIP Database

Posted on January 26, 2017

C. M. Hambleton Davis1,2, B. A. Shirkey3, L. W. Moore1, H. R. Bailey1, X. L. Du2, M. V. Cusick1  1Houston Methodist Hospital,Department Of Surgery,Houston, TX, USA 2The University Of Texas School Of Public Health,Department Of Epidemiology,Houston, TX, USA 3Oxford University,Oxford Clinical Trials Research Unit / Centre For Statistics In Medicine, NDORMS,Oxford, , United Kingdom

Introduction:  Laparoscopy, originally pioneered by gynecologists, was first adopted by general surgeons in the late 1980’s. Since then, laparoscopy has been adopted in the surgical specialties and colorectal surgery for treatment of benign and malignant disease. Formal laparoscopic training became a required component of surgery residency programs as validated by the Fundamentals of Laparoscopic Surgery (FLS) curriculum; however, some surgeons may be more apprehensive of widespread adoption of minimally invasive techniques. Although an overall increase in the use of laparoscopic techniques is anticipated over a ten-year period, it is unknown if a similar increase will be seen in higher risk or more acutely ill patients.

Methods:  Using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2014, colorectal procedures were identified by CPT codes and categorized to open or laparoscopic surgery. The proportion of colorectal surgeries performed laparoscopically was calculated for each year. Separate descriptive statistics were collected and categorized by age and BMI. ASA classification and emergency case status variables were added to the project to help assess complexity of cases.

Results: During the ten-year study period, the number of colorectal cases increased from 3,114 in 2005 to 51,611 in 2014 as more hospitals joined NSQIP. A total of 277,376 colorectal cases were identified, 114,359 (41.2%) of which were performed laparoscopically. The use of laparoscopy gradually increased each year, from 22.7% in 2005 to 41.2% in 2014. Laparoscopic procedures were most commonly performed in the youngest age group (18-49 years), overweight and obese patients (BMI 25-34.9), and in ASA Class 1-2 patients. Over the ten-year time period, there was a noted increase in the use of laparoscopy in every age, BMI, and ASA category, except ASA 5. The percent of emergency cases receiving laparoscopic surgery also doubled from 5.5% in 2005 to 11.5% in 2014.

Conclusion: Over a ten-year period, there was a gradual increase in the use of laparoscopy in colorectal surgery. Further, there was consistent increase of laparoscopic surgery in all age groups, including the elderly, in all BMI classes, including the obese and morbidly obese, and in most ASA classes, including ASA 3-4, as well as emergency surgeries. These trends suggest that minimally invasive colorectal surgery appears to be widely adopted and performed on more complex or higher risk patients. 

 

52.02 Incisional Hernia Risk after Prophylactic Mesh Augmentation: A Systematic Review and Meta-Analysis

Posted on January 26, 2017

S. Shakir1, Z. Borab2, M. A. Lanni1, M. G. Tecce1, J. MacDonald3, W. W. Hope4, J. M. Weissler1, M. J. Carney1, J. P. Fischer1  1University Of Pennsylvania,Plastic Surgery,Philadelphia, PA, USA 2Drexel University College Of Medicine,Philadelphia, Pa, USA 3University Of Western Ontario,London, ONTARIO, Canada 4New Hanover Regional Medical Center,Surgery,Wilmington, NC, USA

Introduction:  Incisional hernia (IH) is a morbid and challenging complication with an extraordinary financial burden to the healthcare system. With nearly 350,000 repairs and expenditures in excess of $3 billion annually, there is a clear need for reparative strategies to diminish hernia recurrence. As greater emphasis is being placed on disease prevention, and as surgical technique and mesh technology evolves, the surgical paradigm must transition from a reparative approach to preventative action. Restoration of tensile strength is paramount in reducing risk of IH, yet the optimal intervention is not known. This systematic review and meta-analysis reviews incidence of IH and complications after elective laparotomy using either PMA or conventional fascial repair.

Methods:  A systematic review of the literature was conducted in accordance with PRISMA guidelines to identify studies comparing PMA to primary suture closure (PSC) repair in elective, midline laparotomies during index operation. The primary outcome of interest was development of IH. Inclusion criteria included patients between the ages of 18-75 years and at least 1 IH risk factor (BMI ≥ 25 kg/m2, prior abdominal surgery, history of AAA, ≥45 years of age, and smoking or history of COPD). Exclusion criteria included prior hernia or existing abdominal mesh, non-elective cases, history of metastatic cancer, immunosuppression, active infection, life expectancy less than 24 months, and pre-existing pregnancy.

Results: Overall, 14 studies were included. Of the total 2114 patients, 1152 participants underwent PMA. PMA significantly decreased the risk of IH compared to PSC (RR=0.15, 95% CI 0.07-0.30). PMA reduced the risk of IH regardless of mesh location (i.e. onlay, retrorectus or preperitoneal), however, PMA use was associated with an increased rate of seroma (RR 1.95, 95% CI 1.31 to 2.91; 10 studies). PMA patients are at increased risk for chronic wound pain compared to PSC [RR=1.70, 95% CI 1.04 to 2.78).

Conclusion: The existing literature provides high level evidence demonstrating that prophylactic mesh lowers the rate of IH after elective, open intra-abdominal surgery. Risk stratification models in conjunction with an increased emphasis on preventative medicine, strategies such as PMA offer safe and efficacious risk reduction in high-risk laparotomy patients. Given the evidence gap, however, further study is undoubtedly warranted.  

 

52.01 Morbidity and mortality for patients with sinistral portal hypertension undergoing splenectomy

Posted on January 26, 2017

M. Neuwirth1, A. J. Sinnamon1, R. R. Kelz1, G. C. Karakousis1, M. K. Lee1  1Hospital Of The University Of Pennsylvania,Department Of Surgery,Philadelphia, PA, USA

Introduction: Patients with sinistral portal hypertension frequently develop gastric varices and are therefore at risk of life-threatening hemorrhage.  Splenectomy is the treatment of choice as it largely eliminates the bleeding risk, but these procedures likely carry increased risk relative to splenectomy performed for other reasons.   We sought to compare the specific morbidity and mortality of splenectomy performed for sinis-tral portal hypertension versus other indications using a national cohort.

Methods: The American College of Surgeons National Surgical Quality Improvement Program (ASC NSQIP) was accessed from the years 2005-2014 for patients undergoing open or laparoscopic splenectomy.  Patients with an operative diagnosis of gastric vari-ces were selected for inclusion in the case cohort.  These patients were compared to two separate control groups: hypersplenism or splenomegaly, and all other indi-cations (OI) for splenectomy with 25 or more cases (excluding trauma).  Pearson’s chi-squared or Wilcoxon rank-sum tests were applied to categorical variable com-parisons as indicated.

Results: Of the 7,522 splenectomies performed during the study period, we identified 28 performed for gastric varices, 1,186 performed for hypersplenism or splenomeg-aly, and 4,128 in the OI group.  Notably, patients in the gastric varices group had lower rates of thrombocytopenia and were similar to the comparison groups with respect to their total bilirubin and INR.  Compared to OI, patients with gastric vari-ces more often had dependent functional status (21.4 vs 5.9%, p < .001), ASA class > III (92.8 vs. 62.5%, p < .001), and albumin < 3 (57.1% vs 11.4%, p < 0.001).  There was no difference in mortality for the varices group as compared with the splenomegaly group (3.6% vs 2.4%; p = 0.678) or OI (3.6% vs 2.4%; p = 0.671).  As depicted in figure 1, serious morbidity was significantly increased in the varices group versus the control group (53.6% vs 19.7%; p < 0.001) and versus the sple-nomegaly group (53.6% vs 23.2%; p < 0.001).  Most major post-operative compli-cations in the varices group were due to respiratory (39.2%), bleeding (42.9%) and sepsis (25.0%) related events.

Conclusion:Patients that undergo splenectomy for sinistral portal hypertension are at substan-tially increased risk for morbidity but not mortality as compared with splenectomy for splenomegaly or other indications.  Most significant are risks of respiratory, renal, bleeding or sepsis-related events.  Careful patient selection must be employed in this cohort. 

 

51.20 Effects of Education and Health Literacy on Post-Operative Outcomes in Bariatric Surgery

Posted on January 26, 2017

S. Mahoney2, D. Tawfik-Sexton1, P. Strassle3, T. Farrell1, M. Duke1  1University Of North Carolina At Chapel Hill,Division Of Gastrointestinal Surgery,Chapel Hill, NC, USA 2University Of North Carolina At Chapel Hill,Dept. Of Surgery,Chapel Hill, NC, USA 3University Of North Carolina At Chapel Hill,Gillings School Of Global Public Health, Department Of Epidemiology,Chapel Hill, NC, USA

Introduction:
In bariatric surgery, strict adherence to diet and lifestyle modifications are necessary for a successful operative course. We hypothesize that lower levels of education and health literacy are associated with increased risks of nonadherence; thus leading to increased morbidity, emergency department (ED) visits, and preventable readmissions postoperatively. If so, pre-operative education and follow up care may be individualized to benefit those at-risk patients.

Methods:
Bariatric surgery patients were administered a pre-operative questionnaire which included education level and the Rapid Estimate of Adult Literacy in Medicine (REALM-SF) assessment. Patients were stratified by education level (≤12 years of education versus >12 years) and health literacy score (a score ≤6 [7th-8th grade or lower] versus 7 [high school]). Poisson regression was used to compare incidence rate of ED visits, readmission, and overall hospital visits. 

Results:
Of the 73 enrolled patients, 16 (22.2%) had ≤12th grade education and 5 (6.9%) scored ≤6 on the REALM-SF. Patients with lower education were significantly more likely to visit the hospital following surgery, 0.40/100 days (95% CI 0.19, 0.84) vs. 0.15/100 days (95% CI 0.08, 0.28), p=0.05. ED visits (0.18/100 days vs. 0.07/100 days, p=0.15) and readmissions (0.18/100 days vs. 0.07/100 days, p=0.16) were higher, but not significant, among patients with lower education.  No significant differences were seen in patients with lower health literacy in the rate of ED visits (0.09/100 days vs. 0.09/100 days, p=0.97), readmissions (0.11/100 days vs. 0.09/100 days, p=0.87), or overall hospital visits (0.22/100 days vs. 0.19/100 days, p=0.85).
 

Conclusion:
Lower level of education is associated with more than double the rate of post-operative hospital visits in our center’s bariatric surgery patients. Very few of our patients made less than a perfect score on the REALM-SF, limiting its effectiveness as a screening tool for risk stratification. A patient’s education level is quick and free to obtain and may identify patients at risk for costly post-operative hospital visits.  Further investigation is warranted in order to improve outcomes and unnecessary costs associated with bariatric surgery.  

51.19 Socioeconomic Disparities Affect Survival in Malignant Ovarian Germ Cell Tumors in AYA Population

Posted on January 26, 2017

L. V. Bownes1, I. I. Maizlin1, K. Gow2, M. Langer5, M. Goldfarb3, M. Raval7, J. Doski6, A. Goldin2, J. Nuchtern4, S. Vasudevan4, E. A. Beierle1  1University Of Alabama at Birmingham,Division Of Pediatric Surgery,Birmingham, Alabama, USA 2University Of Washington,Seattle, WA, USA 3Providence Saint John’s Health Center,Santa Monica, CA, USA 4Baylor College Of Medicine,Houston, TX, USA 5Maine Medical Center,Portland, ME, USA 6University Of Texas Health Science Center At San Antonio,San Antonio, TX, USA 7Emory University School Of Medicine,Atlanta, GA, USA

Introduction: Malignant ovarian germ cell tumors (MOGCT) comprise approximately 5% of primary ovarian malignancies. Although current treatments provide excellent outcomes, survival has been shown to be related to race and age. Socioeconomic (SE) factors have been proposed to affect survival in other cancers, but their effect on survival in MOGCT has yet to be evaluated. Therefore, we examined whether SE status impacted the survival of adolescent and young adult women (AYA) with MOGCT.

Methods: The National Cancer Data Base was used to identify all AYA female patients (14-39 years old) with diagnosis of MOGCT from 1998 to 2012. Three SE surrogate variables were identified: insurance type (private, government, uninsured), median income and percent of people without a high school degree in patient’s ZIP code. Pooled-variance t-tests and χ2 were used to compare tumor characteristics, time from diagnosis to staging and to treatment, and clinical outcome variables within each of the SE surrogate variables, while controlling for the effect of age and race in a multivariate model.

Results: 3125 AYA patients were diagnosed with MOGCT. Controlling for age and race, there were significant differences in tumor stage and size at diagnosis when compared between insurance groups, income, and education quartiles in patients within lower quartiles of all measures having larger and more aggressive tumors (Table). Following diagnosis, there was no significant difference in time to tumor staging between insurance groups (p=0.062), income quartiles (p=0.196) or education level (p=0.417). Similarly, there was no association of insurance (p=0.85), income (p=0.28), or education (p=0.61) levels in time to treatment. No significant difference was found between the groups in type of surgery. Survival analysis demonstrated higher mortality to be associated with lower level of education (p=0.001; Hazard Ratios [HR] = 0.87, 0.52 and 0.39, compared to lowest quartile), income quartile (p=0.002; HR=0.54, 0.39 and 0.34, compared to lowest quartile) and insurance status (p<0.001; HR=0.61 for government insurance, HR=0.46 for private insurance, compared to uninsured). Controlling for stage and size of tumor, the difference in survival loses significance, indicating that the original difference in survival is likely due to disparity in extent of disease at presentation.

Conclusions: Female AYA patients from lower SE status with MOGCT presented with more extensive disease, which translated into lower survival, despite similar treatment patterns and equal time to definitive treatment. The underlying factors resulting in these differences must be further examined as potential targets for improved education and access to initial care. 

51.18 Socioeconomic Factors Impact Receipt of Chemotherapy and Survival in Stage II Colon Cancer

Posted on January 26, 2017

K. M. Ramonell1, W. Liang2, Y. Liu2, T. Gillespie1, V. O. Shaffer1  2Emory University Rollins School Of Public Health,Department Of Biostatistics,Atlanta, GA, USA 1Emory University School Of Medicine,Department Of Surgery,Atlanta, GA, USA

Introduction:  Colon cancer ranks fourth in incidence, and second in cancer mortality in the United States. After curative resection of the primary tumor, adjuvant chemotherapy (AC) may be considered for stage III or for high-risk stage II patients. However, the role of AC in stage II colon cancer remains controversial. This study sought to determine which demographic, socioeconomic, and histopathologic factors affect receipt of AC and how these factors affect overall survival (OS) in stage II colon cancer. 

Methods:  Data from the National Cancer Data Base (NCDB) Participant Use Files were used. All patients with stage II colon cancer diagnosed in the US between 2004 and 2012 who underwent curative resection were included. Univariate and multivariate regression analyses were performed using the chi-square test for categorical covariates and ANOVA for numerical covariates. Propensity score matching was also implemented to reduce treatment selection bias.

Results: Of the total stage II colon cancer patients included, 5,443 (16.9%) received adjuvant chemotherapy and 26,833 (83.1%) did not. An improvement in OS was found in stage II colon cancer patients who received AC (HR 0.78; p<0.001). The following factors were associated with receipt of AC: age <65, white race, positive surgical margins, Charleson-Deyo comorbidity score equal to 0 or 1, residing in a low-income neighborhood, and being insured by Medicare. Of those who received AC, the following factors were associated with worsened OS: male gender (HR 1.25; p<0.001), age at diagnosis >65 (HR 1.06; p<0.001), black race (1.36; p<0.001), having Medicaid as primary insurance provider (HR 1.37; p=0.016). Patients living in lower income areas (HR 1.22; p=0.001) and in areas with lower education rates (HR 1.13; p=0.012) had worse survival. Among histopathologic features analyzed, presence of perineural invasion and lymphovascular invasion were independently associated with a significantly worse OS (HR 1.27; p<0.001) and (HR 1.28; p<0.001), respectively.

Conclusion: The results of this study suggest that the OS benefit observed with the use of AC in stage II colon cancer patients is primarily associated with non-Black patients younger than 65; who are privately insured or have Medicare; and those with no evidence of perineural invasion or lymphovascular invasion. While clinical and histopathologic features are known to affect cancer prognosis; this analysis shows that both socioeconomic and demographic factors play key roles in important outcomes including OS. Thus it is imperative that future research explore underlying reasons for these findings and interventions be tested to improve outcomes among those at risk. 

51.16 Emergent Presentations of Colorectal Cancer in At Risk Populations: A Safety Net Hospital Experience

Posted on January 26, 2017

N. Ullman1, O. Prela1, P. Chung1, M. Smith1, R. Zhu1, H. Talus2, A. Alfonso1, G. Sugiyama1  1SUNY Downstate College Of Medicine,General Surgery,Brooklyn, NY, USA 2Kings County Hospital Center,Surgery,Brooklyn, NY, USA

Introduction:

Colorectal cancer is the second leading cause of cancer related deaths in the US. African Americans have a greater incidence, higher mortality rate and are more likely to present at an advanced stage when compared to their Caucasian counterparts. We explored the difference in African-American and Caribbean born (Afro-Caribbean) patients that underwent surgery for colorectal cancer at two urban safety-net hospitals. 

Methods:

We conducted a retrospective chart review of patients that underwent resection for colorectal cancer from 2007-2015. Patients were stratified by race and country of birth; 119 African American and 203 Afro-Caribbean patients were identified. We then compared rates of disease presentation requiring urgent or emergent surgical intervention and rates of presentation allowing for elective procedures. Emergent/urgent presentation was defined as surgical intervention to treat a tumor complication on the same hospital admission in which the diagnosis of colorectal cancer was made. Tumor complication rates between each group were also compared. Complications included obstruction, anemia requiring transfusion, colonic perforation and hemorrhage. Comparisons were performed using the Chi Square Test for emergent/urgent vs elective case presentations and the Fisher's Exact Test for tumor complication rates.

Results:

There was no significant difference in the rate of urgent/emergent cases of colorectal cancer when compared to elective procedures. We identified 30 (25.2%) African American patients compared to 55 (27.1%) Afro-Caribbean patients that required an urgent/emergent procedure (p = 0.7912). African American compared to Afro-Caribbean patients had no statistically significant differences in the rate of obstruction (9.24% vs 9.85%, p = 1.0), hemorrhage (7.56% vs 5.42% p = 0.4778), and perforation (3.36% vs 2.96% p = 1.0). However Afro-Caribbean patients were more likely to present with anemia requiring transfusion (7.88% vs 1.68%, p = 0.0221). 

Conclusion:

In this retrospective chart review of colorectal cancer in African American and Afro-Caribbean patients treated at two urban safety-net hospitals, there is little difference in the rates of emergent presentations of disease between the two cohorts. Of the tested disease complications, only one was shown to be significantly different. Despite this singular difference, we postulate that there may be a variance in the disease process found in these cohorts. We suspect that an underlying difference in tumor biology contributes to this discrepancy. A follow up study to examine the pathology of the specimens from each cohort may shed light onto this difference.

 

51.15 Regional Variation in Laparoscopic Resection For Diverticulitis in Academic and Non-Academic Centers

Posted on January 26, 2017

A. Talukder1, P. Martinez1, J. McKenzie1, R. Lassiter1, C. White1, D. Albo1  1Medical College Of Georgia,Department Of Surgery,Augusta, GA, USA

Introduction: Studies have demonstrated favorable outcomes for laparoscopic surgery over open surgery in the treatment of a variety of surgical diseases. In this study we analyzed regional differences in the use of laparoscopic surgery with respect to race in academic and non-academic centers in all geographic regions of the US, comparing to them our home state and our region.

Methods:   A retrospective analysis of elective admissions with a primary diagnosis of diverticulitis from 2009-12 was performed using data from the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality. Cases were selected based on diagnosis codes of Diverticulitis of colon with or without mention of hemorrhage and (ICD9 56.11, 562.13). All patients underwent a surgery as defined by non-endoscopic ICD-9-CM procedure codes for colorectal resection.

Results: At academic centers in the US, laparoscopic utilization rate was 44.5% for Whites, 29.5% for Blacks, and 39.4% for Hispanics and 38.2%, 29.6%, 38.0% respectively at non-academic centers. Odds of laparoscopic resection for Whites when compared to Blacks was 1.57 higher (95% CI: 1.45-1.71, p <0.01). At academic centers in the Southeast, the laparoscopic utilization rate was 44% for Whites, 35% for Blacks, and 60.1% at Hispanics academic centers, and 36.7%, 29%, and 57.9% respectively at non-academic centers. Odds of laparoscopic resection for Whites compared to Blacks was 1.45 higher (95% CI: 1.23-1.72, p <0.01). In academic centers in GA, the laparoscopic utilization rate was 48.9% for Whites, 21.4% for Blacks, and 0% for Hispanics and 47.5%, 47.9%, and 28.6% respectively at non-academic centers. Odds of laparoscopic resection for Whites compared to Blacks was 1.65 higher (95% CI: 1.93 – 3.20, p < 0.05). We have completed this analysis for all the Northeast, Mideast, Great Lakes, Plains, Southwest, Rocky Mountain, and Far West regions as well.

Conclusion: These results demonstrate significant disparities in the use of laparoscopic surgery to treat diverticulitis both at academic and non-academic centers at the national, regional, and state level.

 

51.14 Optimizing Colorectal Outcomes: Does Surgeon Specialty play a role?

Posted on January 26, 2017

Y. Alimi1, A. Asemota1, R. Stone3, B. Safar1, S. Fang1, S. Gearhart1, J. Efron1, E. Wick2  3Johns Hopkins University,Department Of Obstetrics And Gynecology,Baltimore, MD, USA 1Johns Hopkins University,Department Of Surgery,Baltimore, MARYLAND, USA 2UCSF,Department Of Surgery,San Francisco, CALIFORNIA, USA

Introduction: There is intense pressure to deliver high value surgical care by optimizing patient outcomes and reducing costs. Surgical site infections (SSIs) are the leading cause of morbidity after colorectal surgery. Most of the quality improvement efforts have focused on general surgeons but other surgical specialists, particularly gynecologic oncologists also perform colorectal resections as part of their practice. Therefore, the objective of this study is to assess the impact of surgeon specialty on morbidity after colorectal surgery to determine the potential impact of broader, transdisciplinary collaboration in colorectal quality improvement.

Methods: The American College of Surgeons National Surgical Quality Improvement Program (Jan 1, 2006 – Dec 31, 2013) was used to identify female patients undergoing colorectal surgery with a diagnosis of a solid organ malignancy. Logistic regression was used to analyze patient and procedure factors in cases with and without SSIs. The primary surgeon specialty was categorized as either general (general, colorectal or surgical oncologist) or gynecologic. Proportion odds ratio of any documented SSI (Superficial, Deep, Organ Space) and readmission occurrence; relative risk hospital length of stay. The National inpatient sample was used to project potential cost savings.

Results: Among the 108,415 patients identified undergoing colorectal surgery for solid organ malignancy, 106,130 were operated on by general surgeons and 2,285 by gynecologists. Patients operated on by gynecologists were, compared to those operated on by general surgeons: younger (64.1 vs 67.3 yrs, p<0.001), more likely to have contaminated/dirty wounds (12.2% vs 9.1%, p<0.001), be more complex (ASA 3/4 61.6% vs 57.5%, p<0.001), have longer mean operative time (264.0 vs 166.2 min, p<0.001), less likely to receive preoperative radiation (3.2% vs 0.57%, p = 0.002); but more likely to receive preoperative chemotherapy (1.9% vs 2.5%, p<0.001). The unadjusted rate of SSIs was higher for cases performed by gynecologists than for cases performed by general surgeons (17.3 vs 10.9, p <0.001). On multivariate analysis, patients operated on by gynecologists remained more likely to have SSIs than did their general surgery counterparts [any SSI: 1.15 (1.05 – 1.27), p <0.001]. 

Conclusion: Although gynecologists only perform a small subset of colorectal surgery procedures, their patients are at higher risk of developing an SSI. These elevated rates of infections results in a potential cost savings of $31,254,070. Further study is needed to understand if this difference is related to a gap in translating best practice evidence into practice, or to surgical technique.

51.13 Socioeconomic Disparities Among Bariatric Surgery Patients

Posted on January 26, 2017

U. Deonarine5, G. Ortega1, C. K. Zogg3, R. Altafi6, D. J. Taghipour6, N. Changoor2, D. D. Tran2, E. E. Cornwell2, T. M. Fullum1  1Howard University College Of Medicine,Division Of Minimally Invasive Surgery/ Department Of Surgery/ Howard University College Of Medicine,Washington, DC, USA 2Howard University College Of Medicine,Department Of Surgery,Washington, DC, USA 3Yale University School Of Medicine,New Haven, CT, USA 4Howard University College Of Medicine,Washington, DC, USA 5Howard University College Of Medicine,Department Of Medicine,Washington, DC, USA 6Howard University College Of Medicine,Outcomes Research Center, Department Of Surgery,Washington, DC, USA

Introduction:
Morbid obesity is a modifiable risk factor for many diseases that substantially impact the burden of care in the United States. Research has shown morbid obesity and obesity related complications to be more prevalent in minorities and lower socioeconomic classes. Bariatric surgery is an effective treatment for morbid obesity but continues to be underutilized in the population that may benefit the most. Our objective is to determine if the utilization of bariatric surgery differs by socioeconomic and demographic categorization among morbidly obese patients by analyzing data from a national database.  

Methods:
We conducted a retrospective review of the Nationwide Inpatient Sample (NIS) database from 2005 to 2013, selecting for patients with a diagnosis of morbid obesity. Data analyzed included patient characteristics such as demographics, co-morbid conditions, inpatient events, and post-operative morbidity and mortality. Cases were dichotomized into those who received bariatric surgery and those who did not. The two groups were compared utilizing t-test and chi-2 analysis when appropriate. A multivariate analysis was performed adjusting for patient characteristics and co-morbid conditions evaluating utilization by socioeconomic and demographic characteristics.

Results:

A total of 2,040,869 patients were morbidly obese. Of those the majority were White (68%), female (67%), and had a mean age of 53 years (SD+- 15). Overall, most patients had Medicare (39%), followed by private insurance (36%) and Medicaid (17%). Regarding median household income (MHI) the majority were in the lowest income quartile (32%), followed by second income quartile (28%), third income quartile (23%) and highest income quartile (17%). Nine percent of patients underwent bariatric surgery (n=184,615). Of the patients undergoing bariatric surgery most were White (72%, p<0.001), female (79%, p<0.001), were younger (45 vs. 54 years, p<0.001), in the third income quartile (27%, p<0.001) and had private insurance (70%, p<0.001). On adjusted analysis morbidly obese Black (OR 0.515, 95%CI: 0.506-0.525), Hispanic (OR 0.751, 95%CI: 0.736-0.768), Asian/ Pacific Islander (OR 0.645, 95%CI: 0.597-0.699) and Native American (OR 0.749, 95%CI: 0.695-0.807) were less likely to undergo bariatric surgery when compared to White patients. Regarding MHI, the second income quartile (OR 1.53, 95%CI: 1.49-1.55), the third (OR 1.85, 95%CI: 1.82-1.89) and fourth (OR 2.71, 95%CI: 2.66-2.76) were more likely to have bariatric surgery. Patients with private insurance were more likely to have bariatric surgery (OR 4.28, 95%CI: 4.19-4.36), while those with Medicaid insurance were less likely (OR 0.67, 95%CI: 0.65-0.69) when compared to Medicare insurance.

Conclusion:
Increased utilization of bariatric surgery may reduce the impact of the obesity epidemic. It is essential that the population most affected by morbid obesity has access to this life changing intervention. 

51.12 Uncovering Temporal Disparities in Outcomes for Patients Undergoing Elective, Weekend Surgery

Posted on January 26, 2017

S. P. Nassoiy1, B. A. Blanco1, E. M. Grindstaff1, Y. Azure1, P. C. Kuo1, A. N. Kothari1  1Loyola University Medical Center,Maywood, IL, USA

Introduction: Temporal disparities of care, including the “weekend effect”, can negatively impact surgical outcomes. Our objective was to determine if patients undergoing elective, weekend surgery were at increased risk for developing adverse postoperative events.

Methods: Patients >18 years old who underwent elective general surgery between 2009 and 2010 in California, Florida, Iowa, New York or Washington were identified using the Health Care and Utilization Project State Inpatient Database. General surgery was defined as procedures of the gastrointestinal, endocrine and integumentary system. The primary outcome was inpatient mortality or major morbidity. Propensity scores were assigned using patient comorbidity and surgical approach. Risk adjustment was performed at the hospital level using multivariable logistic regression.  

Results:489,516 patients at 757 hospitals met our inclusion criteria. Of these, 4,391 patients underwent surgery on the weekend at 541 hospitals. 3,683 were propensity matched (1:1) to patients who had weekday surgery and no difference in the primary outcome was observed (2.1% vs. 2.5%, p=0.212). However, significant outcome variation existed amongst hospitals routinely performing elective weekend surgery (top volume decile), with 17.6% having higher than expected event rates, 22.8% with as expected performance, and 59.6% performing better than expected.

Conclusion: Overall, no population-level temporal disparity was identified in patients undergoing elective general surgery on the weekend. Certain centers did have increased incidence of major adverse events on the weekend than during the week. Future studies will be directed at elucidating hospital characteristics that can reduce this disparity in surgical care.

 

51.11 Regional Variations in Cost and Outcomes of Appendicitis in the United States

Posted on January 26, 2017

R. P. Won1, S. Friedlander1, Y. Lu1, S. L. Lee1  1Harbor-UCLA Medical Center,Surgery And Pediatrics,Torrance, CA, USA

Introduction:
The study of regional variations in costs and outcomes of care has been used to identify areas of savings for several diseases and conditions. This study investigates similar potential regional differences in the cost and outcomes of adult appendicitis. We hypothesized that there would be no difference in rates of perforation, morbidity, length of stay (LOS), and cost among different regions of the US. 

Methods:
Data were obtained from the California (CA), New York (NY), and Florida (FL) State Inpatient Databases spanning 2005-2011. Patients between the ages of 18-70 who underwent non-incidental appendectomies were evaluated with hierarchical and multivariate negative binomial regression analyses. Our primary outcomes included perforation, negative appendectomy, morbidity, hospital cost, and LOS.

Results:

There were 371,354 appendectomies performed between 2005-2011 in CA, NY, FL. The univariate analysis is summarized in the table. Multi-variate analysis confirmed the differences between states. CA had a higher rate of perforation compared to NY (p<0.01). CA also had a higher rate of negative appendectomies compared to both NY and FL (p<0.01). Morbidity was lower in NY compared to CA and FL (p<0.01). The LOS was lowest in CA (p<0.01), despite having the highest median cost per patient when compared to NY and FL (p<0.01)

Conclusion:
Significant regional differences exist with the presentation, outcomes, and costs associated with acute appendicitis. A better understanding of these differences may result in significant cost savings. 

51.10 Racial Disparities in Surgical Outcomes Persist in Emergency General Surgery

Posted on January 26, 2017

M. D. Giglia1, A. A. Gullick1, P. L. Bosarge2, J. D. Kerby2, D. I. Chu1  1University Of Alabama At Birmingham,Gastrointestinal Surgery,Birmingham, AL, USA 2University Of Alabama At Birmingham,Acute Care Surgery,Birmingham, AL, USA

Introduction: Racial disparities have been well-studied in elective specialties. Less is understood about disparities in emergency general surgery. We aimed to determine the contribution of race to readmission rate, length of stay (LOS), and mortality in patients who required emergency general surgery in a contemporary surgical population.

Methods: We queried the 2011-2014 American College of Surgeons National Surgical Quality Improvement Program database for all patients who underwent emergency general surgery and stratified by race. Primary outcomes were readmission rate, LOS and mortality. Predictors of readmission rate, LOS, and mortality were identified with multivariate logistic regression and negative binomial models, from which Odds Ratios [OR] and Incident Rate Ratios [IRR] were obtained.

Results: Of 114,411 patients who underwent emergency general surgery, 69.6% were white, 13.3% were Hispanic, 12.1% were black and 4.9% were Asian. Compared to white, Hispanic and Asian patients, black patients had higher rates of heart failure (2.5% vs 1.8%,1.0% and 0.7%), end-stage renal disease on dialysis (4.9% vs 1.6%,1.8% and 2.3%), total functional dependence (2.6% vs 1.8%, 1.0% and 1.0%), hypertension (49.3% vs 40.3%, 23.9%, and 31.6%), smoking (26.5% vs 21.7%, 15.2%, and 10.9%), diabetes (18.2% vs 12.4%, 12.5%, and 12.8%), presentation with an open wound/wound infection (6.8% vs 4.4%, 3.0% and 1.9%), and  ASA Class 4-5 (20.3% vs 18.0%, 7.6% and 9.0%) (p<0.001), respectively. On unadjusted comparison, black patients had higher readmission rates (9.3% vs 8.5%, 5.9% and 5.5%, p<0.001), mean LOS (7.54 vs 6.43, 3.97, and 5.03 days, p<0.001) and median LOS (5 vs 4, 2, 2 days, p<0.001) than white, Hispanic and Asian patients, respectively. White patients had a higher unadjusted mortality rate compared to black, Hispanic and Asian patients (6.5% vs 5.5%, 2.5% and 3.3%, p<0.001). On adjusted comparison, black race was not independently associated with higher readmission rates compared to white patients (OR 1.01, 95%-Confidence Interval [CI] 0.95-1.08); however, Hispanic (OR 0.88, CI 0.81-0.95) and Asian (OR 0.78, CI 0.69-0.88) race was associated with lower risk for readmission. Black race remained independently associated with longer mean LOS (7.75 days vs 6.60, 4.09 and 5.12 days, p<0.001) and had longer LOS of 11%, 14% and 6% compared to white, Hispanic and Asian patients, respectively (IRR 1.11, 1.14 and 1.06, p<0.0001).  Compared to white patients, black (OR 0.80, CI 0.72-0.88), Hispanic (OR 0.99, CI 0.86-1.13) and Asian patients (OR 0.90, CI 0.74-1.09) had a lower risk of mortality.

Conclusion: Black patients who underwent emergency general surgery had significantly longer LOS than white, Hispanic and Asian patients. Mortality, however, was highest for white patients compared to all other groups. Further studies are needed to better understand these observations and to identify actionable opportunities to reduce these disparities.

51.09 Severe Presentation in Surgically Treated Colorectal Cancer Patients with Psychiatric Disease

Posted on January 26, 2017

K. F. Angell1, V. P. Ho1, N. K. Schiltz2, A. P. Reimer3, E. Madigan3, S. R. Steele1, S. M. Koroukian2  1Case Western Reserve University School Of Medicine,Department Of Surgery,Cleveland, OH, USA 2Case Western Reserve University School Of Medicine,Department Of Epidemiology And Biostatistics,Cleveland, OH, USA 3Case Western Reserve University School Of Medicine,Frances Payne Bolton School Of Nursing,Cleveland, OH, USA

Introduction:
Underlying psychiatric conditions may affect outcomes of comorbid conditions due to confusion or inconsistencies in both diagnosis and treatment. We hypothesized that patients with psychiatric illness (PSYCH) would have evidence of advanced disease at presentation, as manifested by higher rates of colorectal resection performed in the presence of obstruction, perforation, or peritonitis (OPP-resection).

Methods:
Using data from the 2007-2011 National Inpatient Sample (NIS), we identified patients 65 years of age or older with a diagnosis of CRC undergoing colorectal resection.   In addition to somatic comorbid conditions flagged in the NIS, we used the Clinical Classification Software to identify patients with PSYCH, including schizophrenia, delirium/dementia, developmental disorders, alcohol/substance abuse, and other psychiatric conditions.  Our study outcome was OPP-resection.  In addition to descriptive analysis, we conducted multivariable logistic regression analysis to analyze the independent association between each of the PSYCH conditions and OPP-resection, after adjusting for patient demographics and somatic comorbidities. 

Results:
Our study population included 60,147 patients with CRC and undergoing colorectal cancer resection, of whom 17.2% were 85 years of age or older, 51.9% were women, and 8.9% had 5 or more comorbid conditions.   Nearly 17% presented with PSYCH.  The percent of patients undergoing OPP-resection was 15.1% in the study population, but significantly higher in patients psychiatric diagnosed with schizophrenia (18.9%), delirium/dementia (18.9%), and alcohol/substance abuse (19.6%).  Findings from the multivariable analysis showed that these associations were relatively modest and at borderline statistical significance.  The odds ratios and 95% Confidence Interval were 1.24 (1.00, 1.54), 1.13 (1.02, 1.24), and 1.21 (1.05, 1.40), respectively for the aforementioned PSYCH conditions. 

Conclusion:
Patients with PSYCH may have obstacles to receiving optimal care for CRC. Those with select PSYCH diagnoses had significantly higher rates of OPP-resection albeit to a relatively modest extent.   It is important to note, however, that our study could not account for CRC patients who did not undergo surgery and were referred directly to hospice upon presenting with obstruction, perforation, or peritonitis.  Additional evaluation is required to identify the association between PSYCH and related factors affecting the rates of emergency surgery in patients with CRC.
 

51.08 Racial Disparities in Surgical Care after Parathyroidectomy

Posted on January 26, 2017

S. Jang1, C. J. Balentine1, H. Chen1  1University Of Alabama at Birmingham,Department Of Surgery,Birmingham, Alabama, USA

Introduction: Racial disparities in health care and health outcomes have been well documented in most diseases, but there is limited data for hyperparathyroidism. Parathyroidectomy is the only curative therapy for hyperparathyroidism, but its cost and variation in use among different racial and ethnic groups are largely unexamined. The purpose of this study was to examine the association between race and ethnicity and the total hospital cost of parathyroidectomy.

Methods: This retrospective study included 899 consecutive cases in our institution between September 2011 and July 2016 coded as complete parathyroidectomy, parathyroidectomy or exploration of parathyroid, or other parathyroidectomy using ICD-9 and 10 procedure codes. We evaluated demographics, insurance type, and readmission rates. Total length of stay and cost were evaluated using the Mann-Whitney U and the Kruskal-Wallis non-parametric tests. Categorical variables were evaluated with chi-square.

Results: The study population was 66.4% Caucasian, 31.4% African American, 0.7% Hispanic, and 0.3% Asian. Median age was 60 years (range 13-93), 76% were female, and 83% were outpatients. Total hospital costs were greater for African American patients ($5,025.22 ± 6,535.38, P = 0.013) compared to Caucasian patients ($4,787.49 ± $2,241.50) but costs were similar to Hispanic and Asian patients. Compared to Caucasian patients, African American patients were more likely to experience hospital costs greater than $10,000 (6.7% vs 2.1%, P = 0.001). Mean length of stay was 0.99 ± 3.14 for African American patients and 1.33 ± 1.21 for Hispanic patients while it was 0.44 ± 1.28 for Caucasian patients (P <0.001). African American patients were also more likely than Caucasians to be admitted to the ICU (22.7% vs. 13.2%, P < 0.001) and more likely to be readmitted after discharge (4.6% vs. 1.2%, P = 0.001). Among African American patients, male Black patients had a more expensive total hospital cost (trending P = 0.072), higher incidence of cases that cost greater than $10,000 (P = 0.005), longer length of stay (P < 0.001), and higher incidence of ICU admission (P < 0.001) compared to female Black patients.

Conclusion: African American race was associated with higher hospital costs for parathyroidectomy compared to Caucasian patients. The increased cost could be explained in part by longer length of stays after the operation and higher incidence of admission to the ICU. More detailed research and efforts are needed to reduce racial disparity in the management of parathyroidectomy patients.

51.07 Racial Disparities in Length-of-Stay for African-Americans with Metastatic Colorectal Cancer

Posted on January 26, 2017

L. Goss1,2, A. Gullick1,2, M. Morris1,2, J. Richman1,2, G. Kennedy1,2, D. Chu1,2  1University Of Alabama at Birmingham,GI Surgery,Birmingham, Alabama, USA 2VA Birmingham HealthCare System,Surgery,Birmingham, AL, USA

Introduction:

Racial disparities in surgical outcomes such as length-of-stay (LOS) exist with African-Americans having worse outcomes compared to other racial/ethnic groups. Surgery for metastatic colorectal cancer (CRC) is associated with poor outcomes and it is unclear if racial disparities exist. We hypothesized that African-Americans undergoing surgery for stage IV CRC would have worse surgical outcomes including longer LOS compared to other racial/ethnic groups.

Methods:

We queried the 2011-2014 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) colectomy procedure targeted cohort for all patients who underwent surgery for stage IV colorectal cancer and stratified patients by race. Our primary outcome was LOS and secondary outcomes include 30-day mortality, 30-day readmission, and post-operative complications. Chi-square and Wilcoxon Rank Sums tests were used to determine differences among categorical and continuous variables, respectively. Stepwise backwards linear regression was performed to identify risk factors for LOS.

Results:

Of the 28,283 patients who underwent colectomy for colorectal cancer, 1,798 (6.4%) had stage IV cancer. Of these stage IV patients, 1,502 (83.5%) were white, 225 (12.5%) were African-American, and 71 (3.9%) were Asian-American. Similarities were seen between races in sex (p=0.86), smoking status (p=0.37), and steroid use (p=0.47). African-Americans were more likely to be on medications for hypertension (53.3%, p=0.04), have diabetes (19.6%, 0.03), and have an open approach (75.1%, p=0.01). African-Americans had a significantly longer post-operative hospital length of stay (7 days) when compared to white patients (6 days, p<0.01). There were no differences in 30-day readmissions or 30-day mortality by race. African-Americans had the highest rates of post-operative complications when compared to white and Asian-Americans including: wound complications (10.7% vs. 8.8% and 7%, p=0.57), sepsis (9.3% vs. 8.6% and 8.5%, p=0.94), respiratory complications (8.9% vs. 5.2% and 4.2%,p=0.07), renal complications (2.2% vs. 1.3% and 1.4%, p=0.52), and urinary tract infection (4.4% vs. 3.5% and 2.8%, p=0.71) but these were not statistically significant. On adjustment for covariate differences, African-American patients still had the longest LOS compared to white patients (p<0.01, Figure 1).

Conclusion:
African-Americans have a significantly longer LOS after colectomy for stage IV CRC compared to other racial/ethnic groups, but no difference in 30-day mortality or readmissions. Higher complications rates were observed in African-Americans although not statistically significant. Further investigations are needed to better understand the mechanisms underlying these disparities.
 

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