92.02 The Utility of Twitter in Generating High-Quality Conversations about Surgical Care

Posted on January 26, 2017

N. NAGARAJAN1,2, H. Alshaikh1, A. Nastasi1, B. Smart3, Z. Berger6, E. B. Schneider4, M. Dredze5, J. K. Canner1, N. Ahuja1  6Johns Hopkins University School Of Medicine,General Internal Medicine,Baltimore, MD, USA 1Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA 2Brigham And Women’s Hospital,Boston, MA, USA 3University Of Southern California,Surgery,Los Angeles, CA, USA 4Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 5Johns Hopkins University,Computer Science,Baltimore, MD, USA

Introduction:
There is growing interest among various stakeholders in using social media sites to discuss healthcare issues. However, little is known about how social media sites are used to discuss surgical care. There is also a lack of understanding of the types of content generated and the quality of the information shared in social media platforms about surgical care issues. We therefore sought to identify and summarize conversations on surgical care in Twitter, a popular microblogging website.  

Methods:
A comprehensive list of surgery-related hashtags was used to pull individual tweets from 3/27-4/27/2015. Four independent reviewers blindly analyzed 25 tweets to develop themes for extraction from a larger sample. The themes were broadly divided further to obtain data at the levels of the user, the tweet, the content of the tweet and personal information shared (Figure I). Standard descriptive statistical analysis and simple logistic regression analysis was used. 

Results:

In total, 17,783 tweets were pulled and 1000 from 615 unique users were randomly selected for analysis. Most users were from North America (62.4%) and non-healthcare related individuals (31.8%). Healthcare organizations generated 12.4%, and surgeons 9.5%, of tweets. Overall, 67.4% were original tweets and 79.0% contained a hyperlink (11% to healthcare and 8.7% to peer-reviewed sources).  The common areas of surgery discussed were global surgery/health systems (18.4%), followed by general surgery (15.6%). Among personal tweets (n=236), 31.1% concerned surgery on family/friends and 24.4% on the user; 61.1% discussed procedures already performed and 58.0% used positive language about their personal experience with surgical care.

Surgical news/opinion was present in 45% of tweets and 13.7% contained evidence-based information. Non-healthcare professionals were 53.5% (95% CI: 3.8%-77.5%, p=0.039) and 72.8% (95% CI: 21.1%-91.7%, p=0.017) less likely to generate a tweet that contained evidence-based information and to quote from a peer-reviewed journal, respectively, when compared to other users. 

Conclusion:

Our study demonstrates that while healthcare professionals and organizations tend to share higher quality data on surgical care on social media, non-health care related individuals largely drive the conversation. Fewer than half of all surgery-related tweets included surgical news/opinion; only 14% included evidence-based information and just 9% linked to peer-reviewed sources.  As social media outlets become important sources of actionable information, leaders in the surgical community should develop professional guidelines to maximize this versatile platform to disseminate accurate and high-quality content on surgical issues to a wide range of audiences. 

 

92.01 Vena Cava-sparing Piggyback Hepatectomy in Liver Transplant Patients with Hepatocellular Carcinoma

Posted on January 26, 2017

W. J. Bush1, C. A. Kubal1, J. A. Fridell1, B. Ekser1, R. C. Graham1, K. A. Thatch1, R. S. Mangus1  1Indiana University School Of Medicine,Transplant,Indianapolis, IN, USA

Introduction:
Liver transplant (LT) patients with hepatocellular carcinoma (HCC) are at risk for post-transplant tumor recurrence. Risk of HCC recurrence is known to be associated with the size and number of tumors present within the liver. Close proximity of tumor to major vascular structures may also increase the risk of tumor recurrence. For that reason, most surgeons employ a conventional bicaval technique, replacing the entire vena cava as part of the LT. Our center has previously published data suggesting that the vena cava-sparing piggyback (PGB) technique can be safely used without affecting clinical outcomes. This study reviews a large number of LT patients with HCC to determine long-term outcomes of using the PGB technique, as well as the impact of tumor proximity to the vena cava on recurrence rates.  

Methods:
The records of all adult patients undergoing liver transplant (LT) at a single center over a 15 year period were reviewed. Patients with HCC were extracted for further analysis. The operative records for all HCC patients were reviewed to determine if the CONV or PGB hepatectomy technique was utilized. Original computed tomography scans were reviewed to measure distance between the vena cava and the nearest tumor, and to determine which segments of the liver had tumor present. Outcomes included HCC recurrence and long term patient survival. Cox regression 10-year patient survival was calculated.

Results:
There were 1722 LT patients, and 393 were found to have HCC (23%). Among these patients, 367 (93%) underwent LT with PGB technique, while 26 had CONV hepatectomy (7%). The PGB patients were older and had an older donor age, but had lower cold and warm ischemia time. The PGB patients were more likely to have HCC in segments adjacent to the vena cava (57% vs 34%, p=0.02), but the median distance to the nearest tumor was greater for the PGB group (45 vs 28mm, p=0.06). There was no significant difference in tumor recurrence between PGB and CONV (16% vs 19%, p=0.70), nor was there a difference by Cox regression in survival at 10-years (p=0.13). Predictors of recurrence included being outside Milan criteria, and increased tumor size and number, but not tumor distance to the vena cava.

Conclusion:
These results demonstrate no significant difference in clinical outcomes between the PGB and CONV surgical techniques in LT patients with HCC. Tumor presence near the vena cava was not associated with increased risk of HCC recurrence.
 

91.20 Inguinal Hernia Repair In Octogenarians And Beyond

Posted on January 26, 2017

V. Jain1, M. S. Sultany1, T. Madni1, S. Huerta1,2  1University Of Texas Southwestern Medical Center,General Surgery,Dallas, TX, USA 2VA North Texas Health Care System,General Surgery,Dallas, TX, USA

Introduction:  Elective inguinal hernia repair (IHR) in elderly patients might still cause apprehension in general surgerons especially in the era of acceptable watchful waiting. Reports also indicate that elective rather than emergent operations should be performed for octogenarians presenting with an IH. We elected to interrogate a data base in veteran patients that controls for institution and surgeon. We hypothesize that outcomes are similar independent of age.  

Methods:  This is a retrospective review of data from a single institution and by a single surgeon. We reviewed the entire database for outcomes of IHR on all age groups between July 2005 and April 2016, which included 933 patients and over 1000 IHR.  We separated octogenarians (80-89 years) and nonagenarians (90-99yrs) (Group 1) from everyone else under 80 years (Group 2) and proceeded to compare the two groups with primary outcome studied being major complications (Inguinodynia and Recurrence) and secondary outcomes being all other morbidities/minor complications. Descriptive statistics have been used for patient demographics, X2 was used for comparison of categorical data and student t- test was used for continuous variables.

Results: Of the 933 patients, 57 (6.1 %) were octogenarians and 2 (0.2%) were nonagenarians. Mean age in group 1 was 83.68 ± 3.02 years and in group 2 was 59.28 ± 11.35 years. Both groups: Men=99.8%. Group I vs group II: bilateral IH=8.4% vs 8.5% (p=0.97), Incarcerated IH 18 % vs 6.0% (p <0.01), BMI  24.93 ± 3.36 vs. 27.06 ± 10.21 kg/m2 (p=0.06), ASA I/II 20% vs. 49.4 % (p< 0.01), ASA III/IV 79.2%, vs. 49.2% (p< 0.01). OR time 62.59 ± 21.38 min vs. 60.26 ± 23.77 min for unilateral repairs (p=0.22) and 132.8 ± 35.29 min vs. 103.4 ± 25.62 min for bilateral repair (p=0.07).  Rate of inguinodynia was 0% vs. 1.9% (p=0.27), recurrence rate was 1.7% vs 0.8% (p=0.47).  Minor complications were more common in group I (20.3% vs. 9.38% (p=0.006).  Length of stay (LOS)=1.23 ± 5.99 d vs. 0.28 ± 2.01 d (p=0.23), LOS > 2d=8.47% vs 2.4% (p=0.006).  Multivariate analysis did not identify and independent predictors of major or minor complications.  

Conclusion: There is no significant difference in the incidence of major complications for IHR in the octogenarian population.  There is a significantly higher incidence of minor complications and prolonged length of stay in the octogenarian population compared to the younger age group as observed by univariate analysis. 

 

91.19 Bending the Cost Curve for Colon Cancer Surgery: An Analysis of Nationwide Trends from 2002 to 2011

Posted on January 26, 2017

R. H. Hollis1, L. N. Wood1, M. S. Morris1, D. I. Chu1, J. S. Richman1, M. Kilgore3, M. T. Hawn2  1University Of Alabama at Birmingham,Surgery,Birmingham, Alabama, USA 2Stanford University,Surgery,Palo Alto, CA, USA 3University Of Alabama at Birmingham,Health Care Organization And Policy,Birmingham, Alabama, USA

Introduction:
Improvements in colon surgery, including the adoption of laparoscopy, are associated with reduced complications and length of stay.   Whether this has translated into reduced inpatient costs over time is unclear.

Methods:
We identified patients undergoing colectomy procedures with a diagnosis of colon cancer over years 2002-2011 in the Nationwide Inpatient Sample.  Inpatient costs in 2011 dollars were estimated using hospital charges and cost-to charge ratios.  Secondary outcomes included rates of laparoscopy, length of stay, and inpatient complications. A log-level model was used to evaluate the association between inpatient costs and year of surgery adjusting for patient, procedure, and hospital characteristics.  A separate model additionally controlling for laparoscopy, length of stay, and inpatient complications was used to evaluate the effect of these important cost mediators on temporal trends in costs.

Results:
Among 437,607 colectomies performed for cancer over one decade, the median cost for the inpatient hospitalization was $14,703 (IQR 10,779-$21,132).   From 2002 to 2011, laparoscopy use increased from 2.1% to 45.7%, and median length of stay decreased from 6 days to 5 days.   The odds of any inpatient complication in 2011 was significantly lower compared to 2002 (OR 0.79, 95%CI 0.70-0.89).  After controlling for patient, procedure, and hospital characteristics, the costs of surgery in 2011 were not significantly different from costs in 2002 (0.7 percentage point increase, 95%CI: -1.5-3.0) (figure).  When controlling for changes in laparoscopy, length of stay, and inpatient complication rates, inpatient costs were significantly higher in 2011 compared to 2002 (3.4 percentage point increase, 95%CI 1.3-5.6).

Conclusion:
Inpatient costs for patients undergoing colectomy did not significantly differ in 2011 compared to 2002.  Increased laparoscopy, decreased length of stay, and decreased complications were important mediators of costs savings, enabling stable costs over time.  These findings highlight the increased value of inpatient colectomy over time by virtue of stable costs and improved quality.
 

91.18 Patient Factors Predict Length of Stay and Readmission after Laparoscopic Fundoplication

Posted on January 26, 2017

Y. Vigneswaran1,2, K. Kuchta1, J. G. Linn1,2, S. P. Haggerty1,2, R. Joehl2, E. W. Denham1,2, M. B. Ujiki1,2  2NorthShore University HealthSystem,Surgery,Evanston, IL, USA 1University Of Chicago,Surgery,Chicago, IL, USA

Introduction:  Although a common low risk procedure, laparoscopic fundoplication for a small portion of patients can result in a complicated postoperative course.  Expected outcomes such as length of stay and unplanned readmissions have not been well studied for this procedure yet payers have decided on certain standard and expected outcomes. We hypothesize certain patient specific factors are associated with extended length of stay and unplanned 30 day readmission. The purpose of this study was to identify these risk factors from a national database and correlate them in a single institution experience.

Methods:  American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2013 was queried for elective laparoscopic fundoplication. Patient characteristics, comorbidities and operative details were used to determine predictors for complications, readmission and extended length of stay in a multivariate analysis.  These predictors were then retrospectively tested in our single institution cohort from 2009 to 2014.

Results: A total of 9,338 patients underwent laparoscopic fundoplication for reflux (41.0%) or paraesophageal hernia (59.0%).  Complications occurred in 319 (3.4%), 972 had length of stay greater than 3 days (10.4%) and 507 had unplanned 30-day readmission (5.4%).  Most common complications were urinary tract infection (27.6%) and pneumonia (26.3%).  Most common reasons for readmission were related to pulmonary (20.3%) or GI symptoms (14.4%).
From the multivariable analysis, patients at increased risk of complications were aged greater than 80 (OR 2.7, p<0.0001) and higher ASA class (OR 1.7, p <0.0001). Patients at increased risk of extended length of stay were aged greater than 80 (OR 3.9, p<0.0001), higher ASA class (OR 2.0, p <0.0001), black race (OR 1.9, p<0.0001), race listed other/unknown (OR 1.7, p <0.0001), history of pulmonary disease (OR 1.6, p=0.0001) and females (OR 1.3, p=0.004).  The odds of unplanned readmission was also significantly increased for age greater than 80 (OR 1.4, p=0.03), higher ASA class (OR 1.6, p<0.0001) and black race (OR 1.8, p<0.001).  When these predictors were used to create risk calculators and tested in our single institution cohort of 207 patients, extended length of stay had 72% sensitivity (CI: 66-78%), 45% specificity (CI 38-52%) and readmission had 71% sensitivity (95% CI: 65%-78%), 58% specificity (95% CI 51%-64%).

Conclusion: We have identified several patient dependent characteristics that are associated with increased risk of extended length of stay and unplanned 30-day readmission after laparoscopic fundoplication. We hope these results will allow for better patient counseling and patient selection by surgeons when proceeding with laparoscopic fundoplication. Additionally this data suggests outcomes of extended length of stay and 30-day readmission may not be good markers for the quality of surgical care with fundoplications, as currently used by payers.

 

91.17 Emergency Department Admission and Mortality for Inpatient Inguinal Hernia Repairs, 2009-2013

Posted on January 26, 2017

A. Mehta1, S. Hutfless2, A. B. Blair3, A. Dwarakanath4, H. T. Nguyen5  1Johns Hopkins University,School Of Medicine,Baltimore, MD, USA 2Johns Hopkins Hospital,Department Of Gastroenterology And Hepatology,Baltimore, MD, USA 3Johns Hopkins Hospital,Department Of Surgery,Baltimore, MD, USA 4Johns Hopkins Bayview Medical Center,Department Of Surgery,Baltimore, MD, USA 5Johns Hopkins Bayview Medical Center,Comprehensive Hernia Center,Baltimore, MD, USA

Introduction:  While inguinal hernias are common surgical diagnoses, minimally symptomatic patients are often not scheduled for repairs and are asked to seek medical attention if they develop symptoms. When this happens, patients commonly undergo a scheduled operation or go to an emergency department (ED) for expedited care. While emergent repairs of inguinal hernias are associated with higher mortality, little is known regarding how simply presenting through the ED impacts postoperative mortality and the patient characteristics associated with ED admission.

Methods:  We performed a retrospective analysis of the 2009–2013 Nationwide Inpatient Sample for unilateral inguinal hernia repairs. We examined inpatient care to understand the potential severity of outcomes for an otherwise elective condition. Multivariable logistic regressions adjusted for patient and hospital characteristics were used to determine how ED admission affected mortality and the predictors of ED admission. Patient and hospital characteristics included gender, race, age, payer status, comorbidities, obstruction, gangrene, recurrent hernia, hospital type, teaching institution, bed size, region, and discharge quarter.

Results: There were 116,357 inpatient hospitalizations; the majority (57%) resulted from ED admissions and 80% of ED-admitted patients had obstruction or gangrene. Overall mortality decreased from 2.03% in 2009 to 1.36% in 2013. Independent predictors of mortality included patient age (18-44: OR 0.04 [95%-CI 0.01-0.34]; 45-64: 0.27 [0.17-0.44]; ref: 65+), number of comorbidities (1: 2.79 [1.27-6.10]; 2-3: 3.94 [1.87-8.32]; 4+: 16.92 [8.16-35.12]; ref: 0) and admission through the ED (1.67 [1.21-2.29]), even after adjusting for obstruction and gangrene (Figure). Notable predictors of ED admission included black race (1.47 [1.29-1.69]), Hispanic ethnicity (1.35 [1.18-1.54]), self-pay (2.29 [1.97-2.66]) and Medicaid insurance (1.76 [1.50-2.06]), obstruction (9.77 [9.05-10.55]) and gangrene (18.24 [13.00-25.59]).

Conclusion: Inpatient inguinal hernia repairs resulting from ED admissions were predominately associated with complications necessitating urgent care and likely not from ED overutilization. However, we found that simply presenting through the ED was independently associated with a 67% higher postoperative mortality rate compared to that of a scheduled operation, even after adjusting for obstruction and gangrene. Black, Hispanic and self-pay patients were most likely to present through the ED. Our findings suggest a difference in ED utilization and in subsequent outcomes by patient race and insurance for this common surgical condition. Furthermore, additional consideration may be given for elective repairs in older patients with multiple comorbidities.

91.16 Influence of Sociodemographic Factors on Rate of Surgical Treatment in Patients with Graves’ Disease

Posted on January 26, 2017

G. A. Rubio1, T. M. Vaghaiwalla1, P. P. Parikh1, J. C. Farra1, A. R. Marcadis1, Z. F. Khan1, J. I. Lew1  1University Of Miami Leonard M. Miller School Of Medicine,DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA

Introduction: Graves’ disease is the most common cause of hyperthyroidism in the United States. Management regimens include anti-thyroid medication, radioiodine ablation and thyroidectomy. Whereas patient preference and clinical features such as compressive symptoms, intolerance or intractability to medical treatment, and ophthalmopathy are known reasons for thyroidectomy, demographic and socioeconomic factors may also influence the decision for surgical treatment. This study examines the influence of these aforementioned factors in the use of thyroidectomy during hospitalizations for Graves’ disease.

Methods: A cross-sectional analysis was performed using the Nationwide Inpatient Sample (2006-2011) to identify hospitalizations for Graves’ disease. Patient demographic, socioeconomic, and clinical factors including thyroidectomy during hospitalization were assessed. Bivariate and logistic regression analyses were performed to identify characteristics independently predictive of undergoing thyroidectomy during hospitalization for Graves’ disease. Factors associated with non-elective hospitalizations were also evaluated.

Results: Of 33,279 patients admitted for Graves’ disease during the study period, 10,434 (31.4%) underwent total thyroidectomy. Majority of thyroidectomies (84.8%) were performed during elective admissions. Patients in the thyroidectomy group were younger than the non-surgical cohort (mean 40.1 vs. 42.5 years, respectively). This surgical group also had higher proportion of women (83.7% vs. 75.6%, p<0.01) and whites (59.1% vs 42.0, p<0.01) compared to the non-surgical group. Most thyroidectomy patients were covered by Medicare or private insurance (69.8% vs. 48.8%, p<0.01) with a preponderance of patients from the two highest income quartiles (50.3% vs. 38.4%, p<0.01) compared to non-surgical patients, respectively. On multivariate analysis, female sex (OR 1.52; 95% CI 1.37-1.69), white race (OR 1.27; 95% CI 1.17-1.39), Medicare/insured (OR 1.23; 95% CI 1.12-1.35), and highest income quartile (OR 1.28; 95% CI 1.14-1.45) were associated with increased odds of undergoing thyroidectomy during hospitalization for Graves’ disease. In contrast, male sex (OR 1.26; 95% CI 1.14-1.39), non-white race (OR 1.49; 95% CI 1.38-1.62), Medicaid/uninsured (OR 2.53, 95% CI 2.32-2.75), and lowest income quartile (OR 1.30; 95 CI 1.16-1.50) were associated with higher risk for emergency hospitalizations for Graves’ disease.

Conclusion: In the United States, demographic and socioeconomic characteristics may influence utilization of thyroidectomy for definitive treatment of hospitalized patients with Graves’ disease. Rate of emergent hospital admissions for Graves’ disease is also influenced by race, sex, income, and insurance status. Interventions to increase access for definitive care for Graves’ disease in these patients may lower rate of adverse outcomes and emergency healthcare utilization.

91.15 A Stitch in Time: Prevalence and Predictors of Opioid Receipt at Discharge after Traumatic Injury

Posted on January 26, 2017

M. A. Chaudhary1, A. J. Schoenfeld1, A. Ranjit1, R. Scully1, R. Chowdhury1, S. Nitzschke1,3, T. Koehlmoos2, A. H. Haider1  1Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 2Uniformed Services University Of The Health Sciences,Bethesda, MD, USA 3Brigham And Women’s Hospital,Trauma, Burn And Surgical Critical Care,Boston, MA, USA

Introduction: The prevalence of pain at hospital discharge among patients with traumatic injury is as high as 97%; 59% of whom experience moderate to severe pain. Inadequate pain control after trauma is associated with poor quality of life, delayed return to work and chronic pain syndrome. Opioids are considered the first line treatment for acute pain and treatment with opioids is associated with reduced likelihood of developing chronic pain. The Objectives of this study were to describe the prevalence of opioid prescription among trauma patients at hospital discharge and determine the predictors for the receipt of opioids for pain management.

Methods: The Military Health System Data Repository (MDR) was queried for TRICARE healthcare claims data from 2006 to 2014. Opioid-naive patients (18-64) admitted for traumatic injury were included in the study. Patients who died during index hospitalization or were transferred to another healthcare facility were excluded. The outcome variable was defined as at least one prescription of opioids at discharge. Logistic regression models, adjusted for patient  demographic and clinical characteristics, and environment of care were used to determine predictors of opioid prescription.

Results:Among the 27,114 patients included in the study, 14,017 (51.7%) received an opioid prescription at discharge. In risk-adjusted models, older adults (45-64y vs. 18-24y: OR= 1.38, 95% CI: 1.25-1.54), married patients (OR: 1.23, 95% CI: 1.16-1.30) and patients with higher Injury Severity Score (>9 vs. <9; OR: 1.24, 95% CI: 1.17-1.32) were associated with higher likelihood of opioid prescription. Males  (OR: 0.77, CI: 0.71-0.83), Asians vs.  non-Hispanic Whites (OR: 0.84, CI: 0.75-0.95), anxiety diagnosis (OR: 0.80, CI: 0.71-0.89) and traumatic brain injury (AIS head>3) (OR: 0.61, CI: 0.55-0.66) were associated with decreased likelihood of opioid prescription. Pre-existing comorbidities and presence of depression were not significant predictors of opioid prescription.

Conclusion:The rate of opioid prescription in trauma patients was 51.7%. Compared to the reported prevalence of pain among such patients at discharge, the rate of use of opioid for pain control at discharge seems low. Identifying factors associated with receipt of opioids at discharge, might help promote appropriate prescribing patterns among trauma patients thereby reducing incidence of chronic pain in this population.
 

91.14 Pancreatic Adenocarcinoma in Southwest Native Americans: Disparities in Treatment and Survival

Posted on January 26, 2017

A. Greenbaum1, E. Alkhalili1, R. Rodriguez1, J. O’Neill1, O. Estrada Munoz1, F. Qeadan2, O. Myers3, I. Nir1, K. Morris1  1University Of New Mexico HSC,Surgery,Albuquerque, NM, USA 3University Of New Mexico HSC,Internal Medicine,Albuquerque, NM, USA 2University Of New Mexico HSC,Pathology,Albuquerque, NM, USA

Introduction:   Native Americans (NA) have a higher incidence of and mortality from biliary tract cancers, though demonstrate lower pancreatic cancer incidence than non-Hispanic Whites (NHW).  In this study, we examined the treatment and outcomes of pancreatic adenocarcinoma in Southwest NA.  We hypothesized there would be no differences when comparing NA to NHW and Hispanics (H), which compromise the three main ethnic groups in our state.

Methods:   A retrospective chart review was performed of all patients diagnosed with pancreatic adenocarcinoma and treated at a university National Cancer Institute (NCI) Comprehensive Cancer Center between January 2002 and July 2016. Data extracted included patient demographics, AJCC 7th edition staging at presentation, tumor resectability, treatment modalities offered and received, clinical outcomes and survival data.   We employed multivariable logistic regression to determine the odds ratios (OR) and 95% confidence intervals (CI).  Student’s t-Test and ANOVA tests were used to compare means of continuous values.  Chi-square tests were used to assess associations among nominal variables. Overall survival (OS) was examined using Kaplan-Meier analyses. P-values less 0.05 were considered significant.

Results: A total of 457 patients met inclusion criteria.  Our final cohort included 240 (52.5%) NHW, 186 (40.7%) H and 31 (6.8%) NA patients.  After adjusting for age and sex there were no significant differences between ethnic groups in overall stage at presentation, presence of unresectable disease or distant metastases.  All groups were offered surgery and received radiation therapy at similar rates.  NHW (OR 2.41, 1.11 – 5.25. p 0.026) and H (OR 2.37, 1.08-5.24, p=0.032) were more likely to receive chemotherapy than NA at any stage of their treatment and for unresectable disease (OR 2.80, 1.13-6.88; p=0.025 and OR 2.48, 1.00-6.18; p=0.05).  Kaplan-Meier models revealed no significant difference in OS between the three ethnic groups (median OS 12, 13 and 6 months in NHW, H and NA respectively; p=0.224).  However, a significantly larger percentage of NA died within 1 month of diagnosis (25%) compared to 7.5% NHW (OR of being alive after 1 month 4.1, CI 1.56-10.90; p=0.004) and 9.1% H (OR 3.3, 1.24-8.88; p=0.017).     There were no major differences in the number of comorbid conditions or Charlson Comorbidity Index scores between ethnic groups (mean scores 4.46 NHW, 4.58 H and 4.84 NA; p=0.63).

Conclusion:

Southwest NA diagnosed with pancreatic adenocarcinoma are less likely to receive chemotherapy and are significantly more likely to die within 30 days of diagnosis than NHW and H.  The latter may be due to more biologically aggressive disease, though no differences in medical comorbidities, stage at presentation or overall survival were noted.  Larger studies are needed to examine whether cultural factors and access to care due to financial or geographic constraints contribute to these findings.

 

91.13 Undiagnosed Malignancy in Patients Receiving a Surgical Evaluation at an Urban Tertiary Care Center

Posted on January 26, 2017

M. R. Egyud1, M. Plocienniczak2, C. James2, T. Sachs1,2, T. Dechert1,2  1Boston Medical Center,Department Of Surgery,Boston, MA, USA 2Boston University School Of Medicine,Boston, MA, USA

Introduction: The nature of Trauma and Acute Care Surgery (TACS) demands surgeons be able to diagnose and treat a spectrum of disease in complex patients with multi-organ involvement. The proportion of these patients with undiagnosed malignancy is poorly understood. We sought to evaluate the role TACS plays in the early surgical management of patients presenting with undiagnosed malignancy.

Methods: We reviewed records of all patients at an urban tertiary care center, evaluated by TACS for potential operative intervention between 01/2005 and 09/2015. Patients were selected if a malignancy was diagnosed during admission (Cohort A) or within a year of discharge based on findings from the index admission (Cohort B). Cohorts were compared by demographics, type of insurance, comorbidities, operation(s) performed, and hospital course.

Results: We identified 247 patients, with 54% in Cohort A (n=134) and 46% in Cohort B (n=113).  The majority of patients (> 80%) in both cohorts used Medicare, Medicaid, or lacked insurance. There were 21 distinct malignancies identified in Cohort A, with the majority (n=97, 72%) being of gastrointestinal origin. 26 distinct malignancies were identified in Cohort B. Cohort A patients tended to present with more advanced cancers, while Cohort B were earlier stage (Figure 1). Of the Cohort A patients, 111 (83%) required an operation related to their malignancy, 61 (55%) of whom needed an urgent operation.

Conclusion: Patients presenting to TACS may have an undiagnosed malignancy, many of whom are indigent or poor.  A portion of these patients will require an urgent operation. In addition, TACS surgeons often initiate workup for suspicious findings and coordinate care to ensure these patients receive appropriate evaluation in a timely fashion. The underserved are known to present at later stage and have less access to screening and prevention, and further study is needed to improve outcomes in this patient population.

 

91.12 Trends and Disparities in Thyroid Cancer within a Health System

Posted on January 26, 2017

O. Moaven1, R. Xie1, J. Richman1, D. Naftel1, J. K. Kirklin1, H. Chen1  1University Of Alabama at Birmingham,Department Of Surgery,Birmingham, Alabama, USA

Introduction: To improve the quality of care provided to the patients with thyroid cancer, we sought to examine and identify the trends and potential disparities in thyroid cancer diagnosis, various subtypes and patient demographics.

Methods: We assessed electronic medical records of the patients with the diagnostic codes for thyroid cancer in 2011-2016 at our institution. Patient demographics, specific type of cancer, insurance status, time to documented specific diagnosis and follow up visits were studied.  Racial and gender disparities in the documented specific cancer diagnosis, time to specific diagnosis, and time to the first follow-up visit after the initial unspecific diagnosis were examined using univariate and multivariate cox regression modeling. 

Results: There were 1640 patients with a documented diagnosis of thyroid cancer, and the cumulative incidence of thyroid cancer per 100,000 patients per year was highest in white females (60) followed by white males (42), black females (30), and black males (6, p<0.0001). After controlling for age, insurance type, and initial unspecific diagnosis year, white males had a higher likelihood of having a follow up clinic visit within 1 month after initial presentation (62% vs. 56%; HR: 1.19, p=0.01), as well as a documented designation with a specific diagnosis within 6 months (19% vs. 14%; HR: 1.45, p=0.01), when compared to those of white females. These differences were not significant when comparing whites vs. blacks.

Conclusion: There is a gender disparity, but no racial disparity, in a comprehensive workup and diagnosis of thyroid cancer within our health system. Identifying these inequalities is the first essential step in developing a health system that provides equal access to care.

91.11 Surgical Deliveries in Sub-Saharan Africa: Two Methodologies to Estimate Need

Posted on January 26, 2017

K. Garber1,2, R. Groen4,5, O. Ogedengbe3, D. DeUgarte1, A. Kushner2,5  5Surgeons OverSeas (SOS),NEW YORK, NY, USA 1University Of California, Los Angeles,Department Of Surgery,Los Angeles, CA, USA 2Johns Hopkins Bloomberg School Of Public Health,Baltimore, MD, USA 3University Of Lagos,Department Of Obstetrics And Gynecology,Lagos, , Nigeria 4Johns Hopkins Hospital,Department Of Obstetrics And Gynecology,Baltimore, MD, USA

Introduction:  Access to surgical delivery (c-section) is critical for reducing maternal and neonatal mortality rates, which are key aims of the UN Sustainable Development Goals 2030. The Lancet Commission on Global Surgery also recognized c-sections as an important benchmark procedure. Despite the importance, data on actual numbers of procedures performed in sub-Saharan Africa (SSA) is limited. The goal of this study was to estimate the met and unmet need for c-sections in SSA to help plan interventions and inform future policy decisions.

Methods:  Two approaches were used to estimate c-section need. First, annual births for each SSA country in 2015 were calculated using population data from the UN Population Database and crude birth rates from the World Bank Development Indicators. Then, using the World Health Organization optimal c-section rate of 10% and a recently published (Molina et al 2015) higher optimal rate of 19%, the range of c-section need for each country and region was estimated. To determine unmet need, the most recently published actual c-section rates for these countries were obtained (Bertran et al 2016) and raw totals for performed cesarean sections were calculated. Then these numbers were subtracted from the overall need. To support the findings, a second methodology to recalculate SSA c-section needs was used. Data on the prevalence of major maternal conditions (hemorrhage, obstructed labor, sepsis, hypertension, abortion) were obtained from the Institute for Health Metrics and Evaluation 2013 Global Burden of Disease study. Using previously calculated surgical incidence rates for various diseases (Hider et al 2015), the number of needed operations for each maternal condition was estimated, excluding abortions, on the assumption that the overwhelming majority of surgeries for these conditions would be c-sections. Results were summed for each country to provide overall estimates of need.

Results: Using optimal c-section rates of 10-19%, we estimated that 3.6-6.8 million c-sections are needed annually in SSA, with at least 1.8 million, and as many as 4.8 million, of those operations currently unmet. Using 2013 GBD data, a similarly estimated 5.2 million c-sections are needed, well within the range of the first estimate. Regionally, the largest met and unmet needs were seen in Eastern and Western Africa.

Conclusion: A large need and correspondingly large unmet need exist for c-sections in SSA. These data can help inform policymakers of the magnitude of obstetric surgical need in the region as they seek policies to improve maternal and neonatal health. As efforts to improve surgical care in low and middle-income countries increase, planning for and devoting resources to undertake c-sections must be a priority.

91.10 Disparities in Incidence of CRC between Hispanics and Whites: a 10-year SEER database study

Posted on January 26, 2017

J. E. Koblinski1, J. Jandova1, V. Nfonsam1  1University Of Arizona,Department Of Surgery,Tucson, AZ, USA

Introduction:
Overall incidence of colorectal cancer (CRC) has shown a decreasing trend in the last three decades. However, There has been an increasing incidence of CRC in the younger population (<50). It has previously been shown that racial disparities exist in the incidence of CRC. In addition, CRC was the second most commonly diagnosed cancer in Hispanics in 2012. The aim of our study was to assess the trends in incidence of early- (EO) and late-onset (LO) CRC in Hispanics and compare them to White patients.

Methods:
Between 2000 and 2010, we abstracted the national estimates for Hispanic and White patients diagnosed with colon and rectal cancer using the Surveillance, Epidemiology, and End Result (SEER) database. We distinguished between EO and LO cases and then analyzed incidence trends, mortality, gender and stage of disease. Linear regression was performed to compare the trends.

Results:
The overall incidence of CRC increased by 48% in Hispanics while the overall incidence decreased by 12% in Whites (P<0.0001). There was an alarming 80% increase in incidence of EO CRC in Hispanics and a 22% increase in Whites. As expected, there was an observed 19% decrease in incidence of LO CRC in Whites. Surprisingly, 38% increase in incidence of LO CRC was found in Hispanics (P<0.0001). Both Hispanics and Whites showed a higher percentage of distant CRC tumors for both age groups. Neither in Hispanic nor White patients was there any deviation in overall trend between males and females. 

Conclusion:
Although there is an overall decrease in incidence of CRC in Whites, there is an alarming increase in overall incidence of CRC in Hispanics. While incidence of EO CRC is increasing in both races, incidence of LO CRC is increasing in Hispanics but not in Whites. These data suggest that particular policies should be implemented to address these disparities.  

91.09 Hospital Assessment: Examining the Surgical System in Amazonas, Brazil.

Posted on January 26, 2017

J. E. Dos Santos Souza1, S. Saluja2,4, J. Amundson2,3, R. V. Ferreira1, I. Citron2, P. H. Gomes1, J. Correia1, C. Costa1, N. Alonso5,6, M. Shrime2,7  1Universidade Estadual Do Amazonas,Faculdade De Medicina,Manaus, AMAZONAS, Brazil 2Harvard School Of Medicine,Program In Global Surgery And Social Change,Boston, MA, USA 3University Of Miami,Miller School Of Medicine,Miami, FL, USA 4Weill Cornell Medical College,Department Of Surgery,New York, NY, USA 5Universidade De Sáo Paulo,Craniofacial Surgery Unit, Division Of Plastic Surgery, Department Of Surgery,Sáo Paulo, SÁO PAULO, Brazil 7Massachusetts Eye And Ear Infirmary,Department Of Otology And Laryngology And Office Of Global Surgery,Boston, MA, USA

Introduction:  Five billion people lack access to safe and affordable surgical, anesthetic and obstetric care when needed. In 2015, the Lancet Commission on Global Surgery – an academic global consortium – summarized the state of surgical care internationally. The Commission proposed six indicators for evaluating surgical systems. To assess the health of a national surgical system, a mixed-methods qualitative and quantitative Hospital Assessment Tool (HAT) has been developed. The tool will be used in Brazil’s largest and most rural state, Amazonas, to identify priority areas for system improvement and health policy changes, as perceived by local patients and providers. The deployment of the tool involves a partnership between Harvard Medical School and local collaborators at Universidade do Estado de Amazonas (UEA). The aim is to apply this validated tool to a broad range of settings worldwide.

Methods:  An initial pilot of the HAT was undertaken in Cabo Verde, Ethiopia, and India. The tool was then adjusted and validated by 18 experts (Delphi consensus). Over six months, the HAT will be deployed by researchers from UEA at hospitals in 20 municipalities across the state. To select which municipalities to assess, municipalities performing surgery were stratified by population quartile and selected at random within each stratum. At each site, the UEA team will gather quantitative survey data and qualitative interviews. Interview transcriptions will subsequently be evaluated using framework analysis. A selection of sites will undergo repeat data collection at 6-week intervals by a separate team to assess inter-rater and inter-temporal validity.

Results: To date the investigators have visited 6 of 20 target hospitals, with data collection projected to finish by late 2016. Inhalation general anesthesia is available at 1/6 hospitals; IV sedation, spinal and regional anesthesia is available at 3/6 hospitals. Blood bank services are available at 5/6 hospitals, with average time to access less than 30 minutes at 4/5 hospitals. No hospital reported use of the WHO safe surgery checklist. 2/6 hospitals performed procedures other than cesarean section in past 6 months, and 1/6 in the past 30 days. Only 1/6 hospitals reported continuous vital sign monitoring in the PACU. 2/6 hospitals have internet.

Conclusion: This project provides the framework for a successful partnership engaging local stakeholders in meaningful research to influence their own regional surgical agenda. Preliminary quantitative results show a significant lack of basic tools to perform safe surgery across the municipalities of Amazonas.

 

91.08 Characteristics of Patients Presenting to the Emergency Department for Diagnosis of Colon Cancer

Posted on January 26, 2017

D. Weithorn1, G. Umadat1, P. Friedmann1, R. Narang1, R. Huang1, R. Levine1, H. In1  1Albert Einstein College Of Medicine,Surgery,Bronx, NY, USA

Introduction: Patients with colorectal cancer who initially present through the Emergency Department (ED) for colorectal cancer diagnosis have worse outcomes, including poorer stage-adjusted prognosis.  Colonoscopy has been associated with improved survival but has not been studied in the context of persons presenting through the ED. We aimed to examine the characteristics of patients who get diagnosed with colorectal cancer through a visit to the ED, including prior colonoscopy and symptoms.

 

Methods: Patients diagnosed with colorectal cancer in one year (2013) in a single urban academic institution were analyzed.  A detailed retrospective chart review was conducted to identify if the first presentation that lead to the cancer diagnosis was through the ED (ED-Dx), and for colonoscopy history prior to cancer diagnosis. Kaplan-Meier Analysis was used to examine survival. Differences between persons presenting to the ED and not were compared using univariate and multivariate analyses.

 

Results: We identified 226 patients with newly diagnosed colorectal cancer eligible for analysis. 40% of patients had cancer diagnosed through a visit to the ED. Colonoscopy information was available for 72% of patients. About half of these patients had history of colonoscopy prior to their cancer diagnosis. ED-Dx patients were more likely to be either younger than 50 (13% vs 9%) or older than 80 (34% vs 19%) and less likely to be 50-65 years old (16% vs 36%, p=0.005). They presented at an advanced stage (40% vs 15%, P<0.001) and were less likely to have had a prior colonoscopy (20% vs 48%, p<0.001). ED-Dx more commonly presented with symptoms (89% vs. 56%, P<0.001), and “pain” was the most common symptom (47% vs 19%, P<0.001).  ED-Dx had significantly poorer 18-month survival (94% vs 81%, p=0.006). On multivariate analysis adjusting for all variables, we found ED-Dx to be less likely to have had a prior colonoscopy (OR 0.24, CI 0.1 to 0.6), more likely to have had symptoms (OR 4.33, CI 1.69 to 11.1) and have stage IV cancer (OR 8.13, CI 2.44 to 27.1). Patients with Medicare were more likely to be ED-Dx compared to those with private insurance (OR 4.68, CI 1.01 to 21.7).

 

Conclusion: Outcomes of patients with ED-Dx are poor. Identifying the health patterns and clinical attributes of these persons represents an opportunity to develop programs to improve the outcomes of cancer patients. Decreased utilization of colonoscopy during routine health care for patients diagnosed through the ED suggest that these patients may be underutilizing health care services, including cancer screening. Based on our observations, a key modifiable factor may be the increased utilization of colorectal screening.

91.07 Insurance status and choice of surgical therapy in newly diagnosed breast cancer patients

Posted on January 26, 2017

E. C. Feliberti1, R. R. Perry1, R. C. Britt1, J. C. Collins1, E. Feliberti1  1Eastern Virginia Medical School,Surgery,Norfolk, VA, USA

Introduction: Safety net programs aim to minimize disparities in the treatment of breast cancer patients. We hypothesize that differences in the use of breast conservation therapy (BCT) persist in uninsured women despite access to a multidisciplinary clinic.

Methods: A retrospective review of a prospective database was performed on consecutive newly diagnosed female breast cancer patients treated at an academic surgical department form 2001 to 2015. Patients were stratified by insurance status at time of breast cancer diagnosis.

Results: A total of 523 patients were identified meeting the inclusion criteria, 85 without and 438 with medical insurance. The uninsured cohort were younger (mean age: 46.8 vs 58.1, p<0.01) and had a higher proportion of African-American women (68.7% vs 40.4%, p<0.01). Tumor size was similar between the 2 groups (Mean size 2.2 cm vs. 2.0, p=0.8). BCT was selected less often in the uninsured cohort (50.6% vs 64.6%, p=0.02). Differences in the use of BCT in the uninsured were significant in women aged 50 and older (42.*5 vs 68.4%, p<0.01) and for tumors larger than 2 cm (30% vs 54.4%, p<0.01).

Conclusion: Insurance status affects choice of surgical therapy in newly diagnosed breast cancer patients despite access to a safety net program. Increasing tumor size and age play a significant role in the decreased use of BCT.

 

91.06 Anatomic Location of High-Grade Dysplasia from Adenomatous Polyp of the Colon among Black Patients

Posted on January 26, 2017

P. H. Lam1, I. D. Nwokeabia2, A. C. Obirieze3, S. C. Onyewu3, B. S. Li3, N. Enwerem3, G. Ortega3, T. M. Fullum3, W. A. Frederick3, L. L. Wilson3  1Cedars-Sinai Medical Center,Los Angeles, CA, USA 2Washington University,St. Louis, MO, USA 3Howard University College Of Medicine,Washington, DC, USA

Introduction:  Black patients have the highest incidence and mortality rates of colon cancer when compared to other racial/ethnic groups. Screening rates for colon cancer are lower in black patients, and studies have shown varying anatomic locations of adenomatous polyps and colon cancers in these patients. Studying the location of these cancers within the colon could help tailor where to screen and which screening test to use. We aim to investigate the anatomic location of high-grade dysplasia from adenomatous polyp among black patients, using a national tumor registry.

Methods:  The Surveillance Epidemiology and End Results database from 1973 to 2008 was utilized. We identified patients with a single primary diagnosis of a high-grade dysplasia arising from adenomatous polyp of the colon using appropriate ICD-O-3 codes. Age and gender-adjusted proportions of proximal vs. distal lesion location were derived for all patients using multivariable regression analysis.

Results: A total of 18,762 patient records, comprising 16,276 (86.8%) white and 2,486 (13.2%) black patients, met the study criteria. The incidence of high-grade dysplasia of the colon has been increasing in black patients over the last three decades (9.9%, 13.0%, and 15.1% for 1973-1989, 1990-1999, and 2000-2008, respectively).

The most common location in the proximal and distal colon was the cecum (16.6%) and sigmoid colon (48.5%). Most patients had distal lesions (60.0%), most of which occurred at the sigmoid colon (48.5%). On multivariate analysis, black patients were 33% less likely to have a distal lesion compared to white patients (OR: 0.67, p<0.001, 95% CI: 0.61-0.73). 

Black patients were more likely not to undergo surgery (4.9% vs. 3.3%), more likely to undergo partial or hemicolectomy (38.3% vs. 33.5%), or total colectomy (1.9% vs.1.3%), but less likely to undergo local excision with pathology (47.1% vs. 51.9%) (all p<0.001). 

Conclusion: Black patients have increasing incidence of high-grade dysplasia arising from adenomatous polyp, lower likelihood of distal lesions of the colon, and more likely not to undergo surgery. This suggests their importance for screening with colonoscopy. Nonetheless, more research on the use of different screening tests, location of cancer found, and surgical preferences among different race/ethnic groups are needed.

91.05 Burden of Sports Injuries among African Adolescents: A Modeling Study

Posted on January 26, 2017

D. G. LeBrun1,2, J. D. Kelly10, S. Wren8,9, D. A. Spiegel3, N. Mkandawire7, R. A. Gosselin11, A. L. Kushner4,5,6  10University Of Pennsylvania,Sports Medicine, Orthopaedic Surgery,Philadelphia, PA, USA 11University Of California – San Francisco,Orthopaedic Surgery,San Francisco, CA, USA 1Harvard School Of Public Health,Epidemiology,Boston, MA, USA 2University Of Pennsylvania,Perelman School Of Medicine,Philadelphia, PA, USA 3Children’s Hospital Of Philadelphia,Orthopaedic Surgery,Philadelphia, PA, USA 4Columbia University College Of Physicians And Surgeons,Surgery,New York, NY, USA 5Johns Hopkins Bloomberg School Of Public Health,International Health,Baltimore, MD, USA 6Surgeons OverSeas,New York, NY, USA 7University Of Malawi,Orthopaedic Surgery,Blantyre, , Malawi 8VA Palo Alto Healthcare Systems,General Surgery,Palo Alto, CA, USA 9Stanford University,Surgery,Palo Alto, CA, USA

Introduction:
Injuries comprise a major portion of the global burden of disease among adolescents. In particular, injuries sustained while playing sports are extremely common with many requiring surgical management. However, the extent to which sports injuries contribute to the burden of injury in low- and middle-income countries (LMICs) is unknown. The goal of this study was to determine the burden of sports injuries among adolescents in Africa as part of a larger effort to estimate the global burden of sports injuries among adolescents.

Methods:
Data from the World Health Organization (WHO) Global School-Based Student Health (GSHS) cross-national surveys was used to estimate the number of adolescents sustaining sports injuries in Africa. WHO-GSHS surveys have been conducted in 16 African countries since 2003. These surveys measured the number of adolescents sustaining serious injuries (defined as injuries that necessitated treatment or caused the child to miss a day of normal activities) within the past year. Nine surveys contained supplemental data on serious injuries attributable to sports. Gender-stratified sports injury rates were calculated based on weighted averages reflecting the relative sample size of each national survey. These rates were subsequently applied to every African country’s adolescent population to estimate country-specific injury rates and continent-wide totals.

Results:
The 9 countries with supplemental data on serious injuries attributable to sports injuries included: Botswana, Ghana, Kenya, Mauritius, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe. These surveys represented a total of 15,822 males and 18,495 females. In these countries, sports injury rates ranged from 19.7% to 30.4% for males and 6.9% to 20.2% for females. Weighted average sports injury rates for males and females were 23.8% and 13.5%, respectively. When these rates were applied to the adolescent populations of every African country, an estimated 31,303,816 males and 17,295,093 females sustained sports injuries. In total, an estimated 48,598,909 adolescents sustained sports injuries in Africa over a one-year period. 

Conclusion:
By calculating gender-stratified sports injury rates, we estimated that nearly 50 million African adolescents sustained sports injuries over one year. Injuries represent a major burden of disease worldwide and disproportionately affect LMICs, yet there is a paucity of data characterizing injury rates among adolescents in LMICs. The fraction of injuries attributable to sports and the proportion of these injuries necessitating surgical care are poorly understood. Further work will help to more precisely define the burden of sports injuries in LMICs and the role that surgery can play in mitigating this burden.

91.04 Defining Congenital Anomalies in Mongolia

Posted on January 26, 2017

L. F. Goodman1,4, G. Jensen1, T. Nomindelger3, R. Nurjanar2, T. Gantuya3, D. Farmer1  1University Of California – Davis,Surgery,Sacramento, CA, USA 2National Center For Maternal And Child Health,Pediatric General Surgery,Ulaanbaatar, ., Mongolia 3National Center For Maternal And Child Health,Surveillance Department,Ulaanbaatar, ., Mongolia 4Harvard School Of Public Health,Epidemiology,Boston, MA, USA

Introduction:  Neonatal mortality in Mongolia declined from 32 per 1000 live births in 1990 to 7.8 per 1000 in 2015. As  deaths from infectious disease and birth trauma have been reduced, congenital anomalies have become a relatively more important cause of neonatal mortality. This study sought to determine the prevalence at birth of major congenital anomalies, risk factors associated with anomalies and anomaly-associated neonatal mortality, and the proportion of anomalies that are surgically treatable. 

Methods:  The National Center for Maternal and Child Health (NCMCH) has maintained an electronic national database of congenital anomalies since 2014, including ICD10 codes, clinical characteristics, risk factors, and reporting physician response to “Treatable with surgery?” The Center for Health Development (CHD) maintains a nation-wide vital registry. Combining the data, we determined the prevalence at birth of major congenital anomalies, with a particular focus on those that are surgically treatable in Mongolia. We also examined risk factors for anomalies and for neonatal death, including infant characteristics, maternal home, and season of birth, among others. 

Results: Preliminary analyses of the case series of 1,364 infants in the NCMCH registry suggest prevalence at birth of 8.92 major anomalies per 1000 live births in 2014 (95% CI 7.33-8.55) and 8.87 in 2015 (95% CI 8.24-9.54, birth denominator from CHD). Only 265 (19.4 percent) of infants had anomalies diagnosed in the prenatal period. Of 1,364 infants with major anomalies, 234 or 17.2 percent died within the first 28 days of life. Comparing the 234 neonatal mortality cases to the 1,130 alive at 28 days, there was no significant difference in the gender distribution. The group that died had significantly lower mean birth weight, higher proportion of low and very low birth weight, and lower mean gestational age. A larger proportion of those who died were from rural areas, and a smaller proportion of those who died were considered to be treatable with surgery. A larger proportion of those who died had anomalies diagnosed in the prenatal period.

Conclusion: As expected, the neonates who died were smaller, earlier, and more from rural areas. More of those who died were diagnosed in the prenatal period, though this may reflect more severe anomalies, more easily diagnosed with ultrasound. There are many potentially confounding and effect modifying factors that differ among those who died before 28 days and those who did not. Next steps include determining the prevalence at birth of each ICD10 grouping of anomalies, and carefully controlled regression analyses to determine risk factors for anomalies and anomaly-associated neonatal mortality.

 

91.03 Comparative Analsys of Open vs. Laparoscopic Cholecystectomies in El Peten, Guatemala

Posted on January 26, 2017

J. Imran1, A. Ochoa-Hernandez3, J. Herrejon1, S. Huerta1,2  1University Of Texas Southwestern Medical Center,Surgery,Dallas, TX, USA 2VA North Texas Health Care System,Surgery,Dallas, TX, USA 3Hospital Nacional De San Benito,Surgery,San Benito, EL PETEN, Guatemala

Introduction:
While laparoscopic cholecystectomy (LC) is the standard of care in the Western world, many third world countries still perform a number of open cholecystectomies (OC).  We analyzed the outcomes of all patients undergoing cholecystectomy at a referral hospital in El Peten, Guatemala (Hospital Nacional de San Benito: HNSB). Our null hypothesis was that we would find no difference in outcomes between LC and OC.

Methods:  

This a retrospective, single-institution study at HNSB between January 2014 to April 2016 in all consecutive patients who underwent a cholecystectomy during this time period. Differences between LC and OC were analyzed by univariate analysis [(UA): Fisher’s Exact Test for categorical variables and Student’s T-Test for continuous variables]. Clinically relevant factors and those with a p≤0.2 were entered in a logistic regression model with complications and operative time as the dependent variables. The data is expressed as a means±SD. Significance was established at a p≤0.05 (two-sided).

Results: 

One hundred consecutive charts were reviewed and used in our analysis.  58% of the cholecystectomies were performed via the open technique and 42% using the laparoscopic approach.  There were 42% emergent and 58% elective cholecystectomies. Of the cholecystectomies performed in the elective setting, 47 % were done open. Conversion rate, hospital length of stay (LOS) and re-admission rate was 4%, 4.8 days and 5% respectively.  There were no SSIs, UTIs or pneumonia in this cohort; 30d and 90d mortality was 0%.  Patients who underwent OC vs. LC were of similar age (36.2±16.3 vs. 37.4 ± 16.1 yo; p=0.7), female gender (79% vs. 88% p=0.27), and ASA class (1.2 ± 0.69 vs. 1.36±0.81; p=0.3). Patients undergoing OC had higher average weight (164.5 ± 27.2 vs. 145 ±42.9 lbs; p=0.03).  Patients with biliary colic were more likely to undergo OC (79% vs. 51%; p=0.001) in comparison to patients with acute cholecystitis who were more likely to undergo LC (36% vs. 14%; p=0.02).  At presentation, patients undergoing LC had a higher mean temperature in comparison to OC (37.1 ± 0.24 vs. 36.9 ± 0.15; p=0.02), but had similar WBC count (10.3±5.0 vs. 9.1±3.1; p=0.2).   There was no difference in operative time between patients undergoing OC and LC (65.3±20.6 vs. 61.6±31.0 min; p=0.5). LOS was similar (4.9±5.4 vs. 4.8 ± 3.9 d; p=0.8), as was readmission rate (7.5% vs. 3.7%; p=0.6). Logistic regression analysis did not identify any independent predictors of outcomes.  

Conclusion:
For this study, we accepted the null hypothesis.  However, we cannot exclude a type II error.  Nearly half of the open cholecystectomies performed during the study period were done in the elective setting.  This finding could be further explored as a potential route to train our surgical residents in open cholecystectomy though the creation of a residency exchange program.  

« Previous Page
Next Page »