43.01 Understanding Unplanned Readmissions After Hiatal and Paraesophageal Hernia Repairs

Posted on January 25, 2017

R. Bhagat1, E. Juarez-Colunga2, N. O. Glebova1, W. G. Henderson2, D. Fullerton1, M. J. Weyant1, J. D. Mitchell1, R. McIntyre1, R. A. Meguid1  2University Of Colorado Denver,Department Of Biostatistics & Informatics,Aurora, CO, USA 1University Of Colorado Denver,Department Of Surgery,Aurora, CO, USA

Introduction: Hospital readmissions are viewed as a marker of inferior healthcare quality & penalized with decreased reimbursement. Characteristics of unplanned readmissions after hiatal & paraesophageal hernia repairs (HPHR) are not well understood. We sought to determine the association of complications to postoperative unplanned readmission to identify opportunities for intervention.

Methods: We analyzed the ACS NSQIP database (2012-14) to characterize 30-day postoperative related, unplanned readmissions after HPHR identified by CPT code. Timing of, reason for & association between postoperative complication & unplanned readmission was analyzed.

Results: Of 23,257 patients who underwent HPHR, 17,194 (74%) were female, mean age was 55.3 years & mean length of stay (LOS) was 2.4 days. 1,281 (6%) experienced >=1 complication; death occurred in 45 (0.2%) patients. 963 (4.1%) experienced a related, unplanned readmission within 30 days of surgery. Patients who were readmitted were older (mean age 56.4 vs 55.2 years, p=0.02), had a longer mean LOS (3.2 vs 2.3 days, p<0.001), had more complex operations (mean work relative value unit with standard deviation: 20.8 (10.3) vs 18.7 (11.0), p<0.001) & more emergency operations (3.3% vs 1.9%, p=0.001). Among patients who developed >=1 postoperative complications, 55% (706/1,281) had complications while an inpatient & 8% (57/706) readmitted, 41% (532/1,281) were identified after discharge & 54% (285/532) readmitted, & 0.2% (39/1,281) had complications both as an inpatient & after discharge & 74% (29/39) readmitted. Of patients who experienced an unplanned readmission, 39% (371/963) had a documented postoperative complication, with 77% (285/371) developing their complication after discharge. Complications at readmission were mainly gastrointestinal (GI) (42%; 390/937), infectious (13%; 124/937), pulmonary (10%; 98/937) & pain (10%; 97/937). 53% of related, unplanned readmissions occurred within 7 days of discharge, & 79% within 14 days (Figure 1).

Conclusion: Related, unplanned readmission within 30 days of surgery occurred in 4% of patients undergoing HPHR. Over half of patients who developed a complication after discharge were readmitted. Patients who experienced related, unplanned readmissions underwent more complex operations & were older than those not readmitted. The most common reason for readmission was GI complication. Over half of readmissions occurred within 1 week of discharge, & nearly 80% within 2 weeks. Follow-up within the first few days after discharge from surgery may help identify patients suffering post-discharge complications & who are at risk of unplanned readmission. This may facilitate outpatient intervention targeted at common complications to prevent unplanned readmission.

42.01 Neutrophil and Platelet-Lymphocyte Ratios Predict Improved Response in Resectable Pancreatic Cancer

Posted on January 25, 2017

W. R. Doerfler1, J. Miller-Ocuin1, M. Zenati1, H. Zeh1  1University Of Pittsburgh,Department Of Surgery,Pittsburgh, PA, USA

Introduction:
The lack of effective therapy and poor prognosis for pancreatic ductal adenocarcinoma (PDA) necessitates identification of prognostic factors that improve patient risk stratification and inform treatment strategies. Elevation of the neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) in patients with metastatic PDA is predictive of shortened overall survival (OS). We hypothesized NLR and PLR would correlate with improved clinical outcomes in patients with operable PDA treated with neoadjuvant therapy in a randomized phase II clinical trial. 

Methods:
Patients with resectable or borderline resectable PDA were randomized to receive 2 months of neoadjuvant gemcitabine/nab-paclitaxel (GemAbx) or GemAbx + hydroxychloroquine (HCQ), an autophagy inhibitor, prior to undergoing pancreatectomy. Pre- and post-treatment peripheral blood NLR and PLR values were calculated. Primary outcome was OS and secondary outcome was histopathologic response (<50% vs. >50% tumor destruction). OS was determined and hazard ratios for covariates were determined using Cox regression.

Results:
54 patients were included in the analysis [n=27 (GemAbx), n=27 (GemAbx + HCQ)]. Patients with lower pre-treatment NLR appeared to have increased overall survival [(HR=0.690; 95% CI (0.411 – 1.158)] but this did not reach statistical significance (p=0.160). This trend was not affected by receipt of the G-CSF analog filgrastim during treatment (p=0.883). There appeared to be a direct correlation between treatment-related change in NLR and increased histopathologic response [OR =1.501; 95% CI (0.9101-2.478); p=0.112]. A similar trend with change in PLR was also observed [OR = 0.592; 95% CI (0.2717-1.291); p=0.118]. Patients in whom neoadjuvant chemotherapy resulted in >50% histopathologic response had longer median overall survival on Kaplan Meier curves (30 months vs 18 months; p =0.060).

Conclusion:
Patients with PDA treated with neoadjuvant chemotherapy had improved OS with lower pre-treatment NLR and PLR. Patients with greater histopathologic response to neoadjuvant therapy had improved median OS, and histopathologic response appeared to correlate with differences in pretreatment in NLR and PLR. Considering the small sample size of this pilot trial, these results are very encouraging.
 

39.10 Is There an Increased Incidence of Retroperitoneal Malignancies Due to Fracking?

Posted on January 25, 2017

A. Zhong2, Y. Zhang2, J. Price1, E. Villegas1, D. Vyas1, S. Joseph1  1Texas Tech University Health Sciences Center,Department Of Surgery,Odessa, TX, USA 2Texas Tech University Health Sciences Center,School Of Medicine,Lubbock, TX, USA

Introduction:  

Retroperitoneal neoplasms are rare with an annual incidence of 2.7 cases per 1,000,000. In rural West Texas there is a large amount of environmental exposure to chemicals involved in hydraulic fracturing. We suspect that chemical exposures have increased our incidence of retroperitoneal neoplasms.

Methods:  

We did a retrospective review of all retroperitoneal neoplasms seen over the past 4 years. The total patient population of the region is 300,000 served by 3 hospitals.

We reviewed patient demographics and work history. Patients that lived further than 50 miles from the hospital or that recently moved to the area were excluded.  

Results:

The expected number of cases should be 3.24 cases/4yrs. We saw a total of 9 cases that met the inclusion criteria. This represents a 278% increase over expected.

5 patients had sarcomas, 2 had cystic neoplasms, 1 had a primary retroperitoneal neuroendocrine tumor, and 1 had a lymphangioma.

6/9 patients or their spouse worked in the oilfields.  

Conclusion:

We found a 278% increase incidence of retroperitoneal malignancies in this population. 2/3 had been exposed to chemicals involved with oil manufacturing. 1/3 had passive exposure living in this area.

We believe that the incidence of retroperitoneal malignancies is substantially higher than what we report. Many patients are referred to tertiary centers and there are other institutions providing care in the area.

We recommend extensive exposure history on any patient with a retroperitoneal neoplasm. Also, we believe a national registry be developed to track patients. Finally, improved public health monitoring for possible causes of this malignancy is imperative going forward.  

39.09 Surigical Outcome Disparities in Complicated Peptic Ulcer Disease: Setting, Patient, or Procedure?

Posted on January 25, 2017

D. J. Taghipour1,3, G. Ortega1,3, C. K. Zogg2, M. S. Pichardo5, N. R. Changoor1,3, A. Kolluri4, S. M. Siram1, M. Williams1,3, E. E. Cornwell1,3  1Howard University College Of Medicine,Department Of Surgery,Washington, DC, USA 2Yale University School Of Medicine,New Haven, CT, USA 3Howard University College Of Medicine,Howard-Harvard Multidisciplinary Outcomes Research Center, Department Of Surgery,Washington, DC, USA 4Howard University College Of Denistry,Washington, DC, USA 5Howard University College Of Medicine,Washington, DC, USA

Introduction:  There has been a declining role for surgery in the treatment of complicated peptic ulcer disease (cPUD) due to increasingly effective medical management. However, when medical therapy fails or is not obtainable secondary to socioeconomic barriers, emergency surgery may still be required. Surgical intervention is typically a Graham patch repair (GPR) alone, and much less frequently an acid-reducing procedure (ARP). Our objective is to analyze the contemporary outcomes of these two procedures in different hospital settings.

Methods:  We conducted a retrospective review of the National Inpatient Sample from 2007 to 2012 identifying patients with cPUD who underwent a GPR or ARP. Bivariate analysis was utilized to assess outcomes of these two procedures in each of the following hospital

Settings: safety net, non-safety net, rural, urban teaching, and urban non-teaching. Potential confounders were controlled using multivariate logistic regression and generalized linear regression models.

Results: A total of 62,477 patients had cPUD; a little over 51% (32,094) of which had surgery. Among operative patients, nearly 97% (31,182) underwent a GPR, and fewer than less 3% (912) had an ARP. Confounders such as patient’s age, race, co-morbidities, socioeconomic status, and income were adjusted. Overall, mortality was almost two-fold and morbidity was almost three-fold for patients undergoing ARP (table 1) than for those that underwent GPR. In non-safety net hospitals, patients undergoing ARP also had a two- and three-fold increase in mortality and morbidity respectively. Urban non-teaching hospitals had a two-fold increase in both mortality and morbidity. The disparity in complications was greater still at urban teaching hospitals, where patients undergoing an ARP had a four-fold increase in morbidity and in rural hospitals where there was a five-fold increase in mortality. On bivariate analysis there was no difference in Charlson Comorbidity Index between patients receiving the two different procedures. Mortality differences disappear at all hospital settings when only patients treated at hospitals performing at least one ARP are considered.

Conclusion: In 97% of patient’s undergoing ARP for cPUD, GPR was performed. Patients receiving ARP experienced worse outcomes from those receiving GPR alone in all hospital settings. The extent of the disparities varied among hospital settings with rural hospitals having the worst disparities between the two surgeries. Mortality differences disappear among patients where acid reducing procedures are done. Further studies are warranted to elucidate the direct and indirect impact these factors play.

39.08 Risk Factors and Prediction Model for Surgical Site Infection After Major Abdominal Surgery

Posted on January 25, 2017

A. Ejaz1, F. Gani1, S. M. Frank1, C. L. Wolfgang1, M. J. Weiss1, F. M. Johnston1, J. He1, T. M. Pawlik2  1Johns Hopkins University School Of Medicine,Baltimore, MD, USA 2Ohio State University,Columbus, OH, USA

Introduction:  Surgical site infections (SSI) are a common source of postoperative morbidity and a marker of surgical quality.  The ability to predict the incidence of SSI is limited and most models have poor predictive value.  We sought to identify risk factors associated with SSI and develop a prediction model for SSI following major abdominal surgery.

Methods:  1,744 patients undergoing pancreatic, hepato-biliary, and colorectal resections between January 1, 2010 and August 31, 2013 at Johns Hopkins Hospital were identified. Risk factors for any SSI (superficial and deep) were evaluated using multivariable logistic regression. 

Results: Median patient age was 58 years (IQR: 47, 68); operative procedures included  colorectal (59.0%), liver (26.2%) and pancreas (14.8%) resections.  SSI occurred in 7.6% (n=132) of patients. Factors associated with SSI included preoperative weight loss >10lbs. (OR 2.12, 95%CI 1.06-4.25), emergency operations (OR 2.05, 95%CI 1.32-3.17), and colorectal resections (OR 1.65, 95%CI 1.13-2.43)(all P≤0.003).  Intraoperative risk factors included transfusion (OR 2.01, 95%CI 1.33-3.04), estimated blood loss (EBL)>600mL (OR 2.54, 95%CI 1.74-3.71), and maximum respiratory rate (tachypnea) >20 breaths/min (OR 2.65, 95%CI 1.62-4.36)(all P=0.001). Intraoperative hypo/hyperthermia, bradycardia/tachycardia and hypotension/hypertension were not associated with SSI (all P>0.05). After controlling competing risk factors, transfusion, EBL>600mL, tachypnea, and colorectal resection were independently associated with SSI (all P<0.003).  Based on beta-coefficients in the multivariable model, an SSI scoring system was created by assigning 2 points for EBL>600mL, 2 points for a colorectal resection, 3 points for tachypnea, and 3 points for a transfusion. The model showed good discriminatory ability to predict SSI (c-statistic=0.7232; AIC 875.37) (Figure).

Conclusion: A novel, simple 10-point SSI scoring system that incorporated perioperative risk factors such as blood transfusion, EBL, tachypnea and type of surgical procedure accurately stratifies patients according to SSI risk.

 

39.07 Evaluation Of Parathyroid Glands With Indocyanine Green Fluorescence Angiography After Thyroidectomy

Posted on January 25, 2017

A. Rudin1, T. McKenzie1, G. B. Thompson1, D. Farley1, M. Richards1  1Mayo Clinic,Division Of General Surgery,Rochester, MN, USA

Introduction:
Hypoparathyroidism is the most common complication after a total or near-total thyroidectomy (T-NT).  Intraoperative evaluation of parathyroid viability has been limited to visual inspection. Parathyroid function has been confirmed with postoperative lab values.  Indocyanine green fluorescence angiography (ICGA) is a new adjunct that has been used in surgical procedures to assess blood flow.  This study evaluated the utility of ICGA compared to visual inspection to predict parathyroid function, guide auto-transplantation and potentially decrease permanent hypoparathyroidism.

Methods:
This was a single center retrospective study of patients who underwent T-NT between January 2015 and June 2016.  All patients were screened for hypercalcemia and those with hyperparathyroidism were excluded. Patients who had ICGA were compared to T-NT patients without ICGA. All patients had a PTH level on postoperative day 1.  Parathyroid blood supply was scored based on ICGA as none, intermediate or normal. Visual blood supply was either viable or non-viable. Glands with no ICGA uptake were auto-transplanted. Data was analyzed to assess the frequency of auto-transplantation and incidence of hypoparathyroidism between groups. ICGA was also compared to visual inspection of the parathyroid glands.

Results:
112 patients underwent T-NT, 25 with ICGA and 87 without. Auto-transplantation was more common in the ICGA group at 36% compared to 13% in the control (p=0.015). The mean postop day 1 PTH in the ICGA group was 22 vs. 21 in the control group (p= 0.30) (normal 15-65 pg/ml). 22 out of 25 patients with intraoperative ICGA had at least one parathyroid gland with normal ICGA uptake, and 3 with intermediate update.  There was no correlation with postoperative PTH levels (p=1.0). 14 of 25 patients with intraoperative ICGA had at least two parathyroid glands with normal ICGA uptake, which correlated to postoperative PTH levels >=15 in 12 patients and PTH <15 in 2. There was no difference when compared to patients with less than 2 normal ICGA glands (n=11, p=0.08)(note: <2 normal includes patients with ICGA intermediate glands). There were 83 parathyroid glands identified in the ICGA group. Visual and ICGA assessment of normal blood flow were 66/84(78%) and 52/84(61%) respectively. There were 8 glands (9%) that would have undergone auto-transplantation based on visual inspection that had adequate blood supply on ICGA. Hypoparathyroidism was present in 32 out of 87 controls (37.5%) and 8 out of 25 (32% in the ICG group).  No cases of permanent hypoparathyroidism were identified in either group.

Conclusion:

ICGA is a novel technique that may improve the assessment of parathyroid gland blood supply compared to visual inspection.  ICGA can guide more appropriate auto-transplantation without compromising postoperative parathyroid function. At least two vascularized glands on ICGA may predict postoperative parathyroid gland function.

 

39.06 Emergency Leg Bypass is Associated With Worse Outcomes When Performed on Weekends

Posted on January 25, 2017

E. Abotsi1, G. Gilot1, G. Ortega1, C. K. Zogg2, D. J. Taghipour1, D. D. Tran1, E. E. Cornwell1, K. Hughes1  1Howard University College Of Medicine,Department Of Surgery,Washington, DC, USA 2Yale University School Of Medicine,Washington, DC, USA

Introduction:
Studies have demonstrated that there may be an increased risk of postoperative complications for certain surgical procedures when performed during weekends.  This “weekend effect”, however, not been studied for vascular surgical procedures such as lower extremity arterial reconstruction (LEAR). Our objective is to determine if emergent LEAR performed on weekends differ in outcomes as compared to operations performed on weekdays utilizing a national database.   

Methods:
We conducted a retrospective review of the Nationwide Inpatient Sample (NIS) database from 2007 to 2012, identifying patients who had undergone a LEAR. Patient characteristics including demographics and comorbid conditions were recorded as well as post-operative morbidity and mortality. Operations were dichotomized into Weekday (Mon-Fri) and Weekend (Saturday and Sunday). The two groups were compared utilizing t-test and Chi-Square analysis. Postoperative outcomes were evaluated using multivariate analysis adjusting for patient characteristics and comorbidities.  

Results:

A total of 74,236 patients underwent emergent LEAR. Of those, the majority was non-Hispanic White (70%), male (61%), with a mean age of 67 years (SD + 14). The most common comorbid condition was hypertension (65%), followed by diabetes mellitus (31%), respiratory [defined as a diagnosis of chronic obstructive pulmonary disease] (27%), and renal [defined as a diagnosis of dialysis-dependent renal failure (20%). Most operations were performed during the weekday (85%, n=62,946). Comparing the groups Weekday and Weekend, patients on the weekend were majority male (63% vs. 61%, p<0.001) and younger (67 vs. 65 years, p<0.001).

Patients undergoing LEAR on the weekend experienced significantly higher rates of mortality (5.2 vs. 7.9%, p<0.001), wound infection (2.5% vs. 3.3%, p<0.001), and graft infection (12.4% vs. 14.4%, p<0.001). Risk-adjusted differences exhibited similar patterns: mortality OR: 1.47, 95%CI: 1.33-1.62; wound infection OR: 1.32, 95%CI: 1.15-1.52; and graft infection OR: 1.11, 95%CI: 1.04-1.20.

Conclusion:
Emergent LEAR performed on a weekend is associated with an increased risk of post-operative morbidity and mortality as compared to LEAR operations performed on a weekday. While reasons for this disparity are currently unclear, further investigation into the specific reasons is certainly warranted. 

39.05 AAA Size is Associated with Long-term Survival After EVAR

Posted on January 25, 2017

S. Tsai1,2, H. Jeon-Slaughter3, H. Krishnamoorthi1, D. Timaran1,2, A. Wall2, S. Banerjee3,4, C. H. Timaran1,2, J. G. Modrall1,2  1University Of Texas Southwestern Medical Center,Vascular Surgery,Dallas, TX, USA 2Dallas Veterans Affairs Medical Center,Vascular Surgery,Dallas, TX, USA 3Dallas Veterans Affairs Medical Center,Cardiology,Dallas, TX, USA 4University Of Texas Southwestern Medical Center,Cardiology,Dallas, TX, USA

Introduction:  The long-term durability of EVAR has been demonstrated previously, but few studies have investigated risk factors for long-term survival after EVAR.  The purpose of this study was to identify factors associated with late mortality after elective EVAR.

Methods:  Retrospective data were collected from 288 consecutive patients who underwent elective EVAR at a single institution between January 2003 and December 2012.  The primary end-point was death within 10 years from EVAR.  Abdominal aortic aneurysm (AAA) size and age variables were dichotomized, and optimal cut-off points (AAA size ≥ 56mm and age ≥ 70) were determined using Receiver Operating Characteristics (ROC) curves.  A Cox proportional hazard model was used to conduct time to event analysis.

Results: The mean age of patients was 69.4±8.7 years, and 99% were male.  Mean follow-up was 49.3 ± 29.1 months.  In total, 133 patients (46%) died during follow-up.  Thirty day mortality was 1.3% (2/159) in the patients with AAA < 56mm and 2.3% (3/129) in patients with AAA ≥ 56mm (p=0.48).  All-cause mortality was not significantly affected by hypertension, hyperlipidemia, coronary artery disease, smoking status, or estimated GFR.  However, AAA size ≥ 56mm was associated with significantly increased 10-year mortality (Hazard ratio (HR) 1.63, 95% Confidence Interval (CI) 1.16-2.29, p=0.005).  In an adjusted Cox model (Figure) with covariates of age ≥70 and COPD, AAA size ≥ 56mm still increased mortality risk (HR 1.48, 95% CI 1.04-2.10, p=0.027). Both age ≥70 (HR 2.16, 95% CI 1.52-3.09, p<0.0001) and presence of COPD (HR 1.51, 95% CI 1.05-2.17, p=0.026) were also significantly associated with increased 10-year mortality rate.

 

Conclusion: Despite elective AAA repair, larger AAA size is associated with increased 10-year all-cause mortality after EVAR.

 

39.04 Examining variation in Medicare payments for carotid endarterectomy

Posted on January 25, 2017

D. C. Sutzko1, A. Gonzalez2, A. Chakrabarti3, N. Osborne1  1University Of Michigan,Surgery,Ann Arbor, MI, USA 2University Of Illinois, Chicago,Surgery,Chicago, IL, USA 3University Of Michigan,Medicine,Ann Arbor, MI, USA

Introduction:  There is growing interest in providing high quality and low cost care to Americans. Government and private insurers are pursuing avenues to measure not only how well hospitals are performing surgeries, but also at what cost. We sought to examine the variation in Medicare costs associated with a relatively homogenous and commonly performed vascular procedure, carotid endarterectomy (CEA), particularly focusing on total payments, including hospital payments, outlier payments, readmission payments and post-discharge care. 

Methods:  All patients undergoing CEA between 2009 and 2012 were identified in the MedPar database. Risk and Reliability adjusted mortality rates were generated for all hospitals. Hospital payment data was aggregated into DRG payments, outlier payments, physician services, readmission payments and post-discharge payments. Hospital quintiles of cost were then generated and variation in the component costs was examined. Hospital variables were examined using the American Hospital Association Annual Survey Data. 

Results:A total of 277,167 patients underwent CEA between 2009 and 2012, in a total of 1631 hospitals. Median total Medicare payments for CEA were $10,620 (IQR $8,153, $13,678). Table 1 shows the proportion of payments attributable to DRG, outlier, readmission, physician and post-discharge payments. There was wide variation in the distribution of payments, however, minimal variation was observed in outlier payments or payments for readmission. Payments for the DRG itself, nursing care (ICU care) and other physician services (such as consultations) appear to be significant drivers of variation in total hospital payments. Interestingly, low volume hospitals have higher cost (p<0.001), and increased hospital risk and reliability-adjust mortality (p<0.001). High cost hospitals were more likely to be larger hospitals with more ICU beds and training programs. 

Conclusion: Medicare payments for carotid endarterectomy vary significantly across the country. This variation can be broken down into costs incurred at the hospital (DRG, outlier, physician services and readmissions) and outside the hospital (post-discharge care). Variation in payments appears to be due to not only higher DRG related payments, but also nursing care and physician consultations.  Future work is necessary to understand the intersection of cost and quality. 

39.03 Risk Factors Associated With Peri-Operative Myocardial Infarction after Major Open Vascular Surgery

Posted on January 25, 2017

D. C. Sutzko1, A. T. Obi1, P. K. Henke1, N. H. Osborne1  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Objective: Amongst patients undergoing noncardiac surgery, major vascular surgery is associated with a high risk of perioperative MI.  Currently there are no evidence based guidelines to determine appropriate transfusion thresholds in the perioperative vascular surgery patient.  In a recent study on transfusion patterns and outcomes after noncardiac surgery, liberal transfusion protocols were associated with worse outcomes with the exception of patients that suffered from post-operative myocardial infarction (MI). With these results, we aimed to investigate specific risk factors for perioperative MI after major open vascular surgery to determine (1) which patients are at highest risk of MI, (2) the association of perioperative MI with intra and postoperative transfusion and (3) optimal strategies to prevent perioperative MI.

Methods: Patients undergoing major open vascular surgery (defined as open abdominal aortic aneurysm repair (oAAA repair), aorto-femoral bypass (AFB) and infrainguinal bypass (LEB)) were identified from the Michigan Surgical Quality Collaborative (MSQC) between 2008 and 2012. Rates of MI were described for each procedure. Preoperative, intraoperative and postoperative risk factors associated with MI were evaluated using univariate and multivariate statistics after adjusting for intraoperative factors including: anesthesia type, intraoperative blood loss, intraoperative transfusion and intraoperative vasopressor medications.

Results: 3,692 patients underwent major open vascular surgery, including 375 oAAA, 392 AFB, and 2,925 LEB procedures. The overall incidence of MI was 2.44% (N= 90), varying from 1.79% (N=7) for AFB, 2.36% (N=69) for LEB and 3.73% (N=14) for oAAA repair. Although pre-operative risk factors for MI included age, coronary artery disease, and preoperative hematocrit , after adjusting for intraoperative risk factors all preoperative risk factors were not significant. The only risk factors associated with MI after adjusting for intraoperative factors were the nadir hematocrit (OR=0.89, p<0.05) and postoperative transfusion (OR=2.69, p<0.05).

Conclusions: Vascular surgery is an independent risk factor for MI.  Among vascular surgery patients undergoing major open vascular surgery, no preoperative risk factors were independently associated with MI.  However, postoperative variables such as nadir hematocrit and postoperative transfusion were associated with MI.  Taken together, this data suggests that preoperative risk stratification based on co-morbidities is unlikely to successfully predict the most at risk patients.  However, minimizing excessive operative blood loss, avoiding physiologic stress and optimizing intra-operative resuscitation may mitigate risk of MI.

39.01 Uncontrolled Diabetes Increases Morbidity and Mortality after Carotid Endarterectomy

Posted on January 25, 2017

M. S. Parr1, V. Y. Dombrovskiy1, K. H. Nagarsheth1, R. Shafritz1, S. A. Rahimi1  1Rutgers-Robert Wood Johnson Medical School,Division Of Vascular Surgery,New Brunswick, NJ, USA

Introduction:
Single-institution studies demonstrated a negative effect of hyperglycemia on outcomes after carotid endarterectomy (CEA).  In this population-based study, we tested the hypothesis that postoperative morbidity and mortality after CEA in patients with uncontrolled diabetes mellitus (UCDM) might be significantly greater than in those with well-controlled diabetes (WCDM) and no diabetes (NDM).

Methods:
Using the ICD-9-CM diagnosis codes in the National/Nationwide Inpatient Sample 2006-2013 with revised weights in 2006-2011 for computing national estimates we selected patients with UCDM (250.x2 and 250.x3) and WCDM (250.x0 and 250.x1); all others were qualified as NDM patients. Rates of postoperative complications (stroke, transient cerebral ischemia and occlusion of cerebral arteries) as well as hospital mortality were compared between all these groups. Chi-square and multivariable logistic regression analysis with adjustment for patient demographics and comorbidities were used for statistics. Hospital length of stay and total hospital cost were compared with non-parametric Wilcoxon rank sum test.

Results:
A total of 614,190 patients undergoing CEA were estimated: 6,925 (1.1%) had uncontrolled diabetes, in 187,628 patients (30.6%) diabetes was well-controlled, and 419,637 (68.3%) did not have diagnosis of diabetes. Patients with UCDM compared to those with WCDM and NDM patients had higher rates of postoperative stroke (3.27%, 0.93% and 0.94%, respectively; P<0.0001), transient cerebral ischemia (1.73%, 0.74% and 0.78%; P<0.0001) and occlusion of cerebral arteries (5.31%, 1.21% and 1.14%; P<0.0001), and greater hospital mortality (1.43%, 0.25% and 0.27%; P<0.0001). This was confirmed in the multivariable analysis: uncontrolled diabetics compared to controlled counterparts were more likely to develop stroke (OR [odds ratio] =2.85; 95%CI [confidence interval] 2.47-3.27), transient cerebral ischemia (OR=2.10; 95%CI 1.74-2.53) and occlusion of cerebral arteries (OR=3.73; 95%CI 3.33-4.17), and also were more likely to die (OR=3.55; 95%CI 2.85-4.41). However, patients with WCDM compared to non-diabetics were less likely to have postoperative stroke (OR=0.94; 95%CI 0.88-0.99) and to die (OR=0.83; 95%CI 0.74-0.92) and had similar probabilities for transient cerebral ischemia and occlusion of cerebral arteries. Hospitalizations with UCDM had significantly longer hospital length of stay (5.8 days) and higher total hospital cost ($17,446) than those with WCDM (2.4 days and $10,342; P<0.0001), that, in turn, had longer length of stay and higher total cost than cases without diabetes (2.2 days and $9,760; P<0.005).

Conclusion:
Patients with uncontrolled diabetes have poorest outcomes following CEA. In contrast, patients with well-controlled diabetes had comparable and in some cases better outcomes than non-diabetics that confirms the need for strict pre- and post-operative diabetes control for those undergoing carotid endarterectomy.
 

36.10 Admissions Over 48 hours at Rural Trauma Centers: A Disproportionately Old Population?

Posted on January 25, 2017

T. J. Buchanan2, P. Pacurari2, G. Hobbs1, A. Wilson1, J. Con1  1West Virginia University,Department Of Surgery,Morgantown, WV, USA 2West Virginia University,School Of Medicine,Morgantown, WV, USA

Introduction:  Rural hospitals triage and transfer the most severely injured patients; however, the rural practitioner will treat some patients with a relatively low injury severity.  We intend to describe the population successfully treated at Level 3 and 4 Trauma Centers, and to identify factors associated with late transfers which could represent failed attempts at managing these patients. We hypothesize that certain pre-injury and injury characteristics are associated with these failed attempts. 

Methods:  The 2007-2014 West Virginia State Trauma registry was utilized to identify patients who were admitted to a Designated Level 3 or 4 Trauma Center for >48 hours. Two groups of patients were identified: those transferred to a higher level of care, and those discharged to a lower level of care, including home. Descriptive statistics of pre-injury and injury characteristics were obtained between transfer and non-transfer groups. A step-wise multivariate logistic regression model was used to predict which factors were associated with transfers.  

Results: 21,046 patients fit the inclusion criteria, of which 1.54% were transferred, with a mean age of 70 years, and female predominance (64.97%). The majority of the population sustained a blunt injury, most frequently a fall, with a low Injury Severity Score (ISS) (Table 1). An ICU stay was required for 13% of the total population, 1.9% required mechanical ventilation, and 21.6% required a blood transfusion. Multiple factors were identified to be associated with transfers in the step-wise multivariate logistic regression: male gender (Odds Ratio=1.39, p<0.03), age ≥65 (OR=1.39, p<0.01), spine injury (OR=1.51, p<0.03), heart disease (OR=1.69, p<0.0002), diabetes (OR=1.48, p<0.002), functionally dependent health status (OR=0.56, p<0.03), and mechanical ventilation (OR=3.30, p<0.0001). 

Conclusion: The trauma population hospitalized for >48h at West Virginia Level 3 and 4 Trauma Centers appear to be disproportionately older than the general population and have sustained relatively minor injuries from blunt mechanisms such as falls.  A selection bias may be present due to a stay of >48h, but it does reflect the population hospitalized at these institutions at any given time.  Factors associated with being transferred later in their care are not completely dependent on the characteristics of the injury; pre-injury conditions in the trauma patient play a significant role in these late transfers. 

 

36.09 Reconceptualizing Older Adult Traumatic Brain Injury: Incidence And Epidemiology Beyond The ED

Posted on January 25, 2017

C. K. Zogg1,2, R. Haring2, J. K. Canner3, A. H. Haider2, E. B. Schneider2  3Johns Hopkins University School Of Medicine,Johns Hopkins Surgery Center For Outcomes Research, Department Of Surgery,Baltimore, MD, USA 1Yale University School Of Medicine,New Haven, CT, USA 2Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA

Introduction: TBI is an important cause of death and disability among older adults (≥65y), representing >20,000 deaths and 130,000 hospitalizations each year. Much of our understanding comes from work by the CDC, which conceptualized the “silent epidemic” as a TBI pyramid. At the pyramid’s base, expected to be the largest in number, were patients receiving care outside of the ED about whom little is known and for whom no estimates are available. The objective of this study was to estimate the national burden of healthcare-seeking TBI among Medicare-covered outpatients, define epidemiologic characteristics of the population, and assess for temporal and seasonal trends in outpatient presentation.

Methods:  Ten years, 2004-2013, of Truven Health Analytics MarketScan Medicare claims were queried for index older adult TBI visits (≥1 CDC-defined TBI diagnosis) that were managed entirely via outpatient care (office/clinic, urgent care). Index ambulatory ED visits served as a clinically similar reference. Descriptive statistics compared differences among index outpatient visits treated in urgent care and office/clinic settings versus the ambulatory ED, including variations in demographic and clinical factors, managing providers, CDC-defined TBI diagnoses, and post-index visit ambulatory care use within 30/90/180 days. Joinpoint regressions assessed for annual changes in outpatient TBI rates per 100,000 older adult enrollees. Monthly variations in outpatient rates and estimation of the nationwide outpatient burden in 2013, inclusive of privately-insured and uninsured patients, were also compared.

Results: A total of 445,612 Medicare-covered index visits were included, representing an annual burden of 689,100 outpatient cases nationwide (750,800 including ambulatory ED)—a number which encompassed 61.0% of all known healthcare-seeking TBI among patients of this age in 2013 and which significantly increased in magnitude each year (Figure). The vast majority (88.8%) of index visits were managed in office/clinic settings (0.3% in urgent care) versus 10.9% in the ED. While demographic distributions varied across locations, clinical indications were comparable. Seasonal spikes appeared to coincide with winter weather conditions. Outpatients, on average, required 4.6 subsequent ambulatory visits within 180 days (1.3 visits within 30 days), resulting in >3.88 million annual ambulatory TBI visits nationwide.

Conclusion: There is an urgent need to consider the clinical implications and outcomes of the nearly 700,000 annual healthcare-seeking older adult TBI patients within the foundational pyramid-tier who have not been considered in previous estimates and whose clinical course has seldom been studied.

36.08 Patients with Dementia and Acute Surgical Abdomen: Opportunities for Palliative Care

Posted on January 25, 2017

F. J. Hwang2, S. Pentakota2, R. Singh2, A. Berlin2, A. Mosenthal2  2Rutgers New Jersey Medical School,Surgery,Newark, NJ, USA 1University Of Medicine And Dentistry Of New Jersey,General Surgery,Newark, NJ, USA

Introduction:  Patients with dementia who develop acute abdominal emergencies have high risk of morbidity and mortality. Accurate prognostication about outcomes would be helpful in order to make improved patient-centered decisions. Little is known on palliative care (PC) utilization in patients with dementia in need of emergency abdominal surgery. The purpose of this study is to characterize outcomes and factors associated with PC utilization for patients with dementia presenting with acute abdominal emergencies.

Methods:  The National Inpatient Sample database between the years of 2009 and 2013 was queried using ICD-9 codes for patients > 50 years with dementia and acute abdomen (bowel ischemia, obstruction, or perforation). Study variables were patient demographics and hospital information. Outcomes included in-hospital mortality, discharge disposition, length of stay, total charges, and receipt of palliative care. Multivariable logistic regression analysis was used to identify factors associated with receiving PC.

Results: 6,867 patients met the inclusion criteria. Among these patients, 22% (N=1530) underwent surgery; 16% (N=1090) died in hospital; 49% (N=3360) were discharged to a facility; and 10% (N=717) received palliative care. 29% (N=314) of those who died in hospital received PC. PC utilization increased over the study time period (7% in 2009 to 12% in 2013). Patients older than 90 received more frequent PC compared to those aged 60 to 90 years (p<0.01). Those from the highest socioeconomic status were 1.7x more likely to receive PC compared to those from the lowest quartile (p<0.01). Patients who had perforation were 2.6x and 1.6x more likely to receive PC compared to those with obstruction and bowel ischemia, respectively (p<0.01). Non-operative management was associated with 2.7x increase in receiving PC vs patients undergoing surgery (p<0.01). PC was associated with lower median length of stay (4 days vs 6 days) and lower hospital charges ($26,800 vs $33,000) (p<0.01).

Conclusion: Patients with dementia and acute abdomen have high in-hospital mortality and rate of discharge to dependent care, regardless of surgical interventions. Despite this, few receive palliative care. Receipt of PC was associated with age >90, higher socioeconomic status, and having perforation as the indication for surgery. Those who had PC had fewer surgical interventions and lower intensity of treatment, suggesting that patients and their families who received PC may choose a less aggressive form of treatment in the setting of poor prognosis. The high rate of unmet palliative care needs in this population presents an opportunity for improvement in surgical care.

36.07 Study on the Validity of Pancreaticoduodenectomy in the Elderly

Posted on January 25, 2017

Y. Futagawa1, T. Kanehira1, K. Furukawa1, N. Okui1, J. Shimada1, N. Tsutsui1, Y. Fujiwara1, H. Kitamura1, S. Yoshida1, T. Usuba1, T. Nojiri1, S. Fujioka1, T. Misawa1, T. Okamoto1, K. Yanaga1  1The Jikei University School Of Medicine,Surgery,Minato-ku, TOKYO, Japan

Introduction:

~Pancreaticoduodenectomy (PD) is a radical surgical treatment for malignant biliary-pancreatic disorders. To date, indication for PD in elderly patients is determined on a case-to-case basis. However, establishing a certain standardized criteria is important as the aged population (approximately 20% in developed countries) continues to grow. The purpose of this study is to verify the outcomes of PD in the elderly.

Methods:
~We selected 340 patients with pancreatic cancer, bile duct cancer, or papilla of Vater cancer from the 436 patients who underwent PD at our four affiliated hospitals from 2003 to 2010. The subjects were divided into three groups: group A, the non-elderly (aged 64 years or younger; 60 patients with pancreatic cancer, 30 with bile duct cancer, and 25 with papilla of Vater cancer; a total of 115 subjects); group B, the early elderly (65–74 years, 75 with pancreatic cancer, 43 with bile duct cancer, and 26 with papilla of Vater cancer; a total of 144 subjects); and group C, the super-elderly (75 years or older, 43 with pancreatic cancer, 23 with bile duct cancer, and 15 with papilla of Vater cancer; a total of 81 subjects). We compared the long-term outcomes among the three groups. We also examined risk factors for a poor outcome in group C (including 11 subjects aged 81 years or older).

Results:
~The median postoperative hospital stay of groups A, B, and C was 31, 35, and 34 days, respectively (no significant differences). Mortality within 60 days postoperatively in group A was 0.9% (n = 1; liver metastasis); group B, 2.1% (n = 3; pancreatic fistula 1, bone marrow hypoplasia 1, myocardial infarction 1); and group C, 6.3% (n = 5; pseudoaneurysm rupture 1, catheter infection 1, aspiration pneumonia 1, pneumonia 1, liver metastasis 1). (P = 0.04, between groups A and C). The 3- and 5-year overall survival rate (OS) of group A was 44.7% and 38.2%, respectively; 41.6% and 25.7%, respectively for group B; and 19.8% and 9.9%, respectively for group C. (P < 0.05 between groups A and C, and between groups B and C, respectively). In group C, the 50% survival time for pancreatic cancer, bile duct cancer, and papilla of Vater cancer was 410, 820, and 757 days, respectively.  In univariate analysis, primary diseases, postoperative complications (delayed gastric emptying), stage of disease, and comorbidities (diabetes mellitus) were detected as the risk factors of poorer survival in group C.  In multivariate analysis, pancreatic cancer was a significant adverse prognostic factor (hazard ratio 3.70 in comparison with papilla of Vater cancer, P=0.04).

Conclusion:

~The validity of PD for bile duct cancer and papilla of Vater cancer was confirmed by appropriate preoperative evaluation and postoperative management in the elderly. However, the mortality associated with infectious diseases was high in the elderly. On the other hand, caution should be used for patients with pancreatic cancer, particularly advanced cases.

 

36.06 Can Emergency Department Physiologic Parameters Predict Injury Severity in Elderly Trauma Patients?

Posted on January 25, 2017

S. L. Nitzschke1, G. Barmparas2, O. Olugajo3, C. Burns1, Z. Cooper1, A. Haider1, A. Salim1  2Cedars-Sinai Medical Center,Los Angeles, CA, USA 3Washington University,St. Louis, MO, USA 1Brigham And Women’s Hospital,Trauma/Surgery/Harvard,Boston, MA, USA

Introduction:  Although physiologic data has been used to help appropriately triage severely injured trauma patients of all ages, the ability of these parameters to predict injury severity among geriatric patients has not been examined. The purpose of this study is to determine if physiologic and clinical data available at the time of triage in the emergency department (ED) would be predictive of injury severity in elderly trauma patients.

Methods:  A retrospective review of the National Trauma Data Bank (2007-2011) was queried for patients aged 65-90 with blunt trauma.  Data collection included basic demographic data, as well as initial heart rate, systolic blood pressure, and Glasgow Coma Scale (GCS). The shock index (SI) was also calculated. Our primary outcome of interest was moderate-to-severe injury defined as injury severity score (ISS) ≥ 9 or head Abbreviated Injury Score (AIS) ≥3. The other outcome of interest was in-hospital mortality.  Various univariate and multi-variable logistic regression models using different combinations of physiologic data were built and performances of the models were measured with the area under receiver operating characteristic (AUROC) curve. 

Results: A total of 394,727 patients met our inclusion criteria (61% had ISS ≥ 9, 21% had a head AIS ≥3, and overall mortality was 5.2%). None of our models were predictive of ISS ≥ 9 (all AUROC ≤0.5), and ED GCS was moderately predictive of head AIS ≥ 3 (AUROC of 0.639). The ED GCS was the best predictor of in-hospital mortality (AUROC of 0.717).

Conclusion: Our data show that initial physiologic and clinical data appear to have little predictive value on injury severity in an elderly patient population, but ED GCS appears adequate in predicting mortality. In order to facilitate appropriate triage of the severely injured trauma patient in this growing population, this study suggests that a new set of triage criteria may be required for the geriatric patient.

 

36.05 Effectiveness of Local Therapy for Stage I Non-Small Cell Lung Cancer in Nonagenarians

Posted on January 25, 2017

B. N. Arnold1, D. C. Thomas1, J. E. Rosen1, M. C. Salazar1, F. C. Detterbeck1, J. D. Blasberg1, D. J. Boffa1, A. W. Kim1  1Yale University School Of Medicine,Department Of Surgery, Section Of Thoracic Surgery,New Haven, CT, USA

Introduction:  Nonagenarians are the fastest growing subset of the United States population, and non-small cell lung cancer (NSCLC) is the most common cancer in the elderly population. Stage I NSCLC is a potentially curable disease with 5-year survival approaching 50%, yet older patients undergo treatment at lower rates than younger patients. This analysis sought to describe the scope of treatment in nonagenarians with early stage NSCLC and to provide data on outcomes of these patients in order to better guide treatment decisions in this growing population of patients.

Methods:  The National Cancer DataBase was queried for all patients age 90 years and older with stage I NSCLC (tumors ≤4 cm). Patients were divided into three treatment groups: local therapy (surgery, stereotactic body radiation (SBRT)), other therapy, or no treatment. The primary outcomes were 5-year overall and relative survival. Surgery and SBRT were compared in a subset analysis.

Results: Of the 616 patients identified, 202 (33%) were treated with local therapy, 207 (34%) were treated with other therapy, and 207 (34%) underwent no treatment. Of those treated with local therapy, there were 40 (20%) lobectomies, 35 (17%) sublobar resections, and 127 (63%) patients who underwent SBRT. Of those treated with other therapy, 188 (91%) received standard radiation therapy of varying doses, 13 (6%) received combination therapy, and 6 (3%) received chemotherapy. Five-year overall survival was significantly lower with no treatment (8%) and other therapy (13%) compared to local therapy (23%) (p<0.0001). This effect remained significant after adjusting for covariates in a Cox model (HR for other therapy 1.428, 95% CI 1.11-1.83, p=0.0053; HR for no treatment 2.50, 95% CI 1.95-3.21, p<0.0001). The 5-year relative survival differed by treatment, with 81% for local therapy, 49% for other therapy, and 32% for no treatment (p<0.0001). In the subset analysis, there was no difference in overall survival between surgery (26%) and SBRT (20%) (p=0.33).

Conclusion: Nonagenarians who are managed with local therapy for stage I NSCLC (tumors ≤4 cm) have better overall survival than those who receive other therapy or no treatment, regardless of the type of local therapy. Nonagenarians with stage I lung cancer derive a benefit from treatment and should be treated with either surgery or SBRT if able to tolerate treatment.

 

36.03 Updated Nsqip Frailty Index – Validation For Vascular Surgery

Posted on January 25, 2017

A. P. Johnson1, P. J. DiMuzio1, S. W. Cowan1, H. A. Pitt2  1Thomas Jefferson University,Philadelphia, PA, USA 2Temple University,Philadelpha, PA, USA

Introduction:  The Frailty Index (FI), based on the theory of “accumulating deficits,” was introduced in the Canadian Study of Health and Aging. Subsequently, a modified Frailty Index (mFI) was developed with NSQIP data; however, in recent years some of the variables employed in the mFI have been retired.  We recently developed and validated an updated NSQIP Frailty Index (NFI) in colorectal surgery patients.  The aim of this analysis is to validate this updated NSQIP Frailty Index (NFI) in patients undergoing vascular surgery. 

Methods:  The 2011-14 ACS-NSQIP vascular Participant Use File (PUF) was utilized, which samples for carotid stenting and endarterectomy, abdominal aortic aneurysm repair, and aortoiliac and lower extremity revascularizations. The NFI is a weighted product score assigning 2 points each for dependent functional status, transfer from chronic care facility, recent CHF exacerbation, severe COPD, renal failure on hemodialysis, recent ascites, disseminated cancer, hypoalbuminemia and 4 points for ASA IV or V.  A product of eight or more points differentiates frail and non-frail patients.  Receiver operator characteristics (ROC) analysis was performed to determine predictability for death or serious morbidity (DSM) and chi-squared analysis was used to determine association with multiple post-operative occurrences.

Results: Of 41,839 vascular patients, 4,988 (11.8%) were identified as frail per the NFI. The NFI demonstrated good predictability for DSM for vascular procedures (c-statistic = 0.69; CI 0.68-0.70). Frail patients were found to have higher rates of mortality (8.2 vs 1.2%), serious morbidity (18 vs 5.5%) and multiple other outcomes (Table, p<0.001). 

Conclusion: An updated NSQIP Frailty Index (NFI) has been developed and validated in patients undergoing a cross section of vascular surgical procedures. The NFI can be a powerful tool to assist surgeons and patients in shared decision making and as an initial screening tool for more intensive frailty assessments and preoperative optimization.  

 

36.02 Hospital Variation in Outcomes Following Colectomies in Frail Patients

Posted on January 25, 2017

V. C. Nikolian1, N. Kamdar1, I. S. Dennahy1, S. Hendren1, D. S. Campbell1, P. Suwanabol1  1University Of Michigan Health System,General Surgery,Ann Arbor, MI, USA

Introduction:  Geriatric-specific morbidity and mortality are known to increase with frailty. Indices have been developed to predict outcomes in this population, yet it is unclear whether worse outcomes are unavoidable and related to patient factors, or modifiable and influenced by hospital factors. A paucity of data exists comparing outcomes between hospitals for frail patients undergoing colorectal surgery. Using data abstracted from medical records in a statewide surgical collaborative, we sought to determine whether risk-adjusted outcomes related to reoperations, readmissions, and mortality varied between hospitals.

Methods:  Patients ≥ 65 years old who underwent colon and rectal resections in the Michigan Surgical Quality Collaborative (MSQC) from July 2012 – June 2015 were identified. Using a previously published frailty-based surgical risk model, frailty scores were calculated by adding the components of albumin <3.4 g/dL, hematocrit <35%, serum creatinine >2 mg/dL, and ASA score >3. Bivariate analysis was conducted to determine the mean unadjusted outcome rates for each value of the frailty score. Multivariable logistic regression models were developed with frailty score and other adjustment variables as covariates in order to determine risk-adjusted outcome rates for reoperations, readmissions, and mortality. Predicted probabilities and mean unadjusted frailty scores for each hospital were calculated. Using this method, outliers were identified by comparing the MSQC adjusted outcome rates with the 95% confidence interval (CI) of each hospital. Spearman rank correlation coefficients were calculated to determine the association between hospital unadjusted frailty scores and risk adjusted outcome rates.

Results: Of 3594 colorectal resections performed in 64 Michigan hospitals, the unadjusted reoperation, readmission, and mortality rates were 9.5%, 12.2%, and 6.1%, respectively. After controlling for urgent and emergent cases, age, race, operative time, BMI, male sex, medical school affiliation, and hospital size, multivariable analysis demonstrated that outcomes were significantly worse for the most frail patients. Odds ratios of developing complications in these patients were calculated relative to those with a frailty index of 0 (ORs: reoperation: 2.54, 95% CI: 1.2-5.5; readmission: 2.5, 95 CI = 1.2-5.3; mortality: 38.4, 95% CI 8.4-175.7). There was a high degree of correlation between hospital mean frailty scores and hospital-adjusted rates of reoperations, readmissions, and mortality (Spearman rank correlation for: reoperations = 0.81, readmissions = 0.713, mortality = 0.843; p < 0.0001). Using this methodology, outliers related to each outcome were identified. 

Conclusion: Significant variation in postoperative outcomes exists between hospitals caring for frail patients. This suggests that individual hospitals are an appropriate target for interventions to improve outcomes in colorectal operations performed on frail patients.

 

36.01 Predicting Failure to Rescue Following AAA Repair in Octogenarians

Posted on January 25, 2017

C. W. Hicks1, T. Obeid1, S. Locham1, M. A. Cooper1, I. Arhuidese1, M. B. Malas1  1Johns Hopkins University School Of Medicine,Division Of Vascular Surgery And Endovascular Therapy,Baltimore, MD, USA

Introduction: Among older patients, both open aortic aneurysm repair (OAR) and endovascular aortic aneurysm repair (EVAR) are associated with higher risk of death compared to the general population. We aim to describe trends in failure to rescue (FTR) among octogenarians undergoing OAR and EVAR to identify patients at high risk for mortality following elective AAA repair.

Methods: All octogenarians (age ≥80 years) recorded in the Vascular Quality Initiative database (2002-2014) who underwent non-ruptured infrarenal AAA repair were included. Primary outcome was FTR, defined as percentage of deaths in patients who had a complication within 30 days of surgery. Univariable and multivariable statistics were used to identify risk factors for FTR following OAR and EVAR procedures.

Results: 975 octogenarians underwent AAA repair during the study period (EVAR=667, OAR=308). Mean age was 84±2.8 years, 69% were male, and 59% had multiple (≥2) comorbidities. Overall FTR was 10%, most commonly related to acute kidney injury (62%) and respiratory failure (53%). On multivariable analysis correcting for baseline group differences, independent predictors of FTR included female gender (OR 1.95), the presence of multiple comorbidities (OR 1.98), baseline renal insufficiency (OR 1.97), peripheral vascular disease (OR 2.42), and perioperative vasopressor use (OR 4.49) (all, P<0.02). Obesity was protective (OR 0.58, P=0.02). FTR was higher following OAR vs. EVAR on univariable analysis (14% vs. 9%; P=0.02), but there was no significant difference between operative approaches after risk adjustment (OR 1.15, P=0.60). Comparing octogenarians vs. younger patients (N=2,854), FTR was significantly higher for octogenarians for both OAR (OR 2.0, 95% CI 1.36-3.01) and EVAR (OR 1.60, 95% CI 1.07-2.40) after risk adjustment.

Conclusion: Failure to rescue after AAA repair is not uncommon among octogenarians and could explain the higher mortality observed in this group compared to the general population. Female gender, renal insufficiency, concomitant peripheral arterial disease, and frailty, including the presence of multiple comorbidities and poor nutritional status, appear to be the major predictors of adverse outcomes. Overall health status should be carefully considered when weighing the risks versus benefits of performing AAA repair in elderly patients.

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