16.09 Comparison of Outcomes Among Patients With Abdominal Compartment Syndrome in Medical or Surgical ICU

Posted on January 25, 2017

J. Nguyen1, M. Noory1, L. Capano-Wehrle1, J. Gaughan1, J. Hazelton1  1Cooper University Hospital,Trauma And Surgical Critical Care,Camden, NJ, USA

Introduction:
The causes of abdominal compartment syndrome (ACS) are varied but can result from a range of both medical and surgical pathologies. Early recognition of ACS and prompt surgical treatment in the form of decompressive laparotomy has been shown to improve mortality. We hypothesize that earlier recognition of ACS, and therefore, earlier involvement by the surgical team would improve mortality.

Methods:
A retrospective review of patients ≥18y (7/2010 – 7/2015) who developed ACS and underwent decompressive laparotomy was performed. Patients cared for in non-ICU settings or who developed ACS from abdominal hemorrhage were excluded. Patients were divided into SICU and MICU arms based on their physical location at time of diagnosis. Demographics and clinical data points including hemodynamics, lab values, time to intervention, and outcomes were collected. A timeline was established for each patient from time of suspicion of ACS, time to surgical consult, and time to surgical intervention.

Results:
A total of 20 patients were included(MICU=12; SICU=8). There was no difference in age, sex, and APACHE-2 score at time of suspicion of ACS between the two groups (all p>.05). Median time from admission to suspicion of ACS for MICU patients was 60 hr vs 13 hr for SICU patients (p=.013). Time from suspicion to surgical consult for MICU patients was 60 min vs 0 min for SICU patients (p=.003), however time from surgical consult to surgical intervention was not different (MICU 53 min vs SICU 60 min; p=.396). Outcomes revealed that death occurred in the MICU group at 83% vs 12.5% in the SICU (p = .005).

Conclusion:
Patients in the SICU who developed ACS were more quickly diagnosed than those in the MICU. Furthermore, these patients had a shorter time from suspicion of ACS to surgical consultation and eventual surgical intervention, resulting in improved survival. A multidisciplinary approach, including early surgical consultation, for patients in whom there is a suspicion of ACS could improve mortality.
 

16.08 Factors Predicting Radiation Therapy in Early Stage Breast Cancer in Patients Age 70 and Over

Posted on January 25, 2017

S. Larson1, B. Anderson2, G. Leverson3, H. Neuman1, C. Greenberg1, L. Wilke1, J. Steiman1  3University Of Wisconsin,Surgery,Madison, WI, USA 1University Of Wisconsin,General Surgery,Madison, WI, USA 2University Of Wisconsin,Human Oncology,Madison, WI, USA

Introduction:  Radiation therapy (RT) is recommended as standard of care for women undergoing breast conserving surgery (BCS) for an invasive breast cancer as a way to decrease the risk of loco-regional recurrence (LRR). In 2004, Cancer and Leukemia Group B (CALGB) reported the results of a randomized trial (9343) which sought to determine if women with clinical stage I, estrogen receptor (ER) positive breast cancer who were ≥70 years of age could omit radiation in the setting of adjuvant hormonal therapy (HT). Omission of RT resulted in a low rate of LRR at 5 years (4%). Population studies assessing practice patterns after the guideline change (2009-2011) demonstrated that 65-88% of women ≥70 years of age continued to receive RT after BCS. Receipt was often associated with age, tumor size and grade. These studies, however, are limited, as they cannot assess the relationship with other factors that may influence decision making such as Ki67, margin status, and comorbidities. Our objective was to examine receipt of RT for women ≥70 years of age at our institution and identify patient factors associated with its recommendation.

Methods:  Retrospective data was obtained with IRB approval through the institutional cancer registry for women aged ≥70 diagnosed with an invasive BC from January 2014 – December 2015 (n=44). Inclusion criteria were patients with a pathologic stage I, ER+ breast cancer who underwent BCS and received HT. Patient (age), tumor (size, grade, molecular tumor subtype, Ki67), and treatment characteristics (margin status) were abstracted from the patient chart.  Statistical analyses were done using Chi square tests.

Results: Overall, 59% (n=26) were recommended RT (Table 1). Factors associated with a recommendation for RT included Her2neu + status (p=0.05) and grade 3 tumors (0=0.03), with all patients meeting these criteria being recommended RT.  Similarly, all patients with a Ki67 >45% (n=5) were recommended RT. No association amongst age was observed.  Few patients had positive margins, limiting this analysis.

Conclusion: Consistent with prior population studies, the majority of patients ≥70 years of age were recommended RT despite strictly meeting criteria for CALGB 9343. Recommendations appear to be influenced by Her2neu status and grade.  Her2neu was not collected as part of CALGB 9343; thus, further research should focus on the relationship between Her2neu status and outcomes without RT.  Additionally, given the high ongoing use of RT, future studies should identify factors influencing provider decision-making regarding RT and application of CALGB 9343 to patients in their clinical practice. This will allow for opportunities to improve the quality of care provided to older breast cancer patients.

16.07 Reconciling Surgical Outcome with Quality of Life: The Ethical Dilemma

Posted on January 25, 2017

L. Sparber1, A. Warman3, R. McLeod-Sordjan1,5, V. Patel4,5, R. Barrera4,5, W. Doscher1,4,5  1Northwell Health System – Long Island Jewish Medical Center,Division Of Medical Ethics – Department Of Medicine,New Hyde Park, NY, USA 3Duke University,Durham, NORTH CAROLINA, USA 4Northwell Health System – Long Island Jewish Medical Center,Department Of Surgery,New Hyde Park, NY, USA 5Hofstra University School Of Medicine,Hempstead, NY, USA

Introduction: Due to modern resuscitative technologies, critically ill patients undergoing major emergent operations frequently survive to face a post-surgical quality of life quite different than their pre-morbid state. Post-surgical increased morbidity requires the surgical team to communicate harms and benefits of continued interventions in a time sensitive manner. Multidisciplinary meetings including caregivers, the patient, the clinical team, palliative care, clinical ethicists, social work, nursing and chaplaincy can facilitate surrogate decisions regarding goals of care. This pilot study sought to describe the ethical framework necessary to guide medical decision making when patients and caregivers face unexpected near-fatal sequela after surgical intervention.

Methods: Between July 2011 and June 2016, a retrospective study of all ethics consultations was performed. Demographic and clinical data was collected. 22 SICU patients had Ethics consultations. Of those 22 patients, 14 (63.6%) patients were in multi-system organ failure post-operatively. The overall median age was 68 years. Six (42.8%) of the patients were female.  The average length of stay until clinical ethics was consulted was 28.4 days.  Descriptive statistical analysis was utilized to evaluate variations in ethical dilemmas as well as goals of care variations in advanced planning decisions.

Results: The primary outcome was successful mediation of the initial reason the ethical consultation was called. Major ethical dilemmas included mediation of goals of care (85.7%); withdrawal of life sustaining treatments (57.1%) as well as identifying an appropriate surrogate decision maker (14.3%). The secondary outcome was death during incident hospitalization (71.4%, N = 10). Two (14.2 %) patients were discharged but subsequently died on average 60 days after discharge. Two (14.2 %) patients remained alive to hospital discharge. 85.7% (12) of patients at onset of surgical intervention had capacity. Six (42.8%) patients had Health Care Proxy documents. Eight (57.1%) patients had surrogates who were family, while one (7.1%) patient had an assigned legal guardian. Three (21.4%) patients had capacity/restored capacity during their hospital stay.

Conclusion: Patients and their surrogates frequently experience significant distress when patients initially survive high risk interventions but then suffer declining quality of life during the post-operative recovery period.  Additionally, when the patient experiences incapacity post-operatively either due to chemical sedation or physiologic distress, the burden of surrogate decision making may not necessarily accurately reflect the patient’s autonomous choice.  It is imperative to recognize this ethical dilemma to be able to reconcile the conundrum that “surgical success” is not equivalent to “high quality of life.” Additional studies are required to validate the findings of this small study.

 

 

16.06 A Practical Preoperative Geriatric Evaluation

Posted on January 25, 2017

K. Khan1, Y. Chou1, S. E. Wozniak1, J. Coleman1, V. Ahuja1, M. R. Katlic1  1Sinai Hospital,General Surgery,Baltimore, MD, USA

Introduction: Age has been shown in multiple studies to be a risk factor for postoperative morbidity and mortality; however, some centers have reported excellent results in the geriatric population. This leads to the question that began our research study: Is there a concise preoperative evaluation in the elderly that is simple and reliable to assess perioperative risk? Numerous geriatric and frailty evaluations exist; however these have been shown to be extensive and complicated to perform. Therefore, few of these tests are actually applied in routine practice. We have attempted to construct the most practical preoperative geriatric evaluation, and then evaluate it among our geriatric population.

Methods:  At our center for geriatric surgery we provide a comprehensive preoperative assessment on patients aged ≥ 75 years prior to any elective surgery. Issues identified by this preoperative screening lead to further care and assessment.

In contrast to the extensive preoperative geriatric assessment, we selected six simple tests that have each been shown to be predictive of poor outcomes in the elderly: mini-Cog test, gait speed, timed-up-and-go, Charleston Comorbidity Index, activities of daily living, and American Society of Anesthesiologists Physical Classification (ASA).

Results: From October, 2012 to August, 2016 we have prospectively evaluated 1088 patients that have been retrospectively reviewed for implementation into a database consisting of perioperative variables and NSQIP post-surgical outcomes. There were 387 males (36%) and 701 females (64%) that ranged in age from 75-100 years. The 110 patients that underwent minor surgery (ophthalmic surgery, arthroscopy) were excluded. The remaining 978 patients underwent major surgery including orthopedic, surgical oncology, cardiothoracic, general surgery, urologic and vascular surgery (table).

The combination of tests that we selected is currently being evaluated in a validation cohort against Fried’s frailty phenotype, ASA, Charleston Comorbidity Index and the eyeball test.

Conclusion: We believe that this combination assessed in the scoring system that we have developed, will be as accurate as other assessments, while remaining practical and easily remembered by providers.

16.05 Non-Self-Disclosed Payments Reported in the Open Payments Database Do Not Affect Study Favorability

Posted on January 25, 2017

D. V. Cherla1, B. Ibeche1, K. M. Mueck1, J. L. Holihan1, M. Moses1, J. R. Flores1, O. Olavarria1, C. Hannon1, T. C. Ko1, L. S. Kao1, M. K. Liang1  1University Of Texas Health Science Center At Houston,General Surgery,Houston, TX, USA

Introduction:
Conflicts of interest (COI) bias research by increasing the reporting of favorable results and until recently have relied on author self-disclosure.  To increase transparency of COI reporting, the Centers for Medicare and Medicaid established the Open Payments Database (OPD) that reports payments between manufacturers, group purchasing organizations, and physicians and costs $180 million annually to maintain.  Previously, we have shown that COI disclosed by authors as opposed to in OPD have a 30-50% discordance rate.  We hypothesized that studies that fail to self-disclose all payments will express higher favorability towards their subject matter. 

Methods:
PubMed was searched for medical and surgical articles published January 2014-June 2016 and published by US senior authors with an NPI number.  Exclusion criteria included review articles, editorials, replies, and technical papers.  COI were defined as payments received as honoraria or for research or consulting, compensation for serving as faculty or speaker, or company ownerships/partnerships.  COI disclosed in the published manuscripts were compared to those reported in the OPD.  Articles were divided into 3 categories: 1) full disclosure of COI 2) incomplete disclosure of COI and 3) no COI (Table 1).  Independent, blinded reviewers read the abstracts and judged article favorability toward its subject matter.  Favorability was analyzed as a categorical variable using Chi-square.  

Results:
A total of 195 studies were selected for 240 rated topics.  The number of subjects and percentage judged favorably were as follows per category: full disclosure of COI (58/64,90.6%), incomplete disclosure (96/123,78.0%), and no COI (37/57,64.9%).  Unexpectedly, articles with full disclosure were more likely to show favorability towards their subject matters versus articles with incomplete disclosure (p=0.032).  To subsequently adjust for self-perceived, self-reported “relevant COI,” we divided Incomplete Disclosure into Partial and No Disclosure and performed a subgroup analysis comparing Partial Disclosure to Full Disclosure and No Disclosure to No COI.  On subgroup analysis, there were no differences between full disclosure and partial disclosure (56/67,83.6%) groups (p=0.230) or no disclosure (40/56,71.4%) and no COI groups (p=0.457).

Conclusion:
This is the first study to examine the impact of non-self-disclosed COI and demonstrates that they do not significantly affect reporting of favorable results.  This study cannot ascertain if this is due to lack of relevance of non-self-disclosed COI.  Further studies are needed to validate these findings, to evaluate reasons behind incomplete disclosure of COI, and to develop evidence-based guidelines for disclosure.
 

16.04 Analysis of Graft Loss after Elderly Renal Transplantation using a National Registry Database

Posted on January 25, 2017

S. A. Kelso2, J. A. Pineda1, M. C. Prikis3, C. E. Marroquin1  1University Of Vermont Medical Center,Division Of Transplant Surgery And Immunology,Burlington, VT, USA 2University Of Vermont,College Of Medicine,Burlington, VT, USA 3University Of Vermont Medical Center,Division Of Nephrology,Burlington, VT, USA

Introduction:  Patients of all ages and causes of renal disease demonstrate survival benefit with kidney transplantation. This encouraged renal transplantation in elderly patients, traditionally thought to be over 60, that would previously have been maintained on lifelong dialysis. Organ systems including the immune and musculoskeletal systems naturally deteriorate as patients age. This natural senescence produces challenges in the elderly, which are compounded by immunosuppression, and consequently increases the potential for poor outcomes. In an effort to find the inflection point at which the benefits of transplantation are outweighed by the risks, this study analyzed rates of graft survival by recipient age and compared two separate elderly cohorts to younger recipients. We also evaluated the causes of graft failure in both young and elderly recipients. 

Methods:  Data from the United Network for Organ Sharing (UNOS) was used to identify primary renal transplant recipients between 1988 and 2014. The study period was divided into five eras, and the recipient population was divided into 13 age groups. Using the adjusted Scheffe Test of Significance, the graft survival of recipients from 65 to 69 and those over 70 years of age was compared to younger cohorts at 1, 3, 5, and 10 years post-transplantation. We also evaluated the causes of graft failure between these cohorts. 

Results: A total of 192,233 primary renal transplants were performed between 1988 and 2014. In total, 17,476 (9.09%) of recipients were 65 to 69 and 10,930 (5.69%) were over age 70. A comparison of graft survival in patients between 65 to 69 years of age and those over 70 compared to the 25 to 64 age group demonstrated statistical significance (p-value <0.0001) at 1, 3, 5, and 10 years post-transplantation in all eras. Renal graft failure caused by infection and primary failure occurred at increasing rates in the elderly while failure due to hyperacute, acute, and chronic rejection and recurrent disease occurred at lower rates with progression of age and were more common in the younger cohort.

Conclusion:
Elderly renal transplant recipients have decreased renal graft survival compared to younger recipients across all eras. While this could be due to many confounders, our analysis suggests this is more an effect of age than immunosuppression regimens. Elderly recipients are at increased risk for graft loss due to primary failure and infection and lower risk of graft loss due to recurrent disease and episodes of rejection. This may have implications for clinical care in elderly renal transplant recipients to improve graft survival. 
 

16.03 Linked-Data Outcomes Research Demonstrates Age Related Trends in Australian Vascular Surgery

Posted on January 25, 2017

S. J. Aitken1,2,3, V. J. Naganathan1,3, F. Blyth1,3  1University Of Sydney,Concord Clinical School,Sydney, NSW, Australia 2Royal Australasian College Of Surgeons,Adelaide, South Australia, Australia 3Concord Repatriation General Hospital,Concord Institute Of Academic Surgery,Sydney, NSW, Australia

Introduction:
Australian data on clinical outcomes and trends in vascular surgical procedures is limited and the precise impact of age on the results of surgery remain unclear. There is little data on procedure type and volume, patient age and characteristics and surgical outcomes. Large population based clinical trials and registries are infrequent and often exclude older patients. This study is the first to use an Australian government administrative dataset to examine the epidemiology of vascular surgery outcomes in the largest state of Australia, New South Wales (NSW). The aims of this study were to determine the impact of advancing age on the number and type of vascular surgical operations performed; the characteristics of patients having these procedures; the risk of subsequent hospital admissions; and mortality over a three year period.

Methods:
Using data-linkage methods, hospital admission records of all patients undergoing vascular surgical procedures in both public and private hospitals in over the period of 2010-2012 were linked to statewide mortality records until February 2015. Vascular procedures were defined by ACHI codes based on ICD-10AM methods and included both minor and major vascular surgical procedures. Preliminary descriptive statistics were conducted prior to more detailed survival analyses with Kaplan-Meier analysis.

Results:
985,560 surgical procedures were performed between Jan 2010-Dec 2012 on 95,340 patients, resulting in 1,550,560 individual hospital episodes of care. The median age of patients having vascular surgery was 68 years old (interquartile range 20 years). 42% of patients were female. Mean length of stay was 2.8 days. Patients aged 75 years and older had a significantly longer length of stay than younger patients (mean difference 0.9 days, P<.0001) and required more reoperations (11 additional procedures, P<.0001).  14,720 patients died during the study period. All cause mortality for the cohort was 15% within the follow up period, with median survival 278 days after surgery (interquartile range 381 days). Patients who died were older (mean difference 8.7 years, P<.0001) and more likely to be female (P<.0001) compared to those who survived, and had a higher average number of subsequent hospital admissions than patients who did not die during the study period (27 vs 13 hospital admissions respectively). 

Conclusion:
Increasing age is associated with adverse outcomes after vascular surgery in NSW, Australia, including longer length of stay, high rates of surgical reintervention and decreased survival. Greater understanding of the factors contributing to poor outcomes in older patients is required for planning quality improvement initiatives. Data-linkage provides opportunity for further analysis into factors influencing vascular surgical outcomes such as the role of increasing age, frailty and comorbidities, the impact of regionalization and center volume, and outcomes emerging endovascular techniques.  
 

16.02 Decision-Making About the Extent of Surgery for Papillary Thyroid Microcarcinoma

Posted on January 25, 2017

A. K. Price1, R. W. Randle1, D. F. Schneider1, R. S. Sippel1, S. C. Pitt1  1University Of Wisconsin School Of Medicine And Public Health,Department Of Surgery,Madison, WI, USA

Introduction:  Thyroid cancer is the fastest growing malignancy in the United States largely due to a 4-fold increase in papillary thyroid microcarcinoma (PTMC), tumors ≤1 cm.  Nationally, 73% of PTMC patients undergo total thyroidectomy (TT) despite equivalent long-term outcomes with less extensive surgery.  Little is known about what drives these treatment decisions.  The objective of this study was to investigate patient and surgeon decision-making about the extent of surgery for PTMC.

Methods:  We conducted a retrospective review of all thyroid cancer patients operated on at a single institution from 2008 to 2016. Patients were included if their largest tumor was ≤1 cm and no other type of thyroid cancer was present.  For PTMC patients diagnosed preoperatively, decision-making about the extent of surgery was reviewed in all available documentation and categorized into patient or surgeon reasons.  Data analysis was performed using Fisher’s exact, Chi-square, or Student’s t-tests as appropriate.

Results: Of the 853 thyroid cancer patients, 125 (14.7%) had a PTMC as their largest tumor. The mean (± SD) age of the PTMC patients was 50.1 (± 14.6) years, and 85.6% (n=107) were female.  The mean tumor size was 0.51 (± 0.3) cm.  Overall, 27.2% of patients underwent a thyroid lobectomy (TL; n=34), while 72.8% had a TT (n=91).  Of the PTMC patients, 19 (15.2%) were diagnosed preoperatively.  These patients were similar to the rest of the cohort with respect to all preoperative variables; however, a significantly higher proportion of these patients had a TT (94.7% vs. 68.9%, p=0.01). In all documented cases, patients chose the extent of surgery because of the surgeon’s recommendation. Analysis of surgeon decision-making demonstrated that a TT was most commonly recommended because of the potential for multifocal disease (8.7%), ease of follow up (8.7%), and patient history (8.7%).  The graph depicts all of the reasons for which surgeons’ recommended a TT.  Only one preoperatively diagnosed patient had a TL, which was recommended because a history of gastric bypass increased the risk for permanent hypocalcemia.  Analysis of outcomes revealed that 5.3% (n=1) of preoperatively diagnosed PTMC patients had a permanent complication, which was nearly double that of the rest of the cohort (2.8%, n=3; p=0.5).

Conclusion: These data suggest that surgeons drive decision-making about the extent of thyroidectomy in patients with preoperatively diagnosed PTMC.  With recent guidelines recommending TL or active surveillance as primary treatment and a known decrease in quality of life after TT, closer examination of decision-making is needed to ensure that PTMC patients make well-informed, preference-based decisions.

 

16.01 Unstable C-2 Fractures: Does Age Matter?

Posted on January 25, 2017

A. X. Samayoa1, K. Foley1, A. Konopitski1, C. Hodge1, J. Yuschak1, T. Vu1, R. Shadis1  1Abington Jefferson Health,Surgery,Abington, PA, USA

Introduction:
Cervical spine fractures are debilitating injuries. Unstable C-2 fractures in the elderly are especially serious injuries that pose difficult management and disposition challenges. In our institution we describe the prevalence of these injuries in the extremes of the elderly.

Methods:
A single institution retrospective review from 1-2004 to 12-2014 was conducted on patients sustaining C-2 fractures. They were then identified as stable or unstable and subdivided in two groups: A [65-79 yrs] and B [ ≥80 yrs ].

Results:
247 patients had C-2 fractures, 151 were unstable: 35/74 (47%) in group A and 116/173 (67%) in group B. Unstable C-2 fractures were more common in group B [p=0.003]. The most common mechanisms was falling, 25 [71%] in group A and 96 [83%] in group B. Falling from standing height or less [standing, seating, from bed] was higher in group B [p=0.018]. Few patients were treated operatively 23% (group A) and 13% (group B) without difference between groups [p=0.181], however the group B was significantly less likely to be discharged home [p=0.013]. No difference was found in concomitant intracranial bleeding, ICU admission, length of stay, need for feeding tube or in hospital death.

Conclusion:
Unstable C-2 fractures are more prevalent in patients 80 yrs and over [group B]. Additionally, falls from standing height [or less] are more common in this group. We found no significant difference in the two age groups that warranted surgical intervention. As expected, younger patients were more likely to be discharge home. We feel that this study encompasses some important points on unstable C-2 fractures in the elderly and a larger multicenter study would further validate these findings.

15.20 Postoperative Bacteremia: Concordance with Cultures from Other Sites

Posted on January 25, 2017

L. R. Copeland-Halperin1, J. Stodghill1, E. Emery1, A. W. Trickey1, J. Dort1  1Inova Fairfax Hospital,Surgery,Falls Church, VA, USA

Introduction:  Bacteremia is a worrisome postoperative complication. While blood cultures (BCx) are routinely used to evaluate bacteremia, they are costly and may yield conflicting results. We previously reported on the relationship between BCx yield and the timing of culture collection after surgery. Here we present additional analyses of relationships between positive BCx and other cultures obtained concurrently to characterize surgical patients in whom postoperative blood cultures are most likely to identify pathogens.

Methods:  Electronic medical records were reviewed for patients ≥18 years of age who had blood cultures drawn within 10 days after surgical procedures at a referral center in 2013. We collected demographic data and results of cultures of blood, urine, central and peripherally inserted venous catheters, respiratory secretions, wounds, and stool obtained within 24 hours of the highest postoperative temperature before postoperative day 10. Relationships between blood cultures and other culture results were assessed using chi-square tests, or Fisher’s exact tests when assumptions for chi-square were not met.

Results: A total of 1,804 cultures were identified; exclusion of contaminants left 1,780 cultures among 746 patients for analysis. Patients had a mean age of 59 years (range=18-95, SD=16.8). The majority were male (54%). Positive or indeterminate urine and respiratory cultures demonstrated statistically significant associations with positive blood culture results (Table 1). Patterns were similar for wound and stool cultures, but statistical power was limited for those comparisons. Overall, any positive or indeterminate culture increased the likelihood of positive blood culture (9.8% vs. 2.9%, odds ratio=3.58, p<0.001).

Conclusion: These findings from the largest series of its kind help identify clinical predictors associated with early postoperative bacteremia. Specifically, the presence of a positive or indeterminate urine, respiratory, wound, stool, or catheter tip culture significantly increased the likelihood of a positive blood culture. 

15.19 Guideline Maximizes Non-operative Management and Return to Function in Blunt Hepatic Trauma

Posted on January 25, 2017

M. E. Wooster2, M. Spalding1, A. Betz1, S. Sellers1, J. Balingcongan1, S. O’Mara1  1Grant Medical Center,Trauma Surgery And Critical Care,Columbus, OH, USA 2Doctors Hospital,General Surgery,Columbus, OH, USA

Introduction:  The liver is the most commonly affected organ in blunt abdominal injury. Non-operative management of blunt hepatic trauma is the standard of care. The initiation of early deep vein thrombosis (DVT) prophylaxis, oral intake and ambulation was evaluated.

Methods:  This is a retrospective review of 130 trauma patients over two years managed with a blunt hepatic injury guideline. Early serial hemoglobin, liver function tests, and angiography or hepatobiliary iminodiacetic acid (HIDA) scan were recommended for all injuries grade 3 or higher or if contrast blush noted on CT. Angiography and Endoscopic retrograde cholangiopancreatography (ERCP) was performed as warranted. Early DVT prophylaxis, oral intake, and ambulation were encouraged. Failure of non-operative intervention or peritonitis warranted exploratory laparotomy.

Results: 

In grade 3 through 5, eleven leaks were identified, nine underwent non-operative management with success rates from 66% to 100%. Analysis of early liver function tests was not found to correlate with presence of biliary leak. Grade 4 and 5 injuries demonstrated a significantly increased leak rate over grade 3 injuries (38% vs 6%, p=0.012). There was no difference in duration of post trauma day identification of grade 3 versus grade 4 and 5 biliary leaks, respectively (2 vs 2.27, p>0.05).

After 24 hours, initiation of DVT prophylaxis, oral intake and ambulation was inversely related to grade. Eight patients underwent angiography and two underwent embolization. DVT prophylaxis was initiated later in Grade 5 injuries (p=0.03) with no increase in morbidity. Grade 5 patients had statistically significantly less oral intake after 24 hours (p=0.05) but no difference in ambulation.

One grade 4 patient suffered a missed injury with identification of biliary leak on post trauma day 8. One grade 5 patient failed non-operative management on post trauma day 2. There were no deaths.

Conclusion: The proposed blunt hepatic injury guideline enables safe non-operative manage of blunt liver injuries. These guidelines promote safe early initiation of DVT prophylaxis, oral intake and ambulation. Identification of high biliary leak rate in grade 3 and higher leak rates in grade 4 and 5 warrants evaluation of blunt hepatic injury with a HIDA scan for grade 3 or higher blunt hepatic injuries for effective non-operative management.
 

15.18 Early Appendectomy Results in Lower Costs in Children with Perforated Appendicitis

Posted on January 25, 2017

J. T. Church1, E. J. Klein1, B. D. Carr1, S. W. Bruch1  1University Of Michigan,Ann Arbor, MI, USA

Introduction:   Perforated appendicitis can be managed with early appendectomy, or non-operative management with antibiotics with or without percutaneous drainage, followed by interval appendectomy.  It is unclear which management strategy is best.  We aimed to identify the strategy with the lowest hospital costs.

Methods:   We retrospectively reviewed the medical records of all children ≤18yo with perforated appendicitis admitted to a single institution between January, 2009 and March, 2016.  Patients were included if their admission history and physical noted perforated appendicitis or suspected perforated appendicitis as the admission diagnosis; they were excluded if they were immunosuppressed, or if they were transferred from an outside hospital (OSH) after initiation of care.  Data collected included demographics, diagnostic studies and labs, management strategy, and financial data.  The primary outcome was total hospital cost collected over two years starting on the date of admission.  Comparisons were made using t-test, with statistical significance defined as p<0.05.

Results:  203 children with perforated appendicitis were identified.  After exclusion of immunosuppressed patients and OSH transfers, 103 patients were included in the study.  The average age at initial admission was 9.5±4.5 years old, and 58% of patients were male.  42 children underwent early appendectomy, while 61 underwent initial non-operative management, 60 of whom underwent interval appendectomy.  Five of the 61 (8%) patients who underwent initial non-operative management failed and required appendectomy prior to elective interval appendectomy.  There was no difference in total cost for the initial admission between early appendectomy and interval appendectomy (15190±8982 vs. 15043±10430; p=0.94).  However, total two-year hospital costs were 19045±13773 in the early appendectomy group compared to 26228±17830 in the interval appendectomy group (p=0.023). 

Conclusion:  Early appendectomy appears to result in lower hospital costs compared to initial non-operative management with elective interval appendectomy.  A prospective study will shed more light on this question, and can assess the role of non-operative management without interval appendectomy in children with perforated appendicitis.

 

15.17 Value of the Cholecystokinin stimulated HIDA scan in evaluating Abdominal Pain in Children

Posted on January 25, 2017

N. A. Markwith1, J. A. Taylor1, S. D. Larson1, D. Solomon1, W. Drane1, S. Islam1  1University Of Florida,Pediatric Surgery,Gainesville, FL, USA

Purpose: Clinicians have used the cholecystokinin stimulated HIDA scan (CCK-HIDA) to evaluate patients with abdominal pain since 1976. The test is used to identify patients who have symptoms caused by biliary dyskinesia, and help select those who would respond to a cholecystectomy. While the incidence of cholecystectomy for biliary dyskinesia has rapidly risen in children in the past decade, the appropriate use of the CCK-HIDA scan remains controversial. The purpose of this study was to better understand the utility of this test in a cohort of children with abdominal pain.

Methods: Children who underwent a CCK-HIDA scan over a 15 year period were included in the study. Inclusion criteria were scans performed for evaluation of abdominal symptoms, therefore infants, patients after a liver transplant, or for evaluation of other conditions were excluded. Relevant clinical data including symptoms, duration, demographics, results of other labs and imaging, HIDA results, and outcomes including any procedures were abstracted from the clinical records and analyzed. Uni- and multivariate analysis was performed and a p value of less than 0.05 was considered significant.

Results: A total of 190 patients met the inclusion criteria. Mean age was 14.4 years, 74.5% were female and 47% Caucasian. 47.3% were either overweight or obese, and 73.2% presented with right upper quadrant or epigastric pain. Overall, the mean ejection fraction (EF) was 59.5%, with 23.2% less than 35% EF. Comparison of patients with an EF less than 35% and greater than 36% is shown in the Table. Restricting to cholecystectomy, adoption of a stringent EF <20% as criteria, only 53% had surgery, with 50 % long term resolution (partial or complete), compared to overall resolution of symptoms in 48.4% patients. When analyzed using multivariate regression with 'any symptom resolution' as a binary outcome variable, neither EF nor pain reproduction on CCK administration could predict outcome.

Conclusions: These data suggest that the CCK-HIDA scan cannot adequately select patients who would benefit from a cholecystectomy, even with very low EF. Adoption of better criteria to perform the study would be beneficial and result in substantial cost saving during the work up of abdominal pain. Prospective large studies would help in understanding the role of this test better, especially with the advent of increasing surgery for functional gall bladder problems. 

 

15.16 Outcomes and Costs for Thoracoscopic Alone Versus Robotic Assisted Thoracoscopic Procedures

Posted on January 25, 2017

M. Eby1, J. Parreco1, R. Martinez1, R. Kozol1  1University Of Miami,General Surgery,Miami, FL, USA

Introduction:
Previous studies have shown the benefits of thoracoscopic procedures in regards to less postoperative pain, faster recovery, and less overall cost when compared to open surgery. However, the comparison of thoracoscopic alone versus robotic assisted thoracoscopic procedures is less well known. The purpose of this study was to compare overall outcomes and costs associated with thoracoscopic alone versus robotic assisted thoracoscopic procedures.

Methods:
The Nationwide Readmission Database (NRD) was queried for all patients with admissions with elective thoracoscopic and robotic assisted thoracoscopic procedures in 2013. The most common diagnoses with total costs were calculated. Multivariate logistic regression was then implemented using patient comorbidities and demographics as well as hospital characteristics to determine the odds ratios (OR) of outcomes.

Results:
During the study period, 24,707 patients underwent thoracoscopic procedures with 2,837 (11.5%) being robotic assisted and 21,870 (88.5%) thoracoscopic alone. The mean robotic assisted total admission cost was $25,409.16 SD+/-21,523.75 while the mean total thoracoscopic alone was $19,470.92 SD+/-20,380.66 (p<0.01, 95% CI 5,133.20 to 6,743.29). The mean cost of readmissions for robotic assisted was $23,467.70 SD+/-32,578.80 while the mean cost of readmissions for thoracoscopic alone was $23,759.56 SD+/-35,416.83 (p=0.85, 95% CI -3,312.41 to 2,728.70). The most common primary diagnosis for patients undergoing robotic assisted thoracoscopic procedures was malignant neoplasm of upper lobe, bronchus or lung at 777 patients (27.4%) with a mean total admission cost of $27,160.17 (+/-20,299.65). This was also the most common primary diagnosis for patients undergoing thoracoscopic alone procedures with 4,932 patients (22.6%) and a mean total admission cost of $22,382.38 (+/-17,882.993). The OR for mortality in thoracoscopic alone patients was 1.28 (p=0.08, 95% CI 0.97 to 1.68) and the OR for readmission was 1.12 (p=0.03, 95% CI 1.01 to 1.24).

Conclusion:

Initial admission costs are higher in patients undergoing robotic assisted thoracoscopic procedures compared to thoracoscopic alone. However, readmission costs are similar and readmissions occur at a higher rate in patients undergoing thoracoscopic alone procedures. Therefore, with lower readmission rates and equivalent overall survival, robotic assisted thoracoscopic procedures prove to be beneficial and potentially superior in both patient outcomes and reduction in net health care costs when compared to thoracoscopic alone.

15.15 Pre-Surgical Renal Mass Biopsy Reduces Upfront Treatment Costs for Small Renal Masses (SRMs)

Posted on January 25, 2017

M. C. Rozo1, T. J. Ziemlewicz2, S. L. Best1, S. A. Wells2, M. G. Lubner2, J. Hinshaw1,2, F. Shi1, F. T. Lee2, S. Y. Nakada1, E. Abel1  1University Of Wisconsin School Of Medicine And Public Health,Department Of Urology,Madison, WI, USA 2University Of Wisconsin School Of Medicine And Public Health,Department Of Radiology,Madison, WI, USA

INTRODUCTION AND OBJECTIVES: Approximately 15-20% of incidental renal masses ≤4cm are benign tumors such as oncocytomas or lipid poor angiomyolipomas (AML), which can be managed non-surgically. Increasing utilization of small renal mass biopsy (SRMB) may reduce treatment of benign tumors, decreasing upfront costs and preserving renal function in untreated patients. The objective of this study is to evaluate if increasing SRMB utilization reduces surgical treatment and upfront (30 day) costs of care management for patients with benign small renal masses.

 

Methods: Clinical and pathologic data were reviewed from patients with incidental renal masses ≤4cm who were treated surgically and/or received SRMB from 2003-2015. Patients not considering surgery were excluded. Patients were divided into 2 cohorts (2003-2009 and 2010-2015) for analysis to reflect increased SRMB utilization at our institution since 2010. Institution specific Medicare costs for 2015 were used to calculate costs of surgery and biopsy in all patient cohorts.

 

Results: Of 437 patients with renal masses ≤4cm, SRMB was performed in 6% of 199 patients treated from 2003-2009 and 54% of 238 patients from 2010-2015. The rate of surgery for benign tumors from 2003-2009 was higher than 2010-2015, 19.7% vs. 12.3%, p=0.04. For patients treated without biopsy from 2010-2015, the benign surgery rate was 21.8%. From 2010-2015, 42 patients with benign tumors were identified using SRMB and avoided surgery (10 AML, 32 oncocytoma).   

 

Given the upfront cost of $2,020.44 USD for ultrasound guided biopsy and $12,153.01 USD for partial nephrectomy, the cost of care per patient was calculated for each of the two cohorts.

 

The cost per patient in the 2003-2009 vs. 2010-2015 cohort was $12,274.85 USD vs. $11,094.98 USD. Increased biopsy utilization was associated with $1,179.86 (9.6%) cost savings per patient. For 2010-2015, increased use of biopsy saved $280,840 USD in estimated upfront treatment costs.  

 

Conclusions: Pretreatment biopsy reduces surgery for benign tumors and decreases the upfront cost of care per patient by $1,179.86 USD. Increasing utilization of biopsy for small renal masses decreases overall treatment cost and preserves renal function in patients with benign tumors who avoid treatment.

15.14 Surgical ICU Test Stewardship: Checking the Checklist

Posted on January 25, 2017

B. K. Yorkgitis1, J. Louglin2, Z. Gandee2, H. H. Bates2, C. Huang2, G. Weinhouse2  1University Of Florida College Of Medicine- Jacksonville,Division Of Acute Care Surgery,Jacksonville, FL, USA 2Brigham And Women’s Hospital,Surgical ICU Transnational Research Center,Boston, MA, USA

Introduction:  Surgical ICU patients frequently undergo laboratory and diagnostic testing. These tests can lead to iatrogenic anemia and radiation exposure.  Many of these tests and images may be unnecessary for management of a patient’s illness in the SICU and their ordering may be a reflex rather than in response to a clinical question.  Checklists have been used in critical care to identify and address various patient care points.  Through a quality improvement project, we developed and implement additional points to the daily rounding checklist (DRC) for the bedside SICU care team to address ordering clinically relevant laboratory and chest x-ray (CXR).

 

Methods:  To an already established ICU DRC, two additional points were added: “Is a CXR needed for clinical management tomorrow?” and “What laboratory tests are medical necessary for tomorrow?”.  Comparison was made between a three month pre-intervention arm (control group) and three month intervention groups after the addendums were instituted. The groups were compared on a basis of demographics, illness, mean blood test and CXR per day, and average transfusion per day.

Results: A total of 307 adult patients were analyzed, 155 in the control group and 152 in the intervention group. The groups were similar in sex, elective admission status, undergoing surgical procedures, in-hospital death, age, ICU length of stay, ventilator days, and admission SOFA scores (table 1). After the intervention, there was no statistical reduction in laboratory tests or CXR (Table 2).

Conclusion: The addition of these two items to the DRC did not reduce the amount of tests ordered.  Checklist fatigue is a well known factor in healthcare and may have contributed to the results.  Further education on test appropriateness and the possible addition of a clinician decision tool could be studied in the future to assist with reduction of testing in the SICU that may contribute to ordering only clinically relevant tests. 
 

15.13 Understanding Resource Utilization in Congenital Heart Disease

Posted on January 25, 2017

A. Eckhauser1, J. Marietta3, N. Pinto2, M. Puchalski2  1University Of Utah,Cardiothoracic Surgery/Surgery,Salt Lake City, UT, USA 2University Of Utah,Cardiology/Pediatrics,Salt Lake City, UT, USA 3Primary Children’s Hospital,Salt Lake City, UT, USA

Introduction:  Resource utilization and the cost of caring for patients with congenital heart disease (CHD) is largely unknown and often inferred from administrative data. How these costs are broken down into components by operating room, nursing care, rooming, and pharmacy can be used to help better understand opportunities to improve care. We sought to evaluate these costs in three common congenital heart surgeries.

Methods:  We evaluated overall costs for 3 common congenital heart defects- complete atrioventricular canal (AVC), coarctation of the aorta (AA) and D-transposition of the great arteries (DTGA) using linking to a statewide database (1997-2012) of inpatient discharge and vital records thru age 5.  For the subset of patients operated on at our tertiary care center from 2012-2016 we obtained costs associated with the initial surgery using an activity based accounting system that broke down cost components for the index hospitalization and stratified these costs based on major comorbidities to understand resource use. 

Results:  The 1yr-costs for the AVC cohort were $86,271 ± 112,900 (n=213), AA $57,788 ± 84,036 (n=465) and DTGA $108,840 ± 98,768 (n=169) with an additional 18, 10, and 7% respectively added through year 5.  The total average cost at our center for the initial surgical hospitalization for AVC repair was $24,318 ± 22,007, for AA $35,207 ± 32,840 and for DTGA $56,516 ± 28,427.  Figure 1 displays major contributors to surgical costs and differences based on major comorbidities within each cohort for the initial surgical hospitalization. Prematurity had the most profound increase in cost in patients with DTGA.  Trisomy 21 in patients with AVC actually led to a decrease in utilization.

Conclusion:  The majority of hospital costs associated with caring for children with CHD occur in the first year of repair and are related to the surgical hospitalization.  Risk factors such as prematurity and operative strategy can have profound effects on total cost that vary significantly by type of CHD.  Using such data to explore this effect can help to identify leverage points to improve the value of care delivered to these patients.
 

15.12 Cost effectiveness of laparoscopic vs open appendectomy in developing nations, a Colombian analysis

Posted on January 25, 2017

S. Rey1, A. Ruiz Patino1, G. Molina1, S. Rugeles1  1Hospital Universitario San Ignacio,Department Of Surgery,Bogota, DC, Colombia

Introduction: Colombia is a developing nation in need for efficient resource administration in fields such as healthcare, were innovation is constant. Since the introduction of laparoscopic appendectomy, direct costs have been increasing without definitive results in terms of clinical outcomes. The objective of this study is to determine the cost effectiveness of open vs laparoscopic appendectomy and thereby help surgeons in clinical decision making in a limited resource setting.   

Methods: A retrospective cost effectiveness analysis comparing open (OA) vs multiport laparoscopic appendectomy (LA) during 2013 in a third level university hospital (Hospital Universitario San Ignacio) in Bogota, Colombia was performed. Effectiveness was determined as the number of days in additional length of stay due to complications saved. 377 clinical stories were collected by the authors and analyzed for the variables: surgery type, conversion to open laparotomy, complications (surgical site infection, reintervention, re admission), hospital length of stay (LOS) and total cost of hospitalization for initial surgery and subsequent complications related hospitalizations. The total accumulative costs and lengths of stay for OA and LA plus complications were estimated. The cost effectiveness threshold was set at US 46 (139,000 COP), the cost of an additional day in length of stay. An Incremental cost effectiveness ratio (ICER) was calculated for OA as the comparator and LA as the intervention. 

Results: The number of LA was 130 and for OA 247. The two groups were balanced in terms of population characteristics. Complication rate was 13.7 % for OA and 10.4% for LA (p <0.05) and LOS was 2 days for LA and OP (p=0.9). No conversions from LA to OA were recorded. The total costs for complications for OA were US 8,523 (25,569,220 COP) and US 3,385 (10,157,758 COP) for LA. Cumulative costs including cost of surgery and complications and length of stay for OA were US 65,753 (197,259,310 COP) and 297 respectively. For LA were US 66,425 (199,276,948 COP) and 271. The ICER was US 25.86 (77,601 COP) making LA a cost effective alternative with a difference of US 20.76 (62,299 COP) under the Cost-effectiveness threshold.

Conclusion: Laparoscopic appendectomy is a cost effective alternative over open appendectomy with an increasing cost of $25.85 per day of additional hospitalization due to complications saved. This is accounting the low cost of surgical interventions and complications in developing nations such as Colombia.

15.11 Patients with Benign Gallstone Disease Should Be Admitted to a Surgical Team

Posted on January 25, 2017

V. Sandoval1, J. T. Brady1, M. E. Kelly2, S. R. Steele1, V. P. Ho1  1University Hospitals Case Medical Center,Surgery,Cleveland, OH, USA 2Case Western Reserve University School Of Medicine,Cleveland, OH, USA

Introduction:  Benign gallstone disease is a common problem that becomes symptomatic in a minority of patients, but remains associated with significant health care utilization and costs. These patients can be admitted to a surgical or non-surgical (“medical”) team, but not much is known about the impact of this on patient outcomes in the current model of Acute Care Surgery (ACS) services.

Methods:  We performed a retrospective review of patients who underwent cholecystectomy by the ACS service at a tertiary care academic medical center from 7/2013 to 6/2015. Patient were identified by Current Procedural Terminology codes for open or laparoscopic cholecystectomy, percutaneous cholecystostomy or ERCP. Patients who underwent cholecystectomy during the index admission were grouped based on admitting service (ACS vs. medicine). Other data points collected included date of admission, date of surgery consult, diagnostic tests performed, and length of stay Continuous variables were compared using Student’s t test and categorical variables compared using Chi square or Fisher’s exact test where appropriate.

Results: We identified 85 patients during the study period who underwent cholecystectomy, of whom 51.8% (n=44) were admitted to the ACS service. The majority of the patients in the ACS and medicine groups were female (84.1% vs. 75.6%, respectively, P=0.33). Mean age was similar in both groups (ACS: 43.1±20.9 vs. medicine: 49.2±19.2, P=0.17). There were significantly more patients admitted to a medical service who were transferred from an outside facility (43.9% vs. 13.6%, P=0.002). The mean number of days from arrival at the hospital to surgery consult was  0.9±0.2 days in the medicine group. The mean number of days from ACS consult or admission to ACS to procedure date was similar (2.4±1.3 vs. 2.7±1.9, P=0.37). The number of diagnostic tests overall including CT, Ultrasound, HIDA scan and ERCP was similar between groups (ACS: 1.9±1.1 vs. medicine: 2.3±1.1, P=0.09). Significantly more patients in the medical admission group had acute pancreatitis on admission (51.2% vs. 9.1%, P=<0.001). There was no significant difference in the percentage of patients who underwent a laparoscopic approach between groups (ACS: 93.2% vs. medicine: 82.9%, P=0.14). There was an overall decreased length of stay by 1.2 days in the ACS group but it did not reach statistical significance (5.4±2.6 vs. 6.6±2.9, P=.052). 

Conclusion: This study suggests that patients who underwent cholecystectomy and were admitted to the ACS service had a 1 day shorter length of stay compared to patients admitted to a medical service and for which ACS was consulted. Implementing policies that favor admission to a surgery service could lead to decreased costs for patients.

 

15.10 Economic Evaluations of Comprehensive Geriatric Assessment in Surgical Patients: A Systematic Review

Posted on January 25, 2017

G. Eamer1,3, B. Saravana-Bawan1, B. Van Der Westhuizen1, T. Chambers2, A. Ohinmaa3, R. G. Khadaroo1  1University Of Alberta,General Surgery,Edmonton, ALBERTA, Canada 2University Of Alberta,Libraries,Edmonton, ALBERTA, Canada 3University Of Alberta,School Of Public Health,Edmonton, ALBERTA, Canada

Introduction:
Seniors presenting with surgical disease are at increased risk of post-operative morbidity and mortality, and have increased treatment cost. Comprehensive Geriatric Assessment (CGA) has been proposed to reduce morbidity, mortality and cost following surgery. CGA seeks to identify and pre-emptively manage risk factors specific to elderly patients.

Methods:
A systematic review of CGA in emergency surgical patients was conducted. The primary outcome was cost effectiveness and secondary outcomes were length-of-stay, return of function and mortality. Pre-defined inclusion criteria were economic evaluation of CGA verses usual care in patients 65 and over receiving emergency surgery. Exclusion criteria include non-surgical patients, patients under 65, no economic outcomes and incomplete CGA. Systematic searches were done using MEDLINE, EMBASE, Cochrane and NHS-EED. Text screening, bias assessment and data extraction was performed by two authors. Meta-analysis was performed with the random effects model.

Results:
There were 557 articles identified; 495 articles were excluded based on abstract and 52 after full-text review. Ten articles reporting results from 8 studies were identified; 1 non-orthopedic trauma and 7 orthopedic trauma studies. Bias assessment revealed moderate to high risk of bias for all studies. Economic evaluation assessment identified 1 high-quality study and 7 moderate or low quality studies. All studies identified improved overall cost effectiveness. Four studies assessed return of function; combined odds ratio demonstrates improved functional outcome (OR 1.61, 95% CI 1.23-2.11). Seven studies assessed mortality demonstrating a significant decrease (OR 0.72, 95% CI 0.55-0.94). Six studies assessed length of stay; mean difference nears a significant reduction (mean difference -1.19, 95% CI -2.58-0.20) after excluding the non-orthopedic trauma study.

Conclusion:
CGA demonstrates improved return of function and mortality with reduced cost or improved utility in all studies. Our review suggests CGA is economically dominant choice in geriatric orthopedic hip fracture patients; further research should be conducted in other surgical fields. There is evidence that CGA should become standard of care in orthogeriatric patients. To implement perioperative CGA nationwide, workforce modeling should account for the increased demand for trained geriatricians that will occur.
 

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