91.02 Scaling-up Surgical Care in Rural Haiti

Posted on January 26, 2017

L. Ward1,4, D. L. Eisenson2, A. Bowder1,3,4, M. Jean Louis1, M. Raymonville1, T. Pauyo4, M. L. Steer4,9, P. E. Farmer4,8, J. G. Meara4,7, S. R. Sullivan2,4,5,6  1Hopital Universitaire De Mirebalais,Surgery,Mirebalais, CENTRAL PLATEAU, Haiti 2Brown University School Of Medicine,Providence, RI, USA 3Medical College Of Wisconsin,Milwaukee, WI, USA 4Harvard School Of Medicine,Program In Global Surgery And Social Change,Brookline, MA, USA 5Rhode Island Hospital,Plastic Surgery,Providence, RI, USA 6Mount Auburn Hospital,Plastic Surgery,Cambridge, MA, USA 7Children’s Hospital Boston,Boston, MA, USA 8Brigham And Women’s Hospital,Boston, MA, USA 9Tufts Medical Center,Boston, MA, USA

Introduction:

Partners In Health and Zanmi Lasante (PIH/ZL) have provided surgical care in the Central Plateau of Haiti since 1996. These efforts slowly grew to include operating rooms at three hospitals within this catchment area and network of clinics. In 2008, there was an effort to increase surgical capacity with visiting surgical specialists. After the 2010 Earthquake, PIH/ZL partnered with the Haitian Ministry of Health (MSPP) to build University Hospital in Mirebalais (UHM), which opened in 2013. Our purpose is to evaluate the impact of scaling-up surgical care over time.

Methods:

We performed an interrupted time series analysis to compare surgical volume over three time periods: (1) 2007-08, a baseline time-period for surgical care, (2) 2008-09, after the scale-up of visiting surgeons within the existing infrastructure of three hospitals, (3) 2014-2015, after opening UHM with scale-up of surgeons and surgical infrastructure. The primary outcome was total number of operations, measured at monthly intervals from October to March in each time period.

Results:

There was a statistically significant increase in the number of operations performed each month since opening UHM: the average number of operations increased by 121.8 from the baseline trend in time period 1 (95% Confidence Interval 66.2 – 177.4, P = 0.001). The most significant increases were seen in procedures relating to maternal health, orthopedic trauma, and endoscopy.

Conclusion:

Increasing surgical capacity within a health care system in rural Haiti requires more than additional visiting surgical specialists. Scaling-up surgical care requires investments in infrastructure, procurement/supply chains, and of course, skilled surgical specialists – UHM invested in all three areas. UHM provides an impressive model of scaling-up surgical care in a resource poor setting such Haiti.

91.01 The Accessibility, Readability, and Quality of Online Resources for Gender Affirming Surgery

Posted on January 26, 2017

C. R. Vargas1, J. A. Ricci3, M. Lee3, A. M. Tobias3, D. A. Medalie2, B. T. Lee3  1Case Western Reserve University School Of Medicine,Plastic Surgery,Cleveland, OH, USA 2MetroHealth Medical Center,Plastic And Reconstructive Surgery,Cleveland, OH, USA 3Beth Israel Deaconess Medical Center,Plastic And Reconstructive Surgery,Boston, MA, USA

Introduction:  The transgender population is disproportionally affected by health disparities related to access to care.  In many communities, transgender specialists are geographically distant and locally available medical professionals may be unfamiliar with unique needs of transgender patients. As a result, use of internet resources for information about gender affirming surgery is particularly important. Inadequate functional health literacy has been found to contribute to poorer health status, increased mortality, less awareness of preventative health measures, decreased understanding of personal medical conditions, greater likelihood of hospitalization, higher health care costs, lack of self-empowerment, less participation in decision-making in the course of care, and overall worse health outcomes. Minority populations are known to be particularly at risk for these health disparities. This study aims to simulate a patient search for online educational material about gender affirming surgery and to evaluate the accessibility, readability, and quality of the resulting information.

Methods:  An Internet search for the term, “transgender surgery” was performed, and the first ten relevant hits were identified.  Readability was assessed using ten established tests: Coleman-Liau, Flesch-Kincaid, FORCAST, Fry, Gunning Fog, New Dale-Chall, New Fog Count, Raygor Estimate, SMOG, and Flesch Reading Ease. Quality was assessed by two independent raters using JAMA criteria and the DISCERN instrument; these indices were plotted graphically for comparison.

Results: Review of 69 search results was required to identify 10 sites with relevant patient information. 97 articles were subsequently collected; overall mean reading level was 14.7. Individual website reading levels ranged from 12.0 to 17.5.  All articles and websites exceeded the recommended 6th grade level. Quality ranged from 0-4 (JAMA) and 35-79 (DISCERN) across websites. When DISCERN quality was plotted against FRE readability, a nonlinear relationship was observed (Figure).  Peak readability correlated with the middle of the quality index and declined at both extremes. Notably, readability of the highest quality resources was low, suggesting limited utility for average readers.

Conclusion: Websites with relevant patient information about gender affirming surgery were difficult to identify from search results. The content of these sites universally exceeded the recommended reading level. A wide range of website quality was noted and may further complicate successful resource navigation for patients  Barriers in access to appropriately written patient information on the internet may contribute to disparities in referral, involvement, satisfaction, and outcomes for transgender patients.

90.20 Unaccounted Readmissions Following Bariatric Surgery

Posted on January 26, 2017

J. K. Canner1, S. Pourzal1, H. AlSulaim1, K. E. Steele1  1Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA

Introduction:  Hospitals accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) are required to report readmission rates.  However, such rates may not account for readmissions to other hospitals if follow-up data are incomplete.  We calculated a more accurate readmission rate using a nationally representative database that tracks readmissions at all hospitals within the same state. We then investigated factors associated with readmission to a different hospital.

Methods:  The new Nationwide Readmissions Database (NRD) from the Healthcare Cost and Utilization Project (HCUP) contains data on inpatient hospital stays from 21 states that collect data linkage information sufficient for identifying readmissions. We identified patients in the NRD admitted for elective bariatric surgery in 2013 and collected patient demographics, including age, gender, insurance status, and residence, as well as clinical information such as length of stay, Charlson comorbidity index, and APR-DRG severity score. We calculated the proportion of patients readmitted within 30 days after initial discharge and also recorded the APR-DRG severity and elective status for the readmission and whether the readmission was to the same hospital.

Results: A total of 61,220 NRD patients underwent elective bariatric surgery in 2013.  Of these, 3,860 (6.3%) were readmitted within 30 days.  Of those readmitted, 693 (18.0%) were to a different hospital. Patients readmitted to a different hospital were more likely to be covered by Medicare (OR=1.46; p=0.036) or Medicaid (OR=1.62; p=0.011) than be privately insured, less likely to live in a medium-sized metro area than in a large metro area (OR=0.61; p=0.013), and less likely to have their surgery at a teaching hospital than at a non-teaching hospital (OR=0.71; p=0.021).  Readmission to a different hospital was strongly associated with higher APR-DRG severity (OR=1.69; p=0.001) and non-elective status at readmission (OR=2.28; p=0.002). Patient age, sex, income level, out-of-state residence, comorbidities, type of surgery and length of stay were not associated with location of readmission. These relationships persisted with multivariable analysis, with the exception of Medicare coverage.

Conclusion: Failure to account for readmissions to different hospitals may underestimate readmission rates by at least 18%.  Patients with more severe complications are the most likely to be readmitted to different hospitals.  A better understanding and accounting for all readmissions may improve the care and safety of the bariatric surgical patient. Further research using data sets with more detailed geographic information may reveal the role of distance as a factor in readmission location.

 

90.19 Physiologic Drivers Of Intraoperative Transfusion During Major Gastrointestinal Surgery?

Posted on January 26, 2017

M. Cerullo2, F. Gani2, S. Y. Chen2, J. K. Canner2, W. W. Yang3, S. M. Frank3, T. M. Pawlik1  1Ohio State University,Wexner Medical Center,Columbus, OH, USA 2Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA 3Johns Hopkins University School Of Medicine,Department Of Anesthesiology And Critical Care Medicine,Baltimore, MD, USA

Introduction:  Current guidelines for transfusion largely focus on nadir hemoglobin (Hb) levels. Hb triggers may not be helpful, however, in defining appropriate intra-operative use of packed red blood cells (PRBCs).  We sought to define the use intra-operative PRBC relative to quantitative physiologic factors at the time of surgery.

Methods:  Prospective perioperative data on patients undergoing major gastrointestinal surgery between 2010 and 2014 were analyzed. Risk of intraoperative transfusion was assessed with multivariable extended Cox models using clinical covariates (e.g. type of surgery, perioperative Hb, coagulation parameters, American Society of Anesthesiologists (ASA) classification, and Charlson co-morbidity), as well as time-varying intraoperative covariates (e.g. continuously-monitored mean arterial pressure [MAP], heart rate, and estimated blood loss [EBL]).

Results: 2,428 patients were identified; 384 (15.8%) patients received an intraoperative transfusion. Higher risk of intraoperative transfusion was associated with preoperative factors including lower Hb (hazard ratio [HR]=1.22, 95% confidence interval [CI]: 1.14-1.30, p<0.001) and higher ASA class (HR=1.55, 95%CI:1.24-1.93, p<0.001). Intraoperative risk factors for transfusion included higher EBL (HR=1.43, 95%CI:1.27-1.62, p<0.001, per 1000mL), as well as lower instantaneous MAP (HR=1.15, 95%CI:1.08-1.22, p<0.001) and higher heart rate (HR=1.30, 95%CI:1.21-1.39, p<0.001). While the majority of patients had a transfusion for a physiologic indication, among the 384 patients transfused, 27.1% of intra-operative transfusions were delivered to patients who never had a physiologic indication (heart rate>100, MAP<65, or a nadir Hb<8) (Figure). 

Conclusion: Physiologic indicators account for considerable variability in intraoperative transfusion practices among patients undergoing major surgery. Up to 27% of patients who received an intraoperative transfusion had no identifiable physiological reason for a transfusion, thereby suggesting possible overutilization of PRBC in a subset of patients. 

 

90.18 Geographic Proximity of High and Low Quality Bariatric Centers; An Opportunity for Regionalization?

Posted on January 26, 2017

A. M. Ibrahim1, A. A. Ghaferi1, J. Thumma1, J. Dimick1  1University Of Michigan,Ann Arbor, MI, USA

Introduction: Responding to reports about the safety of bariatric surgery, leading surgical societies established criteria to create centers of excellence. As a result, many providers underwent changes to obtain accreditation and now nearly all bariatric procedures occur at these centers. Because clinical outcomes are not part of the accreditation process, it unclear if these centers provide high quality care uniformly. Moreover, the geographic availability of centers with high quality outcomes is unknown.  

Methods: A retrospective review of 137,016 patients undergoing bariatric surgery at centers of excellence between 2009-2011. Data was obtained from the Healthcare Cost and Utilization Project – State Inpatient Database which included unique hospital identification numbers in 12 states allowing comparisons across 188 centers of excellence. For each hospital, we evaluated quality by calculating the risk and reliability adjusted serious complications rates within 30 days of the index operation. Variations across centers of excellence nationally as well as within each individual state and hospital service area was assessed.  

Results:  Wide variation in quality exists across bariatric surgery centers of excellence . At the national level, the risk and reliability adjusted serious complication rates at each individual center varied 42 fold ranging from 0.34% to 14.6%. The top and bottom deciles varied 12 fold (top decile 0.5%; bottom decile 6.1%; p<0.005.) Similar variation was seen at the state level as well; California (N=46) ranged from 0.3% to 5.6% and New York (N=35) ranged from 0.5% to 8.6%. For the 47 hospital service areas with a low quality provider (highest quartile of complications), 34 (72%) of them also had an average or high quality provider in the same or adjacent hospital service area.

Conclusions:  Even among centers of excellence for bariatric surgery, wide variation exists in rates of post-operative serious complications. Given that most low quality providers are geographically located near higher performing providers, opportunities for quality improvement through local regionalization should be considered. 

90.17 Routine Type and Screen is Unnecessary for Patients undergoing Thyroid and Parathyroid procedures

Posted on January 26, 2017

L. Anewenah1, M. Asif1, M. Rasouli1, O. Domingo1  1Mercy Catholic Medical Center,Department Of General Surgery,Darby, PENNSYLVANIA, USA

Introduction:

The thyroid and parathyroid glands are among the most highly vascularized tissue beds. As a result, bleeding from these glands can be life threatening. While approximately only 1% of postoperative bleeding is observed in these procedures, it is common practice to perform type and screening of patients undergoing these procedures.

The purpose of our study is to review records of thyroid and parathyroid procedures performed at our Institution from the beginning of 2012 to the end of 2014 and of that number how many went on to need blood transfusion. We also hope to be able to identify the characteristics of the patients who had postoperative bleeding to inform policy regarding type and screening test for patients undergoing these procedures.

Methods:
This is a retrospective study of patients who underwent thyroid and parathyroid procedures. Demographic, laboratory results and surgical related data were obtained from querying our institutional database. Descriptive analysis was performed. 

Results:

A total 62 patients including 46 females (74%) were included in the study. Mean age of patients at the time of surgery was 55 +/- 13 years.

46 thyroid surgeries (34 total thyroidectomy, 10 thyroid lobectomy, one thyroglossal cyst removal and one completion thyroidectomy) and 16 parathyroid surgeries (3 total parathyroidectomies, 3 left and 3 right parathyroidectomies, 5 single parathyroid gland removal, 1 subtotal thyroidectomy, and 1 exploration of parathyroid) were performed. All surgeries were performed under general anesthesia. Estimated blood loss ranged from 5 to 200 milliliters. Median weight of the removed thyroid gland was 26.3 grams ranged from 2.7 to 409 grams. Median weight of the removed parathyroid gland was 1.5 grams ranged from 0.07 to 10.1 grams. Median length of hospital stay was 1 day ranged from 0 to 28 days.

Preoperative International Normalized Ratio (INR) was high in only three patients, which ranged from 1.4 to 1.5. Only 5 patients (8%) had preoperative platelet counts of less than 150,000 platelet per microliter (ranged from 73 to 139 platelet per microliter). Mean preoperative and postoperative hemoglobin were 12.7 +/- 2.2 g/dL and 11.2 +/- 1.7 g/dL, which was statistically significant (p<0.001).

Type and screen was requested in all cases. Only two patients (3.2%) required postoperative transfusion and 2 units of packed cell transfused in each case (table 1)

Conclusion:

Large volume of blood loss requiring intraoperative or postoperative blood transfusion is extremely rare. For the patients that required a transfusion, the type and screen can be done rapidly and the patients safely transfused. It seems, therefore, that routine type and screen is unnecessary in patients undergoing thyroid and parathyroid.

90.16 Attitudes and Practice Patterns in Management of Adhesive Small Bowel Obstruction Among Surgeons

Posted on January 26, 2017

L. W. Thornblade1, A. R. Truitt1, D. R. Flum1, D. C. Lavallee1  1University Of Washington,Department Of Surgery,Seattle, WA, USA

Introduction:  Classic training instructs surgeons to, “never let the sun set on a small bowel obstruction (SBO)” for concern of bowel ischemia. However the routine use of CT scans for ruling out compromised bowel provides the opportunity for trial of non-operative management, allowing time for spontaneous resolution of adhesive SBO. In light of such advances in practice, little is known about how surgeons choose to manage these patients, in particular whether there is an agreed-upon time window for safe non-operative management.

Methods:  Using a case scenario of a patient with CT-scan confirmed adhesive SBO without bowel ischemia, we interviewed a purposive sample of general surgeons practicing in Washington State to understand approaches to clinical management. Interview questions addressed typical practice, use of an oral contrast study, timing of surgery, and use of laparoscopy. We conducted a qualitative analysis to identify themes in practice and attitudes. 

Results: Surgical practice patterns for patients with SBO vary widely. The importance of timely surgeon involvement and serial abdominal exams emerged as themes among most participants. Many participants identified themes of uncertainty about the diagnosis of a complete obstruction. The period of time that surgeons were willing to manage patients non-operatively ranged from 1-10 days. Most surgeons favored open surgery. All surgeons acknowledged a lack of clinical evidence to support appropriate management of patients with SBO.

Conclusion: Interviews with practicing surgeons across a range of practice sites illuminate a changing paradigm away from routine early operative management of patients with adhesive SBO. However, there is no established length for a trial of non-operative management. The surgeon attitudes and practice patterns identified will inform feasibility and design of future prospective randomized studies of patients with non-ischemic adhesive SBO.

 

90.15 Evolution of Laparoscopic Appendectomy: A 12 Year Experience of a Tertiary Care Hospital

Posted on January 26, 2017

M. H. Siddiqui1, R. Sultan1, F. Shaukat2, H. Zafar1  1Aga Khan University Hospital,Surgery/General Surgery,Karachi, Sindh, Pakistan 2Aga Khan University Hospital,Oncology/Radiation Oncology,Karachi, Sindh, Pakistan

Introduction:  Laparoscopic appendectomy has gained tremendous popularity and acceptance in many countries but has not become the standard of care so far. The aim of this study is to assess the outcomes and trends of this procedure in Aga Khan University Hospital, Karachi, Pakistan, over a decade.

Methods: All adult patients who underwent laparoscopic appendectomy from Jan 2004-Dec 2015 were included in the study. Patients’ demographics, operative details like duration of surgery and conversion rate, histopathology and complications were recorded in proforma.

Results: 831 patients were included in the study and trend showing a significant increase in number of laparoscopic appendectomies. 64% of patients were male, median age of 28 years and median hospital stay was 2 days. Mean duration of surgery is 67.47 (SD 25.86) minutes which has significantly improved over time. 7% of the cases were converted to open with decreased conversion rate in recent years.  Negative appendectomy rate was 7.86% in our study which has decreased since advent of FACT. Total complication rate was 6.37%, there is rising trend in overall complications of laparoscopic appendectomy over time.

 

Conclusion: Laparoscopic appendectomy has become the preferred method of choice in our institution. Results showing improvement in terms of duration of surgery, conversion rate and negative appendectomy rates in addition to all previous known advantages of cosmetics, early recovery, decrease in hospital stay. Our results showing increase in number of complications, but it is reflection of the fact that more complex cases are now being attempted and completed laparoscopically. 

 

90.14 Short-term Outcomes of Patients with Benign Colon Polyps Managed by Combined Endo-Laparoscopic Surgery (CELS)

Posted on January 26, 2017

M. Qi1, M. Kiely1, L. Chen1, J. Yoo1  1Tufts Medical Center,Colon And Rectal Surgery,Boston, MA, USA

Introduction: Despite advanced endoscopic techniques, some benign-appearing colon polyps are not removable endoscopically.  Surgical resection is typically recommended, even though the majority of these polyps do not contain cancer.  Combined Endo-Laparoscopic Surgery (CELS) is emerging as an alternative to bowel resection in this setting.  Simultaneous laparoscopy with CO2 colonoscopy may increase the chance of successful polyp removal without the need for a bowel resection.  However, short-term outcomes regarding this technique have not been widely reported.  Our goal was to review the CELS experience at our institution and evaluate short-term outcomes.

Methods: This is a single institution, retrospective analysis of all patients who underwent CELS from December 2014 to August 2016.  Patient demographics, operating room characteristics, pathology, and post-operative outcomes were analyzed on an intention to treat basis.

Results:We identified 11 patients with endoscopically unresectable polyps who underwent an attempted CELS procedure from December 2014 to July 2016.  Of these 11 patients, 10 (91%) had successful polyp removal using the CELS technique. One patient had a fixed polyp that required a laparoscopic right colectomy.  Her pathology was consistent with a tubular adenoma.

For all patients, the mean operating room time was 180 ± 58 min, and the median length of stay was 1 day (range 0-3 days).  Post-operative complications occurred in 1 patient, who developed a post-polypectomy bleed following resumption of anti-platelet therapy.  Of the 10 patients who had a successful CELS procedure, 9 of these polyps were ultimately benign (90%) and adenocarcinoma was present in one.  This patient underwent a laparoscopic right colectomy 12 days later.  The final pathology was consistent with a T1N0 cancer (0/20 lymph nodes). 

Conclusion:The endoscopic and surgical management of benign colon polyps continues to evolve.  CELS may be an alternative to bowel resection in select patients, and may be associated with improved patient outcomes and lower morbidity.  The inability to accurately determine the presence of cancer in these polyps is a limitation to this approach, and requires a thoughtful pre-operative discussion regarding the need for additional surgery following CELS. 
 

90.13 Outcomes of Inguinal Hernia Repair with Local Anesthesia vs General Anesthesia: Case Series

Posted on January 26, 2017

M. S. Sultany1, V. Jain1, J. Imran1, S. Huerta1,2  1University Of Texas Southwestern Medical Center,Department of Surgery,Dallas, TX, USA 2VA North Texas Health Care System,Department Of Surgery,Dallas, TX, USA

Introduction:

Inguinal hernia repair (IHR) is typically performed under general anesthesia (GA). However, in select patients who are high-risk for surgery under GA, repair under local anesthesia (LA) can be performed safely. There is a paucity of data comparing the outcomes of IHR with either LA or GA. The objective of this study is to compare operative time and postoperative outcomes of patients undergoing IHR with LA to those under GA.

Methods:

A retrospective review of patients undergoing IHR from 2005-2016 was performed. Patient cohorts were divided into those undergoing IHR with either LA or GA. Patient demographics, preoperative data, operative time and postoperative outcomes were analyzed using chi-square test for categorical data and Student’s t-test for continuous variables. 

 

Results:

A total of 931 patients were included in the study, of which 858 patients out of 931 (92 %) underwent IHR with GA and 73 patients (8 %) with LA. Patients undergoing IHR with LA had a higher mean age (68 years vs. 60 years). On univariate analysis, there were no differences in postoperative outcomes such as inguinodynia (1.8 % vs. 1.3 %, p = 0.78), recurrence rate (7.4 % vs. 9.5 %, p = 0.85) and hospital length of stay (0.373 vs. 0.057 days, p = 0.30) for those undergoing IHR with GA versus LA. In addition, there were no differences between groups with respect to the type of inguinal hernia (bilateral, unilateral or incarcerated), body mass index, American Society of Anesthesiologists (ASA) class or operative time.

Conclusion:

There is no difference in operative time, rate of inguinodynia, recurrence or hospital length of stay between patients undergoing IHR with either LA or GA. IHR with LA should be considered in select patients who are high-risk for surgery under GA. 

 

90.12 Optimizing Follow-up in Post-operative Parathyroidectomy Patients

Posted on January 26, 2017

S. R. Brown1, N. Bhutiani1, A. R. Quillo1  1University Of Louisville,Department Of Surgery, Division Of Surgical Oncology,Louisville, KY, USA

Introduction: Patients undergoing parathyroidectomy for primary hyperparathyroidism require long-term follow-up to adequately assess for cure of their disease.  For many of these patients, committing to repeated follow-up appointments, particularly 6 or 12 months after surgery, proves difficult.   The objectives of this study are to identify barriers to follow-up in patients undergoing parathyroidectomy for primary hyperparathyroidism, identify strategies to increase likelihood of follow-up, and sample patient interest in alternatives to traditional clinic visits. 

Methods: 98 patients undergoing parathyroidectomy between December 2012 and June 2015 who had both mailing address and working telephone number were identified.  These patients were sent a survey via mail regarding factors potentially influencing their ability to keep follow-up appointments and their attitudes towards alternative means of follow-up.  Survey results were tabulated and analyzed to identify factors affecting follow-up and potential alternatives.

Results: A total of 21 patients (21%) responded to the survey.  Patients lived an average of 22.6 miles from the surgery clinic offices in downtown Louisville (range 1 to 80 miles).  12 patients (57%) attended scheduled follow-up visits.  Of those patients that did not attend these visits, the majority (67%) cited being unaware of or forgetting their appointment as the reason for their absence.  Most patients stated that they still prefer a face-to-face visit with their surgeon for follow-up, though patients living greater than 35 miles from downtown Louisville and those with disabilities noted a preference for a telephone or videoconference based follow-up.

Conclusion: A number of patient-specific factors represent barriers to long-term surgical follow-up in patients undergoing parathyroidectomy for benign disease, including patient awareness, distance to tertiary referral center, and logistic considerations.  For patients with such considerations, maintaining close communication with patients’ endocrinologists and primary care providers represents a potentially effective strategy to ensure long-term cure of their hyperparathyroidism.        

 

90.11 Preoperative Esophageal Disease Increases Morbidity in Patients Undergoing Abdominal Surgery

Posted on January 26, 2017

A. Ramirez1, A. Tilak1, M. Sohn1, F. Turrentine1, R. S. Jones1  1University Of Virginia,School Of Medicine,Charlottesville, VA, USA 2University Of Virginia,School Of Medicine,Charlottesville, VA, USA

Introduction:  In North America the prevalence of gastroesophageal reflux disorder ranges from 18.1% to 27.8%. We measured the risks posed by preoperative esophageal disease to patients undergoing abdominal operations.

Methods:  2005-2014 ACS NSQIP data were merged with institutional Clinical Data Repository records to identify esophageal disease in surgical patients. Patients with gastro-esophageal reflux disorder, esophageal stricture, spasm, and diverticuli were categorized as having ‘mild-moderate’ disease while patients with achalasia, esophagitis, reflux esophagitis, esophageal ulcer, Barrett’s esophagus, and multiple diagnoses were categorized as having ‘severe’ disease. Thirty-day postoperative mortality and morbidity were modeled as a function of disease severity, adjusting for NSQIP risk of mortality or morbidity, demographic factors (age, sex, race/ethnicity), NSQIP targeted procedure groups, and open surgery indicator.

Results: Of 22,098 patients, 21.1% had preoperative esophageal disease (15.6% mild-moderate and 5.5% severe). Age, male sex, and African-American race were associated with postoperative morbidity in patients with esophageal disease (OR = 1.02, p < 0.001; OR = 1.41, p < 0.000; OR = 1.12, p < 0.032), respectively. Patients undergoing open procedures were more likely to have complications (OR = 2.55, p < 0.001). After adjustment, patients with preoperative mild-moderate and severe esophageal disease were 14% and 27% more likely to experience postoperative complications than patients without esophageal disease (p=0.034 and p=0.046), respectively. Esophageal disease was not associated with postoperative mortality.

Conclusion: Preoperative esophageal disease significantly increased the risk of postoperative complications. Surgeons should use increased caution with esophageal disease patients undergoing abdominal operations. 

 

90.10 Can clinical evaluation determine the need for pelvic x-ray in awake and stable blunt trauma patients?

Posted on January 26, 2017

M. Moosa1, I. Jangda1, H. Zafar1  1Aga Khan University Hospital Karachi,Department Of Surgery,Karachi, SINDH, Pakistan

Introduction:  Pelvic fractures is common and can be potentially life threatening.  The early diagnosis of pelvic fractures resulting from blunt abdominal trauma traditionally relies on the anterior-posterior pelvic radiograph although sometimes it may not give a definitive diagnosis of pelvic fractures. So reliability of pelvic x-ray has been questioned and ways of removing pelvic x-ray from the ATLS protocol are being observed on the basis of finding the reliability of clinical examination in finding out pelvic fractures in alert and awake, hemodynamically stable patient and also to avoid the unnecessary exposure of radiation and reduce the financial burden.

Methods:  This is a cross sectional study conducted in the department of surgery, Aga Khan University Hospital, Karachi. This study included patients with blunt trauma mainly the road traffic accident victims presenting the emergency department with GCS of 15, hemodynamically stable and alert and awake. Clinical examination of pelvis of these patients were done on three different examination maneuvers and assessment of pelvic made which was then compared to routine pelvic x-ray findings.

Results: 

Total of two twenty one (221) of blunt  trauma patients were reviewed having mechanism of injury being road traffic accident and history of fall. Of these 221 patients thirty two (32) were not entered in the study as they had GCS of < 15, fifteen patients were not included as they have abdominal tenderness, fourty one (41) patients had associated lower limb injuries. So the final of one thirty three (133) patients were included in our study. Of these 133 patients majority of patients were male around 91.7% and 8.9% were females. Mean age of patients included in this study 37 with standard deviation of +/- 14.2. Fourteen patients were positive for pelvic fracture on clinical examination and positive on PXR categorized as true positive (TP), fourteen patients were positive for pelvic fracture on clinical exam but negative on PXR and categorized as false positive (FP), two patients were negative for pelvic fracture on clinical exam but positive on PXR categorized as false negative (FN), one hundred and three patients were negative for pelvic fracture both on clinical exam and PXR and were labelled as true negative (TN).

Sensitivity, Specificity, Positive predictive value and Negative predictive value were calculated by using two X two table. Sensitivity of clinic examination was found to be 87.5%, Specificity 88.03%, Positive Predictive Value 50% and Negative predictive value 98.09%.

Conclusion: In relation to above mention findings new protocol can be advised for alert and awake patients and pelvic x-ray can be avoided helping in reducing the financial burden to patient, reducing emergency hassle and unnecessary radiation.  

90.09 Risk Factors Associated with Post Hemi – Closed Hemorrhoidectomy Secondary Hemorrhage

Posted on January 26, 2017

E. Inoue1,2, Y. Shimojima1, M. Matsushima1  1Matsushima Hospital,Coloproctology Center,Tobe Honcho, YOKOHAMA, Japan 2Yokohama City University Medical Center,Inflammatory Bowel Disease Center,Urafune, YOKOHAMA, Japan

Introduction:

Posthemorrhoidectomy secondary hemorrhage (PHSH) is a rare but serious complication after hemorrhoidectomy. The aim was to identify risk factors for this complication and that may provide information to improve outcome.

Methods:

We studied 1813 patients who underwent  hemi – closed hemorrhoidectomies in a single institution between January and December 2015. The hemi – closed hemorrhoidectomy is a most common procedure in  Japan. That is subsequently Millligan-Morgan procedure, close anal canal wound with a continuous suture to anal verge, it’ on this point that this procedure is different from Ferguson’s one. The hemi – closed hemorrhoidectomy is purported to be a less painful and reduce the wound infection rate. 50 patients were developed PHSH (PHSH group), whereas the remainder were classified to the non-PHSH group. The variables analyzed included age, gender, the required time for defecation, Goligher grade, anticoagulant agents, suture materials, operation time, intraoperative bleeding, and number of hemorrhoid excisions for each patient. The logistic regression model was used to assess the independent association of variables with PHSH.

Results:

Among the all patients, 50 developed PHSH (2.76%), and the mean period between operation and PHSH was 8.1 ± 4.8 days. Multivariate analysis revealed that patient’s gender, intraoperative bleeding, and number of hemorrhoid excisions for each patient were independently associated with risk of PHSH. Male patients were more likely than females to develop PHSH (relative risk, 2.04 ; 95 percent confidence interval, 1.10-3.81 ; P < 0.001). Intraoperative bleeding was 62.7±89.4 (ml) in the PHSH group, whereas that was 30.2±39.6 (ml) in the non-PHSH group (relative risk, 1.01 ; 95 percent confidence interval, 1.00-1.01 ; P < 0.001).Under two hemorrhoid excisions for each patient were lower than three and more hemorrhoid excisions to develop PHSH (relative risk, 0.40 ; 95 percent confidence interval, 0.22-0.73 ; P < 0.001).

Conclusion:

Our data suggest that the male patients, the amount of intraoperative bleeding, and more than three hemorrhoid excisions are highly correlated with this risk.

 

90.08 Spontaneous Enterocutaneous Fistula Closure Rates Improve with Standardization of Treatment.

Posted on January 26, 2017

S. Boateng1, N. Kugler1, C. Trevino1  1Medical College Of Wisconsin,Surgery – Division Of Trauma & Critical Care,Milwaukee, WI, USA

Introduction:  Enteric fistulae, an abnormal communication between the lumen of the gastrointestinal tract and the skin, are a devastating complication that can occur following abdominal surgery. Unfortunately, standardized care of these complex patients has not been implemented at the majority of tertiary hospitals. Thus we sought to evaluate the benefit of an evidence based clinical treatment protocol for enteric fistulae. We hypothesized that standardized treatment would increase spontaneous enteric fistulae closure rates and decrease hospital length of stay.

Methods:  We conducted a retrospective review of patients with an enterocutaneous fistula managed by the Division of Trauma and Acute Care Surgery at a tertiary academic medical center. Patients managed prior to implementation of a standardized treatment protocol were considered the control group for those patients managed post protocol implementation. A review of all eligible patient’s hospital and clinic medical records was performed to obtain data collection. The primary outcome of the trial was time to successful non-operative closure. Secondary outcomes included compliance with all elements of the treatment protocol and inpatient length of stay. Inpatient length of stay was determined from time of fistula identification to discharge, for those transferred to our facility length of stay is from time of admission to our facility to discharge.

Results: A total of 18 patients with enterocutaneous fistula managed by the multidisciplinary team were identified over 4 1/2 years with six control patients identified over the first half of this time period. The control group patients had a spontaneous closure rate of 16.7% with four of the remaining five undergoing operative closure, one patient was not offered operative intervention due to extensive medical co-morbidities. The mean length of stay within the control group was 37.5 days (Range 16-67 days). Twelve patients were managed utilizing the protocol with a spontaneous closure rate of 83% noted within this cohort, the remaining two patients within this cohort required operative closure. The mean length of stay post protocol implementation was 13.8 days (Range 4-28 days).

Conclusion: Implementation of a enterocutaneous fistula management protocol focusing on multidisciplinary management provides significant advantages for patients through improved spontaneous closure rates and decreased hospital length of stay.
 

90.07 Adaptation of a Transitional Care Protocol to Reduce Readmissions after Complex Abdominal Surgery

Posted on January 26, 2017

A. V. Fisher5, S. A. Campbell-Flohr5, L. Sell4, E. Osterhaus4, A. W. Acher5, K. Leahy-Gross4, M. Brenny-Fitzpatrick4, A. J. Kind6, P. Carayon7, D. E. Abbott5, E. R. Winslow5, C. C. Greenberg5, S. W. Weber5  4University Of Wisconsin Hospital And Clinics,Madison, WI, USA 5University Of Wisconsin,Department Of Surgery,Madison, WI, USA 6University Of Wisconsin,Department Of Medicine,Madison, WI, USA 7University Of Wisconsin,College Of Engineering,Madison, WI, USA

Introduction: Readmission is common after complex abdominal surgery, occurring in up to 30% of patients. While transitional care protocols are effective at decreasing readmission for medical patients, there is no evidence-based protocol for surgical patients.

Methods: The Coordinated Transitional Care Protocol (C-TraC), initially designed for medical patients, was used as the initial framework for the development of a surgery-specific protocol. Adaption was accomplished using a modified Replicating Effective Programs (REP) model developed by the Center for Disease Control. Hospital system characteristics, pre-existing resources and discharge processes, as well as clinical and social factors specific to surgical patients were first documented. Key-informant interviews were conducted with members of the medical C-TraC team, surgeons, nurses, and clinical team leaders in order to identify core elements of the pre-existing C-TraC protocol, align these elements within the health system and surgical context, and adapt the protocol with multi-disciplinary buy-in. Following this, specialized nurses were trained and the surgical C-Trac (sC-TraC) protocol was launched for high-risk surgical patients. Protocol refinement was accomplished by stakeholder meetings on a biweekly basis to perform rapid iterative adaptations.

Results: Pre-implementation planning through multi-disciplinary engagement allowed for integration with current systems, avoided duplication of processes, and defined goals for the protocol. Findings from key-informant interviews led to several unique elements that were incorporated into the sC-TraC protocol, including pre-discharge identification of red-flag symptoms, a standardized list of questions for follow-up phone calls to detect complications, and identification of unique outpatient resources to manage complications as an outpatient. These elements were intended to specifically address surgical issues such as nutrition, fever, ostomy output, dehydration, drain character, and wound appearance. The protocol maintained elements such as a pre-discharge meeting and inpatient integration by the transitional care nurse. After sC-TraC launch, the rapid iterative adaptation process led to changes in phone call timing, inclusion and exclusion criteria, and discharge instructions. The program was received well by patients with only 3 of 297 (1.0%) patients refusing enrollment, and 278 of 294 (95%) enrolled patients reaching full engagement with post-operative phone calls. Survey results from a random patient sample showed 100% overall satisfaction with the transitional program.

Conclusion: This transitional care protocol is the first to be specifically adapted to surgical patients, which occurred using a modified REP model and resulted in multi-disciplinary buy-in, low refusal rates, and high patient engagement and satisfaction. This adaptive process could be used to implement transitional care protocols at other program sites.

 

90.06 Prolonged Stay After Colectomy: Does Reason Differ Between a County and University Hospital?

Posted on January 26, 2017

D. F. Butler1, J. Anandam1, B. Williams1, S. C. Oltmann1  1University Of Texas Southwestern Medical Center,Colorectal Surgery,Dallas, TX, USA

Introduction:  

The National Surgical Quality Improvement Program (NSQIP) defines a prolonged length of stay (LOS) after colectomy as greater than 6 days, and uses this as a marker for quality of care. Causes for prolonged LOS can vary from medical to social, and understandably can be influenced by patient access to resources for post-hospital care. Protocol driven care may aid in overcoming those discrepancies. The aim of this study was to compare the rate of prolonged LOS after colectomy at a county hospital (CH) to a university hospital (UH), and evaluate the underlying factors contributing to the prolonged LOS. 

Methods:  
NSQIP participant user files from October 2014 to December 2016 from the CH and affiliated UH were utilized to identify all patients captured by respective institutional NSQIP, who underwent colectomy. During this time period, enhanced recovery pathways (ERP) were in place and operational at both institutions. Patients were flagged as prolonged LOS as defined by NSQIP. Charts were reviewed to determine the primary cause of increased LOS on post-operation day 6, and classified as ileus, leak or intra-abdominal abscess (IAA), surgical site infection (SSI), other infection, hemorrhage, medical complication or disposition planning.

Results:
The cohort included 239 patients, 57 from CH and 182 from UH.  There was no statistically significant difference between the number of patients with prolonged LOS between the university and county setting, 37% vs 33% (p=0.75).  The reasons for increased LOS were equivalent at both locations.  Notable differences were apparent in an increased number of Hispanic (30% vs 8%, p<0.001) and African American (42% vs 9%, p<0.001) patients at the county hospital.  Other demographic variables such as BMI, gender and age were similar.  Tobacco use was also increased at the community hospital (39% vs 13%, p<0.001).  All other NSQIP defined comorbidities were equivalent.  There was no difference in emergent case status.  An ERP was in place at both institutions, with usage of 55% at UH and 69% at CH (p=0.072).  Of those patients on an ERP, 3 total patients from UH (4.5%) and 6 total patients from CH (15%) had a prolonged LOS (p=0.003).

Conclusion:
Despite different practice environments, there were no statistically significant differences in the reasons for prolonged LOS between a large charity county hospital and a tertiary university hospital.  In this case the treating physicians practice at both locations and practice patterns can be somewhat standardized despite differences in available resources at the two locations.  This fact may account for the equivalence in both locations.  Additionally, both a large county hospital and a university hospital may be subject to a disproportionately higher volume of more complex patients based on their referral and transfer patterns accounting for increased LOS.  The difference in ERP usage between the two institutions is likely the result of a more inclusive program at the CH.
 

90.05 A Site-Specific Approach to Reducing ED Visits Following Bariatric Surgery

Posted on January 26, 2017

H. Abdel Khalik1, H. Stevens1, A. M. Carlin2, A. Stricklen1, R. Ross1, C. Pesta3, A. Ghaferi1  1University Of Michigan,General Surgery,Ann Arbor, MI, USA 2Wayne State University,Detroit, MI, USA 3McLaren Macomb Hospital,Mt. Clemens, MI, USA

Introduction:
Many emergency department (ED) visits following bariatric surgery do not result in readmission and may be preventable. Little research exists evaluating the efficacy of perioperative measures aimed at reducing ED visits in this population. Therefore, understanding the driving factors, such as patient and hospital characteristics, behind these preventable ED visits may be a fruitful approach to prevention. Furthermore, evaluating the efficacy of current perioperative measures may shed light on how to achieve meaningful reductions in ED visits.

Methods:
We studied 48,035 eligible patients who underwent bariatric surgery at across 37 Michigan Bariatric Surgical Collaborative (MBSC) sites between January 2012 and October 2015. Hospitals were ranked according to their risk-and reliability-adjusted ED visit rates. For hospitals in each ED visit rate tercile, several patient, surgery and hospital summary characteristics were compared. We then studied whether a hospital’s compliance with specific perioperative measures was significantly associated with reduced ED visit rates.

Results:
We found that only three of the 30 surgery, hospital, and patient summary characteristics studied were significant predictors of a hospital’s ED visit rate: rate of sleeve gastrectomies, rate of readmissions, and rate of VTE complications (p= 0.04, p=0.0065 and p=0.0047, respectively). Also, a hospital’s compliance with the perioperative measures evaluated was not a significant predictor of ED visit rates (p=.12).

Conclusion:
Current practices aimed at reducing ED visits appear to be ineffective. Due to heterogeneity in patient populations and local infrastructure, a more tailored approach to ED visit reduction may be more successful.
 

90.04 Weight-based Perioperative Antibiotics Dosing and Surgical Site Infection After Colectomy

Posted on January 26, 2017

J. J. Cedarbaum1, L. Ly1, R. Anand1, A. Hjelmaas1, Y. Chen1, S. Collins1, S. Regenbogen1  1University Of Michigan,University Of Michigan Health System,Ann Arbor, MI, USA

Introduction:
Obesity is a substantial risk factor for surgical site infections (SSIs). Antibiotic prophylaxis guidelines recommend weight-based dosing as one way to mitigate this risk. However, there is little clinical evidence to support this practice, and data on compliance is rarely collected in clinical registries. Using data from a population-based, statewide collaborative, we sought to evaluate the association between appropriate weight-based perioperative antibiotic dosing and the risk of SSI after colectomy.

Methods:
From a retrospective cohort from 73 hospitals in the Michigan Surgical Quality Collaborative (MSQC), we included all patients who underwent elective colectomy between 2012 and 2015. The primary outcome was the development of SSI within 30 days of surgery. SSI rates were compared between patients who did and did not receive compliant weight-based dosing.

Results:
Of the 4,801 patients included, 4,627 (96%) had appropriate weight-based dosing of perioperative antibiotics. Patients who received proper weight-based dosing had an overall SSI rate of 6.2% while those who did not receive weight-based dosing had an observed SSI rate of 9.8% (p=0.15). When evaluating only patients requiring dose-adjustment (those weighing in excess of 80kg, N=2,179), observed SSI rates were 6.9% with compliant weight-based dosing, versus 9.8% for non-compliant dosing (p=0.17). In post-hoc power analysis, there was only 30% power to detect this magnitude of difference in SSI rates for the >80kg subset.

Conclusion:
Weight-based dosing is already commonly used among MSQC hospitals. As a result of the small proportion of patients in the non-compliant dosing group, we did not detect a statistically significant reduction in the incidence of SSI among those with appropriate antibiotic dosing, although the relative risk of SSI was 30% less. As additional data on weight-based dosing compliance becomes available in MSQC we will return to this important question in order to make a more convincing determination as to the efficacy of this practice.
 

90.03 Severity of Diverticulitis in Patients with Polycystic Kidney Disease

Posted on January 26, 2017

M. Parker1, S. Kelley1, K. Mathis1  1Mayo Clinic,Surgery,Rochester, MN, USA

Introduction: Patients with polycystic kidney disease (PKD) who have had a kidney transplant have an increased risk of complicated diverticulitis compared to those who have had a transplant for other reasons. There is limited published literature regarding the risk of diverticulitis in patients with PKD who have not had a transplant.

Methods: We carried out a retrospective review of patients with PKD who were evaluated for diverticulitis in our system between January 2000 and June 2016. Patients were identified using ICD-9 and ICD-10 diagnosis codes. The electronic medical record was reviewed to obtain patient demographics, imaging, laboratory investigations, treatment course and outcomes. Patients without both documented polycystic kidney disease and diverticulitis in the electronic medical record were excluded. We compared patients who were status-post renal transplant at the time of diagnosis of diverticulitis, to patients with PKD and diverticulitis who did not have a renal transplant. Fisher’s exact test was used to compare categorical variables.

Results: Forty-one patients with PKD treated for diverticulitis were identified. Mean age was 60 (± 12), and 56% were female. Thirteen patients had undergone renal transplant. All transplanted patients had functioning allografts at the time of evaluation for diverticulitis (mean GFR 62). Mean GFR for non-transplant patients who were not on hemodialysis was 40. Three patients were on hemodialysis. Twenty-one percent of non-transplant patients had complicated diverticulitis, compared to 38% of transplanted patients (p=0.28). Fifty-four percent of patients in each group had recurrent diverticulitis either with a history of prior episodes reported by the patient, in health records from referring institutions, or with multiple episodes treated at our institution (p=1.0). There was one in-hospital death in each group. Thirty-two percent of non-transplant patients underwent operation, compared to 46% of transplanted patients (p=0.49). One patient in the non-transplant group underwent Hartmann procedure, and 8 underwent sigmoid resection with primary anastomosis without diversion. In the transplanted group, 2 patients underwent Hartmann procedure, one underwent sigmoid resection with diversion, and 3 underwent sigmoid resection with undiverted primary anastomosis.

Conclusion: In our group of patients, there is no statistically significant difference in rate of recurrent diverticulitis, complications from diverticulitis, or operative intervention in patients with PKD status-post renal transplant compared to those with PKD and no transplant.

 

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