14.07 Delta-MELD and Outcomes in Emergency Surgery

Posted on January 25, 2017

M. L. Kueht1, E. Godfrey1, Z. Pallister1, S. Awad1  1Baylor College Of Medicine,Houston, TX, USA

Introduction:  The concept of delta MELD, the change in MELD score over a certain time period, has been shown to be a predictor of waitlist mortality, but not post-operative outcomes in liver transplantation. Liver transplantation is unique in that it improves liver function and transplant patients are generally free from significant cardiac disease; we sought to explore the effect of changing MELD scores on outcomes in non-transplant surgery.

Methods: We conducted a retrospective analysis of all emergency surgeries on patients with documented cirrhosis at the MEDVAMC between 2001 and 2012.  Delta MELD was calculated as the difference between MELD on the day of surgery (acute MELD) and a MELD calculated between 7 days and 9 months prior to the operation. Univariate analysis was used to identify predictors of 30-day mortality, intra- and post-operative complications, and disposition after discharge.

Results:Overall 30-day mortality was 15%.  Predictors of mortality were congestive heart failure (OR 5.57), serum creatinine on the day of surgery (OR 3.39), acute MELD (OR 1.43), and delta MELD (OR 1.34). The most common complication was the need for transfusion (39%).  Predictors of intraoperative complications were congestive heart failure (OR 9.32), coronary artery disease (OR 6.0), intra-abdominal surgery (OR 3.8), delta MELD (OR 1.23), and acute MELD (OR 1.19). Predictors of post-operative complications were intra-abdominal surgery (OR 3.92) and delta MELD (OR 1.22). 50% of patients needed transitional care.  Negative predictors of being discharged to home were INR on the day of surgery (OR 0.05), and acute MELD (OR 0.78).

Conclusion:Delta MELD and acute MELD performed equally well as predictors of intra-operative complications and 30-day mortality. However, only acute MELD was associated with the need for transitional care and only delta MELD was associated with post-operative complications.  The fact that the delta and acute MELD scores were predictive of different aspects of hospitalization suggests both may be of benefit in preparing for the logistics of emergency surgery in cirrhotic patients.

14.06 Should We Be Using More Home Health After Gastrointestinal Surgery?

Posted on January 25, 2017

C. Balentine1,2, G. Leverson3, D. J. Vanness3, S. J. Knight4, J. Turan5, C. J. Brown6,7, G. D. Kennedy1, H. Chen1, S. Bhatia2  1University Of Alabama At Birmingham,Surgery,Birmingham, AL, USA 2University Of Alabama At Birmingham,Institute For Cancer Outcomes And Survivorship,Birmingham, AL, USA 3University Of Wisconsin,Wisconsin Surgical Outcomes Research,Madison, WI, USA 4University Of Alabama At Birmingham,Department Of Preventive Medicine,Birmingham, AL, USA 5University Of Alabama At Birmingham,School Of Public Health,Birmingham, AL, USA 6University Of Alabama At Birmingham,Birmingham/Atlanta VA GRECC,Birmingham, AL, USA 7University Of Alabama At Birmingham,Department Of Medicine, Division Of Gerontology, Geriatrics & Palliative Care,Birmingham, AL, USA

Introduction: Post-acute care services such as home health, skilled nursing facilities, and inpatient rehabilitation play an important role in postoperative recovery.  Recent studies have questioned our ability to identify which setting best addresses each patient’s needs.  The purpose of this study is to evaluate whether patients discharged to skilled nursing facilities or inpatient rehabilitation could also be candidates for home health referral and vice versa, and to calculate potential savings from greater utilization of home health.  We hypothesized that a significant number of patients discharged to skilled nursing or rehabilitation would be similar to patients sent home with home health.

Methods: We analyzed 54,015 patients who were discharged with post-acute care after colectomy, pancreatectomy or hepatectomy from 2008-2011 in the Nationwide Inpatient Sample.  The primary endpoint was the proportion of patients discharged to skilled nursing facilities or inpatient rehabilitation who had an equivalent patient discharged home with home health.  This was determined by propensity score matching based on demographics, co-morbidity, postoperative complications, length of stay, predicted mortality, and insurance.  A secondary outcome was potential cost savings based on average Medicare costs.

Results: A total of 30,843 patients were discharged home with home health and 23,172 were discharged to skilled nursing facilities or inpatient rehabilitation. 66% of patients discharged home with home health were  ≥60 years old, compared to 90 % of the skilled nursing/rehabilitation group (p<0.001) and 70% of both groups were white.  14,163 (61%) patients discharged to skilled nursing or inpatient rehabilitation could be matched to an equivalent patient discharged home with home health. The matched populations did not show any differences in age, race, gender, insurance status, co-morbidity, postoperative complications, length of hospital stay, or predicted mortality (standardized difference <10%).  Potential cost savings from treating at home rather than in skilled nursing or inpatient rehabilitation facilities ranged from $2.5 million to $438 million annually. Potential savings varied based on a two-way sensitivity analysis varying the percentage of the 14,163 patients treated at home and estimated cost differences between home health and skilled nursing or inpatient rehabilitation.

Conclusion: Many gastrointestinal surgery patients discharged to skilled nursing facilities and inpatient rehabilitation are similar to patients treated at home with home health.  This may indicate the potential for significant cost savings by increasing use of home health, but it is also possible that patients sent home with home health might have benefited from discharge to skilled nursing facilities or rehabilitation.  There is an urgent need for evidence-based guidelines to help surgeons match patient needs to post-acute care setting after surgery.

 

14.05 Implications of IBD Status on Post-Colectomy Outcomes for the Value-Based Purchasing Program

Posted on January 25, 2017

Y. Chen1, R. Anand1, L. Ly1, J. Cedarbaum1, A. Hjelmaas1, S. Collins2, S. Regenbogen2  1University Of Michigan,Medical School,Ann Arbor, MI, USA 2University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction:
For Value-Based Purchasing (VBP) and public reporting of surgical outcomes to fairly reflect performance, hospital-based metrics of postoperative complications require balanced comparisons between hospitals. Colectomy is a central component of the Hospital Acquired Infections VBP metric, yet there is no attempt to account for differences in the indication for surgery. Using data from a population-based, statewide collaborative, we sought to understand what influence inflammatory bowel disease (IBD) might have on outcomes after colectomy, and how a greater share of IBD surgery might alter a hospital’s performance score. 

Methods:
This retrospective cohort study draws on data collected from the Michigan Surgical Quality Collaborative (MSQC), a network of 73 Michigan hospitals that prospectively collects data on surgical patient characteristics and outcomes. Among patients who underwent elective colectomy between 2012 and 2015, we compared rates of surgical site infection (SSI), bleeding, sepsis, and urinary tract infection (UTI) for those with IBD, compared with other indications, using chi-square tests for proportions.

Results:
Among the 7271 colectomy patients evaluated, the 297 with IBD had significantly higher rates of organ space SSI (6.7% vs. 2.6%, p<0.0001) and bleeding (8.4% vs. 5.7%, p=0.05). IBD patients also had higher, but not statistically different rates of superficial SSI (5.4% vs. 3.7%, p=0.15), deep SSI (2.0% vs. 1.1%, p=0.12), and sepsis (6.1% vs. 4.1%, p=0.11). There was no difference in the rate of UTI (p=0.97).

Conclusion:

Among patients in the MSQC who underwent non-emergent colectomy, those with IBD had significantly higher rates of organ space SSI and postoperative bleeding. Recognizing that organ space SSI is a core component of VBP metrics, and postoperative bleeding is an Agency for Healthcare Research and Quality endorsed Patient Safety Indicator, hospitals that specialize in the care of IBD may be unjustly identified as high outliers for these and other postoperative adverse events. These findings highlight the importance of detailed risk assessment in surgical outcomes evaluation, especially when it may determine reimbursement penalties.

14.04 Development of a Reference Population for Assessment of Surgical Patient Frailty and Fragility

Posted on January 25, 2017

R. L. Goulson1, C. M. Harbaugh1, P. E. Rabban1, A. R. Peltier1, N. C. Wang1, G. L. Su1, M. J. Englesbe1, B. A. Derstine1, S. C. Wang1  1University Of Michigan,Surgery,Ann Arbor, MI, USA

Introduction:  

Surgeons care for a highly variable patient population whose body composition has a very significant influence on their response to disease/injury and treatment.  Analytic morphomics measures very detailed geometry and material characteristics for tissues, organs and bones throughout the body using high-throughput automated processing of medical imaging scans.  We have previously reported that factors such as psoas muscle size are highly predictive of clinical outcomes following surgery (i.e. how frail patients are).  Analysis of real-world motor vehicle crash cases has demonstrated that morphomic characteristics are highly significant in whether an individual sustains injuries in a motor vehicle crash (i.e. how fragile patients are).  The objective of this research was to define the population distribution of morphomic factors that have been identified to be significantly predictive of patient fragility and frailty in surgical populations.

Methods:  

Chest, abdomen, and pelvis CT scans were collected from over 4700 patients, aged 16 to 91 years, who were scanned for trauma indications.  Customized software was used to perform automated processing of these CT scans and to measure detailed body geometry and composition data in an anatomically-indexed format.  Morphomic measures altered by injury were excluded.

Results: 

Quantile regression was performed to generate curves of morphomic factors corresponding to the 5th, 25th, 50th, 75th, and 95th percentiles from ages 16-91 for both men and women.  

Conclusion: 

We have curated and analyzed a large Reference Analytic Morphomic Population (RAMP) that serves as an excellent control population to determine the effect of body composition on clinical outcome.  Motor vehicle crashes affect a large and generally random portion of the population, including many individuals who are otherwise healthy.  We utilized the CT scans obtained during their trauma evaluation for morphomic analysis and determined the population distribution of body composition and geometry factors that have previously been shown to influence clinical outcome following surgery (frailty) as well as the severity of injuries an individual sustains in a motor vehicle crash (fragility). 

 

14.03 Trends in Emergency General Surgery Interhospital Transfers in the United States

Posted on January 25, 2017

C. E. Reinke1, M. Thomason1, L. Paton1, L. Schiffern1, N. Rozario2, B. D. Matthews1  1Carolinas Medical Center,Department Of Surgery,Charlotte, NC, USA 2Carolinas Medical Center,Dickson Advanced Analytics,Charlotte, NC, USA

Introduction: Emergency general surgery (EGS) admissions account for more than 3 million hospitalizations in the US annually. Patients who require surgery after transfer utilize additional resources and have higher acuity and worse outcomes. We aim to better understand the population of all transferred EGS patients and their subsequent care in a nationally representative sample.

 

Methods: Using the 2002-2011 Nationwide Inpatient Sample we identified patients age ≥18 years with an EGS non-cardiovascular principal diagnosis (AAST EGS DRG ICD-9 codes) who were transferred from another hospital with urgent or emergent admission status.  Patient demographics, hospitalization characteristics, rates of operation and mortality were identified.  Procedure codes were classified into surgery (broad) and procedures (narrow) based on the HCUP Surgery Flag definition.

 

Results: From 2002-2011 there were an estimated 525,913 EGS admissions that were transferred from another hospital. The mean age was 60 years, 51% were female, and over half of patients were Medicare patients. Over 10 years, EGS transfers increased from 1.2% of EGS admissions to 3.0% (Figure 1). More than half of the admissions were due to a HPB, Upper GI, or intestinal obstruction principal diagnosis. A surgery or procedure required for less than half of patients and remained steady over the time period (range 42-47%). Surgery was required for 33% of patients and a procedure for 21% of patients.  On average, there were 2.7 days from admission to first procedure.  The most common surgeries were laparoscopic cholecystectomy, lysis of adhesions and wound debridement.  The most common procedure was endoscopic sphincterotomy, endoscopic removal of bile stone and endoscopic control of gastric hemorrhage.  The median length of stay was 4.4 days.  Mortality was 4.0% in patients who did not have a procedure and 4.4% in those that did.

 

Conclusions: The percent of patients with an EGS diagnosis requiring interhospital transfer is on the rise, which may reflect a trend towards regionalization of EGS.  Transfers require significant resources and may delay care.  More than half of the EGS patients did not require surgical intervention.  Future studies to identify populations who most benefit from interhospital transfer and ideal timing of transfer can identify opportunities for optimizing resource utilization and patient outcomes.  

14.02 The Impact of Missed Ambulation Events After Abdominal Hernia Surgery on Length of Stay

Posted on January 25, 2017

Y. A. Ghazi3, T. W. Stethen2, R. E. Heidel4, B. J. Daley1, L. G. Barnes4, J. M. McLoughlin1  1University Of Tennessee Medical Center,Surgery,Knoxville, TN, USA 2University Of Tennessee Health Science Center,Graduate School Of Medicine,Memphis, TN, USA 3University Of Tennessee,Biology,Knoxville, TN, USA 4University Of Tennessee Graduate School Of Medicine,Knoxville, TN, USA

Introduction:  ~~Enhanced recovery after surgery (ERAS) principles have recently been introduced in abdominal ventral hernia surgery. Early ambulation after surgery has been demonstrated to reduce complications and decreases length of stay (LOS).  This study evaluated the impact of missed and refused ambulation attempts on LOS among those undergoing abdominal hernia repair. 

Methods:  ~~From January 2014–December 2015, all patients who had undergone elective abdominal hernia repair were assigned a dedicated ambulation team with the goal of ambulating three times per day. Clinical data was collected prospectively and compared to similar cohorts from 2010 – 2013.  Statistical analysis of ambulation frequency, percentage of sessions completed and overall LOS was performed using Mann-Whitney U and Spearman’s rho. 

Results: ~~A total of 79 patients were analyzed undergoing a total of 82 hernia repairs. The age range was from 20 to 85 with a mean age of 60. All patients were ambulatory prior to surgery.  There were 74 laparoscopic abdominal procedures and 8 open abdominal procedures. The overall median LOS for all patients was 1.9 days. When ambulation did not occur for 24 hours, the median LOS increased from 1.4 days to 4.0 days (p < .001).  When patients refused to ambulate, the median LOS increased from 1.3 days to 4.1 days (p < .001).  As missed ambulation events increased for any reason, LOS increased (r = 0.3, p = .008). 

Conclusion: ~~A dedicated ambulation team with three times a day ambulation reduced LOS for those undergoing abdominal hernia repairs. Failure to ambulate had a significant impact on increasing length of stay. Investment in a dedicated ambulation team as well as emphasis on a daily ambulation regimen is effective in reducing cost for ventral hernia surgery.

 

14.01 Perforated Appendicitis in Octogenarians: One-Year Operative Outcomes

Posted on January 25, 2017

M. M. Symer1, J. Abelson1, T. Sun2, A. Sedrakyan2, H. Yeo1,2  1Weill Cornell Medical College,Surgery,New York, NY, USA 2Weill Cornell Medical College,Healthcare Policy And Research,New York, NY, USA

Introduction:  Appendectomy is one of the most common surgical procedures in the U.S., with up to 30% of patients presenting with perforation. Despite this, there is no consensus on the optimal surgical management of perforated appendicitis. Older adults have increased operative risk and may represent a subgroup of patients for whom ideal management differs from the general population. In older adults, timing of intervention, as well as the use of laparoscopy may be especially beneficial. We performed a large database analysis of outcomes in early versus delayed surgery for perforated appendicitis in octogenarians.

Methods:  We analyzed the New York Statewide Planning and Research Cooperative database, an all-payer, in- and out-patient database which captures all admissions and surgeries in New York State. ICD-9 codes were used to identify all patients ≥80 years old undergoing appendectomy for perforated appendicitis from 2000 to 2013. Primary outcome was any complication within one year of follow up. Secondary outcomes included length of stay, hospital charges, utilization of laparoscopy, and readmission rate. Outcomes were compared in patients undergoing appendectomy before or after 48h from admission.

Results: 1691 patients were identified for analysis, 1407(83.2%) of whom underwent early appendectomy. Patients undergoing delayed appendectomy were more likely to have a complication (71.5% vs 59.8%, p<0.01). Rates of laparoscopy utilization were low overall, particularly in the late appendectomy group (27.1% vs 33.5%, p<0.01). After multivariate adjustment, patients undergoing delayed surgery were more likely to have complications (OR 1.62 95%CI 1.19-2.19), high hospital costs (OR 3.22 95%CI 2.23-4.65), and a prolonged length of stay (OR 5.06 95%CI 3.54-7.24). The only complication more common in the early group was a cardiac complication, and overall rates of cardiac complications were low (7.2% vs 3.9%, p=0.04).

Conclusion: We present a population-level study of early versus late appendectomy in octogenarians with perforated appendicitis. The nonoperative approach is associated with fewer cardiac complications, but is associated with having any complication, longer length of stay, and higher cost. Laparoscopy use is low in older adults with perforated appendicitis, regardless of timing of intervention.

13.20 The Bifid Recurrent Laryngeal Nerve – Anatomical Details & Operative Implications

Posted on January 25, 2017

J. C. Lee1,2, A. Kiu1, P. Chang1, J. Serpell1,2  1The Alfred Hospital,Department Of General Surgery,Melbourne, VICTORIA, Australia 2Monash University,Endocrine Surgery Unit,Melbourne, VICTORIA, Australia

Introduction:  The identification and preservation of the recurrent laryngeal nerve (RLN) is paramount during thyroid surgery. Due to the slenderness of the branches, a RLN with an extralaryngeal bifurcation is at higher risk of intraoperative injury. When bifid, the motor fibres of a bifid RLN are located mainly in the anterior branch, and the sensory fibres in the posterior branch. However, it has not been documented whether the motor or sensory branch is likely to be thinner and therefore more prone to injury. This study aimed to measure the widths of the bifid RLN trunk and its branches, and to determine their possible associations with demographic factors. 

Methods:  This is a prospective observational study over 18 months at The Alfred Hospital, Melbourne, Australia, in patients undergoing thyroid surgery. The widths of the RLN trunk and branches were measured with Vernier calipers to the nearest 0.1 mm. Demographic data including age, gender, height, weight, and body mass index (BMI) were collected. Nerve widths were compared using Student’s t-test, and RLN widths and demographic data were correlated with Spearman correlation co-efficient (Stata 13).

Results: A total of 150 RLNs were eligible for inclusion during the 12-month study period. Of those, 34 bifid RLNs were identified in 32 patients, and therefore included in the analysis. The main RLN trunk had a mean width of 2.37 (range 1.7 – 4.0) mm. Whereas the mean widths for the anterior and posterior branches were 1.55 (0.8 – 2.5) mm and 1.33 (0.5 – 2.9) mm respectively. Both the anterior and posterior branches were significantly smaller than the main trunk (both p < 0.01). However, the branches were not statistically different from each other in their widths. Body weight and BMI positively correlated to the widths of both the anterior branch (p = 0.003 & p = 0.01 respectively) and posterior branch  (p = 0.02 & p = 0.04 respectively). There was no correlation between age, height and either the main trunk or branches of the RLN.

Conclusion: As expected, the width of the RLN trunk is significantly greater than either of the branches of a bifid RLN. The knowledge of this may help alert the thyroid surgeon to the possibility of a bifid RLN during the process of dissecting along the RLN. More importantly, the similarity in the widths of the branches suggests that it is not possible to determine if a fine nerve branch is likely to be the anterior (motor) or posterior (sensory) branch. Low body weights or BMI may be a clue to possible delicate RLN branches.

 

 

13.19 Postoperative Complications in Patients with Inflammatory Bowel Disease

Posted on January 25, 2017

S. Stringfield1, S. Ramamoorthy1, L. Parry1, S. Eisenstein1  1University Of California,Surgery,San Diego, CA, USA

Introduction:  Patients with Inflammatory Bowel Disease (IBD) are at high risk for postoperative complications. Many patients will receive anti-TNF medications or other biologic medications prior to surgery. There is still controversy as to whether anti-TNFs are associated with complications. Many new biologic medications have not been studied in surgical patients. The purpose of this study is to identify rates and types of postoperative complications in patients with IBD who have undergone abdominal surgery, and identify predictors of these complications. 

Methods:  Retrospective review of patients with IBD who underwent abdominal surgery at our institution June 2014-June 2016. Preoperative, perioperative, and postoperative data was collected. Categorical variables were analyzed using Fisher’s exact test or Chi-square test and continuous variables were analyzed using two sided t-test for independent means. Univariate and multivariate analyses were performed using binary logistic regression. 

Results: We identified 155 abdominal operations performed on IBD patients. Overall complication rate was 40%, with infectious complications the most common with rate of 27% overall. Univariate analysis showed predictors of complications to be age (p=0.028, OR 0.98), BMI (p=0.02, OR 0.93), recent weight loss (p=0.029, OR 2.12), and intraoperative blood loss (p=0.006, OR 0.996). Current use of any biologic medication was not a significant predictor (p=0.144), however vedolizumab use was a predictor (p=0.041, OR 2.46). On multivariate analysis, age (p=0.014, OR 1.03), BMI (p=0.027, OR 1.09), weight loss (p=0.041, OR 2.14), emergent case (p=0.018, OR 2.74), and vedolizumab use (p=0.016, OR 3.27) remained significant predictors of complications. Forty-one percent of patients were on a biologic medication at time of surgery. These patients were more likely to have Crohn’s Disease (59% v 26%, p<0.001), lower preoperative hemoglobin (10.9 v 12.0, p=0.0004) and albumin (3.6 v 3.9, p=0.027), to be on thiopurines (31% v 11%, p=0.003) or steroids (55% v 14%, p<0.001) at the time of surgery, and undergo emergent surgery (36% v 16%, p=0.008). Patients on biologics had a 47% overall and 28% infectious complication rate. Patients not on biologic medications had a 35% overall and 25% infectious complication rate. Complication rates did not vary significantly, except risk of bleeding requiring a transfusion was higher in patients on biologic medications (23% v 11%, p=0.047). 

Conclusion: Patients with IBD have a high rate of postoperative complications. Predictors of complications include age, BMI, weight loss, intraoperative blood loss, and vedolizumab use. Only rates of hematologic complications varied significantly between patients on biologic medications and those not on biologics. 

 

13.18 Body Mass Index is Associated with Surgical Site Infection (SSI) In Patients with Ulcerative Colitis

Posted on January 25, 2017

M. M. Romine1,2, A. Gullick1,2, M. Morris1,2, L. Goss1,2, D. Chu1,2  1University Of Alabama at Birmingham,Gastrointestinal Surgery,Birmingham, Alabama, USA 2VA Birmingham HealthSystem,General Surgery,Birmingham, AL, USA

Introduction:
Controversy persists on the association of Body Mass Index (BMI) with SSI in patients with IBD. Previous studies have been limited by single-institution populations and mixing of Crohn’s disease and Ulcerative Colitis (UC) patients. In this study, we aim to use a national dataset to investigate the association of BMI with SSI specifically in patients with UC. We hypothesize that higher BMI is associated with higher risk for SSI.

Methods:
Using the 2012-2014 ACS-NSQIP Procedure Targeted Database, we identified all patients with UC who underwent colectomy between 2012-2014. Patients with UC were stratified by weight status to underweight, normal weight, overweight and BMI class I (30-34.9), II (35-39.9) and III (>40). Patient demographics, preoperative comorbidities and surgical characteristics were compared. Primary outcomes were wound complications (SSI, organ space SSI, anastomotic leaks) and secondary outcomes were other reported NSQIP-complications. Multivariate analysis was used to identify predictors for wound complications.

Results:
Of 1,487 patients with UC, 39.8% were classified as normal weight as compared to 25.4%, 14.9%, 6.59% and 3.43% for overweight, BMI class I, II and III, respectively. Overall, 10.96% of patients were smokers, 9% of patients were diabetic and 65.77% of patients were on steroids or other immunosuppressant. Patients with higher BMI class were more likely to have diabetes: 6.31% in class I, 10.2% in class II and 13.73% in class III (p value <0.001). At time of surgery, a larger percentage of class III obese patients (27.45%) were classified as ASA 4-5 (p value <0.001). Higher BMI was associated with greater rates of SSI: 7.25% in normal weight class, 8.7% in the overweight class, 9.01% in class I, 18.37% in class II and 27.45% in class III (p-value<0.001). There was no significant difference in organ space SSI (range: 3.92-7.94%) and anastomotic leaks (range: 1.35-6.12%) between the BMI classes (p>0.05). There was an increase in sepsis rate (33.3% vs 15.3%] and respiratory complication rates (23.5% vs 10.2%) with BMI class III vs BMI class II and  continued to decrease with the lower classes (p-value<0.001). On adjustment for covariate differences, BMI remained a significant predictor for SSI with the highest odds in class III (OR 5.0 CI 2.5-10.2) and Class II obesity (OR 3.5 CI 1.9-6.4) when compared to normal BMI individuals.

Conclusion:
Patients with UC and high BMI are at the highest risk for SSI but not for organ space SSI or anastomotic leak rates. Targeting BMI with weight-loss strategies may be one actionable opportunity to reduce post-operative SSI rates.  
 

13.17 Venous Thromboembolism After Incisional Hernia Repair

Posted on January 25, 2017

M. P. DeWane1, A. A. Maung1, K. A. Davis1, J. P. Geibel1, R. D. Becher1  1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA

Introduction: Repair of incisional hernias is one of the most common operations performed by general surgeons. However, outside of its classification as a “major” general surgery operation, little is known about the risk of venous thromboembolism (VTE) after this common procedure. This is concerning as VTE is a leading cause of death in surgical patients. We evaluated VTE rates after emergent and elective incisional hernia repairs to define risk factors, mortality, and determine time to VTE events. We hypothesized that emergent operations would put patients at an increased risk for VTE events.

Methods: Open and laparoscopic incisional hernia repairs were identified in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) participant user files (PUF) over a five year period, from 2010 to 2014. Patient demographics, perioperative variables, and well-established VTE risks were assessed. Logistic regression models determined the risks of VTE development, including the importance of emergent operative classification. Kaplan-Meier and Cox regression analyses determined timing to 30-day VTE events.

Results: A total of 30,372 patients were included in the analyses, 15.7% of whom underwent emergent hernia repair. Compared to elective procedures, incisional hernia operations performed emergently had significantly increased odds for developing VTE (2.16% vs 0.86%; Odds Ratio [OR] 2.51; p<0.0001). Emergent operative classification was found to be an independent predictor of VTE (OR 1.67; p=0.0007) after accounting for common VTE risks. Other VTE risk factors included: respiratory issues such as unexpected or prolonged post-operative intubation (OR 4.12, p<0.0001), need for reoperation (2.52, p<0.0001), and laparoscopic case (OR 1.54, p=0.0287). Variables which did not significantly predict risk of VTE included age, primary vs recurrent hernia, length of operation, need for bowel resection, and obesity. In patients who developed VTE, the risk of mortality was significantly increased (OR 2.57, p=0.0311). Patients presenting in extremis with pre-operative sepsis from incarcerated hernias who required prolonged postoperative ICU stays had a VTE risk 13 times greater than baseline (11.94% vs 0.86%; p<0.0001).

Conclusion: VTE events are significantly more likely to occur in patients undergoing emergent compared to elective incisional hernia repair. Even after controlling for the multiple reasons for this patient-population to develop VTE, emergent operative classification independently predicts VTE, and should be considered a high-risk characteristic. Emergent patients diagnosed with VTE had poorer survival. These findings highlight the importance of VTE prevention and prophylaxis in this high-risk patient population, and suggest that emergent operations may play a role as a thrombogenic stimulus.
 

13.16 Hyperglycemia Following Radical Cystectomy Associated With Shorter Lengths Of Stay And Lower Costs

Posted on January 25, 2017

M. B. Linskey1, D. Brunke-Reese1, E. B. Lehman2, D. I. Soybel1, M. G. Kaag1,3  1Penn State University College Of Medicine,Department Of Surgery,Hershey, PA, USA 2Penn State University College Of Medicine,Department Of Public Health Sciences,Hershey, PA, USA 3Penn State University College Of Medicine,Division Of Urology,Hershey, PA, USA

Introduction:  Post-operative hyperglycemia has been associated with adverse outcomes including increased length of stay (LOS) and increased costs of care. In the cardiac, vascular, general, and trauma surgery populations, post-operative hyperglycemia has also been linked to an increased risk of mortality. Patients without diabetes mellitus who develop acute hyperglycemia post-operatively are at an increased risk of complications compared to their counterparts with diabetes. Radical cystectomy for bladder cancer carries an inherent risk of post-operative morbidity due to the complexity of the procedure and the medical comorbidities of the patients. Morbidity of cystectomy includes frequent readmissions for renal failure, wound occurrences, ileus, failure to thrive, obstruction, and urinary tract infections. We investigate the impact of post-operative hyperglycemia on recovery following radical cystectomy (RC).
 

Methods: A retrospective chart review identified patients undergoing RC between May 2010 and December 2014 with at least one glucose level within 48 hours of surgery. Associations between post-operative hyperglycemia (defined as a first post-operative blood glucose >140mg/dL) and outcomes, including total hospital costs, LOS, and surgical site occurrences were determined.

Results: 176 patients underwent RC; 122 (69%) met our definition of post-operative hyperglycemia. 87 of 128 (68%) patients without diabetes, exhibited hyperglycemia postoperatively. 47 (54%) of these 87 patients required post-operative insulin, including 31 (36%) whose insulin requirement persisting beyond post-operative day 2. On univariate analysis, BMI classification predicted hyperglycemia (obese vs non-obese: Odds ratio (OR) 2.68, [95% Confidence Interval (CI) 1.25-5.75] p=0.01). This association was strong in patients without diabetes (OR 3.55 [95% CI 1.34-9.39] p=0.01), but not significant in those with diabetes. LOS (in days) was shorter in patients who were hyperglycemic post-RC regardless of prior diabetes diagnosis (Difference of medians (DOM) -2.0 [-3.5 to -0.5] p=0.01). This effect remained on multivariable analysis (DOM -2.19 [-3.54, -0.83] p=0.002) controlling for age, gender, race, Charlson score, ASA class, and BMI. Similarly, on multivariable analysis, hospital costs (in US dollars) were lower in patients with post-operative hyperglycemia (DOM -8,863.69 [-12,887.37, -4,840.17] p<0.001).

Conclusion: Post-operative hyperglycemia is common after RC and may occur in patients without diabetes. Contrary to results reported in the general surgery literature, hyperglycemia after RC was associated with shorter LOS and hospital costs. Whether this phenomenon is due to a protective effect associated with hyperglycemia, or is secondary to the aggressive post-operative management afforded these patients, is not yet clear.

 

13.14 Compliance After Bariatric Surgery: Patient-related Factors And Self-reported Barriers

Posted on January 25, 2017

B. Corey1,2, L. Goss1, A. Gullick1,2, D. Breland1, J. Richman1,2, J. Grams1,2  2Birmingham Veteran’s Affairs Medical Center,Surgery,Birmingham, ALABAMA, USA 1University Of Alabama At Birmingham,Surgery,Birmingham, ALABAMA, USA

Introduction:  Patient compliance with attendance at follow-up bariatric appointments is associated with increased weight loss, and reasons for low follow-up compliance are poorly understood. The purpose of this study was to investigate the association of patient-related factors with follow-up compliance after laparoscopic Roux-en-Y gastric bypass (LRYGB).

Methods:  Retrospective review was conducted of all adult patients who underwent LRYGB from 2005-2013 at a single institution. Patients were stratified by follow-up attendance at a total of 8 possible postoperative visits: low 0-2, intermediate 3-5, and high 6-8 visits. Socioeconomic status was determined using 6 measures compared to national census data to generate a neighborhood Summary Z-score. Patients who attended <50% of follow-up visits were mailed a survey to assess reasons for low compliance. Univariate and multivariate analyses were used to compare patient characteristics and compliance. Statistical significance was determined by p <0.05.

Results: Of 756 patients, there were 241 patients in the low, 327 in the intermediate, and 188 in the high compliance groups. The high compliance group was older (p=0.004), white (p=0.020), and had lower preoperative weight (p=0.008) and BMI (p=0.040). There were no differences in overall socioeconomic characteristics based on compliance. On adjusted multivariate analysis, patients were more likely to attend 1 year follow-up appointment if they were older (OR=1.04, CI 1.02-1.05), of lower socioeconomic status (OR=1.04, CI 1.00-1.08), white (OR=1.5, CI 1.03-2.2), had private insurance (OR=1.6, CI 1.02-2.5), and were present at their last appointment (OR=6.30, CI 4.41-8.95); while patients were more likely to attend 2 year follow-up appointment if they were successful at weight loss (OR=1.03, CI 1.00-1.05), if they had shorter driving distance (50-99 miles, OR=2.2, CI 1.4-3.5; <50 miles, OR=1.6, CI 1.0-2.4), or had attended their previous appointment (OR=4.49, CI 3.15-6.40). On survey, patients reported the primary reason they did not follow up was travel time to the clinic (44%), cost of the visits (28%), commitments at work/school (24%), and because of guilt for not following the diet and exercise plan and/or felt ashamed of regaining weight (24%).

Conclusion: Patient-related factors are predictive of follow-up compliance. Based on self-reported reasons, health behaviors and values influence attendance at postoperative bariatric appointments. Since patients self-report travel time and cost as the two primary reasons for failure to follow up, alternative methods of follow-up should be considered such as appointments using telemedicine technology, follow-up “apps” to self-report progress, or stronger collaboration with local primary care physicians. 

 

13.15 Preliminary Experience with Acellular Porcine Liver Matrix in Retrorectus Incisional Hernia Repairs

Posted on January 25, 2017

E. Vo1, C. Y. Chai1,2, D. S. Lee1,2, N. N. Massarweh1,2, K. Makris1,2, L. W. Chiu1,2, H. S. Tran Cao1,2, N. S. Becker1,2, S. S. Awad2  1Baylor College Of Medicine,Houston, TX, USA 2Michael E. DeBakey Veterans Affairs Medical Center,Houston, TX, USA

Introduction:
Acellular dermal matrices have been used since the 1990s for incisional hernia repairs in patients who are considered high risk for surgical site infections (SSI). Porcine dermal matrix is currently the most commonly used biologic mesh. Recently, an acellular matrix derived from decellularized whole porcine liver has been FDA-approved as a new biologic matrix alternative. No studies exist regarding its outcomes. Our objective was to describe our early experience and to compare the short-term outcomes of acellular porcine liver matrix (APLM) with acellular porcine dermal matrix (APDM).

Methods:
Patients undergoing retrorectus incisional hernia repairs were identified from Jan 2013 to Jul 2016 and case-matched in a 2:1 APDM to APLM ratio. Baseline demographics, comorbidities, ventral hernia working group (VHWG) grade, and outcomes such as seroma, hematoma, SSI, dehiscence, length of stay (LOS) were collected. Results were compared between APLM and APDM using univariate analysis with significance set at p<0.05.

Results:
Sixty patients were identified: 20 APLM and 40 APDM with an overall median follow-up of 13.9 months. Cohorts were well-matched in age (APLM 58.6±11.7 vs. APDM 61.5±7.7 years, p=0.26) and BMI (APLM 31.1±6.3 vs. APDM 30.3±5.9, p=0.56). Median VHWG grade (APLM 2.5 vs. APDM 2.0) and ASA (APLM 3 vs. APDM 3), were not statistically significant (both p>0.05). No significant differences in comorbidities were found. Thirty day follow-up demonstrated no difference in SSIs (25% vs. 25%, p=1.00) or readmissions (APLM 10% vs. APDM 17.5%, p=0.70). There was no clinically significant seroma requiring intervention in either cohort. Although LOS was shorter (median APLM 5 (IQR 3-10) days vs. APDM 7 (IQR 6-11) days, p=0.12] and hematoma rates lower (APLM 0% vs. APDM 5%, p=0.60) with the use of APLM, this was not statistically significant.

Conclusion:
There were no significant differences between APLM and APDM with respect to seroma, hematoma, SSI, and LOS. APLM appears to be a safe and feasible alternative for complex ventral hernia repairs. Further study on long-term outcomes is warranted.
 

13.12 Is the Surgical Apgar Score Reliable in Patients on Chronic Beta Blockers?

Posted on January 25, 2017

S. Amodeo1, A. Pinna1,2,3, A. Masi1,2, I. Hatzaras1, E. Newman1,2, S. M. Cohen1, R. S. Berman1, G. H. Ballantyne1,2, H. L. Pachter1, M. Melis1,2  1New York University School Of Medicine,Department Of Surgery,New York, NY, USA 2New York Harbor Healthcare System VAMC,Department Of Surgery,New York, NY, USA 3University Of Sassari,Department Of General Surgery,Sassari, , Italy

Introduction:  The lowest heart rate recorded during surgery is one of the 3 parameters required to calculate the Surgical Apgar Score (SAS), a 10-point prognostication score used to predict postoperative outcomes. We aimed to verify whether SAS maintains its validity in patients undergoing long-term treatment with beta blockers.

Methods:  We queried our institutional clinical database for patients undergoing general surgery procedures between October 2006 and September 2011. Patients on long-term beta blockers were identified and defined the study population. We divided our study population into 4 groups according to their SAS: ≤4, 5-6, 7-8, 9-10. Study end-points were overall morbidity and 30-day mortality. Differences between SAS groups were evaluated with Pearson’s chi-square or ANOVA, as appropriate.

Results: Of the 2125 patients who underwent general surgery over the study period, 568 (26.7%) were taking beta blockers at the time of their operation and represented our study population. They were distributed as follows: SAS ≤ 4: n= 10 (1.8%), SAS 5-6: n= 78 (13.7%), SAS 7-8: n= 181 (31.9%), SAS 9-10: n= 299 (52.6%). There were no differences in age, sex, race, history of smoking or alcohol abuse across SAS groups. Furthermore, no differences were seen in the incidence of diabetes, previous history of transient ischemic attacks, cerebrovascular accidents or peripheral vascular disease. A low SAS was associated with worse functional status (p<0.001), and increased incidence of certain preoperative conditions (congestive heart failure, dyspnea, acute renal failure, ascites: p<0.001; severe COPD: p=0.001; history of esophageal varices: p=0.002; hypertension, history of angina: p<0.05). Accordingly, a low SAS correlated with a higher American Society of Anesthesiologists score (p<0.001). The vast majority of patients with low SAS underwent major or extensive procedures (100% and 85.9% for score ≤ 4 and 5-6, respectively), while high SAS patients mostly underwent minor or intermediate surgery (77.3% for score 9-10). Post-operative morbidity was 60% for score ≤ 4, 46.2% for score 5-6, 27.6% for score 7-8, and 10.4% for score 9-10 (p<0.001). The mean number of complications for each group, respectively, was 1.40 ± 1.7, 1.00 ± 1.4, 0.56 ± 1.2, and 0.15 ± 0.5. Thirty-day mortality rate was 10% for score ≤ 4, 12.8% for score 5-6, 3.3% for score 7-8, and 0.7% for score 9-10 (p<0.001).

Conclusion: Correlation of SAS and risk of surgical complication is maintained in a population of general surgery patients treated with beta blockers. Correlation of SAS with pre-operative conditions and performance status was also confirmed in this patient group.

 

13.11 Duration of Preoperative Hospitalization is Associated With Mortality in Total Abdominal Colectomy

Posted on January 25, 2017

J. Zhang1, A. Lubitz1, M. Philp1, Z. Maher1, A. Pathak1, T. Santora1, L. Sjoholm1, A. J. Goldberg1, E. Dauer1  1Temple University,Department Of Surgery,Philadelpha, PA, USA

Introduction: Total abdominal colectomy (TAC) has been associated with morbidity and mortality rates as high as 62% and 28%, respectively. To date, varying findings regarding risk factors for postoperative complications after emergent colectomy have been reported in the literature. We sought to determine if preoperative length of stay impacts morbidity and mortality in patients undergoing emergent TAC.

Methods:  We conducted a retrospective cohort study of patients undergoing emergent TAC for any indication at our urban quaternary care institution from 2005-2015 (n=94).  Charts were reviewed for patient demographics, preoperative risk factors and Simplified Acute Physiology Score (SAPS), and discrete patient outcomes (leak, abscess, fascial dehiscence, wound infection, hospital length of stay, ventilator days, ICU length of stay and mortality). Patients were then divided into two groups based on whether they underwent TAC prior to hospital day 5 (HD<5) or on hospital day 5 or later (HD≥5). Student’s t-tests were used to compare means for categorical variables, and Chi-squared tests were used to analyze ordinal variables. Statistical analyses were performed using SPSS version 22.

Results: Patients who underwent TAC later in their hospital course had longer total hospital length of stay (Table 1, t=-2.45, df=92, p=0.016) and higher mortality (42.5% v 20.4%, Χ2=5.38, p=0.02). ICU length of stay and ventilator days trended toward being longer in the late group, though these did not reach statistical significance (t=-1.237, df=92, p=0.219 and t=-0.773, df=91, p=0.441, respectively). There was no difference between groups with respect to age, gender, coronary artery disease, hypertension, congestive heart failure, chronic obstructive pulmonary disease, diabetes, chronic kidney disease or stroke. When comparing the early and late operative groups, patient demographics and SAPS did not differ. Intraoperative findings of peritonitis or ischemia also did not differ, nor did postoperative rates of leak, abscess formation, fascial dehiscence or wound infection. Indications for TAC included Clostridium difficile colitis, lower gastrointestinal bleed, large bowel obstruction and inflammatory bowel disease, with more C. diff patients in the early group (Χ2=4.062, p=0.044).

Conclusion: Our data suggest that patients who undergo TAC later in their hospitalization incur longer lengths of stay and greater mortality rates. Age, gender, comorbidities and SAPS scores did not differ among the two groups, suggesting factors external to underlying illness and not reflected in commonly evaluated physiologic markers impact these outcomes. 

 

13.10 The Surgical Apgar Score Identifies Patients at Risk for Prolonged Post-Operative Hospital Stay.

Posted on January 25, 2017

S. Amodeo1, A. Masi1,2, A. Pinna1,2,3, I. Hatzaras1, E. Newman1,2, S. M. Cohen1, R. S. Berman1, G. H. Ballantyne1,2, H. L. Pachter1, M. Melis1,2  1New York University School Of Medicine,Department Of Surgery,New York, NY, USA 2New York Harbor Healthcare System VAMC,Department Of Surgery,New York, NY, USA 3University Of Sassari,Department Of General Surgery,Sassari, , Italy

Introduction:  The Surgical Apgar Score (SAS) is a 10-point score calculated on three intra-operative parameters (lowest heart rate, lowest mean arterial pressure, estimated blood loss), which has been demonstrated to be a reliable predictor of postoperative morbidity and mortality in several types of surgery. We aimed to investigate whether SAS could also predict length of post-operative hospital stay (LOS) in patients undergoing general surgical procedures.

Methods:  We retrospectively evaluated demographics, medical history, type of surgery, and postoperative data for patients undergoing general surgery between October 2006 and September 2011. We categorized our study population into 4 groups according to their SAS: ≤4, 5-6, 7-8, 9-10. The end-point of our study was the length of postoperative hospital stay. We used Pearson’s chi-square or ANOVA, as appropriate, to evaluate differences across SAS groups.

Results: Two thousand one hundred twenty-five patients underwent general surgery during the evaluated period. We excluded 711 patients who underwent outpatient surgery, and included in our analysis the 1414 patients who were admitted post-operatively to the hospital. There were 29 patients in the group SAS ≤ 4, 212 in SAS 5-6, 594 in SAS 7-8, 579 in SAS 9-10. No significant differences in age, sex, race, history of smoking or alcohol abuse among SAS groups were detected. Patients with lower SAS had a worse preoperative functional status (p<0.001) and worse American Society of Anesthesiologists score (p<0.001) than patients with a higher SAS. A low SAS was associated with a higher incidence of certain preoperative conditions (acute renal failure, ascites, history of myocardial infarction, congestive heart failure, severe COPD, dyspnea, history of dialysis: p<0.001; diabetes: p=0.001; history of angina, previous percutaneous coronary intervention, previous cardiac surgery: p<0.05). Most patients with low SAS underwent major or extensive procedures (89.7% and 75.5% for score ≤4 and 5-6, respectively), while high SAS patients mostly underwent minor or intermediate surgery (68.6% for score 9-10). LOS ranged from 0 to 193 days, with a median of 6 days (mean: 11.9 ± 18.8 days). LOS was 29.6 ± 26.5 for score ≤ 4, 24.2 ± 30.8 for score 5-6, 12.1 ± 16.0 for score 7-8, and 6.4 ± 10.9 for score 9-10 (p<0.001). 

Conclusion: In our retrospective analysis SAS correlated with post-operative LOS after general surgery. Moving forward, this information may be used to focus hospital resources (such as social workers and rehabilitation medicine) specifically on patients with low SAS, who are at higher risk for prolonged post-operative length of stay.

 

13.09 A Risk Model and Cost Analysis of Incisional Hernia Following 2,145 Open Hysterectomies

Posted on January 25, 2017

J. M. Weissler1, M. G. Tecce1, M. N. Basta2, V. Shubinets1, M. A. Lanni1, M. N. Mirzabeigi1, M. J. Carney1, L. Cooney1, S. Senapati1, A. F. Haggerty1, J. P. Fischer1  1University Of Pennsylvania,Plastic Surgery,Philadelphia, PA, USA 2Brown University School Of Medicine,Plastic Surgery,Providence, RI, USA

Introduction:  Incisional hernia (IH) is a pervasive complication across surgical specialties and presents a significant burden to both the patient and healthcare system. Morbidity associated with IH permeates all surgical specialties, including gynecologic surgery. Approximately 600,000 women undergo hysterectomy annually in the US and IH is estimated to complicate 8-16.9% of all abdominal hysterectomies. An open approach to abdominal hysterectomy portends increased risk for IH development, however there is a substantial knowledge gap regarding which procedure-specific factors govern risk. The purpose of this study is to assess the incidence and health care cost of surgically repaired IH after open abdominal hysterectomy, identify actionable, perioperative risk factors, and create a predictive risk mode to identify at-risk patients who could benefit from prevention strategies.

Methods:  We conduct a retrospective review of patients who underwent hysterectomy through an open abdominal approach between 1/2005 and 6/2013 at the University of Pennsylvania.  The primary outcome of interest was post-hysterectomy IH.  Univariate and multivariate cox proportional hazard analyses were performed to identify perioperative risk factors.  Patients with prior hernia, less than 1 year follow-up, or emergency surgeries were excluded.  Cox hazard regression modeling with bootstrapped validation, risk factor stratification, and assessment of model performance were performed.

Results: Overall, 2,145 patients underwent open abdominal hysterectomy during the study period. 76 patients developed IH, all of whom underwent hernia repair. 31.3% underwent further reoperation, generating significantly higher costs of care ($71,559 vs. $23,313, p<0.001).  8 risk factors were identified and included in the final adjusted risk model, the strongest of which were presence of a vertical incision (HR=3.73 [2.01-6.92]) and ascites (HR=2.39 [1.40-4.08]). Extreme risk patients experienced the highest incidence of IH after hysterectomy (22%), followed by the high-risk group (9.7%), moderate-risk group (2.7%), and low-risk group (0.8%) (C-statistic=0.82) (Figure 1).

Conclusion: This study presents an internally validated risk model of IH in patients undergoing open hysterectomy after a review of 2,145 cases. The model can serve to accurately stratify patients, facilitate pre-operative counseling, and potentially imply risk reductive techniques.

 

13.08 Financial Burden is Associated with Lower Quality of Life Scores in Adults with MEN-1

Posted on January 25, 2017

B. J. Peipert1, S. Goswami1, S. E. Yount2,3, C. Sturgeon1  1Northwestern University Feinberg School Of Medicine,Surgery,Chicago, IL, USA 2Northwestern University Feinberg School Of Medicine,Medical Social Sciences,Chicago, IL, USA 3Northwestern University Feinberg School Of Medicine,Psychiatry And Behavioral Sciences,Chicago, IL, USA

Introduction: Health-related quality of life (HRQOL) and financial burden among patients with multiple endocrine neoplasia type 1 (MEN-1) is poorly described. It is not known how the financial burden attributed to treatment and disease influences HRQOL in this population. We hypothesized that financial burden attributable to MEN-1 is associated with worse patient-reported outcomes (PROs) reflecting lower HRQOL.

Methods: Adults (≥18 years) recruited from an MEN-1 support group (n=174) completed an online survey that included questions regarding demographics, clinical characteristics, medical/surgical treatment, and various aspects of financial burden. PROMIS-29 was used to assess HRQOL. PROMIS-29 scores across 7 domains (physical function, fatigue, pain interference, anxiety, depression, sleep disturbance, social functioning) were converted to T Scores and compared to normative data for the United States (US) population using a one-sample T-Test. Data are presented as mean T scores ± standard deviation. Subgroup analysis was conducted using Mann-Whitney U for categorical variables and Pearson coefficients for continuous variables. Holms-Bonferroni Sequential Correction was used to control for multiple comparisons.

Results: Eighty-one percent of respondents reported financial burden associated with MEN-1. Respondents reported using up their savings (39%), being contacted by a collection agency (35%), borrowing money (27%), reaching their maximum credit limit (17%), taking out a new loan/mortgage (14%) or declaring bankruptcy (6%) due to the financial burden of MEN-1. Respondents who reported any financial burden due to MEN-1 had worse anxiety (62.9±9.6 vs 53.2±9.4, p<0.001), depression (58.7±10.3 vs 51.2±13.2, p<0.001), fatigue (62.9±10.2 vs 51.2±13.2, p<0.001), pain interference (57.2±11.0 vs 48.7±8.7, p<0.001), physical function (43.0±9.1 vs 52.2±7.6, p<0.001), sleep disturbance (58.3±8.6 vs 52.6±9.4, p<0.01) and social functioning (43.0±9.5 vs 53.2±11.5, p<0.001). Lower PRO scores were significantly associated with greater financial burden (r=0.34-0.52, p<0.001) and the number of negative financial events (r=0.34-0.45, p<0.001) across all domains, which was also true of respondents who were currently unemployed (14%), disabled (13%) or had a history of extended unemployment (37%) (p<0.05). An annual income <$50,000 (34%) was associated with worse anxiety, depression, pain, physical functioning, and social functioning (p<0.05). Monthly cost of prescription medication >$100 was associated with worse PROs across all domains (p<0.05). Skipping medications due to cost (19%) was associated with worse physical functioning and sleep disturbance (p<0.01).

Conclusions: This is the first PRO study to link worse HRQOL to financial burden attributed to the management of MEN-1. The number of negative financial events, unemployment, disability, monthly cost of prescription medicines, and low income were all associated with worse PRO scores in adults with MEN-1.

13.07 The Metabolic Benefit of Bariatric Surgery: Impact of Baseline Disease Status

Posted on January 25, 2017

L. A. Bayouth3, W. J. Pories3, M. B. Burruss3, K. Spaniolas3  3East Carolina University Brody School Of Medicine,Department Of Surgery, Minimally Invasive And Bariatric Surgery,Greenville, NC, USA

Introduction:  Bariatric surgery has been established as a treatment modality for the control and remission of metabolic syndrome. Multiple studies demonstrated that preoperative severity of type 2 diabetes (T2D) affects likelihood of remission postoperatively. Limited data is available for how the severity of other components of metabolic syndrome impact outcomes. The aim of this study is to identify how severity of metabolic syndrome preoperatively affects disease remission following bariatric surgery.

Methods:  We queried the BOLD database from 2005-2011 to identify patients undergoing gastric bypass or sleeve gastrectomy with available 12 month follow up information. Comorbidities at baseline and following surgery were recorded in a five-point Likert scale. A composite score was calculated for patients with all components of metabolic syndrome. Improvement and remission of components of metabolic syndrome (T2D, hypertension, and dyslipidemia) were assessed. Multivariable logistic regression models were built to determine effect of baseline disease, controlling for other baseline characteristics. Odds ratios (OR) with 95% confidence intervals are reported.

Results: Within a cohort of 51,081 patients who underwent bariatric surgery with 12 month follow up, we identified 20,089 (39.3%), 31,695 (62%), and 23,350 (45.7%) patients with T2D, hypertension and dyslipidemia, respectively; 11,075 (21.7%) patients had all three components of metabolic syndrome. Gastric bypass was performed in 46,381 (90.8%) patients. Mean age and BMI for the entire cohort were 47+11.6 and 47.7+8.5, respectively. Comorbidity remission significantly varied by baseline severity score (Fig 1 Comorbidity Remission for T2D, hypertension and dyslipidemia based on composite metabolic score. P<0.001 for all comparisons). After controlling for age, gender, BMI and procedure, the degree of baseline comorbidity independently associated with 12 month remission. In patients with metabolic syndrome, a composite score over 9 (median) was independently associated with lower rate of remission at 12 months (OR 0.46, 95% CI 0.41-0.51). Similarly, score over 9 was independently associated with 12 month remission of T2D (OR 0.37, 95% CI 0.34-0.4), hypertension (OR 0.59, 95% CI 0.54-0.65), and dyslipidemia (OR 0.68, 95% CI 0.63-0.74).

Conclusion: Bariatric surgery leads to remission of metabolic syndrome and individual components in a large percentage of patients. The remission rate at 12 months is significantly affected by preoperative severity of disease. This data proposes that early intervention would lead to significant benefit, improving remission rate. Bariatric surgery should not be reserved as last resort treatment of metabolic syndrome in the severely obese.

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