90.02 Management of Complications by Acute Care Surgeons: Who Do We Fail to Rescue?

Posted on January 26, 2017

M. Dasari1, A. B. Peitzman1, J. W. Marsh1, D. Mohan1, M. R. Rosengart1, R. M. Forsythe1, J. L. Sperry1, M. E. Kutcher2  1University Of Pittsburgh Medical Center,Pittsburgh, PA, USA 2University Of Mississippi Medical Center,Jackson, MS, USA

Introduction:  'Surgical rescue' is defined as the surgical management of an acute complication of a surgical, interventional, or endoscopic procedure, and is a key pillar of Acute Care Surgery (ACS).  We compared complications, interventions, and outcomes between surgical patients who were successfully 'rescued' after a procedural complication and those who 'failed to rescue', defined by death in-hospital or within 30 days of discharge following a surgical complication.

Methods:  A prospective ACS database at an urban academic center was reviewed for acute surgical complications using an ICD-9 code-based screen, and linked with Social Security Death Index long-term mortality data.  Failure-to-rescue (FTR) was defined as in-hospital mortality or death within 30 days of discharge.

Results: Of 2,301 ACS patients screened from 1/2013 to 5/2014, 321 (14%) had an acute complication of a surgical (85%), endoscopic (8%), or interventional (7%) procedure; most commonly, wound complications (31%), uncontrolled sepsis (19%), and bowel obstruction (15%).  206 patients (63%) required operative intervention.  The most common rescue measures were bowel resection (22%), wound debridement (18%), and surgeon-guided resuscitation (17%).  Forty-four patients (14%) died in-hospital or within 30 days of discharge (FTR).  FTR patients were significantly older than rescued patients (55±15 vs. 67±14y, p<0.01), more commonly male (64% vs. 46%, p=0.03), and had more frequent pre-existing coronary disease (48% vs. 16%, p<0.01).  Lowest albumin and hemoglobin, as well as highest creatinine and lactate, were significantly higher in FTR patients (all p<0.01).  Bowel ischemia (20% vs. 12%, p<0.01) and perforation (18% vs. 6%, p<0.01) were more common complications in FTR patients, and more than twice as many FTR patients required bowel resection compared to successfully rescued patients (43% vs. 20%, p<0.01; Table 1).  The FTR rate was higher in consult and transfer patients (17%) compared to primary ACS service patients (8%; p=0.02).

Conclusion: Systematic study of failure to rescue in Acute Care Surgery identifies patients with significant comorbidities, critical physiological derangements, and frequent intestinal compromise; many are referred to an acute care surgeon specifically for rescue after a procedural complication.  Rapid assessment of frailty, appropriate goals-of-care discussion, and careful operative planning are critical in this high-risk population.

90.01 Survival Following Discharge to Post-Acute Care After Complex Surgery

Posted on January 26, 2017

J. T. Killian1, M. C. Mason2, P. J. Richardson3, P. Kougias2,3, F. Bakaeen4, A. D. Naik3,5, D. H. Berger2,3, C. Balentine1,6, D. A. Anaya7  1University Of Alabama at Birmingham,Department Of Surgery,Birmingham, Alabama, USA 2Baylor College Of Medicine,Michael E. DeBakey Department Of Surgery,Houston, TX, USA 3Houston Veterans Affairs Health Services Research And Development Center For Innovations In Quality, Effectiveness And Safety (IQUEST),Houston, TX, USA 4Cleveland Clinic,Department Of Thoracic And Cardiovascular Surgery,Cleveland, OH, USA 5Baylor College Of Medicine,Alkek Department Of Medicine,Houston, TX, USA 6University Of Alabama at Birmingham,Institute For Cancer Outcomes & Survivorship,Birmingham, Alabama, USA 7Moffitt Cancer Center And Research Institute,Department Of Gastrointestinal Oncology,Tampa, FL, USA

Introduction:  After complex surgery, patients are frequently discharged to post-acute care including skilled nursing facilities, inpatient rehabilitation, and long-term care. The purpose of this study was to describe survival after discharge to post-acute care in order to provide accurate information for informed consent and discussions with patients and their families prior to surgery.

 

Methods:  We retrospectively examined 60,666 patients within the Veterans Affairs system who had colorectal surgery, hepatectomy, pancreatectomy, coronary artery bypass grafting, abdominal aortic aneurysm repair, and peripheral vascular bypass from 2008-2011. Patients were classified by their discharge destination to home or to post-acute care (skilled nursing facilities, rehabilitation, or long-term care). We calculated five-year overall survival using the methods of Kaplan and Meier.

 

Results: A total of 4,744 (8%) patients were discharged to post-acute care. Of these, 2,180 (46%) patients were 70 years of age or older and 98% were men. Median follow-up was 3.3 years.  Overall survival at five years for all patients discharged to post-acute care was 50%.  Five-year overall survival for each procedure included: coronary artery bypass grafting (63%), open abdominal aortic aneurysm repair (50%), peripheral vascular bypass (44%), colorectal resection (41%), endovascular abdominal aortic aneurysm repair (40%), pancreatectomy (35%), and hepatectomy (22%). Survival for the total cohort and for each procedure was significantly worse for patients discharged to post-acute care compared to those discharged home (p<0.05). 

 

Conclusion: Discharge to post-acute care is associated with exceedingly poor survival following complex abdominal, cardiac, and vascular surgery.  For high risk patients, this information should be clearly communicated to patients and their families prior to consenting for surgery and during discharge planning.  Patients discharged to post-acute care also represent a highly vulnerable population that may benefit from preoperative and postoperative programs designed to enhance recovery from surgery. 

89.20 Does Sarcopenia Predict Worse Perioperative Outcomes for Ulcerative Colitis Patients?

Posted on January 26, 2017

C. Cadiz1, E. H. Wood1, M. Shah1, J. M. Eberhardt1, T. L. Saclarides1, D. Hayden1  1Loyola University Medical Center,Surgery,Maywood, ILLINOIS, USA

Introduction:
Sarcopenia has been associated with poor postoperative outcomes in cancer patients, and only recently has this been explored in patients with inflammatory bowel disease.  We aim to describe the influence of sarcopenia on perioperative and postoperative outcomes after colectomy for patients with ulcerative colitis.

Methods:
Skeletal muscle mass index was measured on perioperative CT scans (within 1 month of surgery) of patients undergoing colectomy for ulcerative colitis at a single tertiary care center, 2007-2015. Using Mimics® software (Belgium), skeletal muscle area including the paraspinal, psoas and rectus muscles, was measured three times at the L3 level and the mean along with the patient’s height was then used to calculate the lumbar skeletal muscle mass index (cm2/m2).  Sarcopenia was defined as 2 standard deviations below the index cutoff established in adult obese cancer patients: 38.5 in females, 52.4 in males (Lieffers 2012, Prado 2008).

Results:
36 UC patients had any type of colectomy with a CT scan performed within 1 month pre- or postoperatively. Mean age was 49.2 (17-84); 77.8% were male. Mean BMI was 26.8 (16.3-46.2). Overall prevalence of sarcopenia was 61.1%; 37.5% of females were sarcopenic at the time of surgery and 67.9% of males. Gender, race and surprisingly age were not associated with sarcopenia. Operative time was significantly associated with sarcopenia as was BMI. ICU admission trended toward significance (p=0.061). Overall postoperative complications were not associated with sarcopenia but UTIs were much more frequent (p=0.009). Readmissions, unexpected return to the operating room and mortalities were not associated with sarcopenia.   

Conclusion:

Sarcopenia  is extremely prevalent in patients with ulcerative colitis who require colectomy. Operative time, ICU admission and UTIs tend to be more longer and more frequent. Since the majority of patient did not undergo emergency colectomy, there may be time to optimize these patients with “pre-habilitation” if surgery is being considered in the near future.

 

89.19 Utilizing Game Theory to Model Patient Engagement in Self Care Following Surgery: A Pilot Study.

Posted on January 26, 2017

S. A. Castellanos1, G. Buentello1, J. W. Suliburk1  1Baylor College Of Medicine,Houston, TX, USA

Introduction:  Patient engagement is frequently discussed as a goal of patient education/discharge planning, yet remains hard to model and therefore challenging to optimize. Game theory is a field of study in which different models (games) analyze a player’s decision making process when his/her decision is contingent on what another player is going to do. This study seeks to develop a model to characterize patient decision making in engagement and then sought to correlate the model with qualitative analysis of semi-structured interview transcripts.

Methods:  Over a 6-month period, interviews were conducted within 6 weeks of discharge in patients undergoing thyroid, parathyroid or colorectal surgery. Interviews were recorded, transcribed, anonymized and then analyzed using Nvivo software platform. Blinded to transcript coding and results, a signaling game model was developed as follows: two players—Doctor (D) and Patient (P)—and two scenarios—one in which P is “engaged” [probability, α] and another in which P is “unengaged” [probability, (1-α)]. “Engaged” P’s represent patients who will call their doctor with problems at home post-hospitalization, and “unengaged” P’s are patients who will call no one or seek care elsewhere. Transcripts were reviewed for “Discharge Instructions,” “Discharge Process” and “Discharge Education” themes.

Results: As the model (game) evolves only P knows the starting state (engaged vs. unengaged).  The game is played anytime during P’s clinical care episode both pre- and post-operatively. P moves first by deciding to Ask (a) or Refrain (r) from questions. “Engaged” P’s prefer choosing a, but will choose r in certain situations, and the converse is true for “unengaged” P’s. In response to P’s behavior, D moves by deciding to Invest (i) resources in care for P or Maintain (m) the care at normal levels. If D chooses i, then P becomes “engaged” P. Otherwise, P will act according to baseline. Unless they believe P to be “unengaged”, D prefers choosing m over i. The optimal outcome for D and P results if P ends the game as “engaged”. Review of transcripts determined the levels of questioning exhibited by the patients only partly reflected activation towards proficiency in self-care. Across surgeries, there was poor demonstration that the clinical care team altered education efforts based on signaling from the patient.

Conclusion: A game theoretic “signaling model” is able to adequately characterize interactions between the care team and the patient. If the care team cannot perceive a patient’s engagement status via these signals, it must look for other ways to bring clarity into assessment of engagement.  Further work will be done to refine the model in order to optimize strategies to facilitate patient engagement.

89.18 Pre-operative Tylenol and Neurontin Reduces PACU Narcotic Requirements

Posted on January 26, 2017

T. Bernaiche1, G. Hafner1  1Inova Fairfax Hospital,Falls Church, VA, USA

Introduction:

Post-operative pain continues to be a significant problem, even after minimally invasive ambulatory procedures. Our study assesses if administering Neurontin and Tylenol prior to incision can decrease pain scores, PACU length of stay, and post-operative narcotic requirements after laparoscopic cholecystectomies and laparoscopic inguinal hernia repairs.

 

Methods:

Records of a single surgeon’s laparoscopic hernias and laparoscopic cholecystectomies from 2013-2014 were reviewed.  Differences between patients who received pre-operative Tylenol and Neurontin (PTN group) and those who did not (non-PTN group) were assessed using Student’s t test or Wilcoxon-Mann Whitney test and χ2 test or Fisher exact test.

 

Results:

173 patients were included in the study (76 laparoscopic cholecystectomy and 97 laparoscopic inguinal hernia repair).  There were 74 patients in the PTN group and 99 patients in the non-PTN group. Patients in the PTN group were less likely to receive post-operative narcotics (85.9% vs 97.3% [p=0.01]).  There was also a decrease in the median number of doses of post-operative narcotics received in the PTN group (2 (IQR 1-2) vs 2 (IQR 1-3) [p=0.029]).  There were no differences in pain scores between the two groups.  The PTN group had an increased PACU length of stay (179 min vs 142 min [p=0.005]).  The results remained unchanged after stratifying by surgery.

 

Conclusions:

Our study suggests that pre-operative Tylenol and Neurontin may play a role in decreasing post-operative narcotics use for laparoscopic hernia or laparoscopic cholecystectomy patients. Further investigation with prospective, randomized studies would clarify the utility of standardizing pre-operative Tylenol and Neurontin.

 

89.16 Is Colonoscopy Necessary Prior to Giving Neostigmine for Treatment of Colonic Pseudo-obstruction?

Posted on January 26, 2017

M. Nguyen1, D. Strosberg1, A. Brown1, E. Abel1, D. Eiferman1  1Ohio State University,Surgery,Columbus, OH, USA

Introduction:  

Surgical dogma dictates the necessity of ruling out distal mechanical colonic obstruction prior to using neostigmine to treat suspected colonic pseudo-obstruction (CPO) to avoid the risk for colonic perforation.  Gastroenterology guidelines recommend neostigmine as first line therapy for treatment of CPO.  Although colonoscopy provides excellent value as a diagnostic and therapeutic modality in CPO, urgent colonoscopy in the setting of an un-prepped and dilated colon also carries the risk of perforation.  This study examines if CPO can be safely treated with intravenous neostigmine without prior evaluation with colonoscopy to rule out distal obstruction and examines whether Computed Tomography (CT) scan can adequately assess the distal colon instead of endoscopy.

Methods:  

We retrospectively reviewed all patients who received neostigmine for CPO at a tertiary-care academic medical center between 2013 and 2016. Data regarding clinical characteristics including treatment pathways, imaging diagnostics, maximum colonic diameter, clinical response, complications, and need for surgical consultation and/or intervention were collected and analyzed using descriptive methods and student t-test.

Results: 

37 patients received neostigmine for the treatment of CPO. Average colonic diameter was 10.6cm prior to any intervention. 13/37 (35%) of patients were not evaluated for distal obstruction prior to neostigmine administration and 29.7% of patients were not evaluated by the surgical service during their hospitalization.  CT scan was used to assess for distal obstruction in 21/37 (56.8%) patients and colonoscopy was performed on only 8/37 (21.6%) patients. 76% of patients who received Neostigmine without prior colonoscopy to rule out distal obstruction resulted in improvement of symptoms. Two patients required surgical intervention due to complications unrelated to neostigmine administration.  One patient was diagnosed with distal obstruction from a colonic mass. No complications were reported due to neostigmine administration. Mean colonic diameter change was 4.0 cm with decompressive colonoscopy and 2.7 cm with neostigmine (p=0.28). 

Conclusion:

Our review suggests that neostigmine can be safely given for CPO without prior endoscopic evaluation nor surgical consultation to rule out distal mechanical obstruction, which challenges traditional surgical dogma.  In lieu of colonoscopy, CT scan can be safely utilized to rule out distal obstruction.  Administration of neostigmine without colonoscopy can minimize delay in treatment for CPO.

 

 

 

89.15 Endoscopic Retrograde Cholangiopancreatography Performed by Surgeons. A Single Center Experience.

Posted on January 26, 2017

M. Al-Mansour1, J. Hazey1  1Ohio State University,Surgery,Columbus, OH, USA

Introduction: ~~Endoscopic retrograde cholangiopancreatography (ERCP) is traditionally performed by gastroenterologists. We are reporting our institutional experience with a large number of cases performed by surgeons.

Methods: ~~We retrospectively reviewed the charts of 1399 patients who underwent 1810 ERCP procedures performed by surgeons between August 2003 and June 2016. The surgeons were trained in formal surgical endoscopy fellowships. Demographic, procedure-specific and outcome data were collected.

Results:~~The mean age was 52.8 years and 54.8 % of patients were female. A surgical endoscopy fellow was involved in 63.3% of the ERCP procedures. Successful cannulation of the common bile duct and/or pancreatic duct was achieved 91.2% of the time. The rate of major complications was 5%. The rates of post-ERCP pancreatitis, hemorrhage, cholangitis and perforation were 4.6%, 0.5%, 0.6% and 0.1% respectively. All-cause 30 day mortality was 0.5% and there were no ERCP-specific mortalities noted.

Conclusion:~~ERCP can be performed safely by fellowship trained surgical endoscopists with excellent success rates and low complication rates that are consistent with previously reported data.

 

89.14 Racial Disparities Among Patients Undergoing Pancreaticoduodenectomy: A Nationwide Analysis

Posted on January 26, 2017

K. L. Anderson, Jr.1, S. Thomas2,3, M. A. Adam4, R. P. Scheri4, M. T. Stang4, S. A. Roman4, J. A. Sosa3,4,5,6  1Duke University Medical Center,School Of Medicine,Durham, NC, USA 2Duke University Medical Center,Department Of Biostatistics,Durham, NC, USA 3Duke Cancer Institute,Durham, NC, USA 4Duke University Medical Center,Department Of Surgery,Durham, NC, USA 5Duke University Medical Center,Department Of Medicine,Durham, NC, USA 6Duke Clinical Research Instiute,Durham, NC, USA

Introduction:  Understanding and reducing racial disparities in health care is a high priority nationwide. Disparities in outcomes have been demonstrated for pancreatic cancer, but studies have been limited to single institution experiences or analyses focused only on White vs. Black patient groups. Our aim was to investigate how racial disparities have changed over the last two decades in the management of pancreatic cancer. 

Methods:  Adult patients undergoing pancreaticoduodenectomy for Stage I and II pancreatic adenocarcinoma were identified from the National Cancer Data Base, 1998-2011. Univariate analysis was used to compare demographic, treatment, and short-term outcomes. Multivariate regression and survival analyses were used to examine differences between races in access to high-volume (H-V) (≥11 cases/year) facilities and overall survival.

Results: Over the study period, 10520 patients underwent pancreaticoduodenectomy for adenocarcinoma at 1044 institutions, of which 8852 (84.1%) were White, 887 (8.4%) Black, 522 (5.0%) Hispanic, and 259 (2.5%) Asian. Compared to White (56.4%) patients, Black (63.1%), Hispanic (66.5%), and Asian (61.4%) patients were more likely to receive care at low-volume institutions. All other races experienced higher rates of 30-day readmission (Black: 9.6%, Hispanic: 10.7%, Asian: 11.2%) compared to Whites (8.0%, p=0.02), and longer length of hospital stay (Black and Hispanic median 10 days, Asian 11 days,) compared to White patients (9 days, p<0.001). Positive margin and 30-day mortality rates did not differ between races. After adjustment, Black [OR 0.74 (0.63-0.86), p<0.001] and Hispanic [OR 0.78 (0.64-0.95), p=0.01] patients had decreased odds of accessing a H-V facility compared to White patients. Over time, access to H-V facilities improved for Hispanic [p=0.03] and Asian [p=0.04] patients, while there was no significant change for Black patients [p=0.81] compared to Whites (Figure). In unadjusted analysis, there were no differences in overall survival based on race (p=0.47). After adjustment, Hispanic patients had decreased mortality compared to Whites  (HR=0.81, p=0.05), but no differences were seen for Black or Asian patients.

Conclusion:  Over time, access to H-V institutions improved for Asian and Hispanic patients compared to White patients, while the gap in access persisted for Black patients. Improving access to H-V institutions may provide improved outcomes for vulnerable minority patients. 
 

89.13 Factors Predispose Conversion: Laparoscopic to Open Cholecystectomy Mexican-American Population

Posted on January 26, 2017

F. A. Yamin1, L. Puckett1, A. Rios-Tovar2, B. R. Davis1  1Texas Tech University Health Sciences Center El Paso,Surgery,El Paso, TX, USA 2Methodist Hospital Dallas,Surgery,Dallas, TX, USA

Introduction:  Optimal management of cholecystitis and elective gallstone disease is laparoscopic cholecystectomy. Underserved patients on the US- Mexico border undergo more frequent rates of conversion from laparoscopic to open cholecystectomy. Diagnostic staging criteria for acute cholecystitis are described in the Tokyo Guidelines (2007). This study delineates criteria to predict conversion risk for a wide range of gallbladder disease presentations in the Mexican-American population with low access to surgical care on the US-Mexico border.

Methods:  This is a case-matched control study from University Medical Center of El Paso (July 2014- July 2015). Criteria include: demographics, ultrasound measurements, labs, and comorbidities. Multiple ranges are applied to individual variables and ranges were analyzed for statistical significance. Student’s t-test and Wilcoxon rank sum test assess the differences in risk factors for continuous variables. If they were categorical, the Fishers exact test, or chi-squared test was used to assess differences. The logistic regression model assessed likelihood of conversion. P values less than 5% were considered statistically significant. All analyses were performed using SAS V.9.4.

Results: Forty conversion to open and 275 laparoscopic cases were analyzed (male 79, female 208). Ethnicity included Hispanics (235) and Non-Hispanics (52). Elective surgery (132) and cholecystitis (155) were grouped. In an unadjusted model: WBC, total bilirubin, gender, ethnicity and gallbladder dimensions (wall thickness, length, and width) are significant risk factors for conversion. In the adjusted model, only white blood cell count, gender and ethnicity were significant. Odds of conversion in Hispanics are 10 times higher compared to Non – Hispanics. Odds of conversion for males are 3 times more likely. Odds of conversion are 7% more likely for each unit change in WBC. Conversions had an average WBC of 14,000 (max. 18,000, SD 4,000); total bilirubin average of 1.2 (max. 1.53, SD .28); gallbladder wall thickness average 3.30 cm ( SD 1.51), gallbladder length average  9.51 cm (max. 22.1, SD 4.36); and gallbladder width average is 3.79 cm (max. of 5.6, SD 1.31cm). Hospital length of stay and complications to include partial cholecystectomy and bile leak increased parallel with conversion rates. 

Conclusion: Determination of preoperative factors that predispose to conversion from laparoscopic to open cholecystectomy allow for adjunctive treatment measures to include cholecystostomy and delayed operative intervention to reduce complications. Application of specific ranges smaller than the standard deviation would improve reliability of these predictors and demonstrate limitations of this study. This study expands known criteria for severity grading specific to the underserved population on the US-Mexico border. Further investigation creates improved power to predict the best course in complicated gallstone disease in the Mexican-American population with low access to expedient surgical care. 

 

89.12 Temporal Trends in the Management of Small Bowel Obstruction

Posted on January 26, 2017

M. Khalil1, T. Orouji Jokar1, H. Nerkar1  1New York Medical College,General Surgery,Brooklyn, NY, USA 2New York Medical College,General Surgery,Brooklyn, NY, USA

Introduction: Over the past few years the mangaement of small bowel obstruction (SBO) has been transitioned from operative to non-operative management. Furthermore, with increasing expertise in the laparoscopy, an increased use has been observed in emergent cases. The aim of this study was to assess the temporal trends in the management of SBO and outcomes differences of open versus laparascopic adhesiolysis. 

Methods: We performed a five year (2008-2012) retrospective analysis of national inpatient sample. We identified patient with SBO using ICD-9 diagnosis codes for small bowel obstructin with concomitant codes for intra-abdominal or peritoneal lysis of adhesions, gangrenous or obstructed hernia, or small bowel malignancy. Open adhesiolysis was identified using procedure code 54.59 and laparoscopic adhesioslysis was identified using 54.51 and 54.21. Our outcomes were trends in operative versus non-operative management of SBO and differences in outcomes between open versus laparosopic adhesiolysis. 

Results: A total of 503974 patients with SBO were identified, mean age of population was 48 (27) years, and 58% were female. There was no significant increase in total number of SBO over the years (p=0.68). The rate of operative intervention gone down significantly from 21% to 19% over the years (p<0.001). The total hospital charges and length of stay (LOS) was significantly lower in non-operative management (p<0.001 for both inferences). On comparison between open and laparoscopic adhesiolysis, the rate of open adhesiolysis decreased from 81% to 76% (p<0.001). The total LOS (p<0.001) and hospital charges (p<0.001) were significantly lower in laparoscopic group.

Conclusion: The non-operative management appears to be the favored treatment strategy in the management of SBO. However, in the sub-group of patient who require surgery, there has been an increasing role of laparoscopy. Further studies are warranted to better define these outcomes differences. 

 

89.11 Modified dome down laparoscopic cholecystectomy using only three trocars in the left abdomen

Posted on January 26, 2017

H. Bonatti1, N. Kubicki2, S. Kavic2  1Shore Regional,Surgical Care,Easton, MD, USA 2Medical Center,General Surgery,Baltimore, MD, USA

Introduction: The majority of surgeons use four ports for laparoscopic cholecystectomy (LC). We propose a three port technique with access from the left upper quadrant (LUQ).

Methods: Ninety-one LCs performed from 6/2013 – 12/2016, were analyzed. Trocars are placed in the LUQ (5mm), umbilicus (5 or 10-12mm), and between the two (5mm). The third troacar was replaced by a Teleflex minigrasper in 29 cases. After the gallbladder (GB) serosa is incised on both sides, a window is created behind the GB midportion and widened towards fundus and infundibulum. Cystic artery and duct are dissected out obtaining the critical view and after the last fundus adhesion is cut, they are secured with clips or endoloop.

Results: Median age of 60 women and 31 men was 57.2 (range 16.5-89.6 ) years. LC was done for acute cholecystitis (n=12), chronic cholecystitis (n=70), other (n=9). In 79 cases (87%), the procedure could be completed with three instruments, in five cases an additional instrument was inserted for second procedures (paraesophageal hernia repair, cystgastrostomy, appendectomy, extensive lysis of adhesions (n=2)). In seven cases an additional 5mm port was placed for GB retraction; a Keith needle was used for GB suspension in four patients. Ten cases were done with two five mm ports and a minigrasper and in 53 cases the modified dome down technique was completed (remaining cases were done in traditional dome down technique). There were no vascular or bile duct injuries in this series. 39% of cases were done as outpatient procedures, 35% of patients required 23hours observation and 26% were hospitalized.

Conclusion: Three instrument modified dome down technique with trocar placement in LUQ is feasible and safe in easy and difficult cases.

 

89.10 Quadrant Localization Of Parathyroid Adenoma; Performance Of 4D-MRI Neck Parathyroid Protocol

Posted on January 26, 2017

K. O. Memeh1, J. Palacios1, M. Guerrero1  1Banner- University Of Arizona Medical Center,Surgery,Tucson, AZ, USA

Introduction:

Accurate pre-operative image localization is useful in selecting minimally invasive parathyroidectomy in patients with primary hyperparathyroidism (PHPT). Sestamibi scan, ultrasound, compted tomography and conventional magnetic resonance imaging (MRI) has varying accuracy in localizing parathyroid adenoma. Our group has shown that 4D MRI is more accurate than conventional imaign in identifying single adenomas. In this study, we set out to determine if 4D-MRI is able to accuratley localize the quadrant (superior or inferior) of the adenoma.

Methods:

We analysed and matched the result of MRI parathyroid protocol of all patients who underwent parathyroidectomy for PHPT at the University Of Arizona Medical Center between Feb 2015 and May 2016 with the intra-operative findings. All resections were confirmed successful with adequate decrease in intraoperative PTH as defined by the Miami criteria.

Results:

A total of 26 patients with PHPT underwent pre-operative localization with 4D-MRI neck. 14 patients had single adenoma and 12 patients had multi- gland disease. MRI accurately distinguished single from multigland disease in 85% of cases.  MRI accurately identifed single adenomas in 100% of patients. MRI was further able to identify the correct quadrant in all patients with single adenoma. However, MRI was only accurate 67% of the time in identifying multi-gland disease, but accurately idenified all (3) double adenoma’s.

Conclusion:
4D MRI accurately identified single and double adenomas in their respective quadrants. However, accuracy in multigland hyperplasia was lower. This study shows that 4D MRI is a usefule imaging modality in single and double gland disease.
 

89.09 NaMELD and Peri-operative Outcomes in Emergency Surgery

Posted on January 26, 2017

E. L. Godfrey2, M. L. Kueht1, A. Rana1, S. Awad3,4  1Baylor College Of Medicine,Department Of Surgery, Division Of Abdominal Transplantation And Hepatobiliary Surgery,Houston, TX, USA 2Rice University,Department Of Bioengineering,Houston, TX, USA 3Baylor College Of Medicine,Department Of Surgery,Houston, TX, USA 4Michael E. DeBakey Veterans Affairs Medical Center,Department Of Surgery/Critical Care,Houston, TX, USA

Introduction:  Recently, the Sodium-Model for End-Stage Liver Disease (NaMELD) score has been shown to be a superior measure of liver disease severity in transplantation, but has not yet been applied extensively in non-transplant surgery.  We aimed to analyze NaMELD scores and outcomes of cirrhotic patients that underwent emergency surgery with the hypothesis that there would be a discrete NaMELD score threshold at which outcomes would be significantly worse.

Methods:  We conducted a retrospective chart review of all patients with cirrhosis who underwent emergency surgery at our institution between January 2001 and April 2013.  Univariate and multivariate regression was used to identify predictors of peri-operative outcomes: 30-day mortality, peri-operative morbidity, and disposition at time of discharge (home or need for transitional care). NaMELD scores were analyzed at 1-unit increments to determine risk thresholds.

Results: 85 patients with cirrhosis underwent emergency surgery. Univariate threshold analysis identified NaMELD risk cutoffs of 19, 17, and 12 for predictors of 30-day mortality (OR=3.44), peri-operative morbidity (OR 3.08), and discharge to home (inverse relationship, OR=0.31), respectively.  Multivariate analysis revealed independent predictors of intraoperative complications to be congestive heart failure (OR=11.65) and serum creatinine (OR=2.25). Independent predictors of morbidity and discharge to home were estimated blood loss in surgery (OR=1.01) and the presence of a post-operative complication (OR=0.21), respectively. When patients were grouped by NaMELD score, most complication types occur more frequently in higher scored groups.

Conclusion: Although emergency surgery in patients with cirrhosis can be life-saving, knowledge of the significant peri-operative risks should drive the discussion with the patient and family.  While further study is needed to develop a definitive threshold of NaMELD scores to predict negative outcomes of surgery in cirrhotics, this analysis shows an NaMELD of 17 is associated with increased peri-operative complications, 19 with higher 30-day mortality, and 12 with increased need for transitional care after discharge.

 

89.08 Preoperative platelet-to-albumin ratio predicts outcome of patients with bile duct carcinoma

Posted on January 26, 2017

N. SAITO1, Y. Shirai1, T. Horiuchi1, H. Sugano1, R. Iwase1, K. Haruki1, Y. Fujiwara1, K. Furukawa1, H. Shiba1, T. Uwagawa1, T. Ohashi2, K. Yanaga1  1The Jikei University School of Medicine,Department of Surgery,Minato-ku, TOKYO, Japan 2The Jikei University School of Medicine,Division Of Gene Therapy, Research Center For Medical Sciences,Minato-ku, TOKYO, Japan

Introduction:  Several studies on bile duct carcinoma have investigated systematic inflammation-based preoperative prognostic indicators such as platelets, albmin and inflammatory mediators. Since inflammation is associated with prognosis, we hypothesized that the Platelet-to-Albmin Ratio (PAR), a novel inflammation-based prognostic score, is associated with long-term survival in patients with bile duct carcinoma after hepatic or pancreatic resection. The aim of this study is to evaluate a prognostic value of preoperative PAR in bile duct carcinoma.?

Methods:  A total of 59 patients who underwent pancreatic resection for bile duct carcinoma were studied. The patients were divided into two groups as PAR ≥ 72.6 x 103 or < 72.6 x 103 on the basis of ROC curve analysis (2-year survival, AUC=0.709 ± 0.08, p=0.002). Survival data were analyzed using the Log-rank test for univariate analysis. Multivariate analysis was performed by Cox proportional regression model with backward elimination stepwise approach.

Results: The PAR was a significant prognostic index on univariate analysis for DFS and OS. The PAR also retained its significance on multivariate analysis for DFS (HR 4.422, 95%CI 1.168 – 16.732, p=0.029) and for OS (HR 6.232, 95%CI 1.283-30.279, p=0.023). On multivariate analysis, in addition, tumor differentiation (HR 2.711, 95%CI 1.279 – 5.747, p=0.009) was an independent risk factor for DFS. For OS, along with PAR, tumor differentiation (HR 3.238, 95%CI 1.349 – 7.771, p=0.009), intraoperative blood loss (HR 1.001, 95%CI 1.000 – 1.002, p=0.036) and serum CEA (HR 6.051, 95%CI 1.484 – 24.669, p=0.041) were independent risk factors by multivariate analysis.

Conclusion: The preoperative PAR is a novel and significant independent prognostic index for DFS and OS in patients with bile duct carcinoma after pancreatic resection.

 

89.07 Incidental Carcinoma in Multinodular Goiter is Associated with Lower Rates of Recurrence

Posted on January 26, 2017

N. Zern1, A. Glover3, A. Aniss2, M. Sywak2, L. Delbridge2, S. Sidhu2  1University Of Washington,Department Of General Surgery,Seattle, WA, USA 2University Of Sydney,Endocrine Surgical Unit,Sydney, NSW, Australia 3Memorial Sloan-Kettering Cancer Center,New York, NY, USA

Introduction: Incidental malignancy after thyroidectomy for multinodular goiter is not rare. This study examines clinical outcomes of patients with incidental carcinoma after thyroidectomy for benign disease. 

Methods: A retrospective review of our thyroid cancer database was performed for years 2000-2015. Patients were analyzed who underwent total thyroidectomy for benign multinodular goiter. Patients were included for analysis as cases without suspected malignancy if preoperative fine needle aspiration was benign, non-diagnostic or not performed, and if final pathology showed an incidental differentiated thyroid carcinoma > 1 cm. Micro-carcinomas were excluded from this study.  These cases were matched to thyroidectomy patients with suspected malignancy based on gender, age and size of tumor. Primary outcome measure was recurrence defined by need for further surgery. 

Results: 71 patients underwent thyroidectomy for benign goiter with incidental carcinoma >1 cm. 72% were female with average age of 54 years at operation. The predominant histology was papillary carcinoma (77%). 27/71 patients (38%) underwent nodal resection. 10/27 (37%) had positive nodal metastases.   Matched controls with preoperatively suspected malignancy (n=137) showed similar histology, however 53/96 (55%) patients who underwent nodal resection had nodal metastases. Follow up was similar between groups (25 vs. 31 months, p=0.1) as was total dose of radioactive iodine therapy (5.6 vs. 5.4 GBq, p=0.8). Significantly more patients required an operation for recurrence in the control group, 11.7% vs. 2.8% (p=.04). 

Conclusion: Incidental thyroid carcinoma in benign multinodular goiter has low rates of recurrence. Standard investigations in these patients failed to yield a diagnosis of cancer preoperatively, likely due to the favorable features of these tumors. The absence of aggressive pathology leads to a better outcome following surgical resection.

 

89.06 "Second-Look” Laparotomy: Warranted, or Contributor to Excessive Open Abdomens?

Posted on January 26, 2017

N. Z. Hansraj1, A. Pasley1,2, D. G. Harris1, J. J. Diaz1,2, B. Bruns1,2  1University Of Maryland,Acute Care Surgery,Baltimore, MD, USA 2University Of Maryland,Trauma,Baltimore, MD, USA

Introduction:  Previous work from our institution illustrates a 28% rate of open abdomen (OA) utilization for emergency general surgery (EGS) patients undergoing laparotomy, with 27% of those left open to facilitate “second-look” (SL). With varying reports on the utility of SL laparotomy, the purpose of the current study is to determine whether EGS OA patients managed with SL laparotomy required additional bowel resection. We hypothesize that many of these SL patients could be managed with single-stage operative therapy and thus decrease the number of OA patients.

Methods:  This is a retrospective review of prospectively collected data from Jun 2013-Jun 2014, evaluating EGS patients managed with an OA who required bowel resection in either index or SL laparotomy. Demographics, co-morbidities, and clinical variables were collected. Indication for resection at SL, complications, and mortality rates were recorded. Charlson co-morbidity index (CCI) was calculated. Fischer exact t-test was used for statistical analysis. 

Results: 96 patients were managed with OA of which 59 (61%) of those underwent bowel resection and 50 (86%) were left in discontinuity. The mean age of the patients undergoing bowel resection was 62y, with 31 males. Comorbidities included prior MI in 10, DM in 22, CKD in 12, and PVD in 26 patients, with mean CCI of 3. The mean time to SL laparotomy was 25-hours. In the 59 patients with OA and bowel resection, 18 (30%) required resection at SL. Of those 18 patients, 60% (11) had questionable areas while 39% (7) had normal appearing bowel at the end of the index operation. Of those 18 requiring resection at SL, 14 had resection at index operation and only 4 did not. At SL laparotomy, 47% (28/59) of the cohort had fascia closed. Further evaluation of causation for resection at SL laparotomy included: evolution of existing ischemia in 6, new onset ischemia in 5, staple line revision in 4, and “other” causes in 3. Preoperative shock at pre-index operation was a predictor of need for further resection. Leaks, dehiscence, and surgical site infections were higher in the SL no resection group, though not statistically significant. The mean length of stay was 32.8 days, with 23 ICU days, and 19 Ventilator days, with no difference between the groups. The Mortality rate in the SL resection group was 50% (9/18) versus 39% (16/41) in the SL no resection group.

Conclusion: As nearly one-third of patients undergoing SL laparotomy required additional resection, with 39% of those having normal appearing bowel at index operation, SL laparotomy appears to be a justifiable indication for EGS OA techniques. 

89.05 Is Screening for Hypercalcemia worthwhile? An Analysis of 1,302,802 Patients

Posted on January 26, 2017

S. J. Baker1, C. Baletine1, R. Xie1, H. Edenfield1, H. Chen1  1University Of Alabama,Surgery,Birmingham, AL, USA

Introduction:  Laboratory screening and identification of pathology at earlier stages can prevent disease progression, reduce surgical risks, and potentially improve overall outcome. Despite the potential benefits of early screening, the effectiveness is dependent upon the disease incidence and the availability of the test.   Lack of access to care restricts early screening in certain socially disadvantaged populations. This study examined disparities in routine serum calcium screening and the incidence of hypercalcemia within a health system where racial minority groups are adequately represented.   

Methods:  :  All patients at a large academic health center with several hospitals and outpatient clinics during 2011-2015 were included.  Demographic and laboratory data in the Electronic Medical Record (EMR) systems were analyzed to assess the calcium screening rates and incidence of hypercalcemia by age, gender, race, and insurance type. One way frequency, chi-square test of independence and multivariable analyses were conducted. 

Results: In this 5 year period, 1,302,802 patients were evaluated, including 379,021 African Americans (28%), 20,398 Hispanics (2%), 13,022 Asians (1%), 762,915 Caucasians (59%), and 127,446 other ethnicities (10%). Of these patients, 577,994 (48%) had at least one serum calcium level recorded.  Older age, male, black, and covered by Medicare are significantly associated with higher calcium screening rates. The screening rate in patients older than 65 was 57% versus 45% ( in their counterpart. Males had higher screening rate than female (51% vs. 46%).  African Americans were more likely to have a serum calcium level drawn (52%) versus Caucasians (48%), Asians (44%), and Hispanics (35%;).  In addition, patients with Medicare were most likely to have calcium level screening (56%), followed by private insurance (48%), Medicaid (34%), and uninsured (20%).  The overall incidence of hypercalcemia was 2.2%, ranging from 0.9% in Asian males to 2.8% in African American females (see Table).

Conclusion: Significant disparities in laboratory testing exist within a large population cohort. Despite this, the incidence of hypercalcemia is relative low, suggesting that routine screening of any group of patients is likely not cost effective.

 

89.04 Characterizing Early Postoperative Hospital Readmissions Following Bariatric Surgery

Posted on January 26, 2017

K. Levene1, M. Bai2, A. Suzo1, R. Dettorre1, B. Needleman1, S. Noria1  1Ohio State University,Division Of General And Gastrointestinal Surgery,Columbus, OH, USA 2Ohio State University,College Of Medicine,Columbus, OH, USA

Introduction:  Readmission rates are a performance metric in the Pay for Performance model, implemented by the Centers for Medicare and Medicaid Services, which have an effect on hospital reimbursement and hospital ranking. Hospital readmissions, during the early postoperative period after bariatric surgery, range from 5% – 20%, and are predominantly related to poor pain control, nausea, vomiting, dehydration and wound infections. Based on this, we sought to characterize factors related to readmission at our institution to identify actionable targets to reduce rates.

Methods:  A retrospective review was conducted on patients who underwent primary Roux-en-y gastric bypass (RYGB) and sleeve gastrectomy (SG) at The Ohio State University from July 2014 to February 2016.  We included all patients treated according to our standard Care Coaching model throughout their index admission and subsequently readmitted prior to their first postoperative clinic visit.  Variables reviewed included age, gender, ethnicity, co-morbidities, BMI, hospital length of stay, days to readmission, cause for readmission, number of readmissions, postoperative BMI, and insurance status.

Results: From July 2014 to February 2016, 477 patients underwent primary RNYGB or SG. Of these patients, 32 (6.7%) were readmitted (53% RYGB, 47% SG). Within the readmitted cohort, 84% were female, and 78% were Caucasian. Average age and BMI was 41.7 years, and 47.47 kg/m2, respectively. The average length of stay for the index admission was 2.9 ± 1.1 days. The time to readmission was 6.56 ± 4.8 days. Of note, 41% of readmitted patients were covered by Medicaid/Medicare, while 59% had commercial insurance. No self-pay patients were readmitted. Interestingly, breakdown of insurance coverage for patients who undergo surgery demonstrated 14.5% Medicare/Medicaid, 83.2% commercial insurance and 2.3% self-pay. Primary complications leading to readmissions included, nausea/vomiting/dehydration (28%), pain (22%), and surgical site infection (19%).  Nine percent of readmitted patients were readmitted a second time.

Conclusion: At our institution, rates for primary RYGB and SG fall within the national average. However, despite the implementation of the OSU Care Coaching model, our standardized post-operative care pathway, the readmission rate for Medicare/Medicaid beneficiaries is high given they comprise only 14.5% of the total number of patients having surgery. Therefore, future endeavors will include a more in-depth analysis of our Medicare/Medicaid beneficiaries to assess the gaps in care which, in turn, will be integrated into a program of individualized pre- and post-operative preparation with clear recovery expectations. Ultimately, integration of a care-navigator for Medicare/Medicaid beneficiaries may help overcome obstacles to recovery and decrease readmission rates in this patient population.

 

89.03 Outcomes of Surgical Repair for Perforated Peptic Ulcer Disease among the Elderly: A NSQIP Analysis

Posted on January 26, 2017

V. T. Daniel1, J. T. Wiseman1, J. Flahive1, H. P. Santry1  1University Of Massachusetts Medical School,Department Of Surgery,Worcester, MA, USA

Introduction: The management of perforated peptic ulcer disease (PUD) has drastically evolved over the last fifty years due to the advances in medical treatment. Despite medical management resulting in fewer elective surgical repairs, the number of emergent surgical repairs have risen. Furthermore, as the elderly population increases, the demographics of patients requiring emergency general surgery has shifted to an older cohort. Although hospitalizations for PUD are now among older adults compared to younger adults twenty years prior, contemporary national data evaluating operative outcomes for open surgical repair for perforated PUD among the elderly are lacking.  

 

Methods: With use of the National Surgical Quality Improvement Program (2007-2012), patients 65 years and older who underwent open surgical repair for perforated PUD were evaluated. The primary outcome was 30-day mortality. Secondary outcomes were 30-day postoperative complications. Univariate and multivariable regression analyses were performed.

 

Results: Overall, 1422 patients 65 years and older underwent open surgical repair for perforated PUD. At the time of the operation, 19.3% were current or recent tobacco users and 9.2% required steroid use. Mean (± Standard Deviation) total hospital length of stay was 14 days (± 16). The most common postoperative complications were pneumonia (11.4%), septic shock (11%), and superficial site infection (5.1%) The overall 30-day mortality rate was 18.1%. After adjustment for other factors, 30-day mortality was significantly associated with postoperative pneumonia (odds ratio [OR], 2.71; 95% confidence interval [CI], 1.48-4.98; P =.001), higher American Society of Anesthesiologists classification (OR, 2.59; 95% CI, 1.67-4.02; P <.0001), postoperative ventilator dependence (OR, 4.89; 95% CI, 2.91-8.14; P <.0001), and postoperative septic shock (OR, 5.07; 95% CI, 2.85-9.03; P < .0001).

 

Conclusions: At U.S. hospitals, open surgical repair for perforated PUD among the elderly is associated with significant 30-day morbidity and mortality rates. As the U.S. population ages, preoperative risk stratification strategies should focus more on the age of the patient given the high mortality rates among the elderly. 

 

89.02 Can Local Anesthetics Decrease the Use of Postoperative Narcotics in Outpatient Hernioplasty?

Posted on January 26, 2017

T. DiNitto1, D. Hill1, K. Khariton1, M. Castellano1  1Staten Island University Hospital,Northwell Health,Staten Island, NY, USA

Introduction:

Prescription narcotic misuse is an epidemic in the United States. This study set out to examine whether liposomal bupivacaine (Exparel), 0.25% bupivacaine (Marcaine), or 1% lidocaine with epinephrine mixed with 0.25% bupivacaine would decrease the postoperative use of narcotics in ambulatory hernioplasty.

Methods:

A single surgeon performed 427 consecutive tension-free plug and patch mesh hernia repairs under local anesthesia with IV sedation from April 1, 2015 to December 31, 2015. Hernia repairs included inguinal, ventral, incisional, and umbilical. In 9.3% of cases two hernias were repaired during the same procedure. Every patient was seen between six and eleven days post hernioplasty and a standardized pain questionnaire was completed regarding subjective pain, prescription “painkiller”, and over the counter pain medication use in both quantity and duration. The primary endpoint was percentage of patients not requiring narcotics for pain control.

Results:

The Exparel group (147) and the Marcaine group (144) had similar results at 59% and 55% of patients who were able to avoid postoperative narcotics completely. The commonly used lidocaine with epinephrine/Marcaine mixture had only 39% success rate, significantly lower than the other groups.  Included in the study were patients that had two simultaneous hernia repairs where the exparel group only had 5.4% with 14% in the Marcaine.

Conclusion:

Our study demonstrates Exparel and Marcaine performed similarly reducing the need of postoperative narcotic use in outpatient hernia surgery by over 50%.  Both were a considerably better option than the Lidocaine/Marcaine mixture. The average cost difference between Exparel and Marcaine is exponential, with a difference of over 200 dollars per patient. Marcaine provides a significant cost benefit while achieving similar if not better postoperative pain relief and reduces postoperative narcotic use. Because of the similar outcome in pain control as well as the cost benefit, Marcaine has become the standard of care in our hernia center.  

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