82.15 Surgical Performance Dashboard Analysis Affirms that Hypertension is a Biomarker of Surgical Risk

Posted on January 18, 2018

L. A. Gurien1, J. Ra1, H. Kendall1, L. Palmer1, A. J. Kerwin1, J. J. Tepas1  1University Of Florida College Of Medicine – Jacksonville,General Surgery,Jacksonville, FL, USA

Introduction:
The NSQIP dataset tracks specific patient comorbid conditions (CM) and post-operative adverse events (AE). While CM do not always cause AE, analysis of a matrix of concurrent CM and AE demonstrates interaction of CM and AE to define risk from a population perspective. Using our surgical performance dashboard which tracks population risk, categorizes effect of AE using the Clavien-Dindo (C-D) system, and ranks individual provider performance, we evaluated the effect of our surgical quality program over a four year period. We hypothesized that the dashboard would document dominant risk factors, guide analysis of “unexpected” AE occurring with no CM, track AE effect, and define specific procedures and providers for focused assistance in managing risk.

Methods:

Two 12-month cohorts of general-vascular cases from 2013-14 and 2016-17 were evaluated. We analyzed concomitant occurrence of CM and AE to define most common CM with highest AE rate, and most common AE and associated CM. “Unexpected” AE without CM were analyzed by CPT and type of AE. The impact of AE regarding additional resource consumption was compared across study periods using Wilcoxon matched pairs test accepting p<.05 as significant. Reflecting a “march to zero”, individual performance was measured as a surgeon’s proportion of AE divided by proportion of cases performed. Scores within the group mean ±1 SD were classified as “expected” and lower outliers as “exceptional”.

Results:

The 2013-14 cohort consisted of 651 cases with 21% (n=137) incidence of AE. The 2016-17 cohort consisted of 596 cases with 20% (n=120) incidence of AE. For both groups, hypertension was associated with highest incidence and severity of AE, and transfusion within 72 hr. was the most common AE. C-D effect analysis demonstrated a shift over time to less severe AE (Figure), although not statistically significant (p=.625). Of cases with unexpected AE based on no CM, 90% were elective oncologic procedures with infection and sepsis as the most common AE. Provider performance over time identified the same surgeons with the highest AE/volume; however scores improved over time for >50% of participants.

Conclusion:

This dashboard analysis demonstrates that hypertension, which is often clinically silent, is a population time bomb for adverse surgical outcome.  Review of cases with unexpected AE illustrated the primacy of optimization and infection control as major adjuncts in these mostly elective complex cases. Individual provider and group performance identified quality improvement over time and a consistent provider cohort whose case mix mandates more aggressive preemptive strategies for avoidance of adverse events.

82.16 Revised Cardiac Risk Index Poorly Predicts Cardiovascular Complications after Adhesiolysis for SBO

Posted on January 18, 2018

D. Asuzu1, G. Chao1, K. Y. Pei1  1Yale University School Of Medicine,Department Of General Surgery,New Haven, CT, USA

Introduction:

The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) universal surgical risk calculator estimates risk of postoperative cardiovascular complications with a good to excellent overall accuracy in the NSQIP dataset (c-statistic 0.895). However, the NSQIP calculator requires up to 21 variables for prediction including intraoperative details, and its retrospective use is limited by unavailability of individual regression coefficients. The Revised Cardiac Risk Index (RCRI) can be readily estimated prospectively or retrospectively using only six clinical variables, however its accuracy in large surgical datasets has not been tested. Our objective was to determine accuracy of the RCRI for predicting cardiovascular complications after adhesiolysis for small bowel obstruction (SBO) using the NSQIP dataset. 

Methods:
8,196 cases of open or laparoscopic adhesiolysis (Current Procedural Terminology codes 44005 and 44180) for SBO (International Classification of Diseases, tenth edition 560.81 and 560.9) were analyzed from 2005 to 2013 using the NSQIP dataset. RCRI estimates were calculated for each case and compared to reported cardiovascular complications (myocardial infarction or cardiac arrest) using univariable logistic regression. Overall predictive accuracy was assessed by measuring model discrimination (c-statistics) and model calibration (Hosmer-Lemeshow Chi-squared statistics).  

Results:

RCRI predicted cardiovascular complications with odds ratio 1.96, 95% confidence interval (CI) 1.54 – 2.50, P < 0.001. However, c-statistic was poor (0.64, 95% CI 0.59 – 0.68), and Hosmer-Lemeshow Chi-square did not reach statistical significance (X2 35.49, P < 0.001, 3 groups) indicating low model discrimination and calibration.

 

Conclusion:

Despite its relative computational simplicity, the RCRI performed poorly as a predictor of cardiovascular complications after adhesiolysis for SBO. These findings call into question the utility of the RCRI in this patient population. Future studies should aim to develop models that are computationally simple while retaining predictive accuracy. 

82.13 Is Intraoperative Assessment of Small Bowel Resection Accurate?

Posted on January 18, 2018

W. I. McKinley1, B. Strollo1, M. Benns1, A. Motameni1, N. Nash1, M. Bozeman1, K. Miller1  1University Of Louisville,Department Of Surgery,Louisville, KENTUCKY, USA

Introduction: Enterectomy is a commonly performed procedure in trauma and acute care surgery but the term is nebulous in regard to the extent of bowel resected.  There is wide variation in practice between intraoperative assessment of bowel length and the accuracy of that assessment is unknown.  The aim of this study is to determine the accuracy and frequency of intraoperative assessment of bowel length.

Methods: After obtaining IRB approval retrospective chart review was performed of patients from three centers in Louisville, KY having undergone enterectomy (CPT codes 44120, 44202) from 2012-2016.  Patients were excluded if lacking pathology or an operative report.  Subgroups (0 to <10cm, 10 to <30cm, 30 to <50cm, and >50cm) were created based on length dictated by the operative surgeon.  Groups were compared using a 2-tailed Student’s t-test.

Results: 174 patients were included in the study (219 bowel resections) of whom 106 did have an estimate of bowel length resected (48.4%). 24 patients had <10cm removed, 47 patients had 10-30cm removed, 18 patients had 30-50cm removed, and 17 patients had >50cm removed.  Estimated bowel length <10cm showed a statistically significant underestimation in comparison to pathologic specimen, and larger resections tended to be overestimated.

Conclusion: Documentation regarding extent of bowel resected at our institution was poor, as surgeons dictated estimated length in less than half of cases.  Surgeons underestimate short segment resections while overestimating on extensive (>50cm) enterectomy.  Documentation of extent of enterectomy should be standardized and can have future clinical implications.

 

82.14 Outcomes of Femoral Hernias in Veteran Patients

Posted on January 18, 2018

L. R. Taveras Morales1, S. Huerta1,2  1University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA 2VA North Texas Health Care System,Department Of Surgery,Dallas, TX, USA

Introduction: Femoral hernias are much less common than inguinal hernias (2-4% of all groin hernias).  An analysis of 3,980 femoral hernias showed that femoral hernias were more common in women compared to men (63% vs. 37%) and are more likely to present with a hernia complication compared to inguinal hernias (36% vs. 4.9%).  The aim of the present study is to determine incidence and outcomes in patients with groin hernias at a veteran affairs hospital. 

Methods: A retrospective analysis of a prospectively maintained database of a single surgeon’s practice over 12 years (2005-2017) at the VA North Texas Health Care System (VANTHCS). The database included 1153 consecutive groin hernias in 1062 patients. Wilcoxon rank-sum test and Fisher’s exact test were used to compare the continuous and categorical outcomes, respectively. Patient postoperative morbidity was explored in a multivariable logistic regression model. The model was constructed using a forward stepwise technique.

Results:  Of 1153 inguinal hernias performed by the same surgeon over a 12-year period, 15 were femoral (1.3%).  The hernia sac contained an inflamed appendix in one of them (0.09%).  Patients with femoral hernias were older (64.7 ± 17.7 vs. 63.0 ± 5.9; p = 0.03), more likely to present with an incarcerated groin hernia, and would require a small bowel resection more frequently.  Complications following a femoral hernia were higher compared to inguinal hernias (Table). 

Conclusion: Femoral hernias are uncommon in veteran patients. A veteran patient presenting with an incarcerated groin hernia is likely to have a femoral hernia. 

82.12 Laparoscopic versus Open Bowel Resection for Small Intestine Diverticulitis

Posted on January 18, 2018

M. P. DeWane1, A. S. Chiu1, I. Rezek1, K. Y. Pei1  1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA

Introduction: Small intestine diverticulitis is rare and individual surgeon operative experience is generally limited.  As such, optimal surgical management is unknown. This study addresses this knowledge gap by comparing outcomes of laparoscopic versus open operative management of small intestine diverticulitis.

Methods:

This analysis was a retrospective review of the prospectively gathered American College of Surgeons National Surgical Quality Improvement Project from a 5 year period (2010-2014). Patients included for analysis had a primary diagnosis of small intestine diverticulitis (ICD-9 code 562.01) and a primary or secondary procedure listing that indicated bowel resection. Patients were stratified as having undergone either laparoscopic versus open management.

Multivariable logistic regression models controlling for patient variables and comorbidities were constructed to examine risk factors for undergoing extended hospital length of stay (5 days), prolonged operation time (3 hours) or presence of any postoperative complication (including neurologic, cardiac, respiratory, bleeding, renal, infectious, thromboembolic, or wound complications). These models were constructed in a backwards fashion and utilized an inclusion value of 0.1 and significance value p<0.05.

Results: A total of 295 patients were included in this analysis, 22.4% of whom underwent laparoscopic operations. Selected variables and outcomes stratified by cohort are shown in Table I. Emergency cases were more likely to be completed in an open fashion but there were no significant differences in mortality between the operation types. Reoperations were more prevalent in the open cohort. Patients undergoing laparoscopic versus open operation had lower odds of having an extended length of stay (Odds Ratio [OR]: 0.28, p<0.001) and developing any complication (OR: 0.31, p=0.039) and increased odds of undergoing a prolonged operation (OR: 3.67, p<0.001). 

Conclusion: Surgical experience for small bowel diverticulitis is rare. Laparoscopic resection performed for small bowel diverticulitis is associated with decreased length of stay and complications. The laparoscopic approach should be considered a safe option in appropriate patients who can tolerate prolonged operations.
 

82.09 GASTROINTESTINAL BLEEDING IN THE 21st CENTURY: NO LONGER A SURGICAL DISEASE?

Posted on January 18, 2018

D. A. Hill1, L. Khoury1, M. Kopp1, M. Panzo1, T. Bajaj1, C. Schell1, A. Corrigan1, R. Rodriguez1, S. Cohn1  1Northwell Health At Staten Island University Hospital,Department Of Surgery,Staten Island, NEW YORK, USA

Objective: With the advent of proton pump inhibitors and H. Pylori treatment, the old dogma “the most common cause of lower gastrointestinal (GI) bleeding is upper GI bleeding” may no longer be accurate. Similarly the 1994 publication by McGuire describing the correlation between a transfusion requirement of > 4 units of packed red blood cells (PRBCs) requiring operative intervention 60% of the time may also no longer be valid. We sought to determine the most common causes of GI bleeding in patients without an obvious source and the likelihood of transfusion, and endoscopic or surgical intervention.

Method: We queried our hospital database for GI hemorrhage during 2015, excluding patients with obvious upper GI source (hematemesis), or anal pathology. We collected data from patients with GI bleeding defined as bright red blood per rectum, melena or a positive fecal occult blood test. The primary endpoints were etiology of GI bleed, amount of transfusions required and operative, endoscopic or angiographic interventions performed.

Results: 93 patients were admitted with GI bleeding: mean age was 74 years old (range 19 to 95), 52% were male, and mean hemoglobin was 8.2 (range 3.5 to 14.2).  74% received blood transfusions with an average of 2 units transfused per patient (range 0 to 9); 22% received ≥ 3 units of packed red blood cells. The etiology of bleeding was: 17% upper GI source; 15% lower GI source; and in 68% the source remained unknown.  Bleeding stopped spontaneously in 86% of patients and 9% died (deaths were related to refusal of transfusions, requests for comfort care measures or withdrawal of care). 71% underwent inpatient endoscopy with only 6% undergoing a therapeutic endoscopic intervention (none of those undergoing intervention were transfused ≥ 3 units). No patient had surgical or interventional radiologic procedures related to their GI bleed.

Conclusion: Gastrointestinal bleeding, without an obvious source on presentation, rarely requires operative or interventional radiologic intervention. Blood transfusions were not predictive of the need for therapeutic endoscopic intervention which was required in only 6% of patients.

82.10 Opioid Prescriptions in General Surgery: Perception vs Reality

Posted on January 18, 2018

J. S. Danobeitia1, J. R. Imbus1, J. L. Philip1, D. F. Schneider1, D. Melnick1  1University Of Wisconsin,Surgery,Madison, WI, USA

Introduction:

Opioid prescription is a common practice following common general surgical operations. However, over-prescription is a major factor influencing opioid-related mortality. The objective of this study was to compare the general perceptions, beliefs and actual prescribing practices of general surgery physicians in an academic setting.

Methods:

We queried our electronic medical record to identify prescriptions written by physicians at our institution over a three-month period. We evaluated the quantity of pills prescribed after common ambulatory procedures: laparoscopic cholecystectomy (LC, n=62), laparoscopic inguinal hernia repair (LIHR, n=80), open umbilical hernia repair (UHR, n=42) and lumpectomy (LUMP, n=126). We also distributed a survey assessing education in pain evaluation and control, opioid prescription habits and expectation of pain in patients undergoing these operations. We compared prescriber perceptions to actual practices by estimating a perceived to prescribed pill ratio (P:P) for the management of post-operative pain.

Results:

A total of 58 surveys were completed by attending (43.1%) and resident (56.9%) physicians at our institution. Approximately 25% of respondents rated their education regarding pain evaluation/treatment during training as adequate while 22.0% considered it inadequate. Overall, the majority of respondents (72.2%) considered opioids necessary for post-operative pain management. When asked about appropriate duration of opioid treatment post-operatively, the most often selected duration was 3-5 days for LC (19.7%) and LIHR (18.8%). A longer duration (7-10 days) was more often selected for UHR (20.7%) and a shorter duration (1-3 days) was preferred for lumpectomies (28.9%). Further analysis revealed that the P:P ratio for attending physicians for LC and LIHR was higher (+34% each), while residents showed a +37% ratio for LUMP (Table 1). Participants cited procedure type (26%), history of chronic pain (23.8%), anticipated need for refills (17.7%) and patient age (16.6%) as the main variables driving pill quantity per prescription. Respondents reported discussing the details of each opioid prescription with senior residents and/or attending physicians less than half the time.

Conclusion:

The majority of physicians consider opioid medication necessary for management of post-operative pain, but only 25% rate their education regarding pain management as adequate. In addition, there appears to be a tangible discrepancy between provider beliefs and actual opioid prescribing practices. Implementation of educational programs and enhancing communication among care providers regarding best opioid prescription practices may constitute simple approaches to reduce narcotic over-prescription after surgery.

82.11 Outcomes of GI Operations in Neutropenic Patients

Posted on January 18, 2018

M. Harary1,2, J. S. Jolissaint2, A. Tavakkoli1,2  1Harvard Medical School,Boston, MA, USA 2Brigham And Women’s Hospital,Department Of Surgery,Boston, MA, USA

Introduction:  Surgery in neutropenic patients is often avoided due to presumed increased morbidity and mortality although limited data on actual outcomes is available. Here, we report on post-operative outcomes in neutropenic patients undergoing abdominal surgery, stratifying the severity of neutropenia to examine whether there is a critical number below which surgical risks are significantly different.

Methods:  We performed an institutional database search between 1988-2017 to identify patients who were neutropenic in the 24-hours prior to undergoing abdominal surgery. Endoscopic and percutaneous procedures were excluded. Neutropenia was defined as an Absolute Neutrophil Count (ANC) of <1500, determined either via direct measurement or extrapolation from leukocyte values. Patient outcomes were extracted by chart review. Severity of neutropenia was stratified as mild (1,000<ANC≤1,500), moderate (500<ANC≤1,000) or severe (ANC≤500). Comparisons were made using two-sided ANOVA, Kruskall-Wallis test, Chi-Squared test and binary logistic regression on SPSS.  

Results: A total of 134 patients were identified with a mean age of 56 years (SD 15.8); 41% were male. Of these, 69, 37, and 29, were mildly, moderately, and severely neutropenic, respectively (see Table). These subgroups did not vary significantly in age or gender distribution (F(2,131,) p=0.821, p=0.388).  Rates of 30-day mortality significantly vary among the subgroups (p=0.02) with 2.9%, 16.2% and 27.6%, in the mild, moderate and severe neutropenic respectively. The presence of severe neutropenia and urgency of procedure were both independent predictors of 30-day mortality (p=0.013, p=0.02). Severity of neutropenia was not a predictor of 30-day morbidity, ICU stay, disposition status, length of stay or likelihood of 30-day readmission. Overall, 61.2% of procedures were performed as an emergency.  These cases were associated with significantly higher rates of 30 days morbidity in the moderate and severe neutropenia subpopulations (p=0.028, p=0.026) and higher rates of ICU stay in the moderate group (p=0.032), compared to non-urgent cases in the same neutropenia group

Conclusion: Abdominal surgery in neutropenic patients, particularly in those with ANC<1,000, is associated with high rates of mortality regardless of etiology of the neutropenia. Ideally, surgery should be delayed whenever possible in order to allow ANC to rise, however this needs to be balanced against the possibility of an acute worsening and need for emergency surgery which is associated with a significant further increase in mortality.
 

82.07 Significant Proportion of Small Bowel Obstructions Require > 48 Hours to Resolve after Gastrografin

Posted on January 18, 2018

M. B. Mulder1, M. D. Ray-Zack2, M. Hernandez2, D. Cullinane4, D. Turay5, S. Wydo3, M. Zielinski2, D. Yeh1  5Loma Linda University School Of Medicine,Department Of Surgery,Loma Linda, CA, USA 1University Of Miami,Ryder Trauma Center: Division Of Trauma And Surgical Critical Care,Miami, FL, USA 2Mayo Clinic,Division Of Trauma, Critical Care, And General Surgery,Rochester, MN, USA 3Cooper University Hospital,Department Of Trauma Surgery,Camden, NJ, USA 4University Of Wisconsin,Department Of Surgery Marshfield Clinic,Madison, WI, USA

Introduction:  Gastrografin (GG)-based non-operative approach is both diagnostic and therapeutic for partial small bowel obstruction (SBO).  Absence of x-ray evidence of GG in the colon after 8 hours (h) is predictive of the need for operation and a recent trial used 48 h to prompt operation.  We hypothesize that a significant number of patients receiving the GG challenge require >48 h before an effect is seen.

 

Methods: In this post-hoc analysis of a multi-institutional SBO database, only patients receiving the GG Challenge were included. We excluded those without a nasogastric tube (NGT), NGT removal on the same day as insertion, and flatus before NGT insertion. Date of NGT insertion and removal were used to calculate the number of days of NGT decompression.  Passage of flatus and NGT removal were used as surrogate endpoints for evidence of passing the GG Challenge. “Hard” preoperative signs for operation included: closed loop obstruction, septic shock, and peritonitis. Multiple logistic regression analysis controlling for age, prior abdominal operation, and prior SBO exploration was performed to identify predictors of delayed (>48 h) GG Challenge effect.

 

Results: Of 319 patients receiving GG, 225 patients (71%) were successfully managed non-operatively (mean age 64  ±  16 years; 56% female).  X-ray was performed after a median 8 [4-8.5] h and GG was observed in the colon in 179 (80%). A total of 64 patients (28%) had NGT decompression for >48 h (n=58) or required >48 h to pass flatus (n=37), with some requiring both (n=21).  By 4 days, 215 (96%) of those who successfully passed the GG challenge had passed flatus.  Regression analysis demonstrated that previous abdominal surgery was predictive (OR 0.37 [0.16-0.88], p=0.024) of a delayed GG Challenge effect.  Ninety-four patients (29%) receiving GG underwent operative exploration (mean age 63 ±  17 years; 61% female).  X-ray was performed after a median 8 [6-9] h and GG was observed in the colon in 17 (18%).  Of the 94 undergoing operation, 24 (25%) underwent operation before day 4 without “hard” signs and also did not have intraoperative findings of strangulation, perforation, or require bowel resection.  In these 24 subjects, x-ray was performed after a median 8 [6-9] h and GG was observed in the colon in 6 (25%). 

 

Conclusion: A significant proportion of patients (20%) “failed” the 8 h GG Challenge but were successfully managed non-operatively.  At 48 h, a large proportion (28%) still required NGT or had not yet passed flatus, but were nevertheless successfully managed non-operatively.  Extending the GG Challenge to 96 h may help avoid operation in some patients, especially those without previous abdominal surgery.

82.08 Microbiological Patterns and Sensitivity in Necrotizing Soft Tissue Infections in Rwanda

Posted on January 18, 2018

M. CHRISTOPHE1, J. Rickard2,3, F. Charles1,4, N. Faustin1,3  1University Of Rwanda,College Of Medicine And Health Sciences,Kigali, KIGALI, Rwanda 2University Of Minnesota,Surgery And Critical Care,Minneapolis, MN, USA 3University Teaching Hospital Of Kigali,Surgery,Kigali, KIGALI, Rwanda 4Rwanda Military Hospital,Plastic And Reconstructive Surgery,Kigali, KIGALI, Rwanda

Introduction: Necrotizing soft tissue infections (NSTI) remains a challenging emergency surgical condition with rapid clinical deterioration, microbiological variability and increased morbidity and mortality

Methods: This prospective cohort study includes all patients managed in Department of Surgery, University Teaching Hospital of Kigali (CHUK) from April 2016 to January 2017 with NSTI. The objective was to describe patients’ demographics, involved tissue planes, bacterial pathogens involved, antimicrobial sensitivity patterns and outcome of care. Analyses were conducted using student t-test for continuous variables and Pearson chi-square test for categorical variables. P-value < 0.05 was considered significant

Results:A cohort of 175 patients with confirmed diagnosis of NSTI was recruited during the study period. Monomicrobial organisms were identified in 57% of cases: Klebsiella spp (n=28, 16%), Escherichia coli (n=22, 13%, Proteus spp (n=20, 11%, and Staphylococcus aureus (n= 19, 11%. Fifty one (29 %) patients had no bacterial growth. The overall isolated germs were gram negative (n=121, 81%) with predominance of klebsiella spp (n=38, 25%).  Third generation cephalosporins were prescribed in 136 (78%) patients. Forty to sixty five (40-65%) of commonly isolated organisms (klebsiella spp, Escherichia coli) were resistant to most used antibiotics (third generation cephalosporins). The overall mortality was 26%.  The median length of hospital stay was 23days (IQR: 8-41). 

Conclusion:NSTIs are found to be predominantly mono-microbial with high resistance to 3rd generation cepahalosporins. A large scale antibiogram study is needed to guide clinician decision making for empirical antibiotic coverage in NSTI in order to improve patients’ outcomes.

 

82.05 Timing of Post-Operative Complications after Major Abdominal Surgery Varies by Age

Posted on January 18, 2018

C. Bierema1, A. J. Sinnamon1, C. E. Sharoky1, C. J. Wirtalla1, R. E. Roses1, D. L. Fraker1, R. R. Kelz1, G. C. Karakousis1  1University Of Pennsylvania,Philadelphia, PA, USA

Introduction:  The relationship between patient age and timing of postoperative complication is unknown. We hypothesized that advanced patient age may be associated with later presentation of certain common complications following major abdominal surgery.

Methods:  

The American College of Surgeons National Surgical Quality Improvement Program (2001-2011) was used to evaluate timing of postoperative complications in patients undergoing elective major abdominal surgery (colectomy, gastrectomy, hepatectomy, and pancreatectomy). The Jonckheere-Terpstra test was used to assess for significant trends in age and later median postoperative day of complications. Multivariable linear regression adjusting for patient factors was then performed to examine the association between older age and timing of postoperative complications.

Results: 

A total of 108,689 patients met inclusion criteria. There were 8,834 patients <40y (8%), 54,040 patients 40-65y (50%), 36,834 patients 66-80y (34%), and 8,891 patients >80 y (8%). More than half the patients (58%, n=63,004) underwent colectomy. The remainder of the cohort underwent pancreatectomy (26% n=28,388), hepatectomy (10% n=10,687), and gastrectomy (6% n=6,610).  Significant differences in comorbid status by age group were observed. Before adjustment for patient factors, the median number of days to complication for urinary tract infection (p<0.001), pneumonia (p<0.001), superficial surgical site infection (p<0.001) and deep/organ space surgical site infection (p=0.046) was significantly longer with increasing age (see figure). There was no significant difference between median days to complication and age for venous thromboembolism, cardiac or renal complications. After adjustment for patient factors, a significant association between older age and later median day of complication presentation was only observed for urinary tract infection (p<0.001) and pneumonia (p<0.001). Other patient factors being equal, patients >80 years of age presented on average 2.56 days later with urinary tract infection and 1.46 days later with pneumonia than patients <40 years of age.

 

Conclusion: Urinary tract infection and pneumonia present later postoperatively with increasing age. Further study is needed to delineate whether these represent biological differences or delay in diagnosis, as elderly patients may not present with the same classic symptoms as younger patients. Recognition of these trends is important in the postoperative care of elderly patients, which is particularly relevant with the aging population. 

82.06 Staphylococcus aureus Nares Colonization Rates and Decolonization Efficacy of Povidone-Iodine

Posted on January 18, 2018

D. S. Urias1, J. Di Como1, K. Curfman1, M. Marley1, W. Carney1, D. Duke1, R. Dumire1, S. Morrissey1  1Conemaugh Memorial Medical Center,Johnstown, PA, USA

Introduction:
Surgical site infections (SSIs) are the most common hospital acquired infections (HAIs), although rare in abdominal wall hernia repair it is one of the most dreaded complications. Bundle protocols using chlorhexidine-gluconate (CHG) bath, nasal S. aureus decolonization with povidone iodine, and standard preoperative antibiotics have been proven in multiple trials to decrease SSIs. Because of these findings, we added a nasal decolonization bundle protocol to most surgical procedures with similar results. To better understand the impact of this key portion to the bundle protocol, we investigated colonization prevalence to provide insight as to the actual (practical) decolonization efficacy.

Methods:
A prospective observational study enrolling patients undergoing elective abdominal wall hernia repair with mesh. All patients were instructed to bathe with CHG the night before and morning of surgery, preoperatively a nasal culture for S. aureus was obtained from the nares, the nares were then swabbed with povidone-iodine nasal swabs, standard preoperative antibiotics were administered and the patient underwent the procedure. Postoperative nasal cultures for S. aureus were also obtained. Pre and post colonization prevalence were compared, thereby providing an estimate of the actual efficacy of our decolonization protocol in eliminating S. aureus in the nares.

Results:
To date, 80 patients have been consented and enrolled, with 54 patients completing all steps of the bundle and culture series. The study sample demographics include 91% males, mean age 59, mean BMI 29 and mean ASA was 2. The mean length of surgery was 47 minutes and the mean time from end of surgery to obtaining the post decolonization s. aureus nasal culture was 105 minutes.  For our study sample, the estimated prevalence of colonization with MRSA and/or MSSA is 22.2% (12/54) pre decontamination (11 MSSA, 1 MRSA, 0 positive for both) and 9.25% (5/54) after decontamination and surgery (5 MSSA and 0 MRSA), yielding an approximate 68% decontamination efficacy.

Conclusion:
Decreasing the rate of SSIs is a task assumed by a variety of departments within the health system using numerous methods. Evidence based decontamination protocols such as the one we have implemented are being successfully used to decrease SSIs. We have used our protocol in orthopedic and neurosurgical procedures and now have successfully expanded the protocol to repairs of abdominal wall hernias with mesh. The efficacy of povidone iodine in our study population although not as high as stated in recent literature, it does provide evidence for its use in a bundle protocol to decrease SSIs.
 

82.03 Epidurals are Associated with Increased Morbidity and Length of Stay in Open Ventral Hernia Repairs

Posted on January 18, 2018

S. L. Zhou1, M. C. Helm1, J. H. Helm1, M. I. Goldblatt1  1Medical College Of Wisconsin,Department Of Surgery,Milwaukee, WI, USA

Introduction:

Open ventral hernia repair is a common surgical procedure with multiple options for post-operative pain control.   Intravenous narcotics or epidural anesthesia are commonly used options. The primary objective of this study was to determine the morbidity and mortality associated with the use of epidurals for post-operative pain control.

Methods:
This study was a retrospective review of patients who underwent open ventral hernia repair. Data was abstracted from the National Surgical Quality Improvement Program 2015 dataset. Outpatient procedures, emergency cases, patients who did not receive mesh, or patients who remained inpatient for less than two days were excluded from analyses to identify only complex hernias. 

Results:
In total, 1943 patients met inclusion criteria of which 1009 (51.93%) received any combination of non-epidural post-operative pain relief and 934 (48.07%) received an epidural. The patients who received an epidural had a higher incidence of pulmonary embolism, urinary tract infection and had a longer operative time and length of stay compared to those patients without an epidural (Table 1).

Conclusion:
The use of epidurals was associated with in an increased incidence of pulmonary embolism and urinary tract infections.  In addition, epidural use was associated with an increased operative time and length of stay.  The use of epidurals was not associated with an increased incidence of surgical site infections suggesting that the complexity of hernias between the groups was similar. 

82.04 Thyroidectomy In Older Adults: An ACS-NSQIP Study Of Outcomes

Posted on January 18, 2018

Z. T. Sahli1, G. Ansari1, J. K. Canner1, D. Segev1, M. A. Zeiger1, A. Mathur1  1Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA

Introduction:  The rise in the geriatric population in the US along with the increasing prevalence of thyroid nodular disease and cancer will lead to a higher number of thyroidectomies performed in this age group.  The impact of thyroidectomy in older adults is not well defined. The aim of our study was to evaluate surgical outcomes after thyroidectomy in older adults as compared to younger adults.

Methods:  We conducted a retrospective cohort study using the American College of Surgeons National Surgery Quality Improvement Program database from 2012-2015. We included and categorized thyroidectomy patients into three age groups (18-64 years, 65-79 years, and ≥80 years) and analyzed 30-day perioperative outcomes using the bivariate X2 test and multivariate logistic regression to estimate risk of outcomes.

Results: Our study identified 39,859 patients who underwent thyroidectomy. Among our cohort, 31,315 (78.56%) patients were between 18-64 years, 8,544 (21.44%) were between 65-79 years, and 904 (2.27%) were ≥80 years. Compared to younger patients, patients ≥80 years were 2.25 times more likely to develop a complication (95% confidence interval [CI]: 1.58-3.20, p<0.001), 1.52 times more likely to have a longer hospital stay (95% CI: 1.18-1.96, p=0.001) and were associated with higher rates of hematoma (16.67%, p<0.001). Compared to younger patients, patients 65-79 years were 1.36 times more likely to develop a complication (95% CI: 1.12-1.64, p<0.001), 1.31 times more likely to have a reoperation (95% CI: 1.07-1.62, p=0.011), and 0.64 times more likely to have a lower rates of related readmission (95% CI: 0.47-0.87, p=0.004).

Conclusion: Patients ≥80 years have significantly higher rates of complications, longer lengths of stay, and incidence of neck hematomas. Patients 65-79 years have higher rates of complications and reoperation rates and lower rates of related readmission. Further studies are needed to risk stratify individuals within the aging population to counsel patients and potentially mitigate these risks.

 

82.02 Perioperative Factors Associated With Postoperative Pain Following Open Ventral Hernia Repair

Posted on January 18, 2018

W. R. Ueland1, M. Plymale1, D. Davenport1, J. Roth1  1University Of Kentucky,Lexington, KY, USA

Introduction: Effective pain control following open ventral and incisional hernia repair (VHR) impacts all aspects of patient recovery. To reduce opioids and enhance pain control, multimodal pain management including use of epidural analgesia, muscle relaxants, and non-opioid analgesics are thought to be beneficial. The purpose of this study was to identify perioperative characteristics associated with patient-reported pain scores.

Methods: After obtaining IRB approval, surgical databases were searched for open VHR cases performed by one surgeon over three years. Modes of pain management and visual analog scale (VAS) pain scores were recorded in twelve-hour intervals to hospital discharge or up to eight days post-operation. Patient characteristics were determined by medical record review. Forward stepwise multivariable regression (p for entry < .05; exit > .10) was used to assess the independent contribution to VAS scores of the preoperative, operative and postoperative factors.

Results: One hundred and seventy-five patients underwent elective open VHR with mesh implantation and were included in the analyses. Average patient age was 55.1 years (+/- 12.8 years) and slightly over half of the patients were female (50.9%). Just over one in ten patients were morbidly obese (BMI ≥40 kg/m2). No significant (p < .01) associations were found between VAS pain scores at any time point based on gender, ASA class, BMI, smoking status, history of cancer, heart disease or COPD. Patient factors independently associated with increased preoperative VAS scores included: preoperative opioid use, open wound, CDC Wound Class II and prior hernia repair(s). Patients with epidural for postoperative pain had significantly decreased VAS pain scores across the time continuum. Operative factors significantly associated with increased preoperative VAS pain score included: median hernia defect size, concomitantly performed procedure(s), duration of operation and estimated blood loss (EBL). Hospital length of stay and postoperative surgical site occurrence were associated with increased VAS pain scores at the preoperative and 0-11 hour postoperative time points. Greater preoperative VAS pain score predicted increased pain at each postoperative time point (all p < .05). 

Conclusion: Preoperative pain status and opioid use are associated with increased VAS pain scores postoperatively. Epidural analgesia effectively results in decreased patient-reported pain. Increased preoperative VAS pain scores are reflected in increased operative complexity measured by operative duration and EBL. 
 

81.20 RACIAL DISPARITIES AND GENDER DIFFERENCES IN ANAL CANCER

Posted on January 18, 2018

A. Cruz1, D. Chen1, V. Pandit1, C. L. Charlton1, D. Sessinou1, P. Vij1, V. N. Nfonsam1  1University Of Arizona,Department Of Surgery,Tucson, AZ, USA

Introduction:
Racial and gender disparities have been shown in other gastrointestinal cancers. However, there is a paucity of data on racial and gender disparities in anal cancer. The aim of this study was to assess racial and gender disparities among patients with anal cancer (AC). 

Methods:
We analyzed data from the National Inpatient Sample (NIS) 2011 database of patients diagnosed with AC with age ≥ 18. Demographic data including age, race and gender were assessed. Patients were stratified based on race and gender.  Fisher’s exact test and Odds Ratio Statistical analysis was performed to assess disparities. 

Results:
A total of 6,013,105 patients were assessed and 1,956,  (0.03% ) patients had AC.  Patient with AC were more likely to be female (58% vs 42%, p=0.001). Whites and Blacks had the highest incidence followed by Asians/Pacific Islanders. Black males had the highest proportion of anal cancer (0.04%) and had an OR of 1.64 compared to Whites (p-value = 0.00045). On the other hand, in Whites, females had the highest proportion of individuals with anal cancer (0.04%) and had an OR of 1.21 (p-value = 0.02). 

Conclusion:
Racial disparities and gender differences exist in incidence of anal cancer. Potential causes for this disparity are disparate access to healthcare, lack of education, and lack of awareness. Greater understanding of this disease will result in earlier detection, prevention methods, improved treatment, and better prognosis.
 

82.01 Emergency General Surgery Patients With Psychiatric Comorbidities and Increased Resource Utilization

Posted on January 18, 2018

A. Lauria2, V. Haney1, J. S. Kim1, A. Kulaylat1, S. Armen1, M. Boltz1, S. Allen1  1Milton S. Hershey Medical Center,Hershey, PA, USA 2Walter Reed Medical Center,Bethesda, MARYLAND, USA

Introduction: Mental health disorders offer a challenge to the care of patients across medical and surgical specialties. The impact of mental health disorders on the emergency general surgery (EGS) population is largely unstudied. We aimed to identify the prevalence of psychiatric disorders in EGS patients, and hypothesized that those with mental health comorbidities who underwent emergent procedures would have worse postoperative outcomes and require more intensive resource utilization.

Methods: Using standard NSQIP practices, data were collected on adult patients admitted for emergent cholecystectomy or appendectomy at a single academic center between 04/01/07 and 01/01/16. Charts were reviewed for psychiatric comorbidities and psychotropic medications. Logistic regression was used to determine the impact of psychiatric comorbidities on postoperative complications, ED visits, and readmission within 30 days.

Results: Of the 641 patients identified (appendectomy n=491 and cholecystectomy n=150), 115 patients (17.9%) had psychiatric comorbidities. Mood disorders were most common (76.5%), followed by anxiety or adjustment disorders (41.7%). Patients with psychiatric comorbidities experienced longer hospitalizations (median 2 vs. 1 days, p<0.001) and required more subsequent ED visits (18.3% vs. 10.3%, p=0.016) compared to those without a psychiatric diagnosis. On multivariable analysis, the presence of psychiatric comorbidities was associated with nearly twice the odds of ED visits within 30 days (OR 1.92, 95% CI 1.01 to 3.68).

Conclusions: Patients with mental health comorbidities who undergo emergency general surgery burden the healthcare system with longer lengths of stay and more ED visits. Protocols and patient education focused on those with mental health disorders may improve these outcomes.

 

81.18 Racial Disparities in Incidence of Colon Cancer in Patients with IBD

Posted on January 18, 2018

P. Vij1, D. Chen1, V. Pandit1, D. Sessinou1, A. Cruz1, C. Charlton1, V. Nfonsam1  1University Of Arizona,Tucson, AZ, USA

Introduction:  Many studies have explored the relationship between inflammatory bowel disease (IBD) (ulcerative colitis (UC) and Crohn’s disease (CD)) and colon cancer (CC). However, the impact of racial diversity remains unclear. The aim of this study was to assess the impact of racial diversity in patients with IBD developing CC.

Methods:  Using the National Impatient Sample (NIS) database from the year 2011, we included patients with age ≥ 18 and IBD and CC. Patients were stratified by race (Whites, Blacks, Hispanics, Asians/Pacific Islanders, and Native Americans). The primary outcome measure was racial disparities in patients with IBD and CC.  Statistical analysis was performed to compare the groups.

Results: A total of 6,013,105 patients were analyzed of which, 57,358 patients were included (CD: 36,357, UC: 21,001). CD had the highest proportion among whites followed by blacks. Among blacks, 0.48% had CD and 0.22% had UC. 0.56% total had colon cancer.  Patients with UC were more likely to get CC (p=0.059). Among patients with CC and CD, Hispanic patients (0.63%) had the highest proportion followed by whites (0.46%). 

Conclusion: Our results demonstrate racial disparities among patients with IBD and their developing CC. Although IBD is common in white patients, Hispanics are more likely to develop CC after IBD. This can be attributed to the social and economic variability among racial groups. Further national studies are warranted to better understand these disparities. 

81.19 30-Day Hospital Readmission after surgery for colon cancer: Who is at risk of coming back?

Posted on January 18, 2018

V. Pandit1, F. S. Jehan1, C. Martinez1, M. Khan1, M. Zeeshan1, V. N. Nfonsam1  1University Of Arizona,Division Of Colorectal Surgery,Tucson, AZ, USA

Introduction:  The recent era has seen a change of focus from simple mortality and complications to the quality of healthcare delivery. Hospital readmission within 30 days of an index hospitalization is recognized as a marker of poor-quality patient care. The aim of our study was to identify the patient related factors associated with 30-day readmission after colon surgery.

Methods:  We performed a four year (2012-2015) analysis of the National Surgical Quality improvement program (NSQIP) and included all adult patients who underwent colon surgery for colon cancer. Outcome measures were to identify factors related factors associated with 30-day readmission after discharge. We performed regression analysis to control for confounding variables. 

Results: A total of 95,055 patients were analyzed of which 36,279 patients had colon surgery for colon cancer and were included in our analysis. Mean age was 65+13 years, 51% were males and 72% were white. Overall mortality was 2.7% and 16% patients developed one or more complications. The 30-day readmission rate was 10%. On regression analysis, after controlling for confounders, age (OR: 1.4; 95%CI [1.2-2.1], p=0.03), presence of comorbidity (DM, HTN) (OR: 3.2; 95%CI [1.9-4.5], p=0.02), BMI > 30 kg/m2 (OR: 2.1; 95%CI [1.6-4.5], p=0.02), post-operative complication (OR: 5.5; 95%CI [3.2-8.9], p=0.01) and OR time (OR: 1.4; 95%CI [1.2-2.2], p=0.04) were independent predictors of 30-day readmission. 

Conclusion: Risk factors for readmission after colon surgery are multifactorial; however, pre-surgery comorbidities and postoperative complications appear to drive readmissions in colon surgery for colon cancer. Identifying patients at risk of readmission and optimization and decreasing postoperative complications will decrease the risk of postoperative readmissions.

 

81.15 “Practice Patterns and Outcomes of Splenic Flexure Mobilization During Laparoscopic Left Colectomy.”

Posted on January 18, 2018

B. Resio1, K. Y. Pei1  1Yale University School Of Medicine,Surgery,New Haven, CT, USA

Introduction: Historically, splenic flexure mobilization (SFM) was recommended for left colectomies to ensure adequate length for a tension free anastomosis and thus potentially mitigate the incidence of anastomotic complications. Despite the exponential increase in the adoption of the laparoscopic approach to colectomies, the national practice pattern and outcomes of SFM among this group are unknown. This study investigates the use of and outcomes associated with SFM for laparoscopic, partial colectomies with anastomosis for left colon and rectal cancers.

Methods:  The American College of Surgeons NSQIP database from 2007-2015 was queried for elective, laparoscopic, partial colectomies with anastomosis (CPT 44204, 44207, 44208) with/without SFM (CPT 44213) for colon cancer of the left colon or rectum (ICD9 153.2, 153.3, 154.0, 154.1) or (ICD10 C18.6, C18.7, C19, C20). Only cases labeled as elective were included and cases labeled as emergency or ASA 4/5 (life-threatening/ moribund) were excluded.  Primary outcome measures included all complications, superficial, deep and organ space infections, anastomotic leaks, postoperative ileus, return to operating room, death, hospital length of stay (HLOS) and operative time. Logistic regression models were used to compare outcomes, adjusting for patient and operative characteristics.

Results: 17,319 cases were identified of which 39.2% underwent SFM. Specifically, the proportion of SFM for left colon, sigmoid, recto-sigmoid and rectum were 49.3%, 33.3%, 36.9% and 46.9%, respectively. There was an increase in the overall proportion of cases with SFM during the study period (10.9% increase from 2007 to 2015). Compared to colectomies without SFM, patients undergoing SFM had an increase in: all complications (17.6% vs 15.6%, risk adjusted OR 1.11, 95%CI: 1.02-1.20); organ space SSI (4.6% vs 3.4%, risk adjusted OR 1.22, 95%CI: 1.04-1.43); prolonged ileus (10.7% vs 8.1%, risk adjusted OR 1.23 95%CI: 1.05-1.44) and operative time (mean time 234 vs 197 min, p<0.0001, 95%CI: 231.3-236.3 vs 195.4-198.9). There was no significant difference after risk adjustment for superficial SSI, deep SSI, return to operating room, anastomotic leak, death and HLOS.

Conclusion: Splenic flexure mobilization is performed in less than 50% of elective, laparoscopic, left, partial colectomies for colon and rectal cancer and is associated with increased complications, prolonged ileus, and operative time. Study findings support selective splenic flexure mobilization.

 

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