81.16 Does Umbilical Cleanliness Correlate with Colorectal Surgery Patient Outcomes?

Posted on January 18, 2018

J. T. Brady2, A. R. Althans2, M. Nishtala2, S. L. Stein2, E. Steinhagen2, H. L. Reynolds2, C. P. Delaney4, S. R. Steele3  2University Hospitals Cleveland Medical Center,Surgery,Cleveland, OH, USA 3Cleveland Clinic,Colorectal Surgery,Cleveland, OH, USA 4Cleveland Clinic,Digestive Disease And Surgery Institute,Cleveland, OH, USA

Introduction:  Patient risk assessment can aid in stratification, preoperative intervention, and improvement in patient outcomes. While frailty and sarcopenia correlate with outcomes, these can be cumbersome to measure, and a simple objective bedside assessment of patient risk for postoperative complications would be useful. We hypothesized that umbilical cleanliness may be a surrogate for social or hygiene factors that reflect the risk of postoperative complications and discharge disposition. 

Methods:  A prospective, observational pilot study of patients > 18 years old undergoing colorectal surgery was performed over a two-year period at a tertiary academic medical center. Patients were excluded if they had an abdominal surgery in the prior 90 days, a protruding umbilicus, or prior umbilical excision. A scoring system to characterize the cleanliness of a patient’s umbilicus during routine sterile preparation of the abdomen consisted of a 0 to 5 point scoring system (see table).

Results: We enrolled 200 patients (mean age 58.1±14.8; 56% female). The mean BMI was 28.6±7.4. Indications for surgery included colon cancer (24%), rectal cancer (18%), diverticulitis (13.5%) and Crohn’s disease (12.5%). Umbilical scores were 0 (23%), 1 (26%), 2 (21%), 3 (24%), 4 (6%), and 5 (0%). Postoperative complications occurred in 116 (58%) patients. Increasing umbilical score correlated weakly with postoperative complications (Spearman’s rho=0.15, p=0.04) and increasing modified frailty index (Spearman’s rho=0.14, p=0.05). There was also a correlation with length of stay (Spearman’s rho=0.2, p=0.006), umbilical depth (Spearman’s rho=0.23, p=0.001) and ASA score (Spearman’s rho=0.25, p=0.0005). Umbilical score did not correlate with BMI (Spearman’s rho=0.09, p=0.2), surgical site infection (Spearman’s rho=0.05, p=0.5) or 30-day readmission (Spearman’s rho=0.2, p=0.3). There was no correlation between umbilical score and discharge disposition on univariate analysis (p>0.1). 

Conclusion:  Although sterile preparation of the abdomen is an important component of proper surgical technique, umbilical cleanliness does not correlate with patient outcomes.
 

81.17 Morbidity and Mortality in Patients Undergoing Fecal Diversion as an Adjunct to Wound Healing

Posted on January 18, 2018

R. J. Kucejko1, M. E. Pontell1, D. Scantling1, M. Weingarten1, D. E. Stein1  1Drexel University College Of Medicine,Surgery,Philadelphia, PA, USA

Introduction:  Stomas are routinely created for fecal diversion in chronic, non-healing wounds of the sacrum, ischium and perineum. Aside from re-routing stool from the wound bed, they also improve quality of life and prepare the patient for future reconstructive surgery. While these procedures are commonplace, little is published about their safety, with only two studies in the last twenty years. This study aims to analyze patients from our institutional database as well as the NSQIP national database who underwent fecal diversion for non-healing wounds to clarify the safety of fecal diversion in this group of patients and to identify factors that contribute to elevations in perioperative risk.

Methods:  A retrospective analysis was performed using data from the American College of Surgeons National Surgical Quality Improvement Project database between 2005 and 2015. Patients were selected based on a postoperative diagnosis of chronic ulcer of the skin. Patients were considered to have undergone diversion if the entry contained the procedure code for ileostomy or colostomy. Propensity score matching was conducted based on the NSQIP morbidity score. An additional retrospective analysis was performed on our institutions patient database spanning from 2000 until 2017. All patients who underwent fecal diversion for chronic, non-healing wounds were included. 

Results: 4,849 patients meeting inclusion criteria were identified in the NSQIP database. 859 underwent diversion compared to 3,990 patients who did not. In unmatched data, comparison of the two groups revealed no significant differences in mortality rate, postoperative stroke, need for cardiopulmonary resuscitation, myocardial infarction, need for blood transfusion, deep venous thrombosis, renal failure, organ space or superficial surgical site infection. In matched data, diverted patients had a significantly lower 30 day mortality. 56 patients were identified at our institution that underwent fecal diversion for non-healing wounds. 50% of patients with a preoperative ejection fraction of less than 30% died within 30 days of surgery (p = 0.045, likelihood ratio 6.58).

Conclusion: Fecal diversion in patients with chronic non-healing sacral wounds does not increase 30 day morbidity and mortality, based on NSQIP data.  While the 30 day morbidity does remain high, the subgroup of patients with severe cardiac dysfunction likely represent the majority of these cases and remain at a disproportionately elevated risk, based on our institutional data. It is reasonable to suggest that patients with cardiac risk factors undergoing fecal diversion for chronic wounds should undergo preoperative echocardiography. We propose that a preoperative ejection fraction less than 30% should be seen as a relative contraindication to immediate diversion without further optimization.

81.13 Effect of BMI on Outcomes after Surgery for Perforated Diverticulitis

Posted on January 18, 2018

K. T. Weber1, P. Chung2, M. Sfakianos1, V. Patel1, A. Alfonso1, J. Nicastro1, G. Coppa1, G. Sugiyama1  1Hofstra Northwell School Of Medicine,Department Of Surgery,Hempstead, NY, USA 2Coney Island Hospital,Department Of Surgery,Brooklyn, NY, USA

Introduction: For perforated diverticulitis, an open resection with ostomy creation has endured as the standard treatment, despite trends toward laparoscopic lavage in diverticulitis and increasing utilization of minimally invasive techniques in colorectal surgery. With rising rates of both morbid obesity and diverticular disease in the US, we sought to evaluate if findings in the literature suggesting similar outcomes between obese and non-obese patients are substantiated among patients who have open, emergent procedures for diverticulitis.

Methods:  Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2010-2015, we identified cases of emergent admission for diverticulitis (ICD 9 code 562.11) with evidence of preoperative sepsis and intraoperative contaminated/dirty wound classification in which a resection with ostomy (CPT 44141, 44143, 44144) was performed. We excluded cases with age <18 years, ventilator dependence, evidence of disseminated cancer and missing sex, race, BMI, functional status, ASA class, length of stay (LOS), and operative time data. We defined morbid obesity as BMI>35 m2/kg. Risk variables of interest included age, sex, race, medical comorbidities, requirement for preoperative transfusion, preoperative sepsis, and operative time. Outcomes of interest included LOS, 30-day postoperative complications and mortality. Univariate and propensity score analyses were performed.

Results: A total of 2,019 patients met inclusion/exclusion criteria, of which 413 (20.5%) were morbidly obese. Morbidly obese patients tended to be younger (mean 57.2 vs 62.6 years, p<0.001), have higher rate of insulin-dependent diabetes (8.0% vs 4.2%, p<0.0001), and have ASA class 4 (23.5% vs 19.6%, p<0.0001). Morbidly obese patients also had higher rates of postoperative septic shock (17.7% vs 12.1%, p=0.0040), return to operating room (11.1% vs 6.4%, p=0.0015), and surgical site infection (SSI), both superficial SSI (8.9% vs 5.8%, p=0.026) and deep SSI (4.4% vs 1.9%, p=0.0073). We identified 397 morbidly obese patients that were well-matched by propensity score to 397 non-morbidly obese patients. Conditional logistic regression showed increased risk of postoperative septic shock (OR 1.60, 95% CI [1.09, 2.34], p=0.015), however there was no difference in LOS (mean 12.8 vs 12.3 days, p=0.46) and no increased risk of 30-day mortality (p=0.947).

Conclusion: This analysis of a large national clinical database demonstrates that patients presenting with perforated diverticulitis undergoing a Hartmann’s procedure, after adjusting for the effects of morbid obesity, do not have increased mortality or LOS. Among morbidly obese patients, only increased risk of 30-day postoperative septic shock was found to be significant. Further prospective studies identifying risk factors associated with these adverse outcomes are warranted to guide clinicians when faced with these difficult cases.
 

81.14 Laparoscopic Radical Right Hemicolectomy Using Caudal -to-Cranial Versus Medial-to-Lateral Approach

Posted on January 18, 2018

L. Zou1, B. Zheng1, L. Zou1  1Guangdong Provincial Hospital Of Chinese Medicine,Department Of Gastrointestinal Surgery,Guangzhou, GUANGDONG, China

Introduction:
The aim of this study is to compare the safety and feasibility of laparoscopic radical right hemicolectomy using caudal -to-cranial (CtC) approach versus medial-to-lateral (MtL) approach.

Methods:
Using data from a clinical database in our department, we retrospectively analyzed data of 78 cases undergoing laparoscopic radical right hemicolectomy using CtC approach, matching with using MtL approach from January 2013 and October 2015. The matching factors consisted of gender, age, ASA score, BMI, tumor size, tumor location and TNM stage. Data of intraoperative and postoperative characteristics were reviewed. 

Results:
The data of clinicopathological characteristics were similar in both groups. In the intraoperative and postoperative characteristics, there are no significant differences in average time of ambulation, time to first flatus, hospital stay between two groups, but there are significantly shorter operation time (173.9±25.39 min vs.193.5±39.55 min. P = 0.0002) and less blood loss (92.0±21.21ml vs. 107.3±24.67ml. P < 0.0001) in the CtC group than that in the MtL group. The number of lymph nodes dissected in the CtC group is more (26.3±10.92 vs.22±8.93. P = 0.007). The rate of hemorrhage of the major vessels (SMA, SMV, ICV/ICA, RCV/RCA, Henle’s trunk, MCV/MCA) in the CtC group was significantly lower (14.1% vs. 3.8%. P = 0.025). 

Conclusion:
Laparoscopic radical right hemicolectomy using CtC approach is technically feasible for curable right-sided colon cancer with less blood loss compared with MtL approach, especially in the major vessel injury.
 

81.11 Virtual Postoperative Visits for New Ostomates

Posted on January 18, 2018

T. L. White1, J. Moss1, P. Watts1, J. Cannon1, D. Chu1, G. Kennedy1, S. Vickers1, M. Morris1  1University Of Alabama At Birmingham,Birmingham, AL, USA

Introduction: Post-operative education, discharge instructions, and follow-up appointments provide a foundation for new ostomates leaving the hospital, but a gap in care remains.  Studies show that having a stoma is an independent predictor of hospital readmission. Patients with new stomas utilize resources, including hospital based acute care, twice as much as colorectal patients without an ostomy. Telehealth has an emerging role post-operatively, allowing visual inspection of the patient while providing verbal support during virtual visits before clinic follow-up.  The purposes of this project are to determine the feasibility of Virtual Postoperative Visits (VPOVs), to define specific issues patients want addressed during VPOVs, and to assess whether patients are satisfied with a virtual format. Our hypothesis is that virtual post-operative visits will be feasible and will address patient centered goals of care following discharge with a new stoma.  

Methods: In this pilot project, we recruited 10 patients who attended 2 VPOVs following hospital discharge in addition to routine post-operative WOCN education and a post-operative clinic appointment. The VPOVs were conducted and recorded using UAB approved, HIPAA compliant video conferencing software. Descriptive statistics were used to analyze data gathered from a survey assessing patient satisfaction.     

Results: The mean age of our 10 patients recruited was 40 and 80% were women. Surgical procedures included robotic, laparoscopic, and open colectomies with 80% resulting in an ileostomy and 20% in a colostomy. Of the patients enrolled, 90% successfully completed two VPOVs. The mean time to the first VPOV was 9 days post-discharge (range 2-7 days) and none of the patients enrolled were readmitted.  Ninety percent of patients felt VPOVs helped manage the ostomy and agreed that VPOVs should be part of the discharge plan. All patients felt comfortable with the virtual format. Common themes addressed during VPOVs included pouching issues and skin irritation.  Barriers to enrolling patients into our VPOV pilot study included lack of access to technology and HIPPA compliant software for smart phones. 

 

Conclusion: The immediate post-operative period is a tenuous time for new ostomates. Overall, VPOVs are feasible and patients are very satisfied with VPOVs in addressing their patient centered goals of care.  Bridging the period between hospital discharge and initial clinic follow-up by using culturally sensitive, educational, and timely interventions should be a priority in this population. Future work will focus on large scale implementation of VPOVs for patients with new stomas.

 

81.12 Robotic vs Laparoscopic Resection for Colorectal Disease

Posted on January 18, 2018

T. K. Kleinschmidt1, M. Ferrara1, J. Rosser1, M. Parker1  1Brookwood Baptist Health System,Department Of General Surgery,Birmingham, AL, USA

Introduction: The aim of this study is to compare the results of robotic versus laparoscopic colon resection for all causes performed by two high-volume private practice colon and rectal surgeons.  Current recommendations are at least 150-250 cases on the da Vinci platform are needed to become adept.  This study bears significance as current research shows inconsistent results in comparing the two modalities which could be in part because many of the current literature are meta-analyses incorporating multiple centers, surgeons and disparate patient populations. 

Methods:  Retrospective analysis was performed for all patients who had either robotic or laparoscopic colon resection over a 10 month period.  Outpatient records were reviewed to ascertain demographic data such as: age, BMI, tobacco use, comorbidities and prior surgeries.  Hospital records were accessed to determine: case length in OR, estimated blood loss (EBL), need for conversion of case, length of postoperative stay and complication rates.  Complication rates were defined as: surgical site infections (SSI), need for reoperation and/or loss in quality of life as recorded in follow up office visits.  Statistical analysis of data was performed using R software.

Results: The study included 166 patients (109 in the Robotic surgery (RS) and 57 patients in the Laparoscopic surgery (LS) groups). For RS patients: mean age was 57.8 years of age, 57% were female, mean BMI was 29.9 and the most common procedure performed was LAR (67%) and most common indication was diverticulitis (36.7%). For LS patients: mean age was 64.0 years of age, 47.4% were female, mean BMI was 27.5 and the most common procedure performed and indications were also LAR (50.9%) and diverticulitis (36.1%). Mean operative time was longer in RS group (138.3 versus 125.4 minutes, respectively [p=0.0380]). Estimated blood loss was less in RS (59.6 versus 106.3cc, respectively [p=0.0282]). Mean postoperative length of stay was shorter for RS than LS (2.85 versus 4.0 days [p=0.0046]). Complication rates were similar in LS (26.3%) and RS (20.2%) [p=0.3681], and the most common LS complication was SSI (32.3%%) and most common complication for RS was SSI (42.1%). Conversion of operative technique was similar in RS and in LS (19.3% versus 13.8%, respectively [p=0.3524]).

Conclusion: Robotic surgery for colon resection had decreased EBL, and significantly shorter postoperative hospital stay.  Laparoscopic surgery had shorter operating time.  Similar results were found between postoperative complications and conversion rates of surgery.  In the hands of surgeons who have performed the reported amount of surgeries needed to become adept with the da Vinci Surgical System, robotic surgery has significant advantages for colon resection.

 

81.08 Laparoscopic Surgery for Rectal Prolapse: Short-Term Outcomes Should Not Dictate the Approach

Posted on January 18, 2018

P. L. Rosen1, D. J. Gross1, H. Talus5, V. Roudnitsky2, M. Muthusamy3, G. Sugiyama4, P. J. Chung3  1State University Of New York Downstate Medical Center,Department Of Surgery,Brooklyn, NY, USA 2Kings County Hospital Center,Division Of Trauma And Acute Care Surgery,Brooklyn, NY, USA 3Coney Island Hospital,Department Of Surgery,Brooklyn, NY, USA 4Hofstra Northwell School Of Medicine,Department Of Surgery,Hempstead, NY, USA 5Kings County Hospital Center,Department Of Surgery,Brooklyn, NY, USA

Introduction:
Full thickness rectal prolapse is a debilitating condition for which multiple surgical approaches have been described. Laparoscopic transabdominal approaches are frequently employed, but there is a paucity of data comparing outcomes between laparoscopic transabdominal rectopexy (LR) and laparoscopic transabdominal rectopexy with sigmoidectomy (LRS). Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, we compared outcomes between these two commonly employed modalities. 

Methods:
Using ACS NSQIP 2010-2015, we identified cases in which LR (CPT 45400) or LRS (CPT 45402) were performed for a postoperative diagnosis of rectal prolapse (ICD 9 569.1). We excluded cases with missing sex, race, BMI, functional status, and ASA classification data. Outcomes of interest included length of stay (LOS), postoperative major morbidity (wound infections, pulmonary complications, cardiovascular complications, renal complications, sepsis/septic shock, bleeding, return to OR) and mortality.  LR and LRS cases were matched using propensity scores. Matching diagnostics were performed and outcomes were evaluated using conditional logistic regression or the Wilcoxon rank-sum test.

Results:
We identified 1,397 patients of which 841 (60.2%) underwent LR and 556 (39.8%) underwent LRS. Patients undergoing LR tended to be older (mean 61.6 vs 55.8 years, p<0.0001), had lower rates of independent functional status (95.7% vs 98.6%, p=0.0072), had higher proportion of African American race (3.8% vs 2.5%, p<0.0001), diabetes treated with medication (7.3% vs 3.8%, p=0.022),  CHF (1.31% vs 0.0%, p=0.0043), bleeding disorders (2.3% vs 0.72%, p=0.031), and ASA class 3 (39.6% vs 30.4%, p=0.0045). Unadjusted comparison between LRS and LR showed increased LOS (median 4 vs 2 days, p<0.0001), increased rates of superficial surgical site infection (SSI) (2.7% vs 0.6%, p=0.0019), bleeding (3.1% vs 1.3%, p=0.036), and sepsis (1.8% vs 0.5%, p=0.025). Propensity scores were then used to match 509 LRS to 509 LR cases with diagnostics showing that the groups were well-balanced across covariates. Conditional logistic regression demonstrated that LRS compared to LR had no statistically significant increased risk of 30-day postoperative complications or mortality. However LRS was associated with increased LOS compared to LR (median 4 vs 2 days, p<0.0001). 

Conclusion:
In this large observational study utilizing a national clinical database we found no differences in 30-day postoperative outcomes between laparoscopic transabdominal rectopexy without sigmoidectomy versus laparoscopic transabdominal rectopexy with sigmoidectomy after propensity score matching. This suggests that long-term outcomes should dictate the choice between these two procedures.

81.09 Proximal Intestinal Diversion for Colorectal Anastomoses: What Are We Preventing?

Posted on January 18, 2018

A. Sunkerneni1, R. J. Kucejko1, D. E. Stein1, J. L. Poggio1  1Drexel University College Of Medicine,Surgery,Philadelphia, PA, USA

Introduction:  Proximal intestinal diversion is often thought to protect colorectal anastomoses from leak, and reduce leak-related morbidity.  While data for rectal cancer convincingly shows improvement in outcomes, the results for abdominal anastomoses are mixed.  Yet, patients are being diverted, incurring the increased morbidity and mortality surrounding the reversal of stomas without clinical benefit.  Prior studies of abdominal anastomoses have been done on limited patient numbers, and did not control for pre-operative morbidity.  The American College of Surgeons’ (ACS) National Surgical Quality Improvement Program (NSQIP) has collected the largest dataset on anastomotic leak to date.  Our aim is to determine risk-adjusted post-operative outcomes including anastomotic leak on patients undergoing colorectal anastomosis to determine which patients receive the most benefit from diversion.

Methods:  A retrospective analysis of the ACS NSQIP Procedure Targeted Colectomy database from 2012 to 2015 was performed. All patients 18 to 90+ years old in the targeted colectomy database were included.  Patients were excluded if any CPT code corresponded to a surgery that did not have an anastomosis, or a surgery with a pelvic anastomosis, or if their leak status was unknown.  Post-operative outcomes were analyzed using chi-squared and Mann-Whitney U tests.   Propensity score-matched cohorts were developed using the NSQIP morbidity score.  The primary outcomes were 30-day mortality, 30-day reoperation rate, and anastomotic leak.

Results: 61,161 patients underwent abdominal colorectal anastomosis over the 4-year period. 8,352 (13.7%) underwent emergent surgery, and were diverted 30.5% of the time, compared to the non-emergent diversion rate of 11.4%.  Matched patients who were emergently diverted had significant improvements in prolonged intubation, septic shock, 30-day return to OR, mortality rate, and operative leak rate, with no significant difference in other outcome measures.  Matched patients who were non-emergently diverted were only noted to have significant improvements in post-operative pneumonia, rate of reintubation, mortality and operative leak rate.  More importantly, these patients had significantly worse rates of organ space infections, AKI, UTI, DVT, sepsis, return to OR and 30-day readmission. 

Conclusion: Proximal fecal diversion for abdominal colorectal anastomosis is a known trade-off between immediate protection and long-term morbidity.  In emergent cases, significant improvements in mortality and leak rate are seen without significant rises of other complications, suggesting the right patients are being diverted.  But, in non-emergent cases, many operative sequela are made worse by diversion, with only modest improvements in leak rates and 30-day mortality.  Surgeons would benefit from a decision tool to better stratify patients undergoing non-emergent abdominal anastomoses to aid in optimal patient selection.

81.10 Racial Disparities in Opioid Utilization in Patients Undergoing Colorectal Surgery: Does It Exist?

Posted on January 18, 2018

P. K. Patel1, R. K. Burton1, K. E. Hudak1, L. E. Goss1, E. A. Dasinger1, M. Morris1, J. Richman1, G. Kennedy1, J. A. Cannon1, D. I. Chu1  1University Of Alabama at Birmingham,Gastrointestinal Division,Birmingham, Alabama, USA

Introduction: Racial disparities exist in surgical outcomes. Enhanced Recovery After Surgery (ERAS) protocols lead to improved outcomes and may reduce disparities. It is unclear, however, what the effect of ERAS is on post-discharge opioid utilization and whether racial disparities exist in opioid-specific outcomes. We hypothesized that there would be variations in opioid use between racial/ethnic groups with black patients prescribed more opioids and that this disparity would be reduced with ERAS.

Methods: This was a single institution study of patients undergoing ERAS for colorectal surgery in 2015, matched by race, age, sex, and procedure to a pre-ERAS group from 2010 to 2014. Patient, procedure, and opioid use characteristics were included. Each prescribed opioid was converted into standardized Oral Morphine Equivalents (OMEs). The primary outcome was the prescribed OMEs on discharge, OMEs over 1-year, and OME’s per pill (OME/P). Univariate and bivariate comparisons were performed using Chi-square and t-tests as appropriate. A p-value of less than 0.05 determined significance.

Results: Of the 395 patients (198 ERAS and 197 pre-ERAS) included, 28.3% were black. In the pre-ERAS group, a similar proportion of black and white patients were discharged with an opioid prescription (92.7% vs 92.3%, p=0.92). Within 1 year after surgery, opioid use decreased for both black and white patients (50.9% vs 49.3%, p=0.84). In the ERAS group, fewer patients were discharged with an opioid prescription but no difference was seen by race (89.3% for blacks, 85.9% for whites, p=0.53). Both black and white ERAS patients decreased opioid usage within 1 year (42.8% vs. 50.7%, p=0.32). At discharge, there was no difference in the OME/P between white and black patients under pre-ERAS (7.6 vs. 7.5, p=0.86) or ERAS (7.0 vs. 6.6, p=0.41) pathways. ERAS patients, however, did have significantly lower overall OME/P compared to pre-ERAS patients (p<.01). No differences in OME/P between racial groups were observed at 1-year post-discharge.

Conclusion: No racial disparities were observed in post-discharge opioid utilization in either the pre-ERAS or ERAS cohorts. ERAS did reduce overall opioid use, and possibly more for blacks than whites. However, a larger cohort is needed to confirm this hypothesis.

 

81.06 Emergency Room Admits and Complicating Factors are Linked to Poor Outcomes in Colorectal Surgery

Posted on January 18, 2018

M. Kanneganti1, P. Friedmann1, R. Levine1, H. In1  1Albert Einstein College Of Medicine,Surgical Oncology,Bronx, NY, USA

Introduction:
The circumstance of a person’s presentation at time of colorectal cancer (CRC) surgery is likely to influence outcomes. We aim to examine whether an admission through the emergency department and the presence of complicating factors (gastrointestinal bleeding (GIB), obstruction, and perforation) influence outcomes of CRC surgery.

Methods:
Nationwide Inpatient Sample (NIS) database was used. Patients who underwent surgery for CRC between 2007 and 2011 were included. CRC surgery patients were examined according to their admission circumstance; ER admission with complicating factors (ER-Cx), ER admission without complicating factors (ER-nonCx), non-ER admission with complicating factors (nonER-Cx) and non-ER admission without complicating factors(nonER-nonCx). Logistic regression models were used to estimate odds ratios of in-hospital death for admission status after adjusting for patient and hospital characteristics. Analyses were performed using SAS 9.4 (Cary, NC).

Results:
Of 81,774 patients, 5.2% were ER-Cx, 14.6% were ER-nonCx, and 3.8% were nonER-Cx. Patients with any ER admission or any complicating factors were more likely to be older (>75: 43.1% vs. 23.5%), black (12.7% vs. 5.9%) or Hispanic (7.2% vs. 4.1%), and have more comorbidities (3 or more: 22.9% vs.8.2%) compared to nonER-nonCx. These patients were also more likely to have complications (16.5% vs. 9.1%) and ostomies (26.6% vs. 15.0%). They had higher length of stay (LOS) as compared to all other patients [13.3 days (ER-nonCx), 12.9 days (nonER-Cx), 14.3 days(ER-Cx) vs. 7.9 days (nonER-nonCx)) and were less likely to be to be discharged home (65.0% vs. 85.8%). Adjusted logistic model shows that compared to nonER-nonCx, ER-nonCx (aOR 1.50, CI 1.29-1.75), nonER-Cx (aOR 2.06, CI 1.71-2.49) and ER-Cx (aOR 2.07, CI 1.73-2.47) were more likely to have in-hospital death.

Conclusion:
The circumstances for admission for CRC surgery independently influence outcomes. In our analysis, surgery after an ER presentation or surgery in the setting of GIB, obstruction or perforation is associated with worst outcomes. Future investigation should explore modifiable factors of ER admissions and admission with complicating factors, such as the timeliness of surgery. A patient’s presenting circumstance should be considered when evaluating outcomes and developing treatment plans following CRC surgery.
 

81.07 Revolving Door: The Impact of Length of Stay on Readmissions After Colon and Rectal Operations.

Posted on January 18, 2018

D. Peterson1,3, F. Guzman1, L. Yu4, W. Cirocco1, A. Harzman1, A. Traugott1, M. Arnold1, S. Husain1  1Ohio State University,Colon And Rectal Surgery,Columbus, OH, USA 3Penn State Hershey Medical Center,Surgery,York, PA, USA 4Ohio State University,Biostatistics,Columbus, OH, USA

Introduction:
With recent emphasis on pay for performance model for surgery, length of stay and readmission rates have come under renewed scrutiny. An inverse relationship between length of stay and readmission rates has been suggested raising concerns that early discharges may in fact lead to higher readmission rates. We sought to evaluate the relationship between length of stay and readmission rates and the impact of surgical approach, patient demographics and postoperative complications.  

Methods:
Retrospective chart review was conducted of all colorectal surgeries from September 1, 2011-August 31, 2016 at a tertiary medical center. Patient demographics, comorbidities, postoperative complications, length of stay and readmission rates were evaluated. Logistic regression used to evaluate continuous predictors and Fisher exact test used to evaluate categorical predictors.

Results:
A total of 1319 patients were included. The average length of stay was 10.3 days (median: 7) and 260 (19.7%). At least one complication was noted in 226 (17.36%) patients. Univariate analysis revealed that longer hospital stays correlated with higher readmission rates (R= 0.015, p= 0.00953). However, this association lost its statistical significance with multivariate analysis (p=0.858). Multivariate analysis also revealed that the both increased length of stay and readmissions were strongly associated with pre-existing patient comorbidities (age, diabetes, BMI, COPD, renal dysfunction) as well as postoperative complications (wound infection, abdominal abscess, SVT, PE, pneumonia, UTI). Furthermore, utilization of laparoscopic surgery had statistically significant association with shorter length of stay and lower readmission rates (p=0.004 and 0.02 respectively).

Conclusion:

While length of stay is associated with readmission rates in univariate analysis, this relationship is lost when factors like patient comorbidities, operative outcomes and surgical approach are taken into consideration. Our results also indicate that pre-existing comorbidities and postoperative complications result in prolonged hospitalization and increased readmission rates. Finally, our study not only confirms the well documented beneficial effect of laparoscopic approach on length of stay, it also indicates that minimally invasive approach results in lower readmission rates. While most pre-existing medical conditions leading to longer hospital stays and readmissions are not modifiable, a concerted effort is necessary to minimize postoperative complications and to promote utilization of minimally invasive platform.
 

81.04 Treatment & Prognosis of Rectal Squamous Cell Carcinoma: Analysis of the National Cancer Database

Posted on January 18, 2018

K. E. Koch1, P. Goffredo1, A. Beck1, P. Kalakoti1, I. Hassan1  1University Of Iowa,Surgery,Iowa City, IA, USA

Introduction:  Rectal squamous cell carcinoma (RSCC) is a rare malignancy, accounting for approximately 0.01–0.025% of all colorectal cancers. As a result, literature regarding its treatment and prognosis is mainly based on small single institutional series. Our aim was to describe patient characteristics, stage specific management, and outcomes utilizing a national database.

Methods:  We identified 2915 patients with stage I, II, and III RSCCs from the National Cancer Database treated between 2004 and 2014. Management strategies were categorized as local excision or chemoradiation alone, chemoradiation with local excision, and chemoradiation with radical resection. These modalities accounted for approximately 80% of patients in the cohort. Stratified survival analyses were adjusted by gender, age, and race. Data were examined using simple summary statistics, chi-square, student’s-T tests, Kaplan-Meier analysis, and Cox proportional hazards regression.

Results: The majority of patients were females (69%) and Caucasian (86%) with a mean age at diagnosis of 61 years (SD=13). The Charlson/Deyo score was 0 in 81% of patients. Mean tumor size was 41 mm (SD=25).  The 5-year overall survival (OS) was 70% for stage I (1021 pts), 55.8% for stage II (711 pts), and 54.7% for stage III (809 pts, p<0.001). In univariate analysis for patients with stage II and III disease, no difference was observed in the 5-year OS among management strategies (p=0.90 and 0.07, respectively). However, for stage I disease, the combination of chemoradiation and local excision was associated with improved outcomes compared to chemoradiation or local excision alone (p <0.001) (Table 1). The results of the univariate analysis were confirmed in the multivariate model after adjustment for available demographic confounders.

Conclusion: Our data suggest that for stage I disease the combination of chemoradiation with local excision may be the optimal oncologic treatment. Conversely, the addition of local excision or radical surgery to a treatment strategy based on chemoradiation for stage II and III disease was not associated with a survival benefit. Therefore, a treatment approach based primarily on chemoradiation should be considered the optimal management strategy for squamous cell carcinomas of the rectum.

81.05 Risk factors for 30-day readmission after colorectal surgery: does transfer status matter?

Posted on January 18, 2018

S. T. Lumpkin1, P. Strassle1,2, N. Chaumont1  1University Of North Carolina At Chapel Hill,Department Of Surgery,Chapel Hill, NC, USA 2University Of North Carolina At Chapel Hill,Department Of Epidemiology,Chapel Hill, NC, USA

Introduction: Rates of readmission after colorectal surgery (CRS) range from 9-25%, and cost the US $300 million annually. Our hypothesis is that transfer from an outside hospital prior to CRS, as one potential indicator of preoperative access to care, increases odds of 30-day readmission.

Methods: Using the Healthcare Cost and Utilization Project Nationwide Readmissions Database, a retrospective analysis of surviving adult patients who underwent inpatient CRS from 2010-2014 was performed. The primary outcomes were 30-day risks of cause-specific readmissions, listed in Figure 1. A composite ‘any surgical indication’ variable was created to assess if the primary indication for surgery was also a cause for readmission. Using multivariable logistic regression, we assessed the direct effect of potential risk factors for readmission, including demographics, hospital characteristics, comorbidities, indication for CRS, and initial transfer status to the index hospital where the CRS was performed.

Results: Total n=357,696 patients. The cause-specific rate of readmission was 7.1%, n=25269 (Figure 1). Primary indications for CRS were independent risk factors for readmission: relative to cancer, patients with IBD (OR 2.10, 95% CI 1.99, 2.22) and trauma (OR 1.24, 95% CI 1.08,1.43) were more likely to be readmitted, whereas patients with infectious indications (OR 0.74, 95% CI 0.72, 0.77) and non-infectious/vascular indications (OR 0.77, 95% CI 0.73, 0.81) were less likely to be readmitted. Patients treated at small hospitals were less likely to be readmitted (OR 0.94, 95% CI 0.90, 0.98) than patients treated at large hospitals. Treatment at a rural-nonteaching hospital compared to urban-teaching hospital, (OR 0.75, 95% CI 0.71, 0.79) decreased odds of readmission. Younger patient age, 18-34 years old compared to age 35-49 years old (OR1.13, 95% CI 1.05, 1.21), public primary insurance compared to private insurance (OR 1.27, 95% 1.22, 1.31), and multiple comorbidities were also significantly associated with increased odds of readmission. Two percent of patients were transferred from another hospital to the hospital where CRS was performed; this did not affect odds of 30-day readmission (OR 0.97, 95% CI 0.89, 1.06).

Conclusion: Preoperative considerations, such as primary indications for CRS, are important risk factors for readmission, but transfer status was not significant. At large, urban-teaching hospitals, where patients are at higher risk of readmission, targeting interventions towards patients between the ages 18-34, with public insurance, who have comorbidities, or whose primary indication for surgery is cancer, trauma, or IBD patients may reduce readmissions.

81.03 Incidence and Risk Factors of C. difficile Infection in Patients with Ileal Pouch-Anal Anastomosis

Posted on January 18, 2018

P. D. Strassle1,3, J. Samples1, E. E. Sickbert-Bennet2,3, D. J. Weber2,3, T. S. Sadiq1, N. Chaumont1  1University Of North Carolina At Chapel Hill, School Of Medicine,Department Of Surgery,Chapel Hill, NC, USA 2University Of North Carolina At Chapel Hill, School Of Medicine,Department Of Medicine,Chapel Hill, NC, USA 3University Of North Carolina At Chapel Hill, Gillings School Of Global Public Health,Department Of Epidemiology,Chapel Hill, NC, USA

Introduction:  In the last 10 years, recognition of Clostridium difficile infection (CDI) in patients with ileal pouch-anal anastomosis (IPAA) has been increasingly recognized. Despite the growing body of literature, conclusions about the incidence and risk factors of CDI in IPAA patients have been limited by single-institution studies, small sample sizes, and short follow-up. The goal of this study was to estimate the incidence and potential risk factors of CDI in patients with IPAA.

Methods: Patients diagnosed with ulcerative colitis, Crohn’s disease, or familial adenomatous polyposis, and undergoing an ileal pouch procedure between 2004 and 2013 in the Truven Health Analytics MarketScan® database were eligible for inclusion. Patients were required to have health insurance coverage for at least 6 months before and 30 days after surgery.  

Kaplan-Meier survival curves were used to estimate the 2-year risk of infection. CDI was identified using ICD-9 CM code 008.45, which has 78.0% sensitivity and 99.7% specificity. Multivariable Cox proportional hazard regression was used to assess the effect of potential risk factors. Risk factors included patient demographics, Charlson comorbidity score, pre-operative CDI (within 6 months of surgery), recent hospitalization (within 30 days of surgery), and use of corticosteroids, biologics, and immunomodulators (within 30 days of surgery). Inverse-probability of censor weights were used to account for differential follow-up. Age was modeled as a linear variable and centered at 40 years old. 

Results: 2,900 patients were included in the analysis. The median follow-up time was 628 days (IQR 287-730). The 2-year cumulative incidence of C. difficile was 3.3% (n=77). Twelve cases (15.6%) occurred during the surgical hospitalization. Patients with previous CDI (HR 7.33, 95% CI 3.85, 13.94) and patients taking corticosteroids (HR 2.19, 95% CI 1.30, 3.71) or biologics (HR 3.59, 95% CI 1.39, 9.24) prior to surgery were significantly more likely to have a CDI after IPAA. No significant differences in the risk of CDI across gender (p=0.51), age (p=0.70), Charlson score (p=0.99), history of recent hospitalization (p=0.50), or immunomodulator use (p=0.30) were seen.

Conclusion: The 2-year incidence of CDI after IPAA is at least 3%. Patients with a history of pre-operative CDI, and those taking corticosteroids or biologics before surgery are more likely to develop a CDI after surgery. 

81.02 The Association Between Sarcopenia And Myosteatosis And Post-operative Outcomes in patients with IBD.

Posted on January 18, 2018

S. J. O’Brien1,2, O. J. O’Connor3, E. J. Andrews2  1University Of Louisville,Surgery,Louisville, KY, USA 2University College Cork,Surgery,Cork, CORK, Ireland 3University College Cork,Radiology,Cork, CORK, Ireland

Introduction:
Sarcopenia has been defined by the European working group on Sarcopenia in Older People (EWGSOP) as a low muscle mass and either decreased muscle strength or low physical performance. Skeletal muscle index is use to measure muscle mass. Recent studies have demonstrated the association that sarcopenia has with adverse post-operative outcomes in patients with cancer. Few studies have examined the role of sarcopenia or myosteatosis, fatty infiltration of the muscle, in the setting of non-oncological surgery. The aim of this study was to assess the prognostic significance of sarcopenia and myosteatosis in patients with inflammatory bowel disease undergoing surgical resection with respect to post-operative complications.

Methods:
A retrospective analysis of a prospectively maintained surgical database was examined. All patients who underwent an elective or emergent colonic resection for IBD between 2011 and 2016 were included. Patient demographics, clinical indices and peri operative CT scans were collected. Skeletal muscle index was calculated by measuring the total muscle area (cm2),at the level of the L3 vertebra,  and normalising to the patients height squared (m2?) using the Osirix image analysis software (Figure 1). Myosteatosis is calculated by measuring the average Hounsfield unit at the same vertebral level. Regression analysis was used to identify predictors of outcomes.

Results:
39%(30/77) of patients were sarcopenic. Both sarcopenic and non- sarcopenic groups were equally matched with the exception of weight and BMI (p=0.014 and 0.009). There was a significant difference in hospital readmission between sarcopenic and non-sarcopenic patients and between myosteatotic and non-myosteatotic patients (p=0.03 and p=0.018). On univariate analysis, sarcopenia and myosteatosis were risk factors for hospital readmission (OR= 4.778, 95CI: 1.121-20.361 p=0.034 and OR= 6.24 95CI: 1.224-31.811, p=0.028). There was no difference in the incidence of major complications, anastomotic leaks and length of stay between the study groups.

 

Conclusion:
Sarcopaenia and myosteatosis were associated with hospital readmission in this study. As the cut-off values for a low skeletal muscle index are calculated from a cohort of oncology patients, this may accout for the lack of difference in the incidence of major complications, anastomotic leaks and length of stay. Further research is required to elucidate the role of myopenia and myosteatosis in patients undergoing surgery for non-malignant disease. 

81.01 Identifying Factors that Decrease Utilization of Adjuvant Chemotherapy in Stage III Colon Cancer

Posted on January 18, 2018

P. M. Schroder1, M. C. Turner1, B. Ezekian1, Z. Sun1, M. A. Adam1, C. R. Mantyh1, J. Migaly1  1Duke University Medical Center,Department Of Surgery,Durham, NC, USA

Introduction:  Standard of care for stage III colon cancer includes adjuvant chemotherapy, which increases survival by nearly 30%. Despite these results, many patients fail to receive adjuvant chemotherapy. We aim to describe the benefit of adjuvant chemotherapy for stage III colon cancer and to determine factors that influence the likelihood of receiving this treatment. 

Methods:  We queried the National Cancer Data Base 2006-2013 for patients with a single primary stage III colon adenocarcinoma and defined two groups: patients who did and did not receive adjuvant chemotherapy. Subgroup analyses were performed for healthy patients (Charlson-Deyo [CD] score = 0), comorbid patients (CD score ≥ 2), and those with post-operative complications (readmitted within 30 days of surgery). Kaplan-Meier (KM) curves were generated and Cox proportional hazard ratios (HR) were calculated to compare overall survival. Odds ratios (OR) for receiving chemotherapy were calculated to identify factors associated with failure to receive adjuvant chemotherapy. 

Results: Of the 74,588 patients included in this study, 54,235 received adjuvant chemotherapy and 20,353 did not. Overall survival was significantly better in the group that received adjuvant chemotherapy (HR of 0.477, p<0.001). Similar results were obtained in our subgroup analyses (see Figure). Adjuvant chemotherapy conferred a survival advantage for healthy patients (HR 0.485, p<0.001), comorbid patients (HR 0.492, p<0.001), and those with post-operative complications (HR 0.358, p<0.001). Several factors were associated with a reduced likelihood of receiving chemotherapy including older age (OR 0.9, p<0.001), black race (OR 0.728, p<0.001), comorbid patients with CD score ≥2 (OR 0.563, p<0.001), positive surgical margins (OR 0.83, p<0.001), and those with post-operative complications (OR 0.605, p<0.001). Patients with private insurance (OR 1.997, p<0.001) or Medicare (OR 2.184, p<0.001) were comparatively more likely to receive adjuvant chemotherapy.

Conclusion: We demonstrate a consistent survival benefit with adjuvant chemotherapy for patients with stage III colon cancer, even for comorbid patients or those with early post-operative complications. Factors such as older age, black race, more comorbidities, positive margins, post-operative complications, and lack of insurance were associated with a reduced likelihood of receiving adjuvant chemotherapy. These data suggest that adjuvant chemotherapy remains critically important for all patients with stage III colon cancer, but particular attention should be paid to utilizing this therapy in higher risk and underserved patients to avoid undertreating these vulnerable populations.

80.12 Hospital Based Tooth Extractions in the US

Posted on January 18, 2018

A. Gupta1, E. B. Schneider2  1Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 2Ohio State University,College Of Medicine,Columbus, OH, USA

Introduction:
Multiple surgical complications can be associated with dental extraction, such as excessive bleeding, bone sequestration, dry socket, numbness, swelling and trismus. Recent data from several countries demonstrates an increase in hospital based tooth extractions. In this study, using Nationwide Inpatient Sample (NIS) and Nationwide Emergency Department Sample (NEDS), we describe the characteristics of patients, and associated charges with visits for tooth extraction in an in-patient and Emergency Department (ED) settings.

Methods:
All records with an ICD-9 procedure code for tooth extraction (23.0, 23.1, 23.11 and 23.19) were retrieved from NIS and NEDS databases from 2012 to 2014. Using the survey sampling methods for NIS and NEDS, descriptive statistics were used to report the weighted results. Charges were converted to 2014 US dollars.

Results:
Weighted to represent the national population, total hospital admissions and ED visits for tooth extraction were 40,270 and 1,341 respectively. Mean charge per visit for visits with extraction as the primary procedure was $43,372 (±1518) in an in-patient setting and $10,372 (±1069.17) in ED setting, representing total 3-year charges of $385 and $6 million respectively. The three most common primary diagnosis for both in-patient (27.6%) and ED visits (38.5%) were Peri-apical abscess without sinus, cellulitis and abscess of face and cellulitis/abscess of mouth. Mean inpatient LOS with extraction as the primary procedure was 5.6 (±0.31) days. >60% patients were below median income quartile in each setting, and 27.0% and 24.8% were Medicaid insured in in-patient and ED respectively. In the in-patient setting, 1.6% were <6 years of age and 13.7% were >65 years of age; while in the ED, 12.7% were <6 years of age and 4.2% were >65 years of age. Among those who received tooth extraction as the primary procedure, 44.4% had ≥ 1 comorbidity in the in-patient setting, and 13.6% in the ED.

Conclusion:
Hospital-level tooth extractions account for substantial charges and are commonly due to dental conditions that might be preventable/restorable in early stages, with regular access to dental care. Patients undergoing tooth extraction, particularly in the in-patient setting, were more likely to be elderly and to have comorbidities. Dental caries, often the cause of periapical abscess and which may progress to cellulitis, can usually be managed through restorative procedures in a dental setting. Given the cost and resources required to manage these conditions in a hospital/ED setting, improved access to preventative and restorative dental care might particularly benefit identifiable high-risk individuals. Further research on policies to improve access to preventative dental care for individuals at risk for emergent extraction might identify and provide cost-effective opportunities for reducing the incidence of hospital based tooth extractions.
 

80.13 Novel Clinical Implementation of a Magnetic Surgery Center in the US

Posted on January 18, 2018

A. D. Guerron1, S. W. Schimpke1, C. Ortega1, C. Park1, R. Sudan1, J. Yoo1, K. Seymour1, D. Portenier1  1Duke University Medical Center,Durham, NC, USA

Introduction:

Modern surgery is searching for new minimally invasive technologies that improve patient outcomes. Magnetic surgery is a newly developed technology that reduces the invasiveness of the surgical procedures and was recently released for commercialization in the US. In order to translate the benefits of the new technology to the patients, the clinician has to implement the availability and use of the technology within their OR team in their centers. The objective of the present work is to describe the process developed for clinical implementation of a new Magnetic Surgery program in an academic hospital for the first time in the US. 

 

Methods:

The Magnetic Surgical System is the first product released to the market that uses technology based in magnetic fields in order to minimize the incisions on the surgical patient. This system was recently developed by Levita Magnetics Corp (San Mateo, California). The clinical implementation was performed at the Duke Regional Hospital, which is part of the Duke Medical Center. It was a collaborative work between OR management, OR nurses, and surgeons in order to generate policies, training and operative procedures to clinically implement the new technology. 

 

Results:

In January 2017 10 pilot cases were performed at the hospital. After these initial pilot cases, the training material and the policies for use started to be developed. In March the complete training and operative procedures were finished. Between March to August 2017 almost 100 cases have been performed with this new technology, including laparoscopic, single incision and robotic assisted. 

 

Conclusion:

This study shows for the first time the successful implementation of Magnetic Surgery in an academic center in the US. This first center will be the role model and training center for the future implementation and adoption of this new technology across the country and internationally. 

 

8.19 Gastric Cancer: Epidemiologial Features and Analyzes of Cases Treates between 2010 ans 2014

Posted on January 18, 2018

P. Abreu-Reis1, A. Bettega1, R. Goolkate1, M. Kato1, F. Tomasich1  1Hospital Erasto Gaertner – Federal University Of Parana,Department Of Surgery,Curitiba, PR, Brazil

Introduction: Present collected data from the Hospitalar Registry of Cancer of Erasto Gaertner Hospital between 2010 and 2014 referring to patients with gastric cancer admitted to the institution. Study the epidemiological features aiming to define risk
factors for the disease and the treatment outcome. 

Methods:  Data were collected from medical records. The used questionnaire was based on the National Cancer Institutes standards. The absolute and relative frequencies were generated from the SISRHC system and tabulated through the EpiInfo system, version 7.1. The survival rate was calculated using the Kaplan-Meier method.

Results: 983 cases of stomach cancer were admitted in the period from 2010 to 2014, representing the sixth most frequent topography. Mosto f the patients were male (67%). There was a higher prevalence above the fifth decade, with a bimodal 
distribution among women between 45-49 years and 55-59 years. The most frequent histological type was adenocarcinoma (60.6%), followed by carcinoma with signet ring cells (25.7%) and other less frequent histologies. More than 66.1% came from Curitiba and the metropolitan region. Regarding TNM (UICC) staging system, there was a predominance of advanced stages (65%). Family history of câncer was found in 56,1%. A positive personal history of alcoholism was found in 55,3% of men, in  contrast to 14.3% of women. A personal history of smoking was positive in 67,7% of men and only 43.4% of women . Concerning the treatment, 28.6% of the patients underwent surgery and 28.9% isolated chemotherapy. The treatment was combined in 39.9% of the cases. At the end of the first phase of treatment, 82.7% of the patients were still alive. Overall
5-year survival rate was 38.1%, ranging from 11.9% in clinical staging IV to 73.3% in clinical staging I.

Conclusion:Despite advances in the diagnosis and treatment of cancer, gastric cancer persists with a low overall 5-year survival rate, even in early clinical stages.

 

8.20 Surgical Site Infection Rates Increase in Transfer Patients for Orthopedic Injuries in a Rural State

Posted on January 18, 2018

N. R. Bruce1, W. C. Beck1, J. R. Taylor1, M. K. Kimbrough1, J. Jensen1, M. J. Sutherland1, R. D. Robertson1, K. W. Sexton1  1University Of Arkansas For Medical Sciences,Department Of Surgery,Little Rock, AR, USA

Introduction:  

Our state contains only one level 1 trauma center and is a rural sate.  This study sought to categorize the rate of surgical site infection (SSI) in trauma surgery patients with orthopedic injuries and identify correlating factors to detect possible areas for performance improvement within our trauma system. 

Methods:  

IRB approval was obtained and de-identified patient information was provided by the local trauma registry for all patients admitted at a single institution with fractures from April 2014 until April 2015.  Initial sample included 520 patients, 1 patient was excluded due to thermal injury and 9 due to mortality.  Fractures were categorized based on anatomic region and based on treatment by an orthopedist with fellowship training in trauma.  Factors examined included patient demographics, number of trips to operating room, and presentation from scene status. Statistical analyses were performed using JMP Pro 13.1.0 (Cary, NC) with significance set at p<.05.

Results: 

Final sample size consisted of 510 patients; 31% were women, 55% arrived from the scene, 70% arrived via ground, 74% were Caucasian, and 20% were African American.  Lower leg shaft fractures (40%), followed by femoral shaft fractures (22%) and forearm fractures (14%) were the most common injuries.  Of these patients 62% were managed initially by orthopedic surgeons with fellowship training in trauma.  Bivariate analysis revealed that there was no difference in bones fractured between those with SSI and those without.  SSI patients were older (47.8  ± 2.8 years compared to 42.6  ± 0.8 years), had less trips to the operating room (2.1  ± 1.4 vs 3.2  ± 2.8), and were more likely to be transferred from an outside hospital (75%).  There was no difference with infection rates comparing orthopedists with and without fellowship training in trauma orthopedics. 

Conclusions: 

Surgical site infections after orthopedic trauma are a significant burden.  Our data suggests that further research and targets for improvement should be across a trauma system to provide more expedient access to definitive care, as there is a higher risk for SSI in patients transferred from another hospital. 

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