76.04 Multi-institution Evaluation of Adherence to Comprehensive Postoperative VTE Chemoprophylaxis

Posted on January 18, 2018

B. Hewitt1, E. Blay1, L. J. Kreutzer1, K. Y. Bilimoria1, A. D. Yang1  1Northwestern University,Surgical Outcomes And Quality Improvement Center,Chicago, IL, USA

Introduction:  Venous thromboembolism (VTE) is the leading cause of preventable hospital mortality. Current quality measures for VTE prophylaxis are problematic due to surveillance bias, are not comprehensive, do not ensure appropriate administration, and cannot identify reasons why failures to provide chemoprophylaxis occur.

Methods:  We examined adherence to a novel process measure in patients who underwent elective or non-elective colectomy over an 18 month period at 36 hospitals in a statewide surgical collaborative. The process measure assessed comprehensive VTE chemoprophylaxis during a patient’s entire inpatient hospitalization, including reasons chemoprophylaxis was not given. Unadjusted and adjusted analyses were performed to identify reasons for failure to provide defect-free chemoprophylaxis and examine patient- and hospital-level factors associated with failure.

Results: Out of 4,086 total colectomies, the standard SCIP-VTE-2 prophylaxis measure publicly reported by CMS identified failure in care in only 1% of cases; however, the new measure unmasked failure to provide defect-free VTE chemoprophylaxis in 18% of cases. Reasons for failure included medication not ordered (29.6%), patient refusal (29.5%), incorrect dosage/frequency (7.9%), patient off unit (3.3%), and other (29.6%). Patients were more likely to fail the chemoprophylaxis process measure if treated at safety net hospitals (Odds Ratio [OR] 1.60, 95% Confidence Interval [CI] 1.06-2.41; p=0.03) or if they were ≤ 40 years old (OR 1.52, 95% CI 1.05-2.20; p=0.03 compared to age ≥ 75 years). Patients treated at Magnet nursing-accredited hospitals (OR 0.45, 95% CI 0.30-0.67; p<0.001) or undergoing elective colectomy (OR 0.77, 95% CI 0.62-0.96; p=0.02 compared to non-elective colectomy) were less likely to fail chemoprophylaxis. Patients ≤ 40 years old (OR 2.20, 95% CI 1.43-3.40; p<0.001), underweight patients (OR 2.19, 95% CI 1.28-3.77; p=0.004) or those that received treatment at safety net (OR 1.97, 95% CI 1.07-3.62; p=0.03 compared to non-safety net hospitals) or teaching hospitals (OR 2.82, 95% CI 1.37-5.84; p=0.005 compared to non-teaching hospitals) were more likely to refuse chemoprophylaxis.

Conclusion: This is the first multi-institution study examining failure patterns in providing comprehensive postoperative VTE chemoprophylaxis. In stark contrast to SCIP-VTE-2, our measure unmasked chemoprophylaxis failures in 18% of colectomies in a statewide surgical collaborative. Most chemoprophylaxis failures were due to patient refusals and ordering errors, occurring throughout the inpatient postoperative period. Thus, hospitals should focus improvement efforts on ensuring patients receive VTE prophylaxis throughout their entire hospitalization.

76.02 Editorial (Spring) Board?: Gender Composition in High-Impact General Surgery Journals

Posted on January 18, 2018

C. A. Harris1, T. Banerjee7, M. Cramer4, S. Manz6, S. Ward5, J. B. Dimick3, D. A. Telem2  1University Of Michigan,Division Of Plastic Surgery, Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,Michigan Women’s Surgical Collaborative,Ann Arbor, MI, USA 3University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 4Cornell University,Ithaca, NY, USA 5University Of Michigan,Division Of Cardiac Surgery, Department Of Surgery,Ann Arbor, MI, USA 6University Of Michigan,Ann Arbor, MI, USA 7University Of Michigan,Institute For Health Policy And Innovation,Ann Arbor, MI, USA 8University Of Michigan,Institute For Health Policy And Innovation,Ann Arbor, MI, USA

Introduction: Serving on an editorial board is an important step in many surgeons’ careers; however, evidence suggests that access to these positions may differ based on gender. Analyses of medical journals indicate although women’s representation is improving, they remain a clear minority. Whether similar trends exist in surgery and whether women surgeons face different qualification thresholds for appointment remains unknown. To address this knowledge gap, we quantify the current gender composition of ten high-impact surgery journals, evaluate qualification metrics by gender, and delineate how board composition has changed over time.

Methods: Ten prominent general surgery journals were selected for inclusion based on impact factor. Editor characteristics were assigned using faculty websites, Scopus profiles, and the American Board of Surgery certification database. We performed cross-sectional analyses of editorial board composition by gender for 1997, 2007, and 2017 using univariate and logistic regression analysis. Variation in qualifications by gender was assessed by comparing H-index, academic rank, and number of additional degrees. Gender-based differences in editorial board member turnover and multiple board positions were evaluated for each time interval.

Results: Over 20 years, women’s editorial presence has increased from 5% to 19%. Initial univariate analysis demonstrated significant qualification differences. Compared to women, men had higher mean H-indices (39.1 vs 21.9; p<0.001) and more full professorships (70.2% vs 55.8% p=0.02); whereas, a higher percentage of women had additional degrees (36.1% vs 21.9% p=0.004). Following logistic regression controlling for length of time since board certification, these associations became non-significant (degrees p= 0.051; academic rank p=0.56; H-index p=0.35). Both women and men were equally likely to hold multiple board positions (1997 p=0.74; 2007 p=0.42; 2017 p=0.69). Journals retained higher proportions of men in each time interval (1997-2007 p=0.003; 2007-2017 p= <0.001; 1997-2017 p=0.01) and retention rates increased over time (Figure 1).

Conclusion: Women surgeons have a small but growing presence on surgical editorial boards, and any qualification differences by gender are likely attributable to practice length. Although this suggests improved gender parity, gaps remain, and may be perpetuated by inequitable retention. More importantly, rising retention rates may limit next-generation surgeons’ opportunities regardless of gender. Strategies such as imposing term limits or instituting merit-based performance reviews may help balance the need for high-level expertise with efforts to ensure that editorial boards capture the field’s changing demographics.

 

76.03 The Association of Enhanced Recovery Pathway and Acute Kidney Injury in Colorectal Surgery Patients

Posted on January 18, 2018

J. G. Wiener1, L. Goss1,2, D. I. Chu1, J. S. Richman1, J. A. Cannon1, T. S. Wahl1, G. D. Kennedy1, K. D. Cofer1, P. K. Patel1, M. S. Morris1  2Birmingham VA Medical Center,Surgery,Birmingham, ALABAMA, USA 1University Of Alabama at Birmingham,Surgery,Birmingham, Alabama, USA

Introduction:
Enhanced Recovery After Surgery (ERAS) pathways standardize preoperative, intraoperative, and postoperative care including goal directed fluid administration and multimodal pain management. ERAS is associated with shorter hospital lengths of stay, lower costs, and equivalent readmission rates. Since implementing ERAS at our institution in 2015, we sensed an increase in AKI. Although ERAS has benefits for patients and hospitals, little is known about its association with acute kidney injury (AKI). We hypothesize that incorporation of an ERAS pathway for elective colorectal surgery would be independently associated with an increased risk of AKI.

Methods:
A single-institution retrospective review of patients undergoing elective colorectal surgery before and after the implementation of ERAS was conducted. Patient-specific variables were recorded and our primary outcome was development of an AKI. AKI was operationalized using The Kidney Disease: Improving Global Outcomes (KDIGO) definition and staging system. Patients with AKI or dialysis preoperatively were excluded from our analysis. Bivariate comparisons were made using chi-square and Wilcoxon rank sum tests for categorical and continuous variables, respectively. Variables with p<0.05 for bivariate comparisons were included in a multivariate logistic model for AKI.

Results:
Our study cohort included 974 total patients, 604 in the pre-ERAS group and 370 patients in the ERAS group. The two groups were similar except for significantly higher incidences in the pre-ERAS group of diabetes mellitus, hypertension requiring medication, ascites within 30 days prior to surgery, disseminated cancer, and contaminated or dirty wounds in the pre-ERAS group compared to the ERAS group (Table). There was no significant difference in age or BMI at the time of surgery between the two groups. Postoperatively, 9.7% of the ERAS group developed AKI compared to 5.8% of the pre-ERAS group (p=0.02).  After adjusting for significant covariates, our model showed that patients in the ERAS group were 2.4 times more likely to develop post-op AKI than patients in the pre-ERAS group (OR=2.41, CI 1.42-4.08, p < 0.01).

Conclusion:
Implementation of an Enhanced Recovery Protocol is associated with higher levels of acute kidney injury following elective colorectal surgery. Future studies will determine which aspects of the ERAS protocol, such as NSAID use in the multi-modal pain management or intraoperative goal directed fluid delivery, may be associated with this increased incidence of AKI.

76.01 The Affordable Care Act’s Medicaid Expansion and Utilization of Discretionary Inpatient Surgery

Posted on January 18, 2018

A. B. Crocker3, A. Zeymo2,3, D. Xiao3, L. B. Johnson4, T. DeLeire5, N. Shara2,4, W. B. Al-Refaie1,2,3  1MedStar-Georgetown University Medical Center,Department Of Surgery,Washington, DC, USA 2MedStar Health Research Institute,Washington, DC, USA 3MedStar-Georgetown Surgical Outcomes Research Center,Washington, DC, USA 4Georgetown-Howard Universities Center For Clinical And Translational Science,Washington, DC, USA 5Georgetown McCourt School Of Public Policy,Washington, DC, USA

Introduction: Pre-Affordable Care Act (ACA) Medicaid expansion has preferentially increased utilization of elective inpatient procedures. However, the impact of the ACA on such elective and preference-sensitive procedures (also known as discretionary procedures) vs. clinically essential and time-sensitive non-discretionary procedures remains unknown. We hypothesize that the ACA’s expansion led to increased utilization of inpatient discretionary procedures (DP) relative to non-discretionary surgical procedures (NDP) in expansion vs. non-expansion states. As such, we performed hospital-level quasi-experimental evaluations to measure the state-by-state differential effects of the ACA’s Medicaid expansion on utilization of DP vs. NDP.

Methods:  The State In-Patient Database (2012-2014) yielded 476 hospitals providing selected DP or NDP procedures performed on 275,131 non-elderly, adult patients (ages 18-64 years) across three expansion states (Kentucky, Maryland, and New Jersey) vs. two non-expansion control states (Florida and North Carolina). DP included non-emergent total knee arthroplasty and total hip arthroplasty, while NDP included a cohort of nine cancer surgeries. Mixed Poisson interrupted time series (ITS) analyses were performed to determine the impact of ACA’s Medicaid expansion on the number of DP vs. NDP provided: 1) across expanded versus non-expanded states overall, 2) among non-privately insured patients (Medicaid and uninsured payers).

Results: Substantial reductions in the number of uninsured DPs were observed in both expansion (-73%) and non-expansion states (-45%). While the number of Medicaid insured DPs in expansion states nearly doubled, the number of privately insured DPs in non-expansion states increased by 10%.  Observing no overall differential increase in the utilization of DPs in expansion and non-expansion states after 2014 (2.2% per quarter and 2.8% per quarter), subsequent analysis on the mean number of non-privately insured DP and NDP was performed. Mixed ITS estimated a differential increase in DP (+17.7% vs -3.5%) and NDP (+4.7% vs -5.0%) in expansion states compared to non-expansion states.  Additionally, a substantially larger increase in utilization of DP vs NDP was detected within expansion states after 2014 (Figure).

Conclusion: In this multi-state evaluation, ACA’s Medicaid expansion has preferentially increased utilization of DP in expansion vs non-expansion states among non-privately insured patients. This expansion has also differentially increased utilization of DP relative to NDP in expansion states. These preliminary findings suggest that expansion coverage increased use of inpatient surgery. Further research is merited to expand on these early results.

 

75.04 The Malawi Trauma Score: A Model for Predicting Trauma-Associated Mortality in a Resource-Poor Setting

Posted on January 18, 2018

J. R. Gallaher1, M. Jefferson1, C. Varela2, B. Cairns1, A. Charles1,2  1University Of North Carolina At Chapel Hill,Surgery,Chapel Hill, NC, USA 2Kamuzu Central Hospital,Surgery,Lilongwe, , Malawi

Introduction:
Globally, traumatic injury is a leading cause of morbidity and mortality in low-income countries. Current tools for predicting trauma-associated mortality are often not applicable in low-resource environments due to a lack of diagnostic adjuncts. This study sought to derive and validate a model for predicting mortality that requires only a history and physical exam. 

Methods:
We conducted a retrospective analysis of all patients recorded in the Kamuzu Central Hospital trauma surveillance registry in Lilongwe, Malawi from 2011 through 2014. Using statistical randomization, 80% of patients were used for derivation and 20% were used for validation. Logistic regression modeling was used to derive factors associated with mortality and the Malawi Trauma Score (MTS) was constructed. The model fitness was tested. 

Results:
62,425 patients were included. The MTS is tabulated based on initial mental status (alert, responds to voice, responds only to pain or worse), anatomical injury location, the presence or absence of a radial pulse, age, and sex, with a total possible score of 32. A mental status exam of only responding to pain or worse, head injury, the absence of a radial pulse, extremes of age, and male sex all conferred a higher probability of mortality. The ROC area under the curve for the derivation cohort and validation cohort were 0.83 and 0.84, respectively. A MTS of 25 confers a 50% probability of death (Figure 1).

Conclusion:
The MTS provides a reliable tool for trauma triage in sub-Saharan Africa and helps risk stratify patient populations. Unlike other models previously developed, its strength is its utility in virtually any environment, while reliably predicting injury- associated mortality. 
 

73.09 Resident Involvement and Outcomes after Surgery: A Double Edge Sword

Posted on January 18, 2018

M. Zeeshan1, M. Hamidi1, A. Tang1, E. Zakaria1, N. Kulvatunyou1, A. Jain1, L. Gries1, T. O’Keeffe1, B. Joseph1  1University Of Arizona,Tucson, AZ, USA

Introduction:
Diverticular disease is one of the leading causes for outpatient visits and hospitalizations. Resident participation in surgical procedures is essential for training. However, there is paucity of data regarding the outcomes after resident involvement in surgical procedures for diverticulitis. The aim of our study was to determine if the resident participation in surgery correlates with outcomes for patients undergoing surgical procedures in diverticulitis.

Methods:
We analyzed the National Surgical Quality Improvement Program database (2005-2012). We included all patients who had diagnosis of diverticular disease and underwent surgical management. Patients were stratified into two groups based on presence of resident during surgery: attending alone (No-RES) vs. attending with resident (RES). Groups were matched using propensity score matching for demographics, surgical procedure, morbidity probability and comorbidities. Outcomes of interest were compared for patients with and without resident participation in surgery (RES vs no-RES). We performed a sub-analysis of RES group by dividing it into junior (PGY 1-3), and senior residents (PGY 4-5), and fellows (PGY ≥ 6).

Results:
26,172 patients met the inclusion criteria, of which 6912 (3456: No-RES, 3456: RES) were matched. Mean age was 58.8 ± 14.3 years, and 46.7% were males. There was no difference in mortality in both groups (p=0.58), however, overall 30-d complication rates were higher in RES group (18% vs. 15.1%, p<0.01). Operative time (OR time) was longer in the RES group (175 min vs. 142 min, p<0.01), while there was no difference of hospital length of stay (HLOS) between the two groups (p=0.17). Table 1 shows the sub analysis based on level of residency. Mortality rate was highest in senior residents (p<0.01), while operative time was highest in operation performed by fellows (p<0.01).

Conclusion:
Resident involvement in surgical management of diverticulitis increases the rate of complications without an increase in mortality. Resident involvement is an important component of surgical residency. Identifying the factors and increased supervision by attendings may lead to improved outcomes. 
 

73.10 Management of Acute Cholecystitis with Significant Risk of Common Bile Duct Stone:The ‘SaFE’ Approach

Posted on January 18, 2018

K. O. Memeh1, S. Jhajj1, K. Tran1, R. A. Berger1,2, T. S. Riall1, A. Aldridge1,2  1University Of Arizona,Surgery,Tucson, AZ, USA 2Flagstaff Medical Center,Surgery,Flagstaff, AZ, USA

Introduction:

About 3-8% of acute calculous cholecystitis (ACC) present with common bile duct stone (CBDS). The 2010 American Society of Gastrointestinal Endoscopy (ASGE) and the 2016 World Society of Emergency Surgery (WSES) guideline on the management of gallstone with significant risk(high risk[HR] and intermediate risk[IR]) of CBDS recommend pre-operative imaging and ERCP for patient with IR and HR for CBDS respectively. Our group adopted a different approach; primary laparoscopic cholecystectomy (LC) with intraoperative cholangiogram (IOC) for all patients HR and IR for CBDS, and then proceed with intra-operative ERCP (IOERCP) for patients with positive IOC, with the intention of reducing length of stay (LOS) and hospital cost (HoC) without negatively impacting outcome.We believe that this approach is Safe, Fast and cost Effective ( ‘SaFE’) and we thus review the outcome of the ‘SaFE’ approach and compares it with the traditional (ASGE/WSES guided) approach.

Methods:

We retrospectively reviewed the medical record of consecutive patients, 18 years and older presenting with ACC with significant risk for CBDS who underwent LC + IOC +/- IOERCP between Jan 2015 and Feb 2017 in our institution. Patients with cholangitis and pre-operative imaging suggestive of CBD mass (other than stone) were excluded. Patients were stratified into ASGE Intermediate risk (ASGE-IR) and ASGE High risk (ASGE-HR) for CBDS based on the published ASGE criteria. We reviewed pre-operative liver function test, total bilirubin and imaging.Complications( cystic duct leak, post ERCP pancreatitis) and hospital charges (HoC) were evaluated. The student t-test was utilized to analyse difference in LOS when compared to similar patients managed prior to the implementation of the SaFE approach.

Results:

A total of 568 patients presented with ACC and suspicion for CBDS, hence had LC + IOC. IOERCP was performed for positive IOC in 87(15%) patients. Of the 87 patients, 34(39%) was ASGE-HR for CBDS.Medain pre-op T bil was 4.1 and 0.8 for ASGE HR and IR respectively.2 IR patients had negative IOERCP. Average LOS was 1.8 days for both HR and IR patient groups. There was no cystic duct leak and no conversion to open cholecystectomy in any of the 87 patients. Two (1 patient per group) had mild post ERCP pancreatitis. Mean HoC was $10,099 per patient.Prior to implementing the SaFE approach( i.e using the  ASGE/WSES guideline),similar cohort of patients had an average LOS of 3.4 days( p < 0.000) , and mean HoC of $14,320 a diffence of $2,941 with estimated cost saving of $255,867 in the 2 year period.

Conclusion:

Our findings suggest that ACC patients who are ASGE-HR, WSES- HR, and ASGE-IR for CBDS could be managed similarly using the ‘SaFE’ approach with significant reduction in both LOS and HoC without any increase in procedure-related morbidity. 

 

 

 

 

 

 

73.07 Trends in Mortality and Cardiac Complications in Major Abdominal Surgery by Operative Volume.

Posted on January 18, 2018

Y. Sanaiha1, Y. Juo1, K. Bailey1, E. Aguayo1, A. Iyengar1, V. Dobaria1, Y. Seo1, B. Ziaeian2, P. Benharash1  1David Geffen School Of Medicine, University Of California At Los Angeles,Cardiac Surgery,Los Angeles, CA, USA 2David Geffen School Of Medicine, University Of California At Los Angeles,Cardiology,Los Angeles, CA, USA

Introduction:

Cardiovascular complications are the leading cause of death following noncardiac surgery. Major abdominal operations represent the largest category of procedures considered to have elevated risk of cardiovascular complications. The current aim was to examine trends in the incidence of mortality, postoperative myocardial infarction, and cardiac arrest after major abdominal operations and to determine the presence of potential volume-outcome relationships. 

Methods:
We performed a retrospective analysis of the Nationwide Inpatient Sample (NIS) for patients having elective open gastrectomy, pancreatectomy, nephrectomy, splenectomy, and colectomy (major abdominal surgery: “MAS”) during 2008-2014. Chi-squared analysis was used to compare demographic and hospital characteristics between groups. Logistic regression was performed to determine predictors of in-hospital mortality, postoperative cardiac arrest (POCA) and myocardial infarction (POMI).  

Results:
Of the 1,300,794 patients undergoing MAS, 49,589(3.70%) experienced in-hospital mortality, 16,542 (1.24%) POMI, and 9,496 (0.76%) POCA. The annual all-cause mortality and POMI rates remained stable while the incidence of POCA steadily rose.  Average Elixhauser score also increased from 1.8 to 2.2 during this study period. Odds of mortality were significantly lower for medium and large volume hospitals compared to small volume hospitals after adjustment (Table). Hospital operative volume did not significantly impact the odds of POMI or POCA. In contrast, larger hospital bedsize was associated with higher odds of mortality and POCA. Subgroup analysis demonstrated lower odds of mortality with higher operative volume over 2008-2014 for all operations except for splenectomy. Significant risk factors for POMI/POCA included age > 65, peripheral vascular disease, and congestive heart failure, while female gender and higher income quartile had decreased odds of these complications (P<0.02). 

Conclusion:
The rate of POCA amongst patients having MAS has increased in the US without a concomitant rise in POMI or mortality. Hospital operative volume appears to reduce odds of postoperative mortality over the entire study period. The effect of operative volume on rate of postoperative cardiac complications is not consistent over time as odds of POCA are significantly lower for higher volume hospitals only in 2008-2011 population. Operative volume does not significantly impact risk of POMI or POCA in the 2012-2014 subgroup. Increased odds of mortality and POCA at larger hospitals by bedsize could reflect patient or hospital factors that are not well represented in NIS. Non-ischemic causes of POCA need further investigation to delineate opportunities for quality improvement. 
 

73.08 Local Referral of High-Risk Patients to Reduce Surgical Costs

Posted on January 18, 2018

M. Smith1,2, U. Nuliyalu2, S. P. Shubeck1,2,3, J. B. Dimick1,2, H. Nathan1,2  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,Center For Healthcare Outcomes & Policy,Ann Arbor, MI, USA 3University Of Michigan,National Clinician Scholars Program,Ann Arbor, MI, USA

Introduction: Improving the value of healthcare delivery is a major focus of healthcare reform. Previous studies have documented substantial cost savings for surgical care delivered in high quality hospitals, with particularly large cost differences for high-risk patients. Practically, shifting high-risk patients to high-quality hospitals must be done within small geographic areas. We sought to determine the availability of high-quality hospitals, the distribution of high-risk patients, and the potential benefit of referral of high-risk patients for surgery within small geographic areas.

Methods: Using 100% Medicare claims data for 2012-2013, we identified elderly patients undergoing elective colectomy (Col), lung resection (Lung), total hip arthroplasty (THA), and total knee arthroplasty (TKA). Risk- and reliability-adjusted hospital rates of serious complications were assessed using a hierarchical logistic regression model, and hospitals were grouped into quintiles; lowest complication rate = high quality. A similar model was used to stratify patients into quintiles of high and low risk for complications. Price-standardized, risk-adjusted Medicare payments were calculated for the entire “surgical episode” from index admission through 30 days after discharge. The geographic units of analysis were Metropolitan Statistical Areas (MSAs), which consist of a relatively high population density (≥50,000) and include surrounding areas that roughly mirror typical commuting distances.

Results: The proportion of MSAs containing a high quality hospital ranged from 47% (Lung) to 58% (THA). A minority of MSAs contained both a high quality and low quality hospital (n=79, 22% Lung; 118, 30% Col; 120, 31% TKA; 122, 32% THA). In these MSAs, 25% of high-risk patients received care at the lowest quality hospitals (TKA 23%, THA 24%, Lung 26%, Col 27%), and 38% of high-risk patients were treated at high quality hospitals (34% Col, 38% TKA, 39% Lung, 39% THA). There was wide variation in costs between high and low quality hospitals within MSAs, and this difference was particularly large for high-risk patients (Figure). Referral of a high-risk patient from a low to high quality hospital within a MSA would generate an average savings of $13,840 for Lung ($31,659 vs $45,499), $8,981 for Col ($29,230 vs $38,211), $2,583 for THA ($20,954 vs $23,537), and $1,936 for TKA ($19,992 vs $21,928, all P <0.001).

Conclusion: In small geographic areas containing high and low quality hospitals, 25% of high-risk patients received care at the lowest quality hospitals. Triaging of high-risk patients to high quality hospitals within small geographic areas may serve as a template for strategic local referral as a means of reducing costs in Medicare.

73.05 Surgical Coaching Relationships: Early Evidence from the Michigan Bariatric Surgical Collaborative

Posted on January 18, 2018

S. P. Shubeck1,2,3, A. E. Kanters1,2, G. Sandhu1, C. C. Greenberg4,5, J. B. Dimick1,2  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,Center For Healthcare Outcomes & Policy,Ann Arbor, MI, USA 3University Of Michigan,National Clinician Scholars Program,Ann Arbor, MI, USA 4University Of Wisconsin,Department Of Surgery,Madison, WI, USA 5University Of Wisconsin,Wisconsin Surgical Outcomes Research Program,Madison, WI, USA

Introduction: There has been an increased focus on building effective surgical coaching programs for practicing surgeons to develop their technical skills. In this context, we sought to evaluate early coaching conversations in the Michigan Bariatric Surgery Collaborative compared to existing models for effective surgical coaching.

Methods: This qualitative study evaluated 10 video coaching conversations between 20 bariatric surgeons at the Michigan Bariatric Surgery Collaborative meeting in October 2015. Using grounded theory approach, the coaching encounter transcripts were coded in an iterative process with comparative analysis in order to identify emerging themes. For this analysis, we focused on the dynamics between participants and content of coaching conversations.

Results: Two major themes emerged in our analysis when comparing early coaching conversations to existing models. (1) While the roles of coach and coachee were defined before the coaching exercise, participants often did not adhere to assigned roles. For example, there were repeated instances in these interactions when a coach would defer to the coachee, indicating they felt less qualified in a particular technique or procedure. (2) The coaching conversations tended to have limited direct coaching, but rather an emphasis on bidirectional exchange of ideas with both participants offering expertise when appropriate. For example, the coach and coachee frequently engaged in back and forth conversation about specific techniques, instrument selection, and decision points.

Conclusions: In early coaching conversations among bariatric surgeons in the Michigan Bariatric Surgery Collaborative, we observed a propensity for participants to gravitate toward a peer to peer dynamic. Future programs aimed at improving technical skill through surgical coaching should explicitly consider the role of bidirectional feedback. 

73.06 The True Cost of Laparoscopic Cholecystectomy with Routine Intraoperative Cholangiography

Posted on January 18, 2018

N. Cortolillo1, J. Parreco1, R. Rattan1, A. Castillo1, R. Kozol1  1University Of Miami,General Surgery Residency Program,Miami, FL, USA

Introduction:

Many prior comparisons of outcomes and costs associated with intraoperative cholangiography (IOC) have been reported. However, prior studies have been limited to initial hospitalizations or readmissions to single institutions. The purpose of this study was to compare outcomes and costs of hospitals performing routine IOC to hospitals performing non-routine IOC including readmission cost across hospitals in the US.

Methods:
The Healthcare Cost and Utilization Project’s (HCUP) Nationwide Readmission Database for 2013-2014 was queried for all patients aged 18 years or older undergoing laparoscopic cholecystectomy. Hospitals performing intraoperative cholangiography in 90% or more of cases were identified as routine and compared to non-routine hospitals. Total charges and costs were calculated according to HCUP standards. Univariable logistic regression was performed for the outcomes of interest using ten different hospital and patient variables. The variables with p<0.05 were used for multivariable logistic regression. Results were weighted for national estimates.

Results:
There were 628,280 inpatient laparoscopic cholecystectomies during the study period with 2.0% occurring in hospitals performing routine IOC. The mortality rate was 0.4%, length of stay was >7 days in 11.0%, and readmission within 30 days occurred in 6.9%. Multivariable logistic regression revealed there was no statistically significant different risk for these outcomes between routine and non-routine IOC hospitals. Table 1 shows the mean age of patients at hospitals performing routine IOC was older, but had a lower Charlson Comorbidity Index and shorter length of stay. Non-routine IOC hospitals had higher mean index total charges but lower mean index total cost. Readmission charges were similar between the groups while readmission cost was higher in routine-IOC hospitals.

Conclusion:
While outcomes are similar, non-routine IOC hospitals charge more than routine IOC hospitals. Despite this, the costs are higher in routine IOC hospitals suggesting an unnecessary cost burden placed on hospitals performing routine IOC.

73.04 Perforated Peptic Ulcer Surgery: No Difference in Mortality Between Laparoscopic and Open Repair.

Posted on January 18, 2018

V. Gabriel1, A. Grigorian1, S. Schubl1, M. Pejcinovska1, E. Won1, M. Lekawa1, N. Bernal1, J. Nahmias1  1University Of California – Irvine,Division Of Trauma, Burns & Surgical Critical Care,Orange, CA, USA

Introduction:  The lifetime prevalence of perforated peptic ulcer (PPU) in patients with peptic ulcer disease is estimated at 5%. Reported mortality rates after surgery for PPU have ranged from 1 to 24%. A recent meta-analysis by Tan et al demonstrated equivalent morbidity and mortality when comparing laparoscopic repair (LR) to open repair (OR).  However, LR was shown to have lower operative time, less pain, shorter length of stay (LOS), and a lower rate of surgical site infection. We hypothesized a decrease in morbidity and mortality with LR from 2011-2015 compared to 2005-2010. Additionally, we hypothesized a decrease in morbidity and mortality for LR versus OR for the entire duration of 2005-2015.

Methods:  Patients undergoing operative repair of PPU between 2005- 2015 were identified in the NSQIP database by CPT code. Patients with definitive acid-reducing operations were excluded. A comparison of OR from 2005-2010 versus 2011-2015 was performed. A similar comparison was performed for LR. Additionally, a comparison between LR and OR for the entire duration (2005-2015) was conducted. Primary outcomes were the differences in 30-day mortality and overall morbidity. After controlling for significant covariables such as age, American Society of Anesthesiologists class, functional status, pre-operative albumin and creatinine, steroid use, liver disease, time to surgery, and presence of malignancy, a multivariate regression analysis was performed.

Results: 5,413 patients between 2005-2015 were included in the study. From 2005-2010 there were 86 LR cases and 1,924 OR cases.  Between 2011-2015 there were 221 LR cases and 3,182 OR cases. LR demonstrated no difference in 30-day mortality or overall morbidity between the two time periods (p>0.05). There was no significant difference in 30-day mortality for patients undergoing OR between the two time periods. However, overall morbidity (odds ratio (OR), 1.99; 95% CI, 1.71-2.33, p<0.05), development of sepsis (p<0.05), and septic shock (p<0.05) were all more prevalent in patients undergoing OR from 2011-2015. Comparing LR versus OR from 2005-2015, patients undergoing LR had a shorter length of stay (p<0.05), and were less likely to exhibit failure to wean from the ventilator at 2 days (OR, 0.34; 95% CI, 0.18-0.65, p<0.05). 

Conclusion: While a 2.5% increase LR utilization was seen, there was not a decreased morbidity and mortality associated with more recent LR from 2011-2015. This may be secondary to increasing utilization of LR in more debilitated patients over time. When LR was compared to OR there was a significant decrease in LOS. Future prospective research is needed to confirm this finding and evaluate the safety of more widespread adoption of LR for PPU.

 

73.02 Percutaneous Cholecystostomy in Acute Cholecystitis – Predictors of Recurrence & Cholecystectomy

Posted on January 18, 2018

M. N. Bhatt1, M. Ghio1, L. Sadri1, S. Sarkar1, G. Kasotakis1, C. Nasrsule1, B. Sarkar1  1Boston Medical Center,Department Of Trauma And Acute Care Surgery,Boston, MA, USA

Introduction:  Acute cholecystitis (AC) is a common acute illness, with the preferred treatment being cholecystectomy. However, in high-risk patients, a less invasive option of percutaneous cholecystostomy tube placement (PC) is preferable. Patients can subsequently either undergo interval cholecystectomy (IC) or PC can be utilized as definitive treatment. Currently, there is little evidence to guide patient care after PC. We sought to demonstrate the clinical outcomes of PC and identify the predictors of recurrent disease as well as successful IC.

Methods:  A retrospective chart review of patients undergoing PC for AC between 2008 and 2016 at a single tertiary care center was performed. Basic patient demographics, laboratory & imaging findings, and patient outcomes including mortality, readmissions, hospital length of stay (LOS), Intensive Care Unit (ICU) LOS, recurrence, and IC were collected. Univariate and multivariate analyses were performed using logistic regression, Wilcoxon Rank, and multi-variable logistic regression models.

Results: Of 145 patients, 96 (67%) had calculous and 47 (33%) had acalculous cholecystitis. PCs were performed in these patients due to their high preoperative risks; 72 (49%) had chronic prohibitive risks and 73 (51%) had acute prohibitive risks. There were 55 (38%) peri-procedural complications, 44 of which were PC dislodgment. Mean duration of PC was 93 days. Recurrence rate for AC was 18%; median duration to recurrence was 65 days. Patients with calculous cholecystitis were more likely to have AC recurrence (OR = 3.24, p = 0.018), whereas length of antibiotics course or duration of PC had no significant correlation with AC recurrence. 41 (28%) patients underwent IC. Patients with acute prohibitive risks and shorter antibiotics course (≤ 7 days) were more likely to undergo IC (OR = 6.66 & 2.10, p = <0.001 & 0.048), and most were completed laparoscopically (OR = 6.84, p = <0.0001). There were only two peri-operative complications and no peri-operative mortality. Mean hospital and ICU LOS were longer for patients with acalculous cholecystitis compared to calculous (22 vs. 11 days, p = <0.0001). 30-day readmission rate was 29%. Patients with acalculous cholecystitis had higher 30-day readmission rate (OR = 2.42, p = 0.020). 30-day mortality after PC was 9%. The follow up was for 26(3-53) months and survival analysis revealed that patients receiving IC had greater survival compared to PC as a definitive option.

Conclusion: PCs are a viable option for high-risk patients with AC. Calculous cholecystitis is a strong predictor of AC recurrence after PC. A longer (>7 days) antibiotics course is not associated with lower recurrence and should be avoided. Patients undergoing IC have better overall survival. PCs, although safe, should not be considered as a definitive treatment, especially in patients with acute critical illness where a successful IC can be performed laparoscopically with minimal complications.

 

73.03 Opioid Use after Surgery among Preoperative Intermittent Users

Posted on January 18, 2018

E. Harker1, C. A. Keilin1, R. Ahmed1, C. Katzman1, D. C. Cron1, T. Yao3, H. Hu1, J. S. Lee1, C. M. Brummett2, M. J. Englesbe1, J. F. Waljee1  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,Department Of Anesthesiology,Ann Arbor, MI, USA 3University Of Michigan,School Of Public Health,Ann Arbor, MI, USA

Introduction:  A significant number of surgical patients intermittently take opioids prior to elective surgery. Understanding the clinical trajectory of this large number of patients is critical to optimizing their care. We hypothesize that a longer duration of preoperative opioid use will be correlated with a longer duration of postoperative use.

Methods:  We used a national employer-based insurance claims dataset to identify adults age 18 to 64 who were preoperatively either opioid-naïve or intermittent opioid users and who underwent a general, gynecologic, or urologic surgical procedure between January 2010 and March 2014 (N= 309,096). We defined preoperative intermittent opioid users as patients who filled ≤120 days’ supply of opioids between 365 and 31 days before surgery. Our primary explanatory variable was preoperative opioid exposure, measured as the number of months during which an opioid prescription was filled in the year prior to surgery (opioid-naïve, 1 month, 2-3 months, 4-6 months, 7-9 months, >9 months). Our outcome was time until last postoperative opioid script (considered the date of opioid discontinuation). We used survival analysis techniques, including Kaplan-Meier curves to compute estimated proportion of patients continuing to fill opioids postoperatively.

Results: In this cohort, 27% of patients used opioids intermittently in the year before surgery, and the majority of these patients (62%) filled opioids during 1 month preoperatively. Patients with a longer duration of preoperative opioid exposure continued to fill opioids for longer durations postoperatively (Figure). Most patients discontinued opioids after the initial prescription, but the remaining patients continued filling opioids long after surgery. Compared to patients with 1 month of opioid fills preoperatively, patients with >9 months of preoperative opioid fills had a 4-fold longer adjusted mean time until opioid discontinuation (326 vs. 84 days, P<0.001). The estimated proportion of patients continuing to fill ≥1 opioid script beyond 180 days was 90% among patients with >9 months of preoperative opioid use, 23% among patients with 1 month of preoperative use, and 15% among opioid-naïve.

Conclusion: Patients who intermittently use opioids prior to surgery are particularly vulnerable to prolonged postoperative opioid use. The surgical event should be considered an opportunity to wean opioid users postoperatively. Such strategies may have significant positive impact on the overall health and wellness of these surgical patients.

72.10 Predictive Value of GEC for Thyroid Cancer after NIFTP Reclassification

Posted on January 18, 2018

A. R. Marcadis1, B. A. Shah2, D. A. Kerr2, O. Picado1, S. Liu1, J. I. Lew1  1University Of Miami,Division Of Endocrine Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA 2University Of Miami,Department Of Pathology,Miami, FL, USA

Introduction: Thyroid nodules with Atypia of Undetermined Significance/Follicular Lesion of Undermined Significance (AUS/FLUS, Bethesda III) on fine needle aspiration (FNA) pose a management dilemma for clinicians, and molecular assays have been developed in order to better predict thyroid malignancy or benignity. The Gene Expression Classifier (GEC) is one commonly used molecular test, with suspicious results corresponding to a 40% malignancy risk. Recently, encapsulated, non-invasive follicular variants of papillary thyroid carcinoma were reclassified as benign Non-Invasive Follicular Thyroid neoplasms with Papillary-like nuclear features (NIFTP). With this reclassification, such neoplasms previously considered malignant are now benign, which may alter the positive predictive value (PPV) of suspicious GEC results for malignancy. This study examines the impact of NIFTP reclassification on the PPV of GEC for thyroid malignancy.

Methods:  A retrospective, single-institution review of 75 surgical patients with AUS/FLUS thyroid cytology and suspicious GEC was conducted. For all patients, preoperative neck ultrasound and FNA reports were reviewed, and the lobe (right/left/isthmus), location (upper/middle/lower), and size of the suspicious thyroid nodule were correlated with final pathology. All encapsulated, non-invasive follicular variants of papillary carcinoma were re-evaluated by an endocrine pathologist and re-classified as NIFTP when appropriate. The PPV of GEC for malignancy in AUS/FLUS thyroid nodules was calculated both before and after NIFTP reclassification.   

Results: Of the 75 patients with AUS/FLUS thyroid nodules and suspicious GEC results, 61 (81%) were female, and 14 (19%) were male. 58 (77%) underwent total thyroidectomy, while 17 (23%) underwent thyroid lobectomy. On final pathology of the GEC suspicious nodule, 7 patients (9.3%) had encapsulated non-invasive follicular variants of papillary thyroid carcinoma which on pathology re-review were classified as NIFTP. The other 68 patients had final pathology which did not change after NIFTP reclassification; 25 of whom (33%) had malignancy (21 papillary thyroid cancer, 3 follicular thyroid cancer, 1 papillary microcarcinoma), and 43 (57%) of whom had benign pathology. Before NIFTP reclassification, the PPV for malignancy in AUS/FLUS nodules with suspicious GEC was 42% (32/75 malignant), whereas after NIFTP reclassification, the PPV was 33% (25/75 malignant). This decrease in PPV for malignancy after NIFTP reclassification was not statistically significant (p >0.05).

Conclusion: NIFTP reclassification as a benign thyroid neoplasm lowers, but does not cause a statistically significant change in the PPV of suspicious GEC results for malignancy in AUS/FLUS thyroid nodules. Surgeons and other clinicians should take this into consideration when evaluating AUS/FLUS thyroid nodules with suspicious GEC results. 

73.01 A 3 year Follow-up of Nonoperative Management in Ventral Hernia Patients With Comorbidities

Posted on January 18, 2018

K. Bernardi1, J. L. Holihan1, D. V. Cherla1, J. R. Flores1, L. S. Kao1, T. C. Ko1, M. K. Liang1  1University Of Texas Health Science Center At Houston,General Surgery,Houston, TX, USA

Introduction:
Individuals with comorbid conditions (e.g. obesity or smoking) are not only at increased risk to develop a ventral hernia but are at markedly increased risk for complications (including recurrence) following repair.  There is limited high-quality prospective data on the safety and efficacy of non-operative management of patients with ventral hernias.  Our objective was to determine the long term clinical and patient reported outcomes of non-operative management of patients with comorbidities also suffering from ventral hernias.
 

Methods:
This is the 3-year follow-up to a prospective observational single institution study of patient with comorbidities and ventral hernias.  Patients were contacted by phone to complete a standardized interview. Primary outcome was proportion of patients who underwent urgent or emergency surgery. Secondary outcomes were the change in quality of life (QoL) from their baseline interview and proportion of patients undergoing elective or emergent repair.  QoL was measured utilizing the modified activities assessment scale (AAS), a validated, hernia-specific QoL survey.  The minimal clinically important difference was considered a change of 7 points on a scale of 1-100 where 1=poor QOL and 100=perfect QOL.
 

Results:
Overall, 60 patients were followed to completion (Table below).  At the end of 3 years, 3 (5%) patients had died due to non-hernia related causes, 16 (26.7%) patients had at least one emergency room visit related to their hernia, 4 (6.7%) patients underwent urgent/emergent ventral hernia repair, and 15 (25%) patients underwent elective ventral hernia repair.  On average, non-operatively managed patients experienced no change in their QoL, while those who crossed over to operative management experienced a substantial improvement in their QoL.
 

Conclusion:
Non-operative management for patients with ventral hernias appears to be safe; however, there was a substantial crossover to operative intervention. For most patients who successfully completed non-operative management, their QoL did not change over 3 years.  On the other hand, patients who underwent ventral hernia repair had a major improvement in their QoL.

72.07 5-factor replacement index for the 11 factor modified frailty index in NSQIP

Posted on January 18, 2018

S. Subramaniam1, J. J. Aalberg1, R. P. Soriano2, C. M. Divino1  1Icahn School Of Medicine At Mount Sinai,Division Of General Surgery, Department Of Surgery,New York, NY, USA 2Icahn School Of Medicine At Mount Sinai,Department Of Geriatrics And Palliative Medicine,,New York, NY, USA

Introduction:  The modified frailty index (mFI-11) is a NSQIP based 11-factor index that has been proven to adequately reflect frailty and predict mortality and morbidity. These 11 factors, made of 16 variables, map to the original 70 item Canada Study of Health and Aging Frailty Index. In the past years, certain NSQIP variables have been removed from the database; as of 2015, only 5 out of the original 11 factors remain. The predictive power and usefulness of these five factors in an index (mFI-5) have not been proven in past literature. The goal of our study was to compare the mFI-5 to the mFI-11 in terms of value and predictive ability for mortality, post-operative infection and unplanned thirty-day readmission for future research and clinical use. 

Methods: The mFI-5 is made up of the following factors: functional status, diabetes, history of COPD, hypertension, and history of CHF and was calculated by dividing the number of  factors present for a patient by the number of available factors for which there were no missing data. Spearman’s Rho was calculated in order to compare mFI-5 and mFI-11 value. Predictive models, using both unadjusted and adjusted logistic regressions were created for each of the three chosen outcomes using 2012 NSQIP data, the last year all mFI-11 variables existed. Adjusted models were controlled for ASA classification, wound class, age, transfer status, surgical complexity represented by RVU, inpatient status, anesthesia type, and emergency type. Both adjusted and unadjusted models using mFI-5 were run on 2015 data to validate results. All above methods were conducted for the following nine surgical subspecialties including general surgery, cardiac surgery, neurosurgery, gynecology, orthopedics, otolaryngology, plastic surgery, thoracic surgery, urology, vascular surgery and then completed for all surgical subspecialties combined

Results: Correlation between the mFI-5 and mFI-11 were above 0.9 across all surgical specialties except for cardiac and vascular surgery. Adjusted and unadjusted models showed similar C-statistics for mFI-5 and 11 and strong predictive ability for mortality and post-operative complications. Predictive value for thirty day readmission was weak for both the mFI-11 and the mFI -5. 

Conclusion:The mFI-5 is an equally effective predictor as the mFI-11 in all subspecialties and is a strong predictor of mortality and post-operative complication. It has credibility for future use to study frailty within the NSQIP database. It also has potential in other databases and for clinical use.    

 

72.08 Laparoscopic Gastropexy in Elderly Patients with Large Paraesophageal Hernias

Posted on January 18, 2018

A. D. Newton1, D. A. Herbst1, K. R. Dumon1, D. T. Dempsey1  1Hospital Of The University Of Pennsylvania,Surgery,Philadelphia, PA, USA

Introduction: The optimal technique for paraesophageal hernia (PEH) repair has been debated. For the past several years, our surgical treatment algorithm for elderly patients with large symptomatic PEH has been formal laparoscopic repair if gastroesophageal reflux (GER) symptoms predominate, and laparoscopic anterior gastropexy alone if mechanical symptoms predominate. Our goal was to evaluate outcomes with this approach.

Methods: We retrospectively reviewed all first-time operations for large PEH (40% or more intrathoracic stomach) in patients ≥ age 65 performed by a single attending surgeon from 2011-2016. Primary outcome measures were perioperative morbidity and mortality, presence of herniated stomach or GER on upper gastrointestinal radiograph (UGI) 3 months postop, and subjective symptom improvement.

Results:  A total of 83 patients (mean age 76.9 years, 84% female) had a primary laparoscopic operation for large PEH (type 3, n=75; type 4, n=8). Thirty patients had formal repair (sac removal, posterior crural repair, partial fundoplication, gastropexy) and 53 had gastropexy alone. There were no open or esophageal lengthening operations and one 30-day reoperation. Median intrathoracic stomach percentage was 50% vs. 90% for formal repair vs. gastropexy. Mean operative time was 161.7 vs. 100.6 minutes (P<0.0001) for formal repair vs. gastropexy, and mean postoperative length of stay was no different (2.6 vs. 2.8 days). ASA was ≥ 3 for 53% vs. 70% (P=0.133) for formal repair vs. gastropexy. Overall 90-day morbidity was 15.7% (16.7% with formal repair vs. 15.1% with gastropexy, P=0.85). There was one post-discharge 30-day mortality. On UGI 3 months postop, one patient (3%) had > 10% of stomach above the diaphragm after formal repair compared to 59% after gastropexy (P<0.001), and 69% had demonstrable GER on UGI after gastropexy compared to 24% after formal repair (P<0.001). However, 71% were asymptomatic and 98% had improvement in preop symptoms after gastropexy; 76% were asymptomatic and 92% had improvement in preop symptoms after formal repair.

Conclusion: Laparoscopic gastropexy alone is a reasonable treatment for large PEH in elderly patients with predominately mechanical symptoms while formal repair gives good results when GER symptoms predominate. Esophageal lengthening is unnecessary in most patients. Postop UGI findings often do not correlate with clinical symptoms in this group.

72.09 Clinical Significance of NQO1 in Non-neoplastic Squamous Epithelium of Esophageal Cancer Patients

Posted on January 18, 2018

Y. Muneoka1, H. Ichikawa1, S. Kosugi2, T. Hanyu1, T. Ishikawa1, Y. Kano1, N. Sudo1, M. Nemoto1, Y. Shimada1, M. Nagahashi1, J. Sakata1, T. Kobayashi1, H. Kameyama1, T. Wakai1  1Niigata University Graduate School Of Medical And Dental Sciences,Division Of Digestive And General Surgery,Niigata, NIIGATA, Japan 2Uonuma Institute Of Community Medicine, Niigata University, Medical And Dental Hospital,Department Of Digestive And General Surgery,Niigata, NIIGATA, Japan

Introduction:  NAD(P)H:quinone oxidoreductase-1 (NQO1) is an antioxidant protein. Low expression of NQO1 contributes to high response to anticancer agents, particularly to oxidative stress inducers such as cisplatin (CDDP) or 5-fluorouracil (5-FU) in malignant tumors. It was reported that NQO1 expression is constitutively reduced in non-neoplastic esophageal squamous epithelium of patients with single nucleotide polymorphism of NQO1 (C609T). The aim of this study is to elucidate the clinical significance of NQO1 expression in the non-neoplastic squamous epithelium of patients with esophageal squamous cell carcinoma (ESCC) who underwent preoperative chemotherapy with CDDP and 5-FU (CF) followed by a radical esophagectomy.

Methods:  We retrospectively analyzed the cases of 43 patients who underwent preoperative chemotherapy with CF followed by a radical esophagectomy for ESCC between 2001 and 2012. NQO1 expression in non-neoplastic squamous epithelium of the surgically resected specimens were examined by immunohistochemistry. The expression was defined as negative when basal cells and vascular endothelial cells were not stained with anti-NQO1 antibody. We analyzed the associations between NQO1 expression and the patient demographics, tumor characteristics, histological response to CF therapy, and relapse-free survival. The median follow-up period of the relapse-free patients was 51 months.

Results: Twenty-two patients (51%) had non-neoplastic squamous epithelium with negative NQO1 expression (NQO1-negative patients). No histological evidence of primary tumor or pathological T1 (pT1) tumor was more frequent in NQO1-negative patients than in NQO1-positive patients (41% vs. 5%; P < 0.01). Overall, downstaging of the primary tumor was achieved in 46% of NQO1-negative patients and in 10% of NQO1-positive patients (P = 0.02). There was no significant difference in the histological response to preoperative CF therapy between the two groups. The three-year relapse-free survival of NQO1-negative patients was significantly better than that of NQO1-positive patients (76% vs. 48%, P = 0.02). Other significant prognostic factors were pT, pN, and lymphovascular invasion in a univariate analysis. Multivariate analysis demonstrated that negative NQO1 expression (hazard ratio [HR], 0.30; 95% confidence interval [CI], 0.10-0.92; P = 0.04) and lymphovascular invasion (HR, 4.39; 95%CI, 1.43-13.5; P = 0.04) were independent prognostic factors.

Conclusion: NQO1 expression in non-neoplastic squamous epithelium of ESCC patients could be a promising biomarker to predict treatment outcomes after preoperative CF therapy followed by a radical esophagectomy.

 

72.05 Identifying Predictors of Prolonged Levothyroxine Dose Adjustment After Thyroidectomy

Posted on January 18, 2018

T. S. Atruktsang1, J. R. Imbus1, N. A. Zaborek1, D. F. Schneider1  1University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction:

Synthroid (levothyroxine) is one of the most prescribed drugs in the US. Despite its widespread use, and multiple dosing schemes, many patients struggle to achieve euthyroidism after thyroidectomy and suffer symptoms of hyper- or hypothyroidism. The purposes of this study are to describe time required for dose adjustment prior to achieving euthyroidism and to identify predictors of prolonged dose adjustment (PDA+) after thyroidectomy.

 

Methods:

This is a retrospective cohort study of patients from a single institution who achieved euthyroidism between 2007 and 2017 after undergoing total thyroidectomy or completion thyroidectomy for benign disease. Levothyroxine doses were calculated using our published BMI-based dosing algorithm; a single provider adjusted doses at 6 intervals. PDA+ was defined as needing at least 3 dose adjustments (top quartile) prior to achieving euthyroidism. We compared patient and disease characteristics of PDA+ patients to the remaining patients (PDA-) using Wilcoxon Rank Sum test or Chi-squared test where appropriate. Multivariate logistic regression was used to identify predictors of PDA+.

 

Results:

The 605 patients in this study achieved euthyroidism in a median of 116 days (range 14 – 863) and 1 dose adjustment (range 0 – 7). Only 222 (36.69%) patients were euthyroid without any dose adjustments. The 508 (83.97%) patients who were PDA- achieved euthyroidism in a median of 101 days (range 14 – 627) and 1 dose adjustment (range 0 – 2). The 97 (16.03 %) patients who were PDA+ achieved euthyroidism in a median of 271 days (range 52 – 863) and dose adjustments (range 3 – 7). PDA+ patients required more than twice the median number of days to achieve euthyroidism (271 vs. 101 days, p<0.001).

Compared to the PDA- group, the PDA+ group did not differ significantly in the proportion of patients with Graves’ disease or Hashimoto’s. However, PDA+ patients were more likely to have chronic renal insufficiency (5.2% vs. 1.6%, p=0.026). More than 3 times as many patients in the PDA+ group were taking iron (6.2% vs. 1.8%, p = 0.010). Similarly, nearly twice as many patients in the PDA+ group were taking multivitamin with minerals (22.7% vs. 11.6%, p = 0.003). When controlling for all other factors, iron supplementation (OR = 4.4, 95% C.I. = 1.43 – 13.55, p = 0.010) and multivitamin with mineral supplementation (OR = 2.4, 95% C.I. = 1.3 – 4.3, p = 0.004) were independently associated with PDA+. However, plain multivitamins were not associated with PDA+. Age, gender, preoperative thyroid disease, and co-morbidities did not independently predict PDA+. 

 

Conclusion:

After thyroidectomy at a high-volume center, achieving euthyroidism can take nearly four months. Iron and mineral supplementation are associated with PDA+. This information can be useful when counseling patients preoperatively and suggests that education about proper levothyroxine administration and interfering supplements may expedite achieving euthyroidism.

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