68.07 Impact of Hospital Volume on Readmissions Following Interventions for Hypertrophic Cardiomyopathy

Posted on January 31, 2019

H. Khoury1, Y. Sanaiha1, S. Rudasill1, H. Xing1, A. Mardock1, J. Antonios2, P. Benharash1  1David Geffen School Of Medicine, University Of California At Los Angeles,Cardiothoracic Surgery,Los Angeles, CA, USA 2David Geffen School Of Medicine, University Of California At Los Angeles,Los Angeles, CA, USA

Introduction:  Unplanned readmissions are considered a marker for quality of care and are associated with increased resource utilization. The literature on readmissions following alcohol septal ablation (ASA) and septal myectomy (SM) for the treatment of hypertrophic cardiomyopathy remains limited while the impact of center volume on such parameters is poorly characterized.

Methods:  The Nationwide Readmissions Database 2010-2015 containing approximately 17 million annual discharges in the U.S., was used to identify all adult (>18 years) patients with the diagnosis of hypertrophic cardiomyopathy. Diagnosis and procedural codes were used to identify patients undergoing ASA and SM, respectively. Hospitals were characterized based on annual ASA/SM case volume into low (LVH), medium (MVH), and high (HVH) volume tertiles. Student t-tests and chi-squared tests were used to analyze baseline continuous and categorical variables, respectively. The independent impact of hospital volume on mortality and readmission was determined using multivariable logistic regression.

Results: Of 7,957 patients who underwent septal reduction procedures, 4,870 (61.2%) underwent alcohol septal ablation and 2,727 (38.8%) underwent septal myectomy. Patients who underwent ASA at a LVH experienced higher rates of readmission (12.6 vs. 10.0 vs. 7.0%, P<0.001), emergent index admission (50.2 vs. 30.8 vs. 43.4%, P<0.001), overall in-hospital complications (28.1 vs. 24.5 vs. 20.6%, P=0.012), and comorbid atrial fibrillation (51.2 vs. 37.9 vs. 43.2%, P=0.005), and renal failure (12.9 vs. 11.6 vs. 8.2%, P=0.030) than those at MVH and HVH. Additionally, length of stay (5.2 vs. 4.4 vs. 4.2 days, P=0.033) and index ASA costs ($28,022 vs. $25,089 vs. $23,792, P=0.039) were greater in LVH. In contrast, patients who underwent SM at a LVH experienced lower rates of in-hospital complications (37.8 vs. 34.1 vs. 45.6%, P=0.049), and comorbid coagulopathy (8.5 vs. 19.0 vs. 23.5%, P<0.001) than patients who underwent SM at a HVH. For both procedures, rates of in-hospital mortality were not significantly different between hospital tertiles. While hospital SM volume was not identified as an independent predictor for thirty-day readmission, ASA performed LVH (adjusted OR, 1.96; 95% CI 1.20–3.21) or MVH (adjusted OR, 1.55; 95% CI 1.02–2.35) was an independent predictor for emergent thirty-day readmission, compared to HVH (Figure). 

Conclusion: Low and medium hospital volume were found to be associated with increased and thirty-day readmission following ASA, but not SM. Patients with hypertrophic cardiomyopathy should be referred to experienced centers for ASA to reduce rates of readmissions and decrease national healthcare expenditures.

 

68.06 Pre-Op IABP Placement Rates in Coronary Artery Bypass Grafting Patients by Day of Admission

Posted on January 31, 2019

G. A. Del Carmen1, A. Axtell1, D. Chang1, S. Melnitchouk2, T. M. Sundt2, A. G. Fiedler2  1Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA 2Massachusetts General Hospital,Division Of Cardiac Surgery,Boston, MA, USA

Introduction:  Intra-Aortic Balloon Pumps (IABPs) can be utilized to provide hemodynamic support in high risk patients awaiting coronary artery bypass grafting (CABG).  There are many indications for IABP and institutional practice patterns regarding the placement of IABPs is variable.  As a result, the preoperative placement of an IABP in a patient awaiting CABG is not standardized and may vary according to non-clinical factors. We hypothesize that the rate of IABP placement varies by day of the week.

Methods:  A retrospective cohort analysis of the Office of Statewide Health Planning and Development database from 2006-2010 was performed. All patients admitted for CABG were included. Patients who died within 24 hours of admission and those who had absolute contraindications to IABP placement were excluded. The primary outcome was preoperative IABP placement versus non-placement. A multivariable logistic regression analysis to identify predictors of IABP placement was performed, adjusting for patient demographics, clinical factors, and system variables.

Results: A total of 46,347 patients underwent CABG, of which 7,695 (16.60%) had an IABP placed preoperatively. On unadjusted analysis, IABP rates were significantly higher on weekends versus weekdays (20.83% vs. 15.70%, p < 0.001). On adjusted analysis, patients awaiting CABG were 1.31 times more likely to have an IABP placed on weekends than on weekdays (OR: 1.31, 95% CI 1.23-1.40, p <0.001).

Conclusion: The odds of preoperative IABP placement prior to CABG is significantly increased on weekends compared to weekdays, even when controlling for clinical factors. Further exploration of this phenomenon and its associations are warranted.

 

68.05 Correlation Between Air Quality and Lung Cancer Incidence: A County By County Analysis

Posted on January 31, 2019

B. D. Hughes1, S. Maharsi1, H. Mehta1, S. Klimberg1, D. S. Tyler1, I. C. Okereke2  1University Of Texas Medical Branch,Department Of Surgery,Galveston, TX, USA 2University Of Texas Medical Branch,Division Of Cardiothoracic Surgery,Galveston, TX, USA

Introduction:
Lung cancer is the leading cause of cancer-related death with a geographic variability in its incidence.  Poor air quality has previously been associated with lung cancer development, but the risk associated with regional differences in air quality are poorly understood.  We hypothesized that there would be difference in the incidence of lung cancer by county in Texas associated with air quality indicators in that county. 

Methods:
For each county in Texas (n = 254), lung cancer incidence, air quality indicators (average particulate matter greater than 2.5 micrometers [PM2.5], radon levels), and known risk factors were obtained using data from the Texas Commission on Environmental Quality and the Texas Cancer Registry. Linear regression models were constructed to determine the association of air quality indicators with lung cancer incidence and advanced stage at diagnosis (stage III or IV), while controlling for county-level sociodemographic characteristics and smoking rates.

Results:
Lung cancer incidence ranged from 27.6 to 103.4 cases per 100,000 people (Figure 1).  After controlling for risk factors, PM2.5 was associated with increased lung cancer incidence (β = 4.38, p < 0.0001), and radon levels were not significantly associates with lung cancer incidence (β = -2.70, p=0.41).  Air quality indicators (PM2.5 and radon level) were not significantly associated with advanced cancer diagnosis.

Conclusion:
There are wide differences in incidence of lung cancer across Texas.  These differences appear to be related to air quality.  Identifying high-risk areas may help to guide strategies such as implementation of targeted lung cancer screening programs.
 

68.04 Impact of Hospital Safety-Net Status on Failure to Rescue after Major Cardiac Surgery

Posted on January 31, 2019

Y. Sanaiha1, A. Mantha1, H. Khoury1, S. Rudasill1, H. Xing1, A. L. Mardock1, B. Ziaeian2, R. Shemin1, P. Benharash1  1University Of California – Los Angeles,Division Of Cardiac Surgery,Los Angeles, CA, USA 2University Of California – Los Angeles,Division Of Cardiology,Los Angeles, CA, USA

Introduction: An increasingly utilized metric for assessing hospital quality performance is rescue after complications occur. While hospital safety-net status has been associated with inferior surgical outcomes and higher costs, the mechanism of this discrepancy is not well understood. We hypothesized that discrepant rates of failure to rescue following complications of routine cardiac surgery would explain the observed inferior outcomes at safety-net hospitals. 

Methods: The 2005-2014 National Inpatient Sample was used to identify adult patients undergoing elective coronary artery bypass graft, and isolated/concomitant valvular operations. Hospitals were stratified into low (LBH), medium (MBH) or high (HBH) burden categories based on the proportion of uninsured or Medicaid patients to emulate safety-net status defined by the Institute of Medicine. Cardiovascular, respiratory, renal, hemorrhagic, and infectious complication rates were calculated categorically and as a composite variable, minor/major composite comorbidity (MMC). Failure to rescue (FTR) was defined as mortality after occurrence of a complication. Multivariable logistic regression was utilized to perform a risk-adjusted predictive model of complications and FTR. Incremental adjusted cost of MMC was calculated using a linear regression model.

Results:Of an estimated 1,521,129 patients undergoing elective major cardiac operations, 2% experienced mortality while 36.1% suffered MMC. Compared to LBH patients, the HBH cohort was younger (HBH 64.1 vs. 66.7 years, P<0.0001), more commonly female (31.4 vs 30.0%, P<0.0001), and had a higher incidence of diabetes (35.0 vs 29.7%, P<0.0001) and morbid obesity (5.9 vs 3.9%, P<0.0001).  As shown in Figure 1, safety net hospitals are at higher odds of several complications, including tamponade and new dialysis, with a  concurrent higher risk for complication-related FTR. In contrast, HBH had higher odds of FTR of respiratory complications despite a lower adjusted risk of this complication category. Occurrence of MMC at HBH was associated with a $2,494 higher cost than at LBH, which would result in a cost-savings of 42.5 million for MMC if HBH had comparable costs and complication rates to LBH. 

Conclusion:Safety net hospitals were associated with higher FTR after occurrence of cardiovascular and renal complications. Despite elevated odds of septicemia at HBH, rescue of this complication is superior to LBH. Implementation of care-bundles to tackle cardiovascular, respiratory, and renal complications may impact the discrepancy in incidence and rescue of complications at safety-net institutions.

 

68.03 Patient Perceptions of Nurse Communication in HCAHPS Survey Predict 30-Day CABG Mortality Rates

Posted on January 31, 2019

S. J. Masoud1, O. K. Jawitz2, H. R. Phillips3, P. J. Mosca2  1Duke University Medical Center,School Of Medicine,Durham, NC, USA 2Duke University Medical Center,Department Of Surgery,Durham, NC, USA 3Duke University Medical Center,Department Of Medicine, Division Of Cardiology,Durham, NC, USA

Introduction: There is mounting evidence that safety culture and quality of communication within hospitals is linked to patient outcomes. Of outcomes publicly reported by Medicare through its Hospital Compare website, only 30-day mortality following coronary artery bypass graft (CABG) is attached to a specific surgical procedure. Communication quality is in part measured by the 25-item Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, which Medicare uses in adjusting reimbursement to over 3,000 hospitals nationwide. We aimed to assess the relationship between HCAHPS patient ratings of doctor or nurse communication and CABG mortality.

Methods: HCAHPS and complications data were extracted from Medicare Hospital Compare (July 2018 update). Hospitals without CABG mortality data were excluded from the analysis. Pearson and multivariate partial correlation with multiple regression modeling measured the association of HCAHPS ratings, or the percent of surveys reporting providers “always” (rather than usually, sometimes, or never) communicated well, and case volume on log-transformed 30-day CABG mortality rates. Archived data (2014-2018) were used to explore the reciprocal effect of CABG mortality on HCAHPS ratings over time in repeated measures ANOVA with post-hoc main effects tests.

Results: Among 4,973 hospitals, 1,017 had available CABG data and were included in the study. Ratings of nurse and doctor communication each correlated inversely with CABG mortality (Pearson’s r = -.132, p < .001 and r = -.066, p < .035). When controlling for CABG case volume, only ratings for nurses correlated significantly (r = -.092, p < .01), with multiple regression predicting a 0.7% decrease in CABG mortality for each 1% increase in HCAHPS ratings (R2 = .074, p < .001). Repeated measures ANOVA (figure) showed that improvement of HCAHPS ratings was dependent upon whether a hospital ranked in the top or bottom half of included hospitals by CABG mortality (p = .004, ηp2 = .005). While both groups had comparable nurse communication ratings in 2014 (p = .849), low mortality hospitals had significantly higher ratings relative to high mortality hospitals by 2018 (p = .025).

Conclusions: HCAHPS patient ratings of nurse communication, but not doctor communication, had a small albeit significant inverse relationship with 30-day CABG mortality, even when controlling for CABG case volume. Moreover, low mortality hospitals demonstrated greater improvement in nurse communication ratings over time. Though not establishing causal relationships, our study suggests that a better understanding of how frontline staff communicate with patients may also inform efforts to improve surgical outcomes.

68.02 Characterization of Unplanned Early Readmission Following Extracorporeal Membrane Oxygenation

Posted on January 31, 2019

B. Kavianpour1,2, Y. Sanaiha1, H. Khoury1, S. E. Rudasill1, R. Jaman1, P. Benharash1  1David Geffen School Of Medicine, University Of California At Los Angeles,Cardiothoracic Surgery,Los Angeles, CA, USA 2Stony Brook University School of Medicine,Department of Medicine,Stony Brook, NY, USA

Introduction:

With increasing dissemination and improved survival following of extracorporeal membrane oxygenation (ECMO), readmission reduction following ECMO hospitalization is a imminent priority. Early readmissions following hospitalization requiring ECMO have not been characterized at the national level. The present study aimed to identify predictors of early readmission in the largest, all-payer national discharge database.

Methods:

This was a retrospective cohort study using the Nationwide Readmissions Database to identify all adult patients (>=18 years) who underwent ECMO from 2010-2015 and survived index hospitalization. Patients were stratified as requiring ECMO for cardiac or respiratory etiologies. Cardiac ECMO included post-cardiotomy and cardiogenic shock patients while respiratory patients had no other concurrent cardiac diagnosis. All heart and lung transplant patients were excluded. The primary outcome of the study was early (30-day) rehospitalization after index ECMO encounter. Univariate analyses were performed for age, Elixhauser comorbidity index, and cost of readmission.  A multivariable logistic regression model was developed to predict the odds of urgent 30-day readmission.

Results:

Of an estimated 9,391 discharged patients who underwent ECMO, 4,352 (46.3%) required ECMO for primary cardiac indications while 3,669 (39.1%) required ECMO for primary respiratory failure. Unplanned readmission within 30 days of discharge was similar across both cardiovascular and respiratory ECMO groups (18.3 vs 16.2%, P=0.20). Readmission status was not associated with age in both patient populations (Cardiac: 60.2 vs. 58.8 years, P=0.19; Respiratory: 46.0 vs. 43.5 years, P=0.06). Readmitted patients had higher comorbidity score for cardiac indications but not for respiratory indications compared to the non-readmitted cohort (Cardiac: 5.8 vs. 5.2, P<0.01; Respiratory: 5.0 vs. 4.9, P=0.77). Coronary artery disease (CAD) was a significant predictor of readmission within 30 days for both cardiac and respiratory indications (Table 1). Renal failure and bleeding were significant predictors of readmission for cardiac indications while a prolonged length of stay (> 10 days) and infection were significant predictors for respiratory indications. The mean cost of urgent 30-day readmission was $174,713.40 (SE $10,280.97) for cardiac ECMO and $242,422.3 (SE $12.632.89) for respiratory ECMO.

Conclusion:

CAD, renal failure, and complications, such as bleeding and infection, during ECMO place patients at the highest risk for readmission within 30 days. Given the high costs of readmission following ECMO, attention to processes of discharge and outpatient care for this vulnerable population is warranted.

68.01 Lower Episode Payments for Transcatheter versus Surgical Aortic Valve Replacement

Posted on January 31, 2019

P. K. Modi1, M. Oerline1, D. Sukul3, C. Ellimoottil1, V. B. Shahinian2, B. K. Hollenbeck1  1University Of Michigan,Urology,Ann Arbor, MI, USA 2University Of Michigan,Nephrology,Ann Arbor, MI, USA 3University Of Michigan,Cardiology,Ann Arbor, MI, USA

Introduction:  While transcatheter aortic valve replacement (TAVR) was initially developed as a treatment option for patients ineligible for surgical aortic valve replacement (SAVR), its indications have expanded to include patients who would be candidates for surgery. As the use of TAVR continues to expand, it is essential to understand the economic impact of this substitution of TAVR for SAVR in real-world clinical practice. Therefore, we examined Medicare payments for TAVR and SAVR in episodes spanning from 90-days before surgery through 90-days after surgery.

Methods: We used a 20% national sample of fee-for-service Medicare beneficiaries who underwent TAVR or SAVR from 2012 through 2015. We used negative binomial regression models adjusted for age, race, sex, baseline health status (using Hierarchical Condition Categories risk score), socioeconomic class, and place of residence to estimate spending differences between TAVR and SAVR. We also examined the components of episodes to identify specific differences between the spending associated with these procedures. Finally, we assessed the effect of patient health status on the association between procedure type and payments.

Results: We identified 6,455 patients who underwent TAVR (34.3%) and 12,349 patients who underwent SAVR (65.7%) during the study period. The use of TAVR increased from 20.5% of all aortic valve replacements in 2012 to 46.7% in 2015. As TAVR replaced SAVR for the highest risk patients, the average baseline health status improved for both groups. Total adjusted TAVR episode payments were approximately 7% lower than payments for SAVR ($55,545 [95% confidence interval {95%CI} $54,643-56,446] vs $59,467 [95%CI $58,723-60,211], p<0.001). TAVR patients had higher pre-operative payments (Incidence rate ratio [IRR] 1.22 [95%CI 1.17-1.26], p<0.001), but lower payments during (IRR 0.96 [95%CI 0.94-0.98], p<0.001) and after the initial hospitalization for surgery (IRR 0.73 [95%CI 0.68-0.77], p<0.001). Episode payments increased with increasing comorbidity score, but this effect was greater for SAVR than TAVR.

Conclusion: After adjusting for patient factors, TAVR is associated with lower episode spending than SAVR due to savings during and after the initial hospitalization. As baseline health status of treated patients improves, the savings associated with TAVR relative to SAVR diminish.

 

63.20 Lessons from Developing a Mobile App for Postop Recovery following Weight-Loss Surgery

Posted on January 31, 2019

P. Dolan1, H. Yeo1,2  1Weill Cornell Medical College,Surgery,New York, NY, USA 2Weill Cornell Medical College,Healthcare Policy And Research,New York, NY, USA

Introduction: Weight-loss surgery has been shown to be the most effective way to lose weight, but remains under-utilized. One reason is due to the initial cost of surgery, including the subsequent inpatient hospitalization as well as readmissions. Although the complication rate from weight-loss surgery is declining over time, currently about 11% of patients visit an emergency room within 30 days after surgery, leading to 4.4% of patients being readmitted. The most common complications leading to ER visits are dehydration and abdominal pain, both costly and potentially avoidable with appropriate early intervention and triaging. Length of stay after the initial procedure is also becoming shorter, however, most patients stay at least 1-2 days in the hospital after surgery. Mobile health apps have been tested in other patient populations and have been shown to decrease length of stay and improve outcomes. Our goal is to develop and test a mobile health application to assess patients’ recovery and triage common issues in the 30 days after weight-loss surgery, such as dehydration, nausea, and abdominal pain. Use of the app will hopefully decrease cost by shortening length of stay and reducing readmission rates.

Methods:  Mixed methods, single-center prospective pilot/feasibility study of all eligible English-speaking adults undergoing weight-loss surgery. We have been developing and refining the mobile app over the course of the last 12 months. The app has multiple components, one of which is a daily survey. Survey questions were developed to monitor post op recovery and symptoms.  These questions were developed through a review of the literature and by interviewing bariatric nutritionists, bariatric nurse specialists and attending bariatric surgeons in conjunction with an experienced survey developer. Patients also get push notifications with reminders designed to improve recovery. After the first few patients had completed the pilot, the app was revised based on patient feedback.  The app is currently being tested and refined on additional patients.

Results: After our first three 3 patients completed the 30-day trial period they were surveyed to find out preference and usability of the app. All patients expressed satisfaction with the app.  Patients reported that push notifications were helpful. However, patients were frustrated with the length of surveys after the first few days. Especially if they were doing well after surgery, they found the surveys to be redundant. Therefore, we tailored the app to patients’ feedback, to a simpler system with shorter follow-up surveys. We are now testing the app further, for feasibility and usability.

Conclusion: App development is feasible, but complex and must be tailored to the procedure and the patient. They require a significant amount of time to develop and refine to patient needs. Our next steps are to pilot the app a larger set of patients and assess utility and feasibility in practice.

 

63.16 Variation in the Quality of Thyroid Nodule Evaluations Prior to Surgical Referral

Posted on January 31, 2019

L. Jiang1, C. Lee1, D. Sloan1, R. Randle1  1University Of Kentucky,Department Of General Surgery,Lexington, KY, USA

Introduction:

While thyroid nodules are very common, they need an appropriate evaluation given the increasing incidence of thyroid cancer. We hypothesized that most patients do not receive high-quality, streamlined thyroid nodule evaluations. The objective of this study was to describe and characterize the quality of thyroid nodule evaluations prior to surgical referral.

Methods:
We reviewed all consecutive surgical referrals for thyroid nodules from October to December 2017 at a single institution. We defined an efficient initial laboratory investigation as one that obtained a thyroid stimulating hormone (TSH) level without additional thyroid related labs. We defined a high-quality ultrasound as one that included commentary on nodule structure, echogenicity, 3-dimensional size, and lymph nodes since these features help stratify the risk of malignancy.

Results:
The study cohort included 64 patients, with a median age of 51.5 years. Primary care providers referred most patients (51.6%), followed by endocrinologists (40.6%), and other specialists (7.8%). Patients saw a mean of 1.63 providers for their nodule prior to surgical referral. In total, 35.9% of evaluations did not include a TSH value, and 53.1% included additional, unnecessary thyroid labs. Only 14.1% met our definition of an efficient initial laboratory investigation with a TSH as the only thyroid related lab obtained. Almost all evaluations (95.3%) included a thyroid ultrasound, but these were of varying quality. The Figure shows the proportion of ultrasound reports that noted specific characteristics of the dominant nodule. Only12.3% of ultrasound reports commented on the 4 criteria indicative of a high-quality thyroid ultrasound. Of the 6 evaluations (9.4%) that included a thyroid uptake scan, only 2 (33.3%) were indicated, and 4 patients with a suppressed TSH did not receive a thyroid uptake scan as indicated. Overall, 93.1% of biopsy reports appropriately classified thyroid nodule cytology according to the Bethesda System.

Conclusion:
There are marked discrepancies in the quality of thyroid nodule evaluations prior to surgical referral. Even though a TSH is necessary in the work-up of all thyroid nodules, over a third of evaluations did not include one. Additionally, most ultrasound reports do not include sufficient commentary on the sonographic features necessary to stratify the risk of malignancy. Therefore, quality improvement initiatives targeting laboratory testing and ultrasound imaging might promote efficiency and quality in thyroid nodule evaluations. 
 

63.11 Factors Predicting Unplanned 30-Day Readmissions in Surgical Patients

Posted on January 31, 2019

K. Y. Hu1, J. J. Blank1, Y. He2, T. J. Ridolfi1, K. A. Ludwig1, C. Y. Peterson1  1Medical College Of Wisconsin,Division Of Colorectal Surgery, Department Of Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,Division Of Biostatistics,Milwaukee, WI, USA

Introduction:
Unplanned readmissions have negative consequences for hospitals and patients. Preoperative patient factors have been shown to be most predictive of readmission in surgical patients, with improved prediction after inclusion of postoperative variables such as laboratory values. In patients admitted to medicine services, vital sign instability on discharge has been associated with increased readmission and mortality. We hypothesized that certain abnormal laboratory values and vital signs at time of discharge may be predictive of readmission in surgical patients and attempted to identify patients at increased risk for readmission.

Methods:
This was a single-institution retrospective review of patients discharged from surgical inpatient units between 11/1/16 and 11/30/17 after admission for surgery. Patients were stratified into those with unplanned 30-day readmissions from their index admission, and those who were not readmitted. The last filled vital signs, most recent laboratory values (white blood cell count (WBC), hemoglobin, glucose, blood urea nitrogen (BUN), and albumin), number of bowel movements, ASA score, and insurance status were analyzed. Patients with planned readmissions were excluded. The primary outcome was 30-day readmission.

Results:
Of 2607 surgical admissions, 243 were readmitted within 30 days (9.1%). Readmitted patients were more likely to have an increased length of stay during their index admission (12.01 vs 6.55 days, p<0.01). In unadjusted univariate analysis, heart rate (HR) >99 (p=0.03, positive predictive value (PPV) 11.6%), BUN >23mg/dL (p<0.01, PPV 19.4%), albumin <3.8 g/dL (p<0.01, PPV 18.4%) and presence of any abnormal lab value (p<0.01, PPV 13.6%) were associated with readmission. In risk-adjusted multivariate logistic regression, variables associated with readmission were ASA of 4-5 (OR 3.31, 95% CI 1.87-5.84, p<0.01), abnormal HR (OR 1.46, 95% CI 1.07-1.98, p=0.02), and BUN >23mg/dL (OR 1.57, 95% CI 1.05-2.34, p=0.03).

Conclusion:
HR >99, BUN >23mg/dL, albumin <3.8g/dL, and presence of any abnormal lab were associated with readmission, but with poor sensitivity and weak predictive value, limiting their clinical utility. With risk-adjustment, high ASA (4-5), HR >99, and BUN >23mg/dL were associated with readmission; however, ASA and BUN may be reflective of unmodifiable patient factors and of minimal clinical significance. Although identifying key predictors at time of discharge could aid in patient counseling and optimization of high-risk discharges, our results show that readmission is challenging to predict in surgical patients based on discrete numeric data. Focus should be turned to identifying social factors that contribute to readmission.
 

63.10 How do Surgeons Value the Marginal Cost of Operating Room Time?

Posted on January 31, 2019

C. P. Childers1,2, B. Zhao3, J. Tseng4, R. F. Alban4, B. M. Clary3, M. Maggard-Gibbons1  1University Of California – Los Angeles,Surgery,Los Angeles, CA, USA 2University Of California – Los Angeles,Fielding School Of Public Health, Department Of Health Policy & Management,Los Angeles, CA, USA 3University Of California – San Diego,Surgery,San Diego, CA, USA 4Cedars-Sinai Medical Center,Surgery,Los Angeles, CA, USA

Introduction:
New surgical instruments are often proposed to improve operative efficiency, but at added cost. The marginal savings from reducing operative time are small, with previous estimates well under $10/minute. If surgeons overestimate the value of operative efficiency they may choose instruments which add unnecessary costs to the system.

Methods:
A web-based survey was distributed to 100 attending general and subspecialist (eg, colorectal) surgeons at 3 academic health systems. The outcome was the surgeon’s opinion of the marginal cost of one minute of operating room (OR) time, asked through a willingness to pay framework (Figure). Multivariable models were fit to assess factors associated with mean or outlier (top quintile) values. Covariates included institution, gender, fellowship, years after training, specialty, and, for a small subset (n=35), publicized salary information.

Results:
The overall response rate was 83% (83/100) with 75 surgeons providing numeric and reasonable (i.e. ≥ $0) estimates for the marginal cost of OR time. Mean (SD) and median (IQR) values were $28.53 ($27.92) and $21.43 ($7.14-$35.71).  Thirteen (17.3%) responses were  ≥$40 (top quintile). None of the studied covariates were associated with mean or outlier estimates except that surgeons at one institution had consistently higher estimates than those from the other two.  There was no association between marginal cost and surgeon salary.

Conclusion:
On average, surgeons believed it was reasonable for hospitals to spend $20-30 to save one minute in the OR – values likely much larger than the actual money saved. The wide variability in estimates, along with the absence of a significant predictor, may suggest a relative lack of education on the topic. These findings suggest financial education may be necessary to enable surgeons to make the best value decisions in the OR.
 

63.09 Why Can’t Surgeries Start on Time?

Posted on January 31, 2019

J. Y. Zhao1, A. Engelman1, O. Plante1, R. Perez1, G. Yang1, P. L. Elkin1, S. D. Schwaitzberg1  1State University Of New York At Buffalo,Surgery,Buffalo, NY, USA

Introduction:  Errors in surgical case scheduling can lead to inefficiencies, patient and staff dissatisfaction, and direct and indirect cost burdens to the hospital. Perioperative efficiency is difficult to optimize due to a lack of understanding of the causes behind nonadherence to the surgical schedule. Our study aimed to delineate the points along the perioperative process amenable to targeted interventions to promote scheduling accuracy. 

Methods:  During a six-month period, a prospective study was performed to evaluate the perioperative process of adult patients undergoing elective surgeries. Patients were directly monitored from registration all the way through to post-anesthesia care. Scheduled times were compared to actual times. Reasons for nonadherence to scheduled times were recorded. Mid-way through the study, attending surgeons began receiving text notifications as soon as their patients were intubated.

Results: A total of 82 surgical cases were observed. Multiple reasons for surgery schedule nonadherence were noted. Most modifiable barriers leading to delays occurred in the preoperative phase; more than half of these barriers could be attributed to organization-related factors. Staffing-related factors were the cause of two-thirds of the delays that occurred once the patient was already in the operating room. Delays preventing patients from leaving the operating room after surgery occurred infrequently, and when they did occur, were most commonly due to a patient-specific reason. After attending surgeons began receiving text notifications that their patient was ready in the operating room, reductions were appreciated in the number of case delays that would have otherwise occurred equal to or less than 30 minutes. 

Conclusion: Our prospective time analysis study revealed multiple points in the perioperative process where inefficiencies were introduced and jeopardized adherence to the surgery schedule. Delays beyond thirty minutes will likely occur regardless of how timely an attending surgeon is in arriving to the operation room. Interventions that target organizational and staffing barriers are more likely to be met with success, as patient-specific factors will be less amenable to modifiable intervention. 

 

63.08 Gender Variance in NIH K-series Grant Funding in Surgery

Posted on January 31, 2019

J. M. Juprasert1, H. L. Yeo1  1NewYork-Presbyterian Hospital/Weill Cornell Medical Center,Department Of Surgery,New York, NY, USA

Introduction: Over the past 15 years, the number of women in academic surgery has increased dramatically, however, even as recently as 2015, women only accounted for 25% of assistant professors of surgery and <10% of full professors. Based on the current trajectory, women will not reach parity in academic surgery for over 100 yrs.  There is a concern that part of the disparity at the top levels may be attributed to gender discrimination, lack of visible role models, or lack of support and mentorship.  Because early funding is so important in an academic career, we sought to evaluate gender differences in NIH career development funding.

Methods:  Secondary analysis of prospectively collected data from fiscal year 2017 and 2018 from the NIH RePORTer database.  NIH K-series funding awards to principal investigators (PIs) were obtained and used to examine faculty from surgery departments for academic rank and gender.  Awardees with at least an M.D. were included in the study to focus our cohort on clinical academic surgeons.  K1, K07, K08, K22, K23 were included in the study to investigate early career awards; K24 recipients were excluded because they are for mid-career investigators.  The Scopus and Pubmed databases were used to ascertain publication statistics of these PIs.  Statistical trend tests were performed using t-test, ANOVA, and chi-squared test wherever appropriate with STATA v13.1.

Results: 63 surgical PIs (33% women vs 67% men) were identified who received a K-series grant from the NIH between 2017-18. The average number of first author publications for these awardees was 14.5 (+/-10) for women and 15.7 (+/-11) for men (p=0.67). The average number of senior author publications for these K awardees were 9.9 (+/-9) for women and 12.2 (+/-13) for men  (p=0.47).  The average number of total publications for K awardees was not significantly different for women (43.6+/-24) vs. men (53.2+/-32.2, p=0.23). The mean H-index for female faculty was 14.0 (+/-5) and 16.4 (+/-7) for men (p=0.15). Of the grants that were granted, 38 (60%) were basic science, 16 (25%) were translational, and 9 (14%) were health services related.  32 recipients were assistant professors (31% were women).  30 recipients were associate professors (37% were women).  The University of Michigan had the most recipients of any institution with 10 PIS (4 of whom are women) receiving grants; Northwestern University and University of Pennsylvania had the second highest with 5 PIS.  31 total institutions had at least one recipient.

Conclusion: The NIH K grant funding for early career women surgeons has not been previously described. There do not appear to be major gender related discrepancies in early career funding for surgeons.

 

61.20 Cost Efficiency of a Comprehensive ASC Evaluation for Patients with GERD in a Rural Surgical Clinic.

Posted on January 31, 2019

A. Miller1,2, M. Bempah1, S. Clarke1, C. Cruz Pico1,2, A. Postoev1,2, C. Ibikunle1,2  1Medical College Of Georgia,Surgery,Augusta, GA, USA 2Augusa State University,Surgery,Augusta, GA, USA

Introduction:
An estimated prevalence of GERD is 59% in the US, with more than 7,067,209 annual visits and more than $10 billion of annual treatment cost. GERD has multifactorial pathophysiology requiring several diagnostic procedures as esophagogastroduodenal endoscopy (EGD), Ph probe, Manometry, and Biopsy for correct diagnostics and prevention of Barrett's esophagus and cancer. Objectives of the study is to examine cost efficiency of a comprehensive evaluation for the patient with GERD in one visit by an Ambulatory Surgical Center (ASC) evaluation protocol (EGD, Ph probe, Manometry, Cellvisio) at a rural ambulatory surgical center.

Methods:
We examined retrospectively AthenaHealthNet electronic medical records of patients evaluated by ASC protocol with procedure codes: “43239 EGD Transoral biopsy single/multiple”, “91010 Manometry Esophagus motility study”, “91035 Bravo Esoph/Gastroesoph reflux test”, “43252 Cellvizio w/mucous telemetry Ph electrode place/Rec/Interp” from 08/22/2017 to 08/22/2018.

Results:
We evaluated total 344 patients, with average age 51.47 (range 19-87). The most common diagnostic codes applied were: 120 (34.8%) “K219: Gastroesophageal reflux disease without esophagitis”; 65 (18.9%) “K2270: Barrett's esophagus without dysplasia”; 42 (12.2%) “K635: Polyp of colon”; 38 (11.0%) “E6601: Morbid (severe) obesity due to excess calories”; 29 (8.4 %) “K449: Diaphragmatic hernia without obstruction or gangrene”; 19 (5.5 %) “K2970: Gastritis, unspecified, without bleeding”;13 (3.8 %) “R1310: Dysphagia, unspecified”;12 (3.5 %) “R109: Unspecified abdominal pain”. Total annual cumulative billed chargers for all procedures were $ 807,784, comprising charges for EGD/Biopsy ($ 467,935), EGD Flex Biopsy ($ 126,492), Manometry Motility study ($ 126,492), Bravo Reflux test ($ 156,024). Annual billed charges for total evaluation protocol applied in one visit ranged from $ 3,927 to $ 4,763 in contrast to applied in two visits ranged from $ 6,081 to $ 7,820.   

Conclusion:
ASC evaluation protocol (EGD, Ph probe, Manometry, Cellvizio) is more cost efficient in complex evaluation of patients at one visit.
 

61.19 Laparoscopic Esophagomyotomy with Concomitant Paraesophageal Hernia Repair

Posted on January 31, 2019

K. A. Schlosser1, S. R. Maloney1, T. Prasad1, B. T. Heniford1, P. D. Colavita1  1Carolinas Medical Center,Division Of Gastrointestinal And Minimally Invasive Surgery,Charlotte, NC, USA

Introduction:

The successful management of achalasia can be complicated by the presence of paraesophageal hernias, a combination that is felt to be uncommon.  This study examines short term outcomes Laparoscopic Heller Myotomy(LHM) with or without concomitant paraesophageal hernia repair (PEHR).

Methods:

The American College of Surgeons National Surgical Quality Improvement Program was queried for patients who underwent LHM with or without PEHR (2010-2016). Concomitant bariatric procedures were excluded. Demographics, operative approach, and outcomes were compared over time and by procedure group. Overall complication rate was defined as Clavien-Dindo ≥1, while major complication was defined as Clavien-Dindo ≥ 3.

Results:

3,579 patients underwent LHM from 2010-2016. 8.0% of procedures included PEHR, and 1.2% included PEHR with mesh placement. LHM with concomitant PEHR accounts for 1.3% of all PEHR in this time period (286 of 20,798 PEHR). Mean age of LHM was 52.6±16.3yr, mean BMI was 27.6±6.5m2/kg, 50.2% were female, 9.9% had diabetes, and 15.8% were active smokers. Most cases were elective (94.5%). When compared to LHM, patients undergoing open LHM with PEHR were older (58.2±16.3 vs 52.1±16.2yr, p<0.0001), more often inpatients (77.0 vs. 88.1%, p<0.0001) and had higher rates of hypertension (31.1% vs. 45.5% p<0.0001) and long-term steroid use (2.4 vs 4.9%, p=0.01). LHM with PEHR patients had higher rates of reoperation, mortality, overall complications, and major complications (1.5 vs. 3.6%, 3.5 vs. 4.7%, 3.8 vs. 9.1%, respectively; p<0.0009 all values). Over time, the frequency of LHM performed with concomitant PEHR increased from 2.3% of all LHM in 2006 to 10.7% in 2016 (p<0.0001).

Multivariate analysis was used to control for multiple potential confounding factors including concomitant PEHR, age, BMI, steroid use, and hypertension. PEHR with LHM was associated with double the rate of reoperation (OR 2.3, CI 1.1-4.7), and double the overall and major complication rate (OR 2.0, CI 1.2-3.1; OR 2.0, CI 1.1-3.6, respectively). Chronic steroid use was associated with increased length of stay (+2.8d, SE 0.4, p<0.0001), with readmission (OR 3.2, CI 1.6-6.7), and with overall complication rate (OR 3.0, CI 1.6-5.8). Hypertension treated by medications was also associated with increased length of stay (+0.4d, SE 0.15, p=0.01), overall complication rate (OR 1.8, CI 1.2-2.7), and major complications (OR 2.1, CI 1.3-3.7).

 

Discussion:

The performance of LHM with concomitant PEHR has increased in frequency from 2010 to 2016 for unclear reasons. While patients who have LHM with PEHR have higher complication rates, multivariate analysis demonstrates equivalent short-term outcomes when controlling for confounding factors. 

61.18 Experience with IVC Filters for Robotic Gastric Bypass Procedures

Posted on January 31, 2019

M. Aman1, G. AlAwwa1, L. Flores1, P. Haser1, A. J. Tortolani1, M. Khalil1, N. J. Gargiulo1  1The Brookdale University Hospital and Medical Center,Vascular,Brooklyn, NEW YORK, USA

Introduction: It has been previously suggested that inferior vena cava (IVC) filter placement at the time of open gastric bypass in patients with a body mass index (BMI) > 55 kg/m2 reduces both the pulmonary embolism rate and perioperative mortality.  This has not been observed in patients undergoing laparoscopic gastric bypass.  Little is known regarding the necessity of IVC filter placement in patients undergoing robotic gastric bypass surgery.

Methods:   Over a 3 year period, 51 morbid obese patients have undergone robotic gastric bypass procedures, and 37 (72.5%) had a BMI > 55 kg/m2.  All 51 patients had routine preoperative subcutaneous lovenox injections and systemic compression devices prior to the administration of general anesthesia.  Robotic gastric bypass was completed utilizing the da Vinci system.

Results:  Fifty of 51 (98%) patients remained free of thrombo-embolic phenomena over the 3 year period (range 6 months-3 years) following successful robotic gastric bypass with the da Vinci system.  One patient (2%) with a BMI > 55 kg/m2 developed a pulmonary embolism (PE) 1 month post procedure.  She was treated  successfully with intravenous heparin and had complete resolution of the PE.  She was incidentally diagnosed with a Factor V Leiden deficiency and placed on long-term oral anticoagulation. 

Conclusion:  It appears that IVC filter placement at the time of robotic gastric bypass is not required even in patients with a BMI > 55 kg/m2.  A note of caution should be exerted in those obese patients who have a hypercoagulable disorder.  An aggressive posture should be advocated in this small sub-group of morbid obese patients which may consist of immediate anticoagulation (when it is deemed safe) following their procedures.   

 

61.17 Obesity Years: Clinical Variation by Age Pre/Post Biliopancreatic Diversion/Duodenal Switch (BPD/DS)

Posted on January 31, 2019

M. L. Gott1, P. R. Osterdahl2, G. J. Slotman1  1Inspira Health Network,Department Of Surgery,Vineland, NEW JERSEY, USA 2Inspira Health Network,Department Of Obstetrics/Gynecology,Vineland, NEW JERSEY, USA

Introduction:

Pre-operative conditions and bariatric surgery outcomes of Medicare patients vary significantly versus other insurances, with Medicare often faring worse than others.  However, since some morbidly obese Medicare insured are younger patients on disability, whether or not obesity effects vary strictly by age is unknown.  

Objective:

Identify clinical variation by age of pre/post BPD/DS.

Methods:

Using the BOLD database, 1673 BPD/DS patients were analyzed retrospectively in 6 age groups: <30(177), 30-40(456), 40-50(486), 50-60(407), 60-70(138), >70(9). Data: Demographics, Pre-/Post-op BMI and 33 obesity co-morbidities. Statistics: ANOVA and General Linear Models including pre- and post-operative data modified for binomial distribution of dichotomous variables.

Results:

Pre-op BMI varied inversely by age, from <30 (55+-10) to >70 (44+-8) p<0.01, as did 12 month BMI <30 (32+-6) to 60-70 (31+-5) p<0.05. Female/male %:<30 (76/24) to >70 (44/56) p<0.05, Race and health insurance (Medicaid, Medicare, Private, Self-Pay) varied widely (p<0.0001). Panniculitis, alcohol/substance use, asthma, obesity hypoventilation, PVD, back pain, fibromyalgia, mental health diagnosis, depression, psychological impairment, pseudotumor cerebri, irregular menses, DVT/PE did not vary by age. Gout varied directly by age and tobacco abuse varied inversely at baseline. 12 month liver disease and pulmonary hypertension varied directly by age. Hernia, cholelithiasis (Chole), CHF, impaired function (IFS), diabetes, hypertension (HTN), dyslipidemia (Lipids), lower extremity edema (LEE), somatic pain (MS pain), angina, sleep apnea (OSA), stress urinary incontinence (SUI) all varied directly by age pre-op, and their increased persistence correlated with increasing age at 12 months. In the 60-70 and >70 sets angina, MS pain, LEE and SUI increased from baseline: see Table.

Conclusion:

In spite of lower pre-operative BMI in older age groups, the incidence of serious obesity co-morbidities varied directly with age among BPD/DS patients. In addition, while BMI for all age groups at 12 months after BPD/DS was clinically identical, post-operative improvement in 12 weight-related medical derangements was inversely proportional to age. Only diabetes resolved more completely among older patients. Although BOLD did not record the duration of each patient’s obesity, these findings suggest the concept of “obesity years”, meaning that those who have obesity the longest accumulate more co-morbidities and are less likely to resolve them than those who have obesity a shorter length of time. This advance knowledge may assist patient selection for BPD/DS. Data-informed planning could yield superior BPD/DS outcomes.
 

61.16 Blockade of the TCA Cycle in Type 2 Diabetes and the Metabolic Syndrome

Posted on January 31, 2019

W. Pories1, T. E. Jones1, J. Houmard1, C. J. Tanner1, D. Zeng1, K. Zou3, P. M. Coen2, B. H. Goodpaster4, W. E. Kraus2, J. Yang1, G. L. Dohm1, W. Pories1  1East Carolina University,Brody School Of Medicine,Greenville, NC, USA 2Duke,Metabolism,Durham, NC, USA 3Boston University,Biochemistry,Boston, MA, USA 4Sanford Bunham Prebys Medical Discovery Institute,Orlando, FL, USA

Introduction:
Blood lactate, an indicator of metabolic failure in critical care, indicates dependence on the anaerobic partitioning of glucose, reflected by increased lactate production. In this study, we explored basal lactate levels in normal individuals and preoperative patients with the metabolic syndrome, before and after correction of glucose metabolism, with surgery and with exercise.

Methods: Fasting lactate levels and insulin sensitivity were determined during IVGTT in non-obese subjects and patients with metabolic disease prior to Roux-en-Y gastric bypass as well as 1 week, 1-3 months, 7-9 months and more than 12 months following RYGB.  Subjects with the metabolic syndrome were also studied at baseline and after 9 months of exercise.

Results: Subjects with the metabolic syndrome have higher lactate (1.67 +/- 0.11 mM) than non-obese controls (1.06 +/- 0.05 mM, P< .001) and respond to a glucose/insulin challenge with higher lactates.  Lactate concentrations, including basal levels, were significantly reduced a week after RYGB and remained at levels like non-obese for more than a year.  The greatest improvement in fasting lactate occurred in those who were most metabolically impaired (highest lactate). Fasting lactate was also reduced by exercise in metabolically impaired subjects (by 0.21 mM, p = 0.028) (Figure 1).

Conclusion: Elevated blood lactate levels reflect metabolic impairment, correctible in the severely obese with the gastric bypass and/or exercise.  These data suggest that the metabolic syndrome is caused by a signal, perhaps from the foregut, which limits entry of pyruvate into the TCA cycle.

 

61.15 Factors Associated with Excess Weight Loss Percent Among Adolescent Bariatric Surgery Patients

Posted on January 31, 2019

E. C. Victor1,2, N. V. Mulpuri3, L. S. Burkhalter1, M. Lott2, F. G. Qureshi1,3  1Children’s Medical Center,Division Of Pediatric Surgery,Dallas, Tx, USA 2University Of Texas Southwestern Medical Center,Department Of Psychiatry,Dallas, TX, USA 3University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA

Introduction: Adolescent bariatric surgery is associated with significant weight loss with a reduction in medical comorbidities and improved psychological functioning. To date, there has been limited research exploring individual medical, demographic, and family factors associated with excess weight loss percent (EWL%) postoperatively in adolescents.

Methods: A retrospective chart review of adolescents who underwent sleeve gastrectomy between 2015 and 2018 was performed. A series of forward stepwise linear regressions at 6 weeks, 3 and 6 months postop were conducted to examine medical, family, and demographic factors associated with EWL%. IRB approval was obtained.

Results:47 patients were identified (age 17.6±1.16, body mass index(BMI) 50.71±7.50kg/m2). At 6 weeks, males (M EWL% = 17.68,p=.017) had a greater EWL% than females (M EWL% = 16.52) . Patients with lower BMIs at first surgical appointment (p < .001) also had a greater EWL%. Patients referred from primary care providers and/or a pediatric high-risk obesity clinic (M EWL% = 17.72,p= .003) had a greater EWL% compared to patients referred from a specialty care clinic (M EWL% = 12.30).  EWL% at 6 weeks was the greatest predictor of EWL% at 3 months (p<.001) and 6 months (p<.001) post-op. Interestingly, patients with higher BMIs at first surgical appointment, had higher EWL% at 6 months (p<.001).  At all post-operative time points, there were no differences in EWL% outcomes with regard to race, ethnicity, age at surgery intake appointment, medical diagnoses (obstructive sleep apnea, hypertension, hyperlipidemia, non-alcoholic fatty liver disease, or type 2 diabetes), mental health diagnosis, insurance type, family  history of weight loss surgery, or family members’ successful weight loss maintenance post-op.

Conclusion:For adolescents undergoing bariatric surgery, greatest EWL% at 3 and 6 months post-op was most associated with the amount of weight a patient is able to lose in their first 6 weeks following surgery. Boys also had greater EWL% and BMI at first surgical appointment impacted EWL% differently at 6 weeks and 6 months, perhaps reflecting different rates of weight loss.  Additional longitudinal data will be required to validate these findings.

 

61.14 Skeletal muscle loss in laparoscopic gastrectomy: differences between laparoscopic procedures.

Posted on January 31, 2019

Y. Yamazaki1, S. Kanaji1, G. Takiguchi1, H. Hasegawa1, M. Yamamoto1, Y. Matsuda1, K. Yamashita1, T. Oshikiri1, T. Matsuda1, T. Nakamura1, S. Suzuki1, Y. Kakeji1  1Kobe University Graduate School Of Medicine,Division Of Gastrointestinal Surgery, Department Of Surgery, Kobe University Graduate School Of Medicine,Kobe, HYOGO, Japan

Introduction:
Gastrectomy is an essential treatment for gastric cancer. However, it is well known that gastrectomy causes not only body weight loss (BWL) but also skeletal muscle loss (SML), which can impair quality of life of the patients. Several reports showed the type of open gastrectomy had an effect on BWL and SML. However, the difference in SML between types of laparoscopic gastrectomy and correlation between BWL and SML are still unclear. The aim is to reveal the differences in SML between laparoscopic procedures for gastric cancer and to identify the risk factors for SML.

Methods:
We retrospectively obtained data of 207 consecutive patients who underwent laparoscopic gastrectomy for gastric cancer between March 2011 and May 2017. Out of the patients, 157 patients underwent laparoscopic distal gastrectomy (LDG group) and 50 patients underwent laparoscopic total gastrectomy (LTG group). We analyzed psoas major muscle area (PMA) of the L3 for evaluation of skeletal muscle mass using CT image taken before the surgery and at 1 postoperative year and compared PMA change between the laparoscopic procedures. Comparisons of BW and PMA were performed between the types of laparoscopic procedures including LDG (Billroth 1), LDG (Roux en Y) and LTG. Univariate and multivariate analysis to identify risk factors for PMA rate of less than 90% were performed for LDG group. Further, we performed the same analysis for the population whose BW was relatively preserved.

Results:
 There was no significant difference in the characteristics. Longer operative time and more blood loss were observed in LTG group. Pathological findings showed more advanced diseases in LTG group, which resulted in more adjuvant chemotherapy undergone. Anastomotic leakage in LTG group was more frequent, while the overall complications rate was not different. The median PMA rate (1POY / Pre) was 94.0% in LDG (B-1), 95.2% in LDG (R-Y) and 84.4% in LTG group respectively. BW and PMA were preserved significantly better in both LDG subgroups. Univariate analysis showed that high BMI (25 or above) and postoperative complications were significantly associated with more PMA loss, while multivariate analysis identified only postoperative complications as an independent risk factor in LDG group. BW and PMA rate were well correlated in overall patients, and PMA rate of 90% was equivalent to BW rate of 88%. Out of 118 patients whose BW rates was 88% or above, 29 patients had their PMA rate fall below 90%. Univariate and multivariate analysis showed that LTG was the independent risk factor for PMA rate less than 90 % in patients whose BW rate was 88% or larger.
 

Conclusion:
 We showed that postoperative PMA loss occurred in laparoscopic gastrectomy as well as previous reported open surgery. Postoperative complications were harmful for SML after LDG. Because LTG can cause great PMA loss even when BW are relatively preserved, SML should be cared especially after LTG.

 

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