61.13 Effect of Distance from Surgical Center on Bariatric Postsurgical Outcomes and Follow-up Compliance

Posted on January 31, 2019

S. Monfared1, D. Selzer1, A. Butler1  1Indiana University School Of Medicine,Bariatric And Minimally Invasive Surgery,Indianapolis, IN, USA

Introduction:
Patients seeking bariatric surgery are traveling longer distances to reach Metabolic and Bariatric Centers of Excellence. The purpose of this study was to evaluate the impact of travel distance on adherence to follow up and outcomes after bariatric surgery.

Methods:
A retrospective review of all consecutive patients who had undergone bariatric surgery at a Center of Excellence from June 1, 2013 to May 30, 2014 was performed. The patients were divided into two groups: those who traveled 50 miles or less and those who traveled more than 50 miles. Demographic data was obtained including age, gender, initial body mass index (BMI), type of surgery and insurance type. Primary outcome assessed was the influence of distance on postoperative weight loss over 4-year follow up period. Secondary outcomes assessed were follow-up compliance, length of stay (LOS), 30-day complication and readmission rates.

Results:
A total of 231 patients underwent bariatric surgery at our institution during that year with 4 years of follow up available. Of these, 147 patients traveled 50 miles or less and 84 patients traveled greater than 50 miles. Patient demographics were similar between the two groups. There was no difference in percent excess weight loss at each follow visit between the two cohorts (Figure 1). Furthermore, there was no difference in readmission rates (2% in ≤50 mile group vs 5% in > 50 mile group), minor complications rates (13% vs 10%), major complications rates (3% vs 2%) and LOS (2.6 vs 2.6 days). Over the four year period, patients who lived within 50 miles of the surgery center followed up an average of 5.6 out of 9 required visits which was statistically greater than an average of 4.6 visits for those who lived greater than 50 miles away.

Conclusion:
As expected, distance impacted long term follow up, but despite longer travel, there was no difference in bariatric patients’ postoperative weight loss success, length of stay, 30-day complication or readmission rates. Travel distance should not be a significant factor to providing patients with access to bariatric surgery at a Center of Excellence.
 

61.12 Postoperative Urinary Retention After Bariatric Surgery: An Institutional Analysis

Posted on January 31, 2019

D. F. Roadman1, M. Helm1, M. Goldblatt1, T. Kindel1, J. Gould1, R. Higgins1  1Medical College Of Wisconsin,Milwaukee, WI, USA

Introduction:  Postoperative urinary retention (POUR) can significantly impact quality outcomes, leading to urinary tract infections, longer lengths of stay, and increased healthcare costs. The incidence of POUR in bariatric patients has limited information in the literature. The primary objective of this study was to determine the incidence of and risk factors contributing to POUR in primary bariatric surgery patients. 

Methods:  A retrospective chart review was performed of patients who underwent a laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) at a single institution from 2013 to 2017. POUR was defined as the inability to urinate postoperatively requiring urinary straight or indwelling catheterization prior to discharge. Univariate analyses were performed on perioperative variables and their correlation with POUR. 

Results: In total, 603 patients underwent primary bariatric surgery during the study period: 317 (52.6%) LSG and 286 (47.4%) LRYGB. Overall, 49 (8.1%) patients developed POUR with a mean volume at time of urinary catheter intervention of 682.5 ± 319.7 mL. There were no significant differences in pre-operative demographics between patients with and without POUR. Patients who underwent a LSG had an increased incidence of POUR at 11.4% compared to 4.5% after LRYGB (p=0.002). Additionally, POUR was significantly associated with decreased neostigmine usage, isolated non-depolarizing muscle relaxant usage, and reduced intraoperative fluid administration (Table 1). Female patients with POUR had a significantly longer length of stay at 2.14 ± 1.17 days compared to those without POUR at 1.71 ± 1.25 days (p=0.046). There was no significant difference in length of stay for male patients. 

Conclusion: Risk factors associated with POUR after primary bariatric surgery include LSG, less intraoperative neostigmine and intravenous fluids, as well as isolated non-depolarizing muscle relaxants. Female patients who developed POUR had a longer length of stay. These risk factors can be used to educate patients, as well as identify quality initiatives that focus on perioperative and anesthetic management. Creating a standardized protocol for the management of urinary retention in these patients could also impact its effect on length of stay. 

 

61.11 Lack of Lymphocyte Recovery After Esophagectomy Predicts Mortality and Recurrence

Posted on January 31, 2019

B. M. Hall1, T. Geraci1, J. Machan1, S. Milman1, W. Cioffi1, T. Ng1, S. Monaghan1  1Warren Alpert Medical School of Brown University,Department Of Surgery,Providence, RI, USA

Introduction:
Esophagectomy performed for esophageal cancer is a relatively high morbidity and mortality operation.  The immediate morbidities have been shown to have major impacts on patient’s long term survival.  Prior research at our institution has found decreased lymphocyte counts to be an independent predictor of mortality in some populations.  We hypothesized the lymphocyte count postoperatively would predict outcomes in esophagectomy patients as well.

Methods:
A retrospective review was performed of all esophagectomies for adenocarcinoma performed over 13 years at our center by a single surgeon.  The routinely obtained postoperative lymphocyte counts were analyzed for their trend, separating patients into three groups: never low, low with by recovery, and low without recovery.  Resolution of lymphopenia was assessed at postoperative day four.  Outcomes between these groups were then compared, with the primary end points being all cause mortality and recurrence analyzed with Kaplan Meier curves.

Results:
In total, 207 patients were included in the review with a minimum one year follow up.  Our 5 year mortality and recurrence rates were 49% and 44% respectively.  Recurrence was significantly higher in patients in patients with persistent lymphopenia [41% (64/158)] compared to those who did recover [13% (5/39)] (p = 0.0019) and those whose counts never dropped [10% (1/10)] (p = 0.0024).  For mortality, the persistent lymphopenia group was significantly higher [54% (85/158)] as compared to the two other groups combined [33% (16/49)] (p = 0.0225).  There was no significant difference in immediate complications including leak rate and infections, nor hospital length of stay.  There were more patients with persistent lymphopenia who had a higher clinical stage (36 vs 13% p = 0.0051) and received neoadjuvant chemotherapy (86% vs 28% p < 0.0001).  However, neither of these preoperative factors were predictive of mortality.

Conclusion:
There is a significant increase in the mortality and cancer recurrence rates in those patients whose lymphocyte count drops without recovery following their esophagectomy.  These data imply differences in immune responses to the stress of surgery that that can be measured and are indicative of overall outcomes.  As a portion of already routine postoperative labs, consideration of lymphocyte trends would an early indicator of potential poor outcomes in these patients.  
 

61.10 Treatments Modalities for Esophageal Adenocarcinoma in the US: Trends and Survival Outcomes

Posted on January 31, 2019

M. Di Corpo1, F. Schlottmann1, P. D. Strassle2, C. Gaber2, M. G. Patti1,2  1University Of North Carolina At Chapel Hill,Department Of Surgery,Chapel Hill, NC, USA 2University Of North Carolina At Chapel Hill,Department Of Medicine,Chapel Hill, NC, USA

Introduction:  The rise in incidence of esophageal adenocarcinoma in the United States over the last decade has been well documented; however, data on trends in use of different therapies and their impact on long-term survival are lacking. We aimed to: a) assess the national trends in the use of different treatment modalities; and b) compare survival outcomes among the different treatment strategies. 

Methods:  A retrospective, population-based analysis was performed using the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) Program registry for the period 2004-2014. Adult patients (>18 years old) diagnosed with esophageal adenocarcinoma were eligible for inclusion. Treatments of interest included chemoradiation, esophagectomy, and chemoradiation plus esophagectomy. The yearly incidence of each treatment strategy was calculated using Poisson regression. A weighted Cox regression model was used to assess the overall effect of each treatment on mortality. Inverse-probability of treatment weights were used to account for potential confounding by year of diagnosis, sex, age, race/ethnicity, tumor grade, and derived AJCC TNM value. 

Results: A total of 10,755 patients were included. The median follow-up time was 15 months (interquartile range 7 – 33). During the study period, the percentage of esophagectomy alone significantly decreased from 14.6% to 4.8% (p<0.0001), the percentage of chemoradiation alone significantly decreased from 25.45% to 28.5% (p=0.08), and the percentage of chemoradiation plus esophagectomy significantly increased from 13.7% to 19.8% (p<0.0001). The 60-month survival rate was 13.0% for chemoradiation only, 33.0% for esophagectomy only, and 36.3% for chemoradiation plus esophagectomy (figure). After accounting for patient and cancer characteristics, both esophagectomy (hazard ratio [HR] 0.62, 95% CI 0.55, 0.70, p<0.0001) and chemoradiation plus esophagectomy (HR 0.45, 95% CI 0.41, 0.48, p<0.0001) had significantly lower rates of mortality compared to chemoradiation only.

Conclusion: The use of esophagectomy alone has decreased, and both the use of chemoradiation plus esophagectomy and chemoradiation alone have increased for patients with esophageal adenocarcinoma. Considering the better survival outcomes achieved with surgical resection, the use of chemoradiation alone should be discouraged in surgically fit patients.    

 

61.09 Referral to surgery:What Factors Are Associated with Completion of Adolescent Weight Loss Surgery?

Posted on January 31, 2019

N. V. Mulpuri2, E. C. Victor1,3, G. P. Wools1, M. Lott1,3, F. G. Qureshi1,2  1Children’s Medical Center,Pediatric Surgery,Dallas, Tx, USA 2University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA 3University Of Texas Southwestern Medical Center,Department Of Psychiatry,Dallas, TX, USA

Introduction: Bariatric surgery has been used to treat severe obesity in adolescents. However, only a limited number of adolescents referred to surgery successfully complete the surgical program. Better identification of pre-surgical factors associated with completing bariatric surgery may determine successful referrals to surgical programs versus alternative behavioral health interventions.

Methods: A retrospective chart review of all patients referred from 2015 to 2018 to an adolescent surgical weight loss program was performed. Pre-operative factors, weight loss, and resolution of premorbid conditions among surgery completers (n=47) was compared to surgery non-completers (n=149) using backward stepwise logistic regression. Choice of procedure was laparoscopic sleeve gastrectomy.  IRB approval was obtained.

Results:196 adolescents were identified (17.1±1.61 yrs, body mass index (BMI) 50.2±8.8kg/m2, 66% female). 47 (24%) underwent sleeve gastrectomy (age (17.6±1.16 yrs, BMI 50.71±7.50kg/m2, 78% female) and 149  (16.2±1.51 yrs, body mass index (BMI) 49.98±9.19kg/m2, 62% female)) did not complete the surgical program. There was no difference between completers and non-completers in terms of age, race, ethnicity, BMI, premorbid medical conditions (hypertension, fatty liver disease, type 2 diabetes, hyperlipidemia), current or past mental health diagnosis, insurance type, referral source, or family history of weight loss surgery at surgical referral.  Regression analyses revealed that boys (p=.045), patients with sleep apnea (OSA p=.009), and those that spent shorter time in the preoperative phase of the bariatric program (p<.001) were significantly more likely to have surgery.  Surgery completers lost weight successfully (figure 1) p<0.05

Conclusion:The conversion rate from adolescent referral to weight loss surgery is 24%.  Male patients, and patients with OSA are more likely to undergo weight loss surgery.  Patients who make significant changes upon surgical referral spend less time in the preoperative phase and are more likely to complete surgery.  Laparoscopic sleeve gastrectomy is successful in helping completers lose significant weight. These factors may help streamline referrals to adolescent surgical weight loss programs. 

 

61.08 Defective Homologous Recombination in Platinum-based Chemotherapy for Gastric Cancer

Posted on January 31, 2019

T. Katada1, H. Ichikawa1, Y. Hirose1, M. Nagahashi1, Y. Shimada1, T. Hanyu1, T. Ishikawa1, Y. Kano1, Y. Muneoka1, 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

Introduction: Defective homologous recombination (HR) due to genetic alteration of HR genes contributes to a high response of platinum therapy in ovarian and breast cancers. The aim of this study is to clarify the clinical significance of defective HR in platinum-based chemotherapy for gastric cancer (GC).

Methods: A total of 26 patients (19 men and 7 women, with a median age of 66 years) who underwent platinum-based chemotherapy for unresectable metastatic GC were enrolled. Metastatic sites after gastrectomy were lymph node in 10 (38%), liver in 8 (31%), peritoneum in 8 (31%), others in 2 (8%) patients. Genetic alterations of HR genes (BRCA1, BRCA2, RAD50, RAD51C, RAD51D, BLM, PALB2 and FANCD2) in the primary tumor were assessed by cancer gene-panel. We evaluated the association between defective HR and treatment response (RECIST ver. 1.1), progression free survival (PFS) and overall survival (OS).

Results: BRCA1, BRCA2, RAD50, BLM, and FANCD2 mutations were shown in 3 (12%), 2 (8%), 2 (8%), 1 (4%) and 1 patient (4%), respectively. Overall, 6 patients (23%) had genetic alterations of HR genes (defective HR group). Objective response rate (complete or partial response) was 60% in the defective HR group and 27% in the proficient HR group (P = 0.29). Disease control rate (complete or partial response or stable disease) was 100% in the defective HR group and 47% in the proficient HR group (P = 0.06). PFS was significantly longer in the defective HR group than in the proficient HR group (median 6 months vs. 3 months; P = 0.035). OS was also significantly longer in the defective HR group than in the proficient HR group (median 18 months vs. 8 months; P = 0.025).

Conclusions: Genetic alteration of HR genes was significantly associated with a high response of platinum-based chemotherapy and favorable patient outcome in unresectable metastatic GC. Clinical utility of the assessment of defective HR in GC is worth considering further large-scale validation studies.

61.06 Weight Loss for Patients with Severe Obesity: An Analysis of Long Term Electronic Health Record Data

Posted on January 31, 2019

N. Liu1, J. Birstler3, M. Venkatesh1, L. P. Hanrahan2, G. Chen3, L. M. Funk1,4,5  4University Of Wisconsin,Department Of Surgery / Division Of Minimally Invasive, Foregut, And Bariatric Surgery,Madison, WI, USA 5William S. Middleton VA Hospital,Madison, WI, USA 1University Of Wisconsin,Department Of Surgery,Madison, WI, USA 2University Of Wisconsin,Department Of Family Medicine And Community Health,Madison, WI, USA 3University Of Wisconsin,Biostatistics And Medical Informatics,Madison, WI, USA

Introduction:  Obesity is a significant health problem in the US, affecting one-third of all adults. Numerous studies have reported that losing as little as 5% of total body weight (TBW) can improve comorbidities, specifically cardiovascular health. However, for adults with severe obesity, 5% TBW loss rarely results in resolution of comorbidities. The objective of this study was to quantify clinically significant weight loss during a 5-year window for severely obese patients who had not undergone bariatric surgery. We defined clinically significant weight loss as a final BMI of < 30 kg/m2. We hypothesized that less than 10% of our patients would achieve clinically significant weight loss.

Methods:  All 18-75 year old patients at a single institution academic health center who had at least 2 height and weight measurements 5 years apart between 1/1/2011 and 12/31/2016 were retrospectively identified from the electronic health record (EHR). We excluded all underweight patients with BMI ≤ 18.5 kg/m2, pregnant and cancer patients using ICD-9 and -10 codes, and bariatric surgery patients using the bariatric surgery registry. We categorized patients by their initial BMI measurement: normal (18.5-24.9 kg/m2), overweight (25.0-29.9), class 1 (30.0-34.9), class 2 (35.0-39.9), and class 3 (≥ 40.0) obesity. BMI changes from initial to end date were plotted. Within each BMI group, we identified patients who lost ≥ 5% TBW.

Results: 23,769 patients met our study inclusion criteria. 19.8% were severely obese (class 2 or 3) at baseline. 25.6% of class 2 obesity patients and 29.6% of class 3 patients lost ≥ 5% TBW; 17.8% and 21.7% of overweight and class 1 patients, respectively, lost ≥ 5% TBW. The majority of patients with severe obesity (51.5% for class 2 and 81.3% for class 3) remained in the same BMI category (Figure 1). 22.4% of class 2 and 14.4% of class 3 patients lost enough weight to drop down 1 obesity class. Only 3.1% of class 2 patients and 0.5% of class 3 patients achieved clinically significant weight loss, or BMI of < 30 kg/m2.

Conclusion: Patients with severe obesity were more likely to lose at least 5% of their total weight compared to overweight and class 1 obesity patients. However, weight loss into a non-obese weight class was very uncommon over a 5-year period for patients with severe obesity. The vast majority either remained in the same obesity class or increased classes. This pattern of ongoing weight gain for the most obese patients is concerning and requires solutions at societal and health systems levels.

 

61.05 Safety, Efficacy and Cost Analysis of Robotic Sleeve Gastrectomy Compared to Standard Laparoscopy

Posted on January 31, 2019

J. P. Kuckelman1, T. Holtestaul1, D. Lammers1, J. Bingham1  1Madigan Army Medical Center,General Surgery,Tacoma, WA, USA

Introduction: The increasing comfort with robotic methods in concert with technological advances has led to a surge in robotic approaches for bariatric operations, the most common of which being sleeve gastrectomy (SG).  The progression of robotic use for bariatric procedures has forged forward despite a lack of evidence-based support. Current database studies have demonstrated conflicting data regarding the safety of the robotic approach for sleeve gastrectomy. We evaluate the safety and effectiveness of robotic methods when compared to a standard laparoscopic approach.

Methods: Retrospective review of all SG performed between 2010 and 2017 at a single bariatric center of excellence. Patients were followed for a minimum of 3 months with ongoing follow up to one year. Cases were grouped as laparoscopic (LSG) or robotic (RSG) and propensity matched for age, sex, BMI, and co-morbidities. Patient characteristics, intra-operative indices as well as follow up data including weight loss was collected. Patients were categorized based on operative approach and propensity matched for comparison.

Results: 479 patients were included with the majority being categorized as laparoscopic sleeve gastrectomy (LSG, N=403) with 76 patients included in the robotic group (RSG).  There was 99% follow up for 30 day outcomes. LSG had significantly more patients with pre-operative diabetes at 15.8% compared to 1.3% in the RSG group (p=0.003). There were no differences in terms of pre-operative age, weight, BMI, smoking status, ASA, or rates of any other comorbidity. Operative time was significantly longer with RSG at 138 minutes compared to 104 minutes with LSG (p=<0.001). There were no differences in rates of intra and post-operative blood transfusions, hospital length of stay, unplanned return to the operating room or readmission (Figure). Propensity matching resulted in reduction to 75 patients in each group and did not alter the primary results. Estimated percent weight loss (EWL%) was similar at 3 and 6 months between the two groups. Only 41 patients met had 12-month follow-up in the RSG group but EWL% was significantly lower with RSG at 101% compared to 60% in the LSG group (p=<0.001, see figure).

Conclusion:Robotic sleeve gastrectomy was found to be safe and effective with similar results in terms of weight loss when compared to laparoscopic sleeve gastrectomy. Operative times were longer with a robotic approach which did not result in any adverse postoperative events.
 

61.04 Feeding Outcomes in Neonates with Trisomy 21 and Duodenal Atresia

Posted on January 31, 2019

M. D. Smith2, M. P. Landman1  1Indiana University,Division Of Pediatric Surgery, Department Of Surgery,Indianapolis, IN, USA 2Indiana University-Purdue University, Indianapolis,Department Of Biology,Indianapolis, IN, USA

Introduction:

Duodenal Atresia (DA), a common cause of congenital duodenal obstruction, is commonly repaired early in life via intestinal bypass. Many of these patients can have feeding difficulties in the early, postoperative period.  DA has a known association with Trisomy 21.  The postoperative feeding issues are not well described in this population.  We hypothesize that the combination of DA and Trisomy 21 is associated with worse postoperative feeding outcomes and increased need for gastrostomy button placement when compared to non-trisomy DA patients.

Methods:

A retrospective review of patients at Riley Hospital for Children between 2010-2017 with the diagnosis of duodenal atresia or stenosis was performed.  Prenatal and postnatal clinical data was abstracted.  Additionally, intra-operative and postoperative data was collected.  Univariate analyses were performed.  

Results:

We identified 43 patients with duodenal atresia; 22 (51.2%) were male.  Patients were born at a median gestation age of 37 (IQR 34-38) weeks. Thirty-one (72.1%) of all DA patients were diagnosed prenatally.  Nineteen patients (44%) were diagnosed with Trisomy 21. Repair occurred at a median age of 2 (IQR 1-5) days.  Postoperative feedings were started on average by day 7 (+/- 3.2 days) and there was no difference between patients with Trisomy 21 (6.47 +/- 3.89 days) and those without Trisomy 21 (7.42 +/- 2.47 days; p = 0.34).  There was no difference in days to full enteral nutrition between these groups (13.47 +/- 4.55 vs. 16.46 +/- 9.43 days; p = 0.21). Sixteen patients (84.2%) with Trisomy 21 required gastrostomy at any point versus only 6 (25%) patients without Trisomy 21.  On univariate analysis, there was significant association between Trisomy 21 and the lifetime need for gastrostomy button placement (p < 0.001); however, this association did not hold when evaluating the association of gastrostomy during the index admission (p = 0.11).

Conclusion:

Our data suggests that a correlation exists between Trisomy 21, duodenal atresia, and the eventual need for gastrostomy, that may not be evident when only looking at the index admission alone.  Surgeons should consider placement of gastrostomy button at the time of DA repair in this population to facilitate postoperative feeding and prevent the need for additional operations to obtain durable feeding access. 
 

61.03 Endoscopic Gastro-Jejunostomy Outlet Reduction (EGOR) after Roux-en-Y gastric bypass: Is it worth it?

Posted on January 31, 2019

A. Valencia1, D. E. Azagury1, L. Voller1, T. E. Mokhtari1, P. Pradhan1, N. Strauch1, S. Koontz1, J. Morton1  1Stanford University,Surgery,Palo Alto, CA, USA

Introduction:
Roux-en-Y Gastric Bypass (RYGB) remains the gold standard in bariatric surgery and can lead to significant, sustainable weight loss. However, weight regain remains a long-term risk and very few options are available in the setting of significant weight regain. Previous studies have demonstrated a relationship between increased gastrojejunal stoma diameter and impaired weight loss/weight regain. In this setting, endoscopic suturing may be a useful tool in order to help patients struggling with weight regain and recurrence of their comorbidities. We present a review of full thickness endoscopic gastro-jejunal outlet reductions (EGOR) performed at our institution and resulting weight loss, comorbidity resolution, and perioperative outcomes.

Methods:
Thirty-eight patients underwent EGOR after RYGB and were included in this retrospective analysis of a prospective bariatric database. Pre-EGOR data collected included patients’ demographic information, body mass index (BMI), and percent excess weight loss (%EWL). Perioperative data were recorded. Postoperative complications, BMI, %EWL, and comorbidities were collected at 3, 6 and 12 months. Dichotomous and continuous variables were examined by Chi-Square analysis and Student’s t-test, respectively. Fisher’s exact test was used for categorical variables if cell counts were less than five.

Results:
Average time between RYGB and EGOR was 120.6 ± 67.2 months [range: 37 – 436]. Average BMI at the time of EGOR was 42.0 ± 9.9 kg/m2 [range: 32.7 – 55.2]. Mean operative time was 70.4 minutes [range: 25 – 177]. All cases were performed as outpatient procedures. Average BMI decreased from 42.0 ± 9.9 kg/m2 preoperatively (n=38) to a nadir of 34.4 ± 5.4 kg/m2 (p=0.0038) 6 months after EGOR. At both 3- and 6-months postop, all patients had lost weight from their preop baseline. At 12 month post-operative visit, the weight of five patients either returned or surpassed baseline weight. Of the seven patients with recurrent diabetes, three experienced remission at the 12-month visit. Recurrent hypertension was resolved in four of nine patients, hyperlipidemia was resolved in six of eight patients, and six of eight patients reported significant improvements in sleep apnea at the 12-month post-operative visit.

Conclusion:
This study is one of very few reports regarding outcomes for EGOR after RYGB. Our results show that EGOR can be performed as an outpatient procedure with an excellent safety profile. This procedure may lead to very significant weight loss in select patients, but results vary between individuals and more so beyond 6 months. Importantly, impact on recurrence of comorbidities, including diabetes, is significant even in the setting of modest weight loss. Further studies are needed to assess the long-term sustainability of weight loss following EGOR and to evaluate methods to identify which patients might benefit most from this intervention.
 

61.02 The Impact of Self-Efficacy on Pursuit of Bariatric Surgery

Posted on January 31, 2019

S. M. Jafri1, C. A. Vitous1, D. A. Telem1,2  1University Of Michigan,Center For Healthcare Outcomes And Policy, Institute For Healthcare Policy And Innovation,Ann Arbor, MI, USA 2University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction:
Underutilization of bariatric surgery, even for persons who initiate interest in these operations, is well accepted, but poorly understood. Current estimates demonstrate up to 60% of persons who initiate the process leading to bariatric surgery will ultimately not pursue an operation. It is imperative to understand the rationale behind why individuals discontinue their pursuit of weight-loss surgery (WLS) in order to design effective intervention strategies aimed at obesity treatment. While the reasons for the elevated dropout rate are multifactorial, we hypothesized that self-efficacy, one’s belief in the one’s ability to succeed in specific situations or accomplish a task, would impact pursuit of surgery.

Methods:
To determine the self-efficacy of potential WLS patients, a validated 8-question self-efficacy questionnaire that utilized a five-point Likert scoring scale was administered to 276 participants who participated in bariatric surgery information sessions held at a single institution from 2017-2018. The information session is standard at most bariatric programs and held prior to scheduling the initial consult that initiates the path towards surgery. Patients were then longitudinally followed to determine how far along the process they progressed. Initial consultations were used as the primary outcome metric. Data relating to the patient’s demographics, insurance, medical history, and bariatric progress records were collected and analyzed using varied analysis to determine the significance and independence of self-efficacy as a preoperative predictor. 

Results:
Of the 276 patients who presented to an initial information session, the survey completion rate was 100%. In total, 50% (n=138) proceeded to initial consultation. Patients who proceeded to consultation were significantly younger as compared to older (43.0 ± 12.6 vs. 47.5± 13.6, p-value=0.007) and commercially insured versus insured by Medicare (44.9% vs. 27.5%, p-value=0.02). No significant difference was demonstrated in perception of self-efficacy between populations that went on to consultations versus those that did not (Table 1). Furthermore, no difference in self-efficacy was demonstrated when comparing older and younger counterparts and Medicare to commercially insured persons. 

Conclusion:
Older adults and those with Medicare insurance are less likely to proceed with initial consultation. Self-efficacy, conversely, was not influential in patient decision to proceed with initial consultation. We will continue to explore whether self-efficacy impacts actual completion of operation or weight loss outcomes in this patient population.
 

61.01 Short- and Long-term Respiratory Functions After Esophagectomy for Esophageal Cancer

Posted on January 31, 2019

H. Ichikawa1, T. Otani1, T. Hanyu1, T. Ishikawa1, K. Usui1, M. Nemoto1, T. Sakai1, Y. Kano1, Y. Muneoka1, 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

Introduction: The impact of surgical procedures on respiratory functions after esophagectomy for esophageal cancer is not fully investigated. The aim of this study is to clarify the difference in short- and long-term respiratory functions after esophagectomy between the surgical procedures.

Methods: A total of 48 patients who underwent curative esophagectomy for thoracic esophageal cancer from 2003 to 2012 were enrolled in this single-institutional prospective study. We evaluated volume capacity (VC) and forced expiratory volume 1.0 (FEV1.0) at six points as follows: before esophagectomy (baseline), 3, 6, 12, 24 and 60 months after esophagectomy. We compared the change ratio to baseline values between the three surgical procedures: open esophagectomy (OE, N = 19), minimally invasive esophagectomy (MIE, N = 16), and transhiatal esophagectomy (THE, N = 13). The baseline respiratory functions before esophagectomy were not significantly different between the three groups.

Results: The decline of VC in THE group (median change ratio: 0.91) were significantly less than that in OE (0.75) and MIE group (0.80) 3 months after esophagectomy (P < 0.01). VC in MIE and THE group recovered at 0.94 and 0.98 of the median change ratios; however, VC in OE group remained at 0.85 and lower than that in MIE and THE group 12 months after esophagectomy (P = 0.016). The median change ratios of VC in OE (0.83), MIE (0.84) and THE groups (0.88) were not significantly different 60 months after esophagectomy (P = 0.176). FEV1.0 in OE (0.78) and MIE (0.81) group significantly more declined than that of THE group (0.97) after 3 months (P < 0.01). FEV1.0 in OE and MIE group recovered at 0.89 and 0.89; however, they were significantly lower than that in THE group (0.99) 12 months after esophagectomy (P = 0.015). Although FEV1.0 in THE group kept the baseline value after esophagectomy, the median change ratios of FEV1.0 in OE (0.84), MIE (0.86) and THE groups (0.94) were not significantly different 60 months after esophagectomy (P = 0.46).

Conclusion: THE contributes to maintaining short-term respiratory function after esophagectomy for esophageal cancer. MIE is advantageous in the early recovery of VC as compared with TTE. The differences in respiratory functions after esophagectomy between the surgical procedures are not observed after a long-term follow-up.
 

60.20 Injury Severy and Alcohol Intoxication in the "Found Down" Trauma Patient

Posted on January 31, 2019

L. T. Knowlin1, S. Siram1, E. E. Cornwell1, M. Williams1  1Howard University College Of Medicine,General Surgery,Washington, DC, USA

Introduction: The “Found Down” descriptor for trauma patients in our urban setting is common.  It often is unclear whether these patients have experienced significant traumatic injury necessitating an extensive trauma workup versus medical conditions that require acute management. Furthermore, many “Found Down” patients are not severely injured, but rather are suffering from acute substance abuse. We evaluated the association between overall blood alcohol levels (BAL) and injury severity.

Methods: A retrospective cohort study using trauma registry data for non-motorized patients presenting to a Level I Trauma Center between 2015-2018.  Patients who had elevated BAL measurements were included.  Patients were divided in 4 distinct subgroups based on BAL: 1. < 200 mg/dl  2. 200-300 mg/dl  3. 300-400 mg/dl  4. > 400 mg/dl.  Descriptive analysis of the cohort was performed.  Bivariate analysis was conducted comparing injuring level of patients in the 4 groups.

Results:The “Found Down” descriptor was utilized in 554 trauma patients in the study time frame.  There were a total of 325 patients were included in this study with 312 (96%) having a BAL > 50 mg/dl.  Concomitant substance abuse with an additional drug was seen in 39 patients (12%).  Of the 325 patients labelled “Found Down” 314 (97%) had injuries on evaluation and 6 (2%) required surgical intervention. Of the 2% with surgical intervention, 3 (50%) had an Injury Severity Score (ISS) greater than 16. Moderate to severe injuries (ISS ≥ 8) was seen highest in patients with BAL < 200mg/dL. Found down patients with a BAL > 400 mg/dl were more likely to present with minor injuries (extremity and trunk contusions and lacerations) and have a lower Injury Severity Score.

Conclusion:The “Found Down” descriptor for urban trauma patients is associated with alcohol intoxication.  Most of the cohort of “Found Down” trauma patients in this study were mildly injured.  Alcohol intoxication of > 400 mg/dl (Group 4) was not associated with increased injury severity when compared to similar patients with BAL of < 200 mg/dl.  Most “Found Down” trauma patients who were moderately to severely injured were found in Group 1 (BAL < 200 mg/dl).  “Found Down” patients are likely to have a low injury severity and there is no association with injury severity and increasing BAL.

 

60.19 Predictors of Mortality Following Hemorrhagic Shock from Blunt Thoracic Trauma

Posted on January 31, 2019

J. O. Hwabejire1,2, B. A. Adesibikan2, T. A. Oyetunji3, M. Williams2, S. M. Siram2, E. Cornwell III2, W. R. Greene4  1Massachusetts General Hospital,Division Of Trauma, Emergency Surgery, And Surgical Critical Care/Department Of Surgery,Boston, MA, USA 2Howard University College Of Medicine,Surgery,Washington, DC, USA 3Children’s Mercy Hospital- University Of Missouri Kansas City,Surgery,Kansas City, MO, USA 4Emory University School Of Medicine,Surgery,Atlanta, GA, USA

Introduction:  Major thoracic injury is one of the causes of hemorrhagic shock in patients who suffer severe blunt trauma. The goal of this study is to determine the factors that contribute to increased mortality in blunt traumatic hemorrhagic shock necessitating a thoracic surgical procedure.

Methods:  The Glue Grant database was retrospectively examined. Patients aged ≥ 16 years and had either a thoracotomy, sternotomy or video-assisted thoracoscopic surgery (VATS) were included in the analysis. Univariate analysis was used to compare survivors and non-survivors, while multivariable analysis was used to ascertain predictors of mortality.

Results: A total of 205 patients were included in the analysis. Their average age was 43 years (SD=18), 72% were males, and 87% were White.  This subset had an in-hospital mortality of 37 %.  When compared to non-survivors, survivors had a higher BMI (28.0 ±6.7 vs. 22.3 ±12.4 kg/m2, p<0.001), higher emergency room (ER) systolic BP (104±36 mmHg vs. 90 ±36 p=0.010), lower ER lactate (5.1 ±3.0 vs. 8.0 ±3.8 mg/dL, p<0.001), were less coagulopathic (ER INR: 1.4 ±0.5 vs. 2.0±1.9, p=0.002 ), and received a lower volume of blood products within 12 hours of presentation (3599±3249 vs. 8470±6978 mL, p<0.001). There were no differences in age, gender, race, Injury Severity Score (ISS), multiple organ dysfunction score, volume of crystalloids received within 12 hours of presentation, and pre-injury comorbidities between the two groups. About half of survivors (53.4%) underwent a laparotomy compared to 73.7% of non-survivors (p=0.004). In the multivariable analysis, ER lactate (OR: 1.21, CI 1.07-1.37, p=0.002) was the only independent predictor of mortality. Higher BMI appeared to be protective against mortality (OR: 0.951, CI 0.905-0.998, p=0.043).

Conclusion: In blunt traumatic hemorrhagic shock requiring a thoracic surgical procedure, the degree of tissue hypoperfusion as represented by the serum lactate on presentation in the ER is an independent predictor of mortality.  

 

60.18 Validating the ATLS Shock Classification for Predicting Death, Transfusion, or Urgent Intervention

Posted on January 31, 2019

J. Parks1, G. Vasileiou1, J. Parreco1, R. Rattan1, T. Zakrison1, D. G. Pust1, N. Namias1, D. D. Yeh1  1University Of Miami,Department Of Surgery,Miami, FL, USA

Introduction:
The Advanced Trauma Life Support (ATLS) Program of the American College of Surgeons shock classification has been accepted as the de facto conceptual framework for most clinicians caring for trauma patients.  We sought to validate its usefulness and ability to predict mortality, blood transfusion, and urgent intervention.

Methods:
We performed a retrospective review of trauma patients using the 2014 National Trauma Data Bank. Adults (age ≥18) were included in the analysis if they were not missing data for vital signs, GCS, sex, or disposition. Using emergency department vital signs data, patients were categorized into shock class based on the 10th edition of ATLS, rates for blood product transfusion within 24 h, urgent operative intervention (laparotomy, thoracotomy, or IR embolization within 24 h), and in-hospital mortality were calculated.

Results:
After exclusions, 630,635 subjects were included for analysis. Classes 1, 2, 3, and 4 included 312,404, 17,133, 31, and 43 patients, respectively. 300,754 (48%) patients did not meet the criteria for any ATLS shock class and were not categorized. Clinical outcomes are presented in the Table. Uncategorized patients had a higher mortality (7.1%) than the patients in shock classes 1 and 2 combined. Additionally, Shock Classes 3 and 4 each only accounted for 0.009% and 0.013%, respectively, of the categorizable patients.

Conclusion:
Almost half of all trauma patients do not meet the criteria for any category of shock according to the ATLS classification definitions and Class 3 and 4 Shock accounted for <0.1% of all injured patients. The current classification system requires better calibration in order to include more patients and to be clinically useful in predicting meaningful outcomes.
 

60.17 Management of Isolated Blunt Splenic Injuries: OIS Grade III versus Grade IV

Posted on January 31, 2019

J. Wycech1,2, J. Owens2,3, M. Gomez1, A. Tymchak1,2,3, M. Crawford2, A. A. Fokin2, I. Puente1,2,3,4  1Broward Health Medical Center,Trauma Services,Fort Lauderdale, FL, USA 2Delray Medical Center,Trauma Services,Delray Beach, FL, USA 3Florida Atlantic University,College Of Medicine,Boca Raton, FL, USA 4Florida International University,College Of Medicine,Miami, FL, USA

Introduction:
Non-operative management (NOM) is the standard of care for blunt splenic injuries (BSI) in hemodynamically stable patients. Traditionally, use of NOM is debatable when solid organ injury scale (OIS) Grade is III or higher with a tendency to expand the use of NOM to Grade IV injuries of liver, pancreas and kidneys. The goal of this study was to investigate whether NOM should be extended to higher grade spleen injuries, and to examine failure of NOM in isolated blunt splenic injuries (IBSI) in relation to the severity of spleen injury.

Methods:
This IRB approved retrospective cohort study included 133 adult patients with IBSI who were delivered to a level I trauma center between 2012 and 2017 and had attempted NOM of abdominal trauma. Patients were grouped by their OIS Grades and their management approach and outcomes, such as failure of NOM (FNOM), were compared. Furthermore, age, Injury Severity Score (ISS), comorbidities, packed red blood cells transfused within 24 hours (PRBC24), rate of hemoperitoneum, angiography, embolization, repeat abdominal computed tomography (CT), hospital length of stay (HLOS) and mortality were compared in OIS Grade III and IV groups. FNOM was defined as laparotomy after initially attempting NOM.

Results:

The average Spleen OIS was 2.4 (range I-V) with overall FNOM of 11.5% (n=12) and 1.9% (n=2) mortality. There were 33 patients with OIS I, 24 with OIS II, 32 with OIS III, 35 with OIS IV, 7 with OIS V. 2 patients did not have an assigned OIS Grade, because of the lack of precise radiological description of their spleen injury. Rate of attempted NOM in each OIS Grade group was as follows: OIS I 100.0%, OIS II 95.8%, OIS III 71.9%, OIS IV 65.7%, OIS V 28.6%. FNOM was 0% for OIS Grades I and II with no mortalities. In OIS Grades III and IV, FNOM rates were the same (21.7% vs 21.7%; p=1.0) with 1 mortality in patients with OIS Grade III. All patients with OIS Grade V, who had attempted NOM (n=2) failed NOM and underwent laparotomy.

Between OIS Grade III and IV, mean ISS (13.6 vs 19.4; p=0.001) and hemoperitoneum rate (69.6% vs 95.7%; p=0.02) were significantly higher in OIS Grade IV patients. Age (40.2 vs 41.1), comorbidities (65.2% vs 65.2%), PRBC24 (34.8% vs 34.8%), rates of angiography (52.2% vs 65.2%), embolization (30.4% vs 26.1%), repeat CT (30.4% vs 39.1%), HLOS (6.8 vs 9.4 days) and mortality (4.3% vs 0.0%) were not statistically different between patients with OIS Grades III and IV (all p>0.1).

Conclusion:
The rate of FNOM in patients with OIS Grade III and IV was the same, despite a significantly higher ISS and hemoperitoneum rate in Grade IV patients. Expansion of NOM to higher grade splenic injuries is cautiously recommended.

60.16 Non-operative Management vs. Laparotomy for Abdominal Gunshot Wounds: A Matched Analysis

Posted on January 31, 2019

S. W. De Geus1, C. D. Barrett2, M. Neufeld1, C. D. Graham1, S. E. Byerly3, S. Ng1, M. B. Yaffe2, J. F. Tseng1, S. E. Sanchez1  1Boston Medical Center,General Surgery,Boston, MA, USA 2Beth Israel Deaconess Medical Center,General Surgery,Boston, MA, USA 3Ryder Trauma Center,Miami, FL, USA

Introduction: Non-operative management of penetrating trauma has been increasing in the last decade. The purpose of this study was to compare the outcomes of selective non-operative management (NOM) versus laparotomy (LAP) in patients with gunshot wounds to the abdomen.

Methods: Patients with gunshot wounds to the abdomen were extracted from the Healthcare Cost and Utilization Project Florida State Inpatient Database. Patients with brain and/or spinal cord injuries, or who were hemodynamically unstable were excluded. Propensity-score models were created predicting the odds of undergoing NOM. Patients were matched based on propensity-score. Inhospital mortality, complicationd, and length of stay were compared.

Results: In total, 743 patients were identified. 74% (n=548) of patients underwent LAP. Unadjusted, NOM was associated with age  ≤28 year (59% vs. 51%; p=0.035), black/Hispanic race (73% vs. 63%; p=0.011), absence of insurance (51% vs. 39%; p=0.004), low-volume (< 10 abdominal gunshot wounds/year) treatment center (69% vs. 58%; p=0.005), a lower complication rate (14% vs. 27%; p<0.001), and shorter length of stay (median length of stay: 4 vs. 9 days; p<0.001). Unadjusted, in-hospital mortality (6% after NOM vs. 5% after LAP; p=0.853) was similar for both groups. After matching, baseline characteristics were equally distributed, with 170 patients in each group.  Adjusted, NOM remained associated with shorter length of stay (median length of stay: 4 vs. 8 days; p<0.001). However, the prevalence of complications (14% after NOM vs. 19% after LAP: 25% vs. 22%; p=0.191) were comparable.

Conclusions: The results of this study suggest that NOM may be safe in well selected patients with abdominal gunshot wounds. NOM was associated with shorter length of stay, possibly reducing overall cost.
 

60.15 A Statewide Assessment of Rib Fixation Patterns Reveals Missed Opportunities

Posted on January 31, 2019

C. L. Mullens1,2, M. J. Seamon1, A. Shiroff1, J. Cannon1, L. Kaplan1, J. Pascual1, D. Holena1, N. D. Martin1  1Hospital Of The University Of Pennsylvania,Department Of Surgery; Division Of Traumatology, Surgical Critical Care, And Emergency Surgery,Philadelphia, PA, USA 2West Virginia University School of Medicine,Morgantown, WV, USA

Introduction:

Rib fractures are a common consequence of traumatic injury and can result in significant debilitation.  Rib fixation offers fracture stabilization, resulting in improved outcomes and decreased pulmonary complications, especially in high-risk groups such as those with flail segments.  However, commercial rib fixation has only recently become clinically prevalent and we hypothesize that significant opportunity exists in the broader population to offer this clinical advantage.

Methods:
The Pennsylvania Trauma System Foundation database was queried for all rib fracture patients occurring statewide during calendar years 2016 & 2017.  Demographics including Abbreviated Injury Scores (AIS) for all body areas, the presence of flail, and the occurrence of rib fixation was abstracted.  Outcomes were compared between the fixation group and all rib fracture patients using t-test and chi-square where appropriate.  Each repaired patient was used to identify matched peers in the unrepaired, multiply-fractured cohort using age, sex, ISS, and AIS.  De-identified treating trauma center was used to elicit center-level disparities. 

Results:
During the study period, there were 16,302 patients with rib fractures of which 12,910 had multiple rib fractures and 135 had flail segments.  57 patients underwent rib fixation, 10 of which had a flail.  As compared to the non-operative, multi-rib fractured cohort, those who underwent rib fixation were younger (52.5 vs 61.5, p=0.0009) but similar in gender (68% vs 62% male, p=0.373) and race (80% vs 86% white, p=0.239).  The rib fixation group had higher Injury Severity Scores (19.4 vs 15.4 p=0.0011).  Cumulative non-thorax AIS score means were similar between groups as well (0.58 vs 0.64, p=0.76).  4,430 matched peers were identified in the multiply-fractured, unrepaired group as compared to the rib fixation group.  18 of 42 accredited trauma centers performed rib fixation during the study period.  4,796 (37.1%) of multiple rib fracture patients were cared for at centers not performing rib fixation. 

Conclusion:
Rib fixation is underutilized as compared to the contemporary population of those who underwent repair.  Center-level disparities exist as well, suggesting that further penetrance of this treatment into clinical practice is warranted. Additionally, patient-level disparities suggest further research is needed to illicit better defined indications for operative fixation.

60.14 The Challenge of Enteroatmospheric Fistulas

Posted on January 31, 2019

D. J. Gross1, B. Zangbar1, K. Chang1, E. H. Chang1, P. Rosen1, L. Boudourakis2, M. Muthusamy2, V. Roudnitsky2, T. Schwartz2  2Kings County Hospital Center,Department Of Surgery,Brooklyn, NY, USA 1SUNY Downstate Medical Center,Department Of Surgery,Brooklyn, NEW YORK, USA

Introduction:
With the popularization of damage control surgery and the use of the open abdomen, a new permuation of fistula arose, the entero-atmospheric fistula(EAF); an opening of exposed intestine splling ucontrollably into the peritoneal cavity.  EAF is the most devastating complication of  the open abdomen.  We describe and analyze a single institution's experience in controlling high-output deep exposed (entero-atmospheric) fistulas (DEFs) in patients with peritonitis in an open abdomen.

Methods:
We analyzed 189 consecutive procedures to achieve and maintain definitive control of 24 DEFs in 13 patients between 2006 – 2017. DEFs followed surgery for either trauma (7 patients, 53%) or non-traumatic abdominal conditions (6 patients, 46%). All procedures were mapped onto an operative timeline and analyzed for: success in achieving definitive control, number of reoperations, and feasibility of bedside procedures in the SICU. The end point was controlled enteric drainage through a healed abdominal wound  (superficial exposed fistula) that was no longer life threatening.

Results:

There was a mean delay of 8.5 days (range 2 – 46 days) from the index operation until the DEF was identified. Most DEFs required several attempts (mean: 2.7 per patient, range 1 – 7) until definitive control was achieved. Reoperations were then required to maintain control (Table). While the most effective techniques were endoscopic (clipping and stenting) and proximal diversion, these were applicable only in select circumstances. A "floating stoma" where the fistula edges are sutured to an opening in a temporary closure device, while technically effective, required multiple reoperations in the OR. Tube drainage through a negative pressure dressing (Tube Vac) required the most maintenance usually through bedside procedures. Primary closure almost always failed [18/20]. Twelve of the 13 patients survived

Conclusion:
A DEF is a unique and highly complex surgical challenge. Successful source control of the potentially lethal ongoing peritonitis requires tenacity and tactical flexibility.  The appropriate control technique is often found by trial and error, and must be creatively tailored to the individual circumstances of the patient.

60.13 Relationship Between Sleep-Disordered Breathing And Outcomes After Trauma: A Nationwide Analysis

Posted on January 31, 2019

F. S. Jehan1, J. Con1, M. Khan1, A. Azim1, R. Latifi1  1Westchester Medical Center,Surgery,Valhalla, NEW YORK, USA

Introduction: Sleep-disordered breathing (SDA) also known as obstructive sleep apnea is feared to be associated with respiratory complications especially in surgical patients. Trauma patients with SDA may have increased risk of these complications usually due to complex nature of injuries, increase use of opioids/ sedative medications and decreased consciousness levels. However, the association between SDA and outcomes in trauma patients has not been evaluated.

Methods: We performed a 2-year (2011-2012) analysis of the Nationwide Inpatient Sample (NIS) and included all adult (>18 year) trauma patients. Patients were stratified into those with history of SDA and those without history of SDA. Primary outcomes were complications; respiratory and cardiac; the need for non-invasive ventilation and tracheostomy. Secondary outcomes were hospital length of stay, and mortality. Multivariate regression analysis was performed.

Results: A total of 63,284 trauma patients were included in the study. Mean age was 43±17 years and 60% were males. 7.5%(4746) of patients had a SDB. Overall 16.7% patients developed a complication and overall mortality rate was 5.1%.The unadjusted rate of complications between SDA and non-SDA group was (26% vs. 16%, p=0.01) while the unadjusted mortality was (7.6% vs. 4.9%, p=0.02). After performing regression analysis and controlling for all the possible confounders, trauma patients with SDA had higher adjusted rates of developing any complication (OR: 1.5[1.2-2.5], p=0.03), cardiac complications (OR: 1.7[1.3-2.4], p=0.02), respiratory complication [OR: 3.1[2.1-3.9], p<0.01], the need for non-invasive ventilation (OR: 2.5[1.9-.3.2], p<0.01) and tracheostomy (OR: 1.8[1.3-.2.2], p=0.02). The adjusted hospital length of stay was higher (3 days vs. 2 days, p=0.02) in the SDA group compared to the non-SDA group. However, there was no difference in the adjusted mortality between the two groups.

Conclusion: Trauma patients with sleep-disordered breathing are associated with higher risk of cardiac and respiratory complications, the need for non-invasive ventilation, and tracheostomy rates. Patients with SDA spend longer time in the hospital; however, there was no difference between the mortality compared to patients without SDA. These effects of SDA might be attributed to Use of screening criteria including the STOP BANG, will lead to early identification of these patients, and allocation of resources to prevent these complications.

 

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