55.14 Risk Factors Associated with Nationwide Readmission After Parathyroidectomy

Posted on January 26, 2017

J. L. Buicko1, J. P. Parreco1, M. A. Lopez1, R. A. Kozol1  1University Of Miami,Palm Beach General Surgery Residency,Atlantis, FL, USA

Introduction:

Readmission rates after surgery receive significant attention as a measurement of quality of patient care.  According to a recent study in the New England Journal of Medicine, almost one in seven patients hospitalized for a major surgical procedure were readmitted within 30 days of discharge.  The morbidity and mortality of parathyroidectomy is low and readmission data is poorly characterized in the literature.  Our objective is to identify national readmission rates after parathyroidectomy and to characterize reasons and risk factors for readmission after parathyroidectomy.

Methods:

The Nationwide Readmission Database (NRD) was queried for all patients undergoing parathyroidectomy in 2013 who survived the initial admission. Multivariate logistic regression was then implemented using patient comorbidities and demographics as well as hospital characteristics to determine the odds ratios (OR) for nonelective readmission within 30 days.

Results:
During the study period, 4,082 patients underwent parathyroidectomy and 357 (8.7%) had nonelective readmissions within 30 days. The most common primary diagnoses on initial admission were benign neoplasm of parathyroid gland (1,232, 30.2%) and primary hyperparathyroidism (899, 22.0%). There were 772 patients (18.9%) with a diagnosis of secondary hyperparathyroidism and these patients had an OR for readmission of 2.38 (p<0.01, 95% CI 1.77 to 3.22).  The most common primary diagnoses on readmission were hypocalcemia (57, 8.0%) and hungry bone syndrome (31, 4.3%). The comorbidities associated with the highest ORs for readmission were weight loss (OR 3.08, p<0.01, 95% CI 1.88 to 5.03), renal failure (OR 2.37, p<0.01, 95% CI 1.79 to 3.13), and congestive heart failure (OR 2.13, p<0.01, 95% CI 1.47 to 3.08).

Conclusion:
Overall, 8.9% of patients who underwent parathyroidectomy had a nonelective readmission.  Hypocalcemia and hungry bone syndrome were the most common reasons for readmission. As thirty-day readmission rates are frequently used as a quality metric for patient care, identifying risk factors for readmission is of paramount importance, and efforts should be made to reduce readmission rates for these patient groups at higher risk.
 

55.13 Predictors of Recurrent Emergency Department Visits in Patients with Benign Biliary Disease

Posted on January 26, 2017

B. F. Goldberg1, K. M. Mueck1, H. M. Starkey-Smith1, C. C. Wan1, J. P. Hasapes1, T. C. Ko1, L. S. Kao1  1University Of Texas Health Science Center At Houston,General Surgery,Houston, TX, USA

Introduction: Benign biliary disease accounts for a disproportionate amount of recurrent emergency department (ED) visits and readmissions. It is unknown what factors present at ED consultation predict subsequent readmission with more severe disease such as acute cholecystitis, choledocholithiasis, gallstone pancreatitis, or ascending cholangitis. The aim of this study was to determine if there are patient or radiologic factors which predict recurrent ED visits, readmission with complicated biliary disease, and worse outcomes.

Methods: This was a retrospective cohort study of all patients presenting to a single safety-net hospital ED June 2014-2016 who received an abdominal ultrasound (US) for benign biliary disease. Demographic, admission, and outcome data were recorded. Univariate and logistic regression analyses were performed to identify factors associated with readmission with complicated biliary disease.

Results: Of 288 patients, 189 (66%) were admitted for surgery, and 99 (34%) were discharged. Of those discharged, 71 (72%) were not evaluated by a surgeon at index ED visit. There was no difference in age, gender, race/ethnicity, language, or ASA score between the groups. Discharged patients were more likely to have diabetes (10% vs 19%, p=0.03), heart disease (3% vs 10%, p=0.01), cancer (1% vs 6%, p=0.02), or chronic liver disease (3% vs 9%, p=0.02). 15 (15%) patients underwent elective outpatient cholecystectomy, and 15 (15%) were readmitted with complicated biliary disease. There was no difference in age, gender, race/ethnicity, language preference, ASA score, or comorbidities between the readmitted and non-readmitted groups. Readmitted patients had more prior ED visits (p=0.02) and hospitalizations (p<0.01). They were more likely to have an impacted stone (40% vs 0%, p=0.02), or a stone in the gallbladder neck (p<0.01). Rates of postoperative complications, reoperation, and conversion to open were similar between patients undergoing elective versus urgent surgery, while postoperative readmission rate was higher in the latter group (31% vs 7%, p=0.02).

Conclusion: Patients with comorbidities, with sonographic findings of complicated biliary disease, and without surgical consultation were more likely to be readmitted after discharge from the emergency department. Further study is necessary to determine what factors contributed to discharge and to assess whether admission on index presentation would have resulted in improved outcomes.

55.12 The Effects of Promotion and Tenure on Surgeon Productivity

Posted on January 26, 2017

A. Lam1, M. Heslin1, C. D. Tzeng2, H. Chen1  1University Of Alabama At Birmingham,Surgery,Birmingham, ALABAMA, USA 2University Of Kentucky,Surgery,Lexington, KENTUCKY, USA

Introduction:
In the dynamic environment of academia, tenure has recently come under investigation.  Nationally, more academic faculty members are now appointed to non-tenure track positions than tenure-track positions. However, studies investigating the impact of promotion and tenure on surgeon productivity are lacking. The aim of this study is to understand the relationship of promotion and tenure to surgeon productivity.

Methods:
We reviewed data for the 114 faculty members in the Department of Surgery at our institution. Two metrics were used to assess surgeon productivity: relative value units (RVUs) billed per year and publications per year from the period 2010-2016. Publication number was measured by Pubmed search, and affiliations were used to verify authorship. We analyzed two groups: tenure track (TT) surgeons and non-tenure (NT) track surgeons and compared productivity within these groups by faculty rank: Assistant (ASST), Associate (ASSOC), and Full (FULL) Professor. Kruskal-Wallis test was used to assess significance, and Mann-Whitney U tests were used to ascertain relationships between groups.   

Results:
As TT faculty were promoted, they had more research production, with publication rates highest among TT FULL.  TT faculty publishing rates increased from ASST to ASSOC (1 vs 2, p=0.006) and from ASSOC to FULL (2 vs 4, p<0.001). There were no differences in the low publication rates between NT ranks.  Clinical production (RVUs) was highest among TT ASSOC and NT FULL. TT faculty increased productivity between ASST and ASSOC (7,023 vs 8,384, p=0.001) and decreased between ASSOC and FULL (8,384 vs 6,877, p<0.001). Among NT faculty, RVUs were stagnant between ASST and ASSOC levels (4877 vs 6313, p=0.3121) and increased between ASSOC and FULL levels (6,313 vs 8,975, p<0.001). Comparing TT to NT, TT faculty published more than their NT counterparts (p<0.001 for all groups). TT ASST and TT ASSOC produced more RVU than NT counterparts (p=0.006 and p<0.001 respectively), while NT FULL outproduced TT FULL (p=0.003).

Conclusion:

Tenure and non-tenure pathways appear to appropriately incentivize surgical faculty over the course of their advancement. TT FULL have the highest research production and NT FULL have the highest clinical production. Interestingly, TT faculty paradoxically has more clinical production at the ASST and ASSOC levels than their NT counterparts, and only NT FULL had greater clinical production than their TT parallels.

 

55.03 The Infundibular Approach is Often Mistaken as the Critical View of Safety during Cholecystectomy.

Posted on January 26, 2017

L. Traub1, C. Chen1, F. Palazzo1, E. Rosato1, H. Lavu1, J. Winter1, C. J. Yeo1, M. J. Pucci1  1Thomas Jefferson University,Surgery,Philadelphia, PA, USA

Introduction: Over 700,000 laparoscopic cholecystectomies (LC) are performed annually in the United States; and, while widely considered a safe operation, over 2000 bile duct injuries (BDI) occur.  The critical view of safety (CVS) is a method of secure ductal identification to prevent BDI.  Although, widely publicized, it remains unclear if surgeons understand its criteria, or may instead mistake the CVS for the “infundibular” approach, where BDI is possible.

Methods: Fifty-one LC were recorded via video and scored on a 6-point scale consisting of scores from 0 to 2 for each of the three criteria of the CVS.  The operative notes were reviewed. A survey was sent to surgical faculty who routinely performed LC during the study period, asking them to label various commonly performed maneuvers as: potentially harmful, not necessary, preferred but not necessary, or safe and mandatory.

Results: Thirty-seven (73%) of the 51 operative notes reviewed documented CVS achievement. Only 8 (16%) cases scored > 4 (considered adequate) when reviewed on CVS assessment. Of the three criteria, “exposure of the cystic plate” scored lowest, with a mean of only 0.3.  Twelve surgeons responded to the survey with 83% indicating visualization of only 2 structures entering the gallbladder is mandatory, 42% indicating that clearance of the hepatocystic triangle is mandatory, and only 25% responding exposure of the cystic plate was mandatory. However, 92% of respondents believe the “infundibular” approach is safe.

Conclusion: While experienced surgeons routinely mention the CVS in operative notes, these data suggest a misunderstanding of the three criteria, with a tendency towards the infundibular approach. Greater education is necessary, as the infundibular approach may result in BDI.

 

55.01 Does the Stapler Size Matter?

Posted on January 26, 2017

C. Shwaartz1, B. Cohen1, J. Leanza1, C. M. Divino1  1Icahn School Of Medicine At Mount Sinai,General Surgery,New York, NY, USA

Introduction:
A stapled anastomosis is commonly used during colorectal surgery for different indications. Stapled anastomoses have many advantages such as ease and speed of performance, potentially less manipulations of the anal canal, and more uniformity. The purpose of this study was to determine whether stapler size used at colorectal anastomosis affects outcomes.

Methods: This is a retrospective review of 230 patients that underwent colorectal anastomosis with the use of circular stapler between October 2013 and April 2016 at The Mount Sinai Hospital. Patients were divided into two groups based on size of the circular stapler (stapler size 25-29 mm vs 31-33 mm). Preoperative and postoperative factors including outcomes such as stricture, anastomotic leak, and functional outcomes such as the number of bowel movements per day, and incontinence were recorded and compared between the two groups.  A multivariate statistical analysis was carried out to assess the associations between the stapler size and the outcomes. Patients were then called for follow up in order to assess for functional outcome using the Wexner score along with other measures.

Results:

 230 patients who underwent rectal surgery were identified. 72.2% had an anastomosis performed using a 25 – 29mm circular stapler while 27.8% used a 31 – 33mm stapler. Both groups were comparable in regard to age, sex, comorbidities, smoking history, recent use of immune modulating medications or chemoradiation, procedure, indication, and the presence of bowel diversion. Those in the large stapler group were more likely to have an ASA of 3-5 vs 1-2 (P=0.05), they had a longer mean hospital stay (P=0.04) and those in the small stapler group were more likely to have a lower preoperative albumin (P=0.02). Multivariate analysis revealed that the stapler size did not predict the rate of anastomotic leak or stricture. Patients undergoing a low anterior resection with a colorectal anastomosis, compared to an anterior resection/sigmoidectomy, was significantly associated with anastomotic leaks. Additionally, the presence of bowel diversion significantly predicted stricture formation.
Regarding functional outcomes and quality of life, there was no difference found between the small and large stapler groups concerning number of bowel movements per day, presence of urgency, incontinence, pad use, clustering, need for constipating agents, any change in lifestyle reported, and mean Wexner score. Additionally, functional outcomes did not significantly differ between those asked within 1 year of bowel continuity and those who were asked after 1 year. 

Conclusion:
Different stapler sizes used in rectal surgery are not associated with long term outcomes.

 

55.02 A Cost Effective Approach to Surgical Simulation: Use of Inanimate Surgical Simulation Models

Posted on January 26, 2017

B. R. Veenstra2, A. Wojtowicz1, N. Walsh1, J. Velasco1,2  1Rush University Medical Center,Center For Clinical Skills And Simulation,Chicago, IL, USA 2Rush University Medical Center,Department Of General Surgery,Chicago, IL, USA

Introduction:  With the current duty hour restrictions in effect for 10 plus years, the consequences in terms of resident training and skill acquisition, specifically those in the surgical disciplines, are just coming to light.  In recent years, studies have suggested that some general surgery chiefs are graduating without the ability to independently complete routine general surgery cases (ie laparoscopic cholecystectomy).  As academic surgeons, this should make us question our current system of training, that which was implemented by Halsted so many years ago.  Gradually, this call is being answered by investing more time, effort, and money into surgical simulation.  Various modalities are available, from trainer boxes to virtual reality simulators to cadaver and animal labs, but no clear consensus exists as to which is most effective.  With healthcare becoming ever more cost conscious, it is important to take note of not only the effectiveness of each of these modalities, but the cost as well.

Methods:  Using both surgical and moulage expertise, we constructed four inanimate models: a carotid endarterectomy, laparoscopic vena cava repair, laparoscopic inguinal hernia repair and laparoscopic para-esophageal diaphragmatic hernia repair.  Our focus was to create a realistic and tactile experience in the lab for residents, while taking cost into consideration.  All models were revised and validated by a core group of attending surgeons.  Seven PGY-5, six PGY-4, and two PGY-3 residents participated in an inaugural inanimate simulation lab and provided feedback through pre and post surveys.

Results:  All participants agreed that the four inanimate models were accurate representations of the anatomy, and were worthwhile in their surgical training.  When looking at the cost of creating and using our inanimate models, we found our cost to be less than both those associated with virtual simulation and animate models (See Table 1).  Compared to animate models (ie cadavers), all four inanimate models are a small fraction of the cost, a mere 8.5-22.5%.  Similarly, our inanimate models are only 0.1-0.5% of the cost of virtual reality simulators, whose costs range from $94,000-$100,000.

Conclusion: As we continue to modify and improve upon the traditional, Halsted method of surgical training, it is clear that simulation will play an increasingly larger role.   We propose that inanimate surgical models provide a cost effective avenue that help bridge the existent gap between cognitive learning and psychomotor skill training, as produced by the duty hour restrictions.

 

54.20 Barriers to Creating a Surgery Clinic-Based Opioid Retrieval Program

Posted on January 26, 2017

E. Blay1, J. Thomas1, J. Stulberg1  1Northwestern University,Surgical Outcomes & Quality Improvement Center,Chicago, IL, USA

Introduction: Opioid analgesic therapy remains a cornerstone of post-operative pain management, yet the majority of pills dispensed at discharge are not consumed by patients.  While there are myriad factors leading to the current opioid epidemic, there is mounting evidence to suggest that surgeons significantly contribute to the problem primarily through unused narcotics leading to diversion. While the Office of National Drug Control Policy’s 2011 Prescription Drug Abuse Prevention Plan has recommended the creation of opioid retrieval or take-back programs to help prevent diversion of opioids to the community, many barriers exist. We describe our experience and review of the legal and medical literature to help identify these barriers and discuss key elements to implementation of an Opioid Retrieval program.

Methods: A comprehensive literature review was performed using MEDLINE, Embase and Google Scholar for studies or articles describing clinic-based opioid retrieval program, and an extensive legal document search was performed with the help of our legal counsel to identify the federal and local legal barriers.
 

Results: In 2014, The Drug Enforcement Agency (DEA) released the “Final Rule” to provide guidance on the implementation of programs geared towards the disposal of controlled substances. The following components are necessary: 1) A hospital/clinic needs to first register through the DEA; 2) There must be an on-site pharmacy or retail pharmacy; 3) There must be a secured one-way collection receptacle, and 4) The rules governing collection are separate from those of destruction.  The destruction of controlled substances must take place in an on-site incinerator or use of a reverse distributor approved by the DEA.  We were unable to find medical articles which described the implementation of such programs into medical or surgical clinics, but did find a handful of studies that evaluated drug disposal programs within pharmacies and community events.  It was found that while the creation of these disposal programs can decrease the risk of diversion in the community, and get more unused drugs out of individual’s homes, it was still necessary that these programs are combined with integrated proper disposal education to further increase knowledge and expand efforts.

Conclusion: Creation of a clinic-based drug take-back program is possible but legal barriers exist. There are federal laws that detail how this can occur but guidance for the medical community is lacking. Take-back programs have been successful public health tools in pharmacies and community-based programs suggesting they could have similar success in clinic-based programs, and offer greater opportunity as a location to provide disposal education. More research is needed to answer questions about the role surgeons’ play in the opioid epidemic and how various reduction efforts can benefit our patients and our communities.

 

54.18 Safety of Bariatric Surgery vs Total Joint Replacement in The Severely Obese patients

Posted on January 26, 2017

K. Spaniolas2, M. Grzybowski1, M. Ball1, Z. Schafer1, W. Pories1  1East Carolina University Brody School Of Medicine,Greenville, NC, USA 2Stony Brook University Medical Center,Stony Brook, NY, USA

Introduction:  With the national increase in obesity, total knee/hip arthroplasty (TKHA) rates in the severely obese are accelerating. Success rates in this patient population are less established. Bariatric surgery, however, leads to sustainable weight loss, decreased symptoms of osteoarthritis, and broader health benefits apart from osteoarthritis. This study investigated 30-day morbidity in severely obese patients undergoing TKHA and elective laparoscopic bariatric (BAR).   

Methods:  Using ACS-NSQUIP 2006-2013 data, a retrospective cohort of 105,108 severely obese patients were eligible following the application of exclusion criteria (TKHA n=31436, BAR n=73672). Propensity matching kept 6,282 in each treatment group (c=.94). Rates and odds ratios (ORs) and 95% confidence intervals (CIs) were computed for the ORs: unadjusted (ORu), age and sex-adjusted (ORa), and propensity-adjusted (ORp) associations for serious morbidity.

Results: Among 12,564 matched patients, the mean age (SD) and BMI (SD) were 56 (8.1) and 43.3 (5.7), respectively, with 70% being female.  For serious morbidity the unadjusted and propensity-adjusted rates for TKHA and BAR, respectively, were 54.7% vs 45.3% and 8.2% vs 2.8%. The ORu=.32 (.30-.33), p<.0001; OR(a)=.44 (.41-.46), p<.0001, and ORp=.25 (.21-.29), p<.0001.

Conclusion: Our findings suggest BAR is associated a 75% less likelihood of developing serious early postoperative morbidity after matching on many confounders than TKHA.  However, more evidence-based longitudinal studies are needed to assess the efficacy of both procedures. 

 

54.16 Improving Coordination of Care in Surgical Patients: A Systematic Review

Posted on January 26, 2017

E. F. Yates1, S. T. Hawley1, A. M. Morris1  1University Of Michigan,Ann Arbor, MI, USA

Introduction: Coordination of care has been identified as a priority by the United States Institute of Medicine and is frequently cited as an area for improvement in surgical care. Despite the wide recognition of this deficiency, little is known about the effectiveness of interventions specifically targeting care coordination in the surgical setting.  

Methods: We performed a systematic review of published literature from 2000-2016 adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines with key words indicating surgical care and [“coordination” OR “continuity” OR “surgical home”], in the Central, CINAHL, EMBASE, Ovid and Scopus online databases. Exclusion criteria were non-English language, non-U.S. health care system, patients <18 years, absence of primary or secondary data, absence of an intervention to improve coordination of care with evaluation of outcomes. Identified papers were screened by abstract for exclusion. Remaining articles were independently reviewed by two investigators using a data abstraction tool to assess eligibility, purpose, design, results, conclusion and study quality. Studies were discussed to consensus.

Results: The initial search identified 1870 potential articles, of which 26 were duplicates. Abstract screening yielded 165 articles for full review. Among these, 24 were appropriate for inclusion in the final evaluation. 

Coordination of care was referred to but never explicitly defined in any article. All interventions were tailored to institution or system specific challenges, and consisted of planning sessions (e.g. value stream mapping), e-tools linked to electronic medical records, interpersonal communication tools, assignation of personal responsibility, and interdisciplinary use of midlevel providers. Interventions were deployed in 5 setting types: outpatient clinics (n=2), operating rooms (n=2), in-hospital patient hand-offs (n=2), in-hospital perioperative care (n=16), and transitions to outpatient management (n=2). Measured outcomes included clinical outcomes (n=17), cost/resource savings and timeliness (n=9), and staff perceptions (n=7). Several studies measured outcomes in multiple categories. Clinical outcomes included symptom resolution, mortality and complication rates, and satisfaction with care. Staff perceptions addressed a wide variety of issues ranging from perceived safety climate to perceived patient education. Overall methodological rigor was low; 25% of quantitative studies failed to use any statistical tests and all mixed or qualitative studies had an absent or insufficient methodology.

Conclusion: In spite of the widely acknowledged critical importance of improving coordination of care in U.S. surgical settings, it remains inconsistently defined and studied. Agreement regarding fundamental concepts and standardization of relevant measures could potentially improve coordination, which is applicable to all facets of quality in surgical care.

54.15 Overlapping or Concurrent Surgery – Resident and Faculty Assessment of the "Critical Portion"

Posted on January 26, 2017

J. A. Marks1, P. M. Batista1, S. M. Devitt1, F. Palazzo1, G. A. Isenberg1, C. J. Yeo1, K. A. Chojnacki1  1Thomas Jefferson University,Surgery,Philadelphia, PA, USA

Introduction:
With recent increased public awareness of concurrent surgery as a putative quality or outcome metric, delineating the critical part(s) of an operation for which a surgeon must be present is essential. We aim to define the critical portions of operations as seen by residents and faculty and hypothesize the two lack concordance.

Methods:
Each of our section chiefs (n=12) was asked to outline the key portion(s) of their most commonly performed operations for which attending surgeon presence is imperative. Our senior surgical residents (PGY≥3; n=24) were asked to submit the steps for a list of operations that required direct attending involvement. Residents did not collaborate across years. We had five lists with outlined critical steps submitted by faculty leadership and each PGY class. Results were tabulated and compared.

Results:
Data were obtained for 35 operations. PGY3s tended to list more critical steps (not all correct and in greater detail) than more senior residents. Attending surgeons were most concise in their descriptions and number of key steps. Residents noted most bedside procedures did not require attending presence. For some complex or emergent procedures, residents indicated the attending should be present for the entirety. Faculty noted the critical portions could differ given the resident’s skill. Residents identified many of the same steps as faculty, yet intermittently left out some or listed all operative steps.

Conclusion:
We demonstrated a greater concordance between residents and faculty in identifying critical portion(s) of operations than expected. There was a clear trend towards fewer critical portion(s) and more agreement with attending perceptions as residents progressed through training. Further evaluation of critical portions for which faculty must be present could have profound impact on resident education, reimbursement practices, and the delivery of surgical care.
 

54.14 An Estimation of Population-Level Obesity Rates Using Electronic Health Record Data

Posted on January 26, 2017

L. M. Funk1,2, Y. Shan1, C. I. Voils3,4, J. Kloke5, L. Hanrahan6  1University Of Wisconsin,Surgery,Madison, WI, USA 2William S. Middleton (Madison) VA,Surgery,Madison, 53792, USA 3Duke University Medical Center,Medicine,Durham, NC, USA 4Durham VA,Medicine,Durham, NC, USA 5University Of Wisconsin,Biostatistics & Medical Informatics,Madison, WI, USA 6University Of Wisconsin,Family Medicine,Madison, WI, USA

Introduction: The measurement of population-level obesity rates is important for informing policy and targeting treatment. The gold standard method of estimating obesity rates in the U.S. is the National Health and Nutrition Examination Survey (NHANES). Given that NHANES requires household visits for height and weight measurement, NHANES samples < 0.1% of the adult population and does not target state- or and health system-level measurement. The objective of this study was to assess the feasibility of using body mass index (BMI) data from the electronic health record (HER) in a large health system to assess rates of overweight and obesity. To explore the possibility of selection bias in EHR data, we also compared overweight and obesity rates in the EHR to national NHANES estimates.

Methods: Using outpatient data from 42 clinics, we studied 388,762 patients who had at least one primary care visit in 2011-2012. We compared crude and adjusted overweight and obesity rates by age category and ethnicity between EHR patients and NHANES participants. Adjusted rates of overweight (BMI>25.0-29.9) and obesity (class I: BMI 30.0-34.4; class II: 35.0-39.9; and class III: >40) were calculated in a two-step process. The first step accounted for missing BMI data using inverse probability weighting via a multivariable logistic regression, while the second included a post-stratification correction to adjust the EHR population to a nationally representative sample.

Results: 59.6% (n=192,039) of patients in the EHR had at least one BMI value in the dataset. 70.0% (95% CI 69.8-70.2) of adults were overweight or obese, while 17.0% (95% CI 16.8.-17.1) had class II or III obesity. Adjusted rates of obesity for EHR patients were 37.3% (95% CI 37.1-37.5) compared to 35.1% (95% CI 32.3-38.1) for NHANES patients. Adjusted class III obesity rates were 7.4% (95% CI 7.3-7.5) and 6.4% (95% CI 5.2-7.7) for EHR and NHANES participants, respectively. Among the 16 obesity class and ethnicity (White, Black, Hispanic, Other) strata that were compared between EHR and NHANES patients, 14 (87.5%) contained similar obesity estimates (i.e. overlapping 95% CIs; Figure).

Conclusions: Obesity estimates from the analysis of electronic health records were largely similar to national estimates generated by NHANES. The electronic health record may be an ideal tool for identifying and targeting patients with obesity for implementation of public health and/or individual level interventions, such as behavioral, medical and/or surgical treatment.

54.04 The Effect of Surgeon “Experience” on Postoperative Mortality following Colorectal Surgery

Posted on January 26, 2017

F. Gani1, M. Cerullo1, J. K. Canner1, A. E. Harzman2, S. G. Husain2, W. C. Cirocco2, M. W. Arnold2, A. Traugott2, T. M. Pawlik1,2  1Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA 2Ohio State University,Department Of Surgery,Columbus, OH, USA

Introduction:  Although the relationship between laparoscopic surgery and improved clinical outcomes has been well established across a variety of procedures, the effect of surgical “experience” with laparoscopic surgery remains less defined. The current study sought to assess the comparative benefit of laparoscopic colorectal surgery relative to surgeon “experience.”

Methods:  Commercially insured patients aged 18-64 years undergoing a colorectal resection were identified using the MarketScan Database from 2010-2014. Individual surgeons were identified using surgeon-specific identifiers. For each surgeon, an annual surgical volume, and the degree of “experience” defined as the annual number of laparoscopic operations was calculated. Surgeons were categorized based on their annual laparoscopic surgical volume (1-4, 5-14, and ≥15 laparoscopic operations / year). Multivariable logistic regression analysis was used to calculate and compare postoperative mortality and morbidity relative to surgeon “experience.” 

Results: A total of 34,066 patients were identified who met inclusion criteria. The median age of all patients was 53 years (IQR: 45-59) and 51.9% (n=17,689) patients were female. The average Charlson comorbidity index (CCI) score was 1.4 (SD=2.0) and 36.4% of patients presented with a CCI score ≥2. Laparoscopic operations were performed in 36.8% (n=12,522) of patients. Postoperative morbidity and mortality were 17.3% (n=5,875) and 0.9% (n=288), respectively. On multivariable analysis, laparoscopic surgery was associated with 70% decreased odds of developing a postoperative complication (OR=0.30, 95%CI: 0.28-0.32, p<0.001) and 84% lower odds of mortality (OR=0.16, 95%CI: 0.10-0.25, p<0.001). The comparative benefit of laparoscopic surgery was, however, greater among surgeons who had a greater experience with laparoscopic surgery. Compared with surgeons with less laparoscopic surgery experience (<5 laparoscopic operations / year), surgeons who had greater experience with laparoscopic surgery (≥15 laparoscopic operations / year) demonstrated a 33% lower odds for postoperative morbidity (OR=0.67, 95%CI: 0.62-0.71) and a 55% lower odds for postoperative mortality (OR=0.45, 95%CI: 0.33-0.62) when a laparoscopic approach was utilized (Figure).

Conclusion: Although laparoscopic surgery was associated with improved postoperative clinical outcomes, the effect of laparoscopic surgery was highly variable relative to surgeon experience with laparoscopic surgery. 

 

53.20 Biliary Duct Injury During Laparoscopic Cholecystectomy: a NSQIP Data Analysis

Posted on January 26, 2017

S. Cassaro1,2, A. Meshesha2, S. Kesavaramanujam2, N. Atherton1,2  1University Of California – Irvine,Surgery,Orange, CA, USA 2Kaweah Delta Health Care District,Acute Care And Trauma Surgery,Visalia, CA, USA

Introduction:

Biliary duct injury (BDI) is a dreaded complication of cholecystectomy. The incidence of BDI during laparoscopic cholecystectomy (LC) is not exactly known. Major BDI is defined as an injury requiring biliary repair or reconstruction and is reported to occur in 0.1 to 0.55% of the cases. Since approximately 750,000 patients undergo LC each year in the US, it can be inferred that at least 750 patients sustain a major BDI every year.

Methods:

We reviewed the most recent five years of NSQIP data to assess the incidence and 30-day outcomes of major BDI after LC. The 2010-2014 NSQIP database of 158,278 cases of LC was searched for diagnostic and procedural codes associated with BDI.

Results:

The query returned a total of 33 cases of LC that listed one of the selected procedural codes either as additional procedure at the time of the initial surgery, or as reoperation.

A BDI was repaired during the initial procedure in 19 cases. An IOC was performed during the LC in ten of the patients.  Six of the patients were men and 13 women. The injury was repaired with a bilio-enteric anastomosis in eleven patients, using a Roux-en-Y loop in nine. The remaining nine injuries were repaired primarily in eight patients and with an end-to-end reconstruction in one. The average postoperative length of stay after repair was 6.5 days (range 1 to 16 days), and there were no readmissions. One of the patients who underwent biliary diversion died within thirty days from the procedure.

Fourteen patients underwent BDI repair within 30 days from the index procedure, which included an only in two cases. Eleven of the patients were women and three were men. Seven of these patients were discharged on the day of the initial procedure, while the other seven remained hospitalized after the index LC for an average of 7 days (range 1 to 16 days). A bilio-enteric diversion was used to repair the injury in six patients, and a Roux-en-Y reconstruction was the technique selected in all but one of the cases. A direct ductal repair was performed in the other eight patients. There were no postoperative deaths in this group.

Conclusion:

There is substantial evidence that the incidence of major BDI after LC is between 0.1 and 0.5%, and the vast majority of those injuries should be identifiable within thirty days of the index procedure.

NSQIP is designed to capture all the significant events occurring in the thirty days following each procedure tracked, but a query of NSQIP data for codes associated with major BDI after LC yields results that are grossly inconsistent with the expected ones and reflect a BDI incidence lower than 0.002%.

In its current format NSQIP data are inadequate to benchmark the risk of major BDI injury after LC, and may grossly underestimate the incidence of such occurrence. The implementation of procedure-specific registries for commonly performed surgical interventions such as LC may provide better data quality.

 

53.19 Wound Dehiscence after Laparotomy: Who Needs Retention Sutures?

Posted on January 26, 2017

A. Pal1, E. Mahmood3, J. Nicastro2, M. Sfakianos2, T. Dinitto1, S. M. Cohn1  2North Shore University And Long Island Jewish Medical Center,Department Of Surgery,Manhasset, NY, USA 3Northwestern University,Feinberg School Of Medicine,Chicago, IL, USA 1Staten Island University Hospital, Northwell Health,Surgery,Staten Island, NY, USA

Introduction: There is a need for predictive models that can help surgeons identify patients at greatest risk for wound dehiscence in order to guide their management to avoid evisceration. We sought to use a large database in order to examine risk factors for developing this complication after midline laparotomy.

Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) is a prospectively collected surgical outcomes database compiled by manual chart abstraction. Exploratory laparotomy cases were queried using the primary CPT code from 2005-2013. The independent factors associated with wound dehiscence were examined by multivariate analysis using SAS JMP Pro 11 (Cary, NC, US). The cohort was split into a training dataset of patients from 2005-2009 and a prospective validation dataset from 2010-2013. A backwards logistic regression analysis was performed to identify predictors of wound dehiscence in the training set. The model was then tested in the validation set to estimate the receiver operating curves (ROC) and goodness of fit.

Results: A total of 16,793 patients were included in our analysis. 248 (1.47%) of these patients had a wound dehiscence. Significant predictors of wound dehiscence: deep wound infection (AOR=5.98, 95% CI 3.06 to 10.9, P<0.0001), postoperative pneumonia (AOR=3.25, 95% CI 1.99 to 5.11, P<0.0001), preoperative weight loss (AOR=3.11, 95% CI 1.29 to 10.2, P<0.0083), preoperative sepsis (AOR=3.03, 95% CI 1.91 to 4.70, P<0.0001), superficial wound infection (AOR=2.97, 95% CI 1.63 to 5.05, P<0.0007), and previous operation in the last 30 days (AOR=1.82, 95% CI 1.19 to 2.73, P<0.0061), smoking (AOR=1.49, 95% CI 1.01 to 2.18, P<0.044). The c-statistic for our model was reasonable: 0.73 in the training set and 0.70 in the validation set. The Hosmer-Lemenshow goodness-of-fit statistic was 0.89.

Conclusion: We identified a number of independent risk factors for the development of wound dehiscence which may inform the clinician and lead to improved selection of patients for measures which could reduce the likelihood of evisceration (retention sutures) after laparotomy.   

53.18 Novel Method For Confirming Appropriate Nerve Integrity Monitor (NIM) Endotracheal Tube Positioning

Posted on January 26, 2017

I. J. Behr1, S. Mansoor1, M. McLeod1  1Michigan State University,Surgery,Lansing, M, USA

Introduction:

Surgical injury to the recurrent laryngeal nerve (RLN) is a feared complication of head and neck surgery due to potential for significant permanent functional disability. Originally recommended by Lahey, intra-operative identification and protection of the nerve, remains the gold standard for minimizing RLN injury. Over time, less invasive monitoring systems and methods to protect the RLN during surgical procedures have developed. One such method is the endotracheal Nerve Integrity Monitoring (NIM) system. This study demonstrates a novel method to more accurately ensure placement of the NIMS device.

Methods:

176 patients were enrolled in this prospective clinical trial. Each patient underwent surgery involving dissection around the recurrent laryngeal nerve thus requiring monitoring. These surgeries included partial thyroidectomy, near total thyroidectomy, and total thyroidectomy. All patients were placed under general anesthesia and intubated with a NIMs endotracheal device. 

All patients had both the tap test and the train of 4 stimulation performed prior to beginning surgery. The results were determined from recordings through the NIMs monitoring system. 

The tap test was performed by percussion to the midline trachea and recording the results through the NIMs device. The train of 4 was performed by the anesthesia team with 2 electrical pads placed over the facial musculature. A train of 4 stimulation was created with a electrical stimulator and the results were recorded through the NIMs device. 

The most accurate method to ensure placement is by direct stimulation/contraction of the vocal cords through stimulation of the vagus nerve. 3 of the 176 patients consented to direct stimulation of the vagus nerve as a control study.  This was done by opening the carotid sheath, freeing a small 1cm section of the nerve from the surrounding tissue and directly stimulating the nerve. The results of this test were also recorded through the NIMs device.  

Results:
Out of 176 patients 131 were found to have adequate positioning using the tap test (74.4%). With a train of 4 stimulation 170/176 (96.6%) were found to have accurate positioning. Using the McNemar test, train of four peripheral nerve stimulation showed significantly more positive findings than the tap test , p < 0.001

Conclusion:

This clinical prospective study of 176 patients showed a novel method to determine accurate positioning of the NIM device using a train of four electric stimulation. By causing contraction of the musculature and vocal cords overlying the NIMs device more accurate placement was established compared to a less accurate but commonly used method of simply tapping the larynx (p < 0.001).  This minimally invasive and improved method to determine accurate positioning of the NIMs device could therefore minimize the risk of RLN injury. 

53.17 Body Mass Index is Associated with Surgical Site Infection (SSI) in Patients with Crohn’s Disease

Posted on January 26, 2017

M. M. Romine1,2, A. Gullick1,2, M. Morris1,2, L. Goss1,2, D. Chu1,2  1University Of Alabama at Birmingham,Gastrointestinal Surgery,Birmingham, Alabama, USA 2VA Birmingham HealthSystem,General Surgery,Birmingham, AL, USA

Introduction:
Controversy exists on the association of Body Mass Index (BMI) with SSI in patients with IBD. Previous conclusions have been limited by single-institution studies and inclusion of both Crohn’s disease (CD) and Ulcerative Colitis patients. In this study, we used a national dataset to investigate the association of BMI with SSI in patients with CD. We hypothesize that higher BMI is associated with higher risk for SSI in CD patients.

Methods:
Using the 2012-2014 ACS-NSQIP Procedure Targeted Database, we identified all patients with CD who underwent colectomy between 2012-2014. Patients with CD were stratified by weight status to underweight, normal weight, overweight and BMI class I (30-34.9), II (35-39.9) and III (>40). Patient demographics, preoperative comorbidities and surgical characteristics were compared. Primary outcomes were wound complications (SSI, organ space SSI, anastomotic leak) and secondary outcomes included other reported NSQIP-complications.  Chi-square and Wilcoxon Rank Sums tests were used to determine differences among categorical and continuous variables, respectively. Stepwise backwards logistic regression analyses were performed to identify risk factors for SSI.

Results:
Of 3734 patients with CD, 12.29% were underweight, 43.92% were normal weight,  24.24% overweight, 12.35% BMI class I, 4.79% class II,  and 2.41% class III. Overall, 24.4% of patients were smokers, 4.05% were diabetic and 62.94% were on steroids or other immunosuppressant. Patients with higher BMI class were more likely to have diabetes: 3.47% in class I, 6.7% in class II and 8.89% in class III (p value <0.001). A larger percentage of class III obese patients (27.45%) were classified as ASA 4-5 (p value <0.001). Higher BMI was associated with a greater rate of SSI: 6.75% in underweight, 6.4% in normal weight class, 10.06% in the overweight class, 8.89% in class I, 12.85% in class II and 16.67% in class III (p-value<0.001). Organ space SSI rates were highest in underweight patients 12.2%, 7.13% in the normal weight class, 6.85% in the overweight class, and 7.38%, 5.59%, and 2.22% in the BMI classes I, II and III, respectively (p-value<0.001). There was no significant difference in anastomotic leak rate (range 2.8-7.6%, p>0.05). Higher BMI was also associated with respiratory complications (class III 8.9% vs  normal 2.2%, p=0.1) and Ileus (class III 20.2% vs 13.4% p=0.01). On multivariate analysis, BMI remained an independent predictor for SSI where BMI class III had highest odds of SSI infection (OR 2.8 CI 1.5-5.2) in addition to class II (OR 2.1 CI 1.3-4.5),  class I (OR 1.4 CI 0.9-2),  and overweight status (OR 1.5 CI 1.1-2.1) when compared to Normal weight individuals.

Conclusion:
Patients with CD and high BMI are at increased risk for SSI but not organ spaces SSI or anastomotic leak. Underweight CD patients are at increased risk for organ space SSI. Targeting BMI may be one actionable opportunity to reduce post-operative SSI rates. 
 

53.16 Indocyanine Green (ICG) Fluorescence-Guided Parathyroidectomy for Primary Hyperparathyroidism

Posted on January 26, 2017

J. C. DeLong1, E. P. Ward1, T. M. Lwin1, K. T. Brumund1, K. J. Kelly1, S. Horgan1, M. Bouvet1  1University Of California – San Diego,Surgery,San Diego, CA, USA

Introduction:  Surgical resection is the only definitive treatment for primary hyperparathyroidism. Effective treatment requires successful intraoperative localization of the aberrant gland. Classic preoperative imaging includes ultrasound, nuclear scintigraphy, and in some cases axial imaging, however, these modalities have limited utility in the operating room. Indocyanine green (ICG) is a nontoxic organic dye with a high safety profile that can be detected with near infrared fluorescence imaging systems when administered intravenously. ICG is currently used in other surgical procedures as fluorescence intensity is correlated with relative blood supply. In the present report, we evaluated the utility of using ICG for intraoperative localization of parathyroid glands. 

Methods:  ICG fluorescence angiography was performed during 30 open parathyroidectomies for primary hyperparathyroidism over a 12 month period. 7.5mg of ICG was administered intravenously to guide surgical navigation and confirmation using a commercially available fluorescence imaging system. Video files were evaluated and graded by three independent surgeons for strength of enhancement using an adapted numeric scoring system (Fig. 1).

Results: 70% of patients were female. Patient age ranged from 40 to 87 years old (average 64). 26 (87%) patients had a single adenoma, 1 (3%) patient had a double adenoma, and 3 (10%) had hyperplasia.  Of the 30 patients, 22 (73.3%) of the parathyroid glands were rated to have shown strong enhancement, 5 (16.6%) demonstrated mild to moderate enhancement. and 3 (10%) exhibited little or no enhancement. Of the 27 patients who had a preoperative sestamibi scan, parathyroid adenoma was identified in 14 while 13 failed to localize. Of the 13 patients who failed to localize, all 13 patients (100%) had an adenoma that fluoresced on ICG imaging—10 patients (76.9%) had strong fluorescence and 3 patients (23.1%) had moderate fluorescence. There were no adverse events.

Conclusion: ICG fluorescence angiography can effectively be used for intraoperative localization and confirmation of parathyroid glands for patients with primary hyperparathyroidism. ICG proved reliable even in cases where the glands were not identified on preoperative sestamibi scanning. The technique can be used to quickly distinguish parathyroid glands from lymph nodes, thymus, and other benign fatty tissue that may grossly resemble a parathyroid due to variation in blood supply/gland hypervascularity. The technique does not replace intraoperative parathyroid hormone (PTH) testing because ICG angiography cannot distinguish an adenoma from a normal gland presently. ICG angiography has the potential to assist surgeons in identifying parathyroid glands rapidly with minimal risk.

53.15 BMI Class Increases Risk of Complication In Open Ventral Hernia Repair: A NSQIP study

Posted on January 26, 2017

L. Owei2, K. Dumon3, R. Kelz3, D. T. Dempsey3, N. Williams4  2University Of Pennsylvania,Department Of Surgery,Philadelphia, PA, USA 3University Of Pennsylvania,Department Of Surgery, Perelman School Of Medicine,Philadelphia, PA, USA 4University Of Pennsylvania,Division Of Surgical Education, Department Of Surgery, Perelman School Of Medicine,Philadelphia, PA, USA 1Hospital Of The University Of Pennsylvania,Philadelphia, PA, USA

Introduction:

Recent studies have been inconclusive about whether the degree of obesity is an independent risk factor for adverse outcomes following ventral hernia repair (VHR). This study aims to elucidate the influence of BMI class on complications in open VHR.   

Methods:

A retrospective analysis was conducted using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2015. Univariate analyses, namely the Chi-square test for categorical variables and ANOVA for continuous variables, were used to examine the association between BMI class and patient characteristics, comorbidities, re-operation, and risk of perioperative complication. Logistic regression was also used to assess the risk of complication by BMI class with adjustment for potential confounders. All analyses included the entire cohort.

Results:

Of the 19,145 patients who underwent VHR between 2005 and 2015, 53.6% were obese. When stratified by BMI class, we found significant differences in age, gender, race, comorbidities (p < 0.001 for all). In the cohort, 65 patients (0.3%) lost > 10% of their body weight in the 6 months prior to surgery. The average operating time was 80.1 minutes. Higher BMI class was significantly associated with increased mean operating time (p < 0.001).  Unplanned re-operation occurred in only 0.98% and eight patients died within 30 days of surgery; however, neither of these outcomes were significantly associated with BMI class. In contrast, all other complications (surgical, medical and respiratory) were significantly associated with BMI class (p < 0.0001). This association remained even after adjusting for age, sex, race and comorbidities. Patients with a BMI > or equal to 30 kg/m2 were found to be significantly more likely to have a complication compared to patients with BMIs < or equal to 25kg/m2 (Table 1). This risk of complications further increased with increasing BMI class.

Conclusion:

Being in a higher BMI class is a risk factor for surgical, medical and respiratory complications after VHR. Moreover, patients with BMIs > 40kg/m2 have 2.38 times greater risk for complications, with the odds ratio increasing with increasing BMI class. As only 0.3% of patients were able to lose > 10% of their body weight preoperatively, our findings suggest that bariatric surgery prior to VHR might be considered for patients with BMIs > 40kg/m2 to reduce their risk of complications.

53.14 Ultrasound Guided FNA of Thyroid With and Without Sedation

Posted on January 26, 2017

R. M. Kholmatov1, F. Murad1, D. J. Monlezun1, E. Kandil1  1Tulane University School Of Medicine,Surgery,New Orleans, LA, USA

Introduction:
Ultrasound guided Fine Needle Aspiration (FNA) biopsy is a crucial method of preoperative diagnosis of thyroid diseases. It is usually well tolerated with utilization of local anesthesia. However, many physicians offer their patients sedation. Herein, we aim to examine the correlation of performing the procedure under sedation and specimen’s adequacy.

Methods:
We performed retrospective review of electronic medical records of patients who underwent ultrasound guided FNA of thyroid nodules by single surgeon over eight years period. Patients’ clinicodemographic characteristics such as age, gender, race, BMI, nodule size, vascularity, anticoagulation status, and cytopathology results were collected. Patients were divided into two groups, sedated and non-sedated.

Results:
Total 1568 thyroid biopsies were performed in 802 patients. Mean age was 52.5±14.5 years and 80.2% of patients were women. Sixty patients requested sedation and underwent biopsies of 96 (6.1%) nodules. There was no statistical difference between sedated and non-sedated groups in regards age, gender, nodule size, nodule vascularity, and anticoagulation status (p>0.05). Non-diagnostic sample rate was 81 (5.5%) in non-sedated group, and 7 (7.3%) in the sedated group (p=0.46). A post-FNA hematoma rate was 8 (0.5%) in the non-sedated group, and 1 (1.04%) in the sedated group (p=0.53).

Conclusion:
Performing FNA of thyroid nodules under sedation is safe but doesn’t improve the non-diagnostic sample rate or post-FNA hematoma rate. Further studies are warranted to decide whether sedation is appropriate in particular hospital settings.
 

53.13 The management of adhesive small bowel obstruction: a decision analysis of competing strategies.

Posted on January 26, 2017

R. Behman1, P. Karanicolas1, A. Nathens1, J. Jung1, N. Look Hong1  1University of Toronto,Department Of Surgery,Toronto, Ontario, Canada

Introduction:
Adhesive small bowel obstruction (aSBO) is one of the most common reasons for general surgery admission.  Current guidelines advocate for a trial of conservative management (TCM) in patients without signs of bowel ischemia. However, emerging evidence suggests conservative management may be associated with increased risk of recurrence.  Furthermore, when TCM fails, patients undergoing delayed operative management experience increased mortality and morbidity.  The purpose of this decision analysis is to compare two competing strategies for the management of aSBO: early operative management (EOM) and the current standard of care, TCM.

Methods:
We performed a decision analysis with microsimulation and Markov modeling to compare short- and long-term outcomes following treatment with either TCM or EOM at the index admission for aSBO.  We defined EOM as operative management within 24 hours.  The TCM strategy could succeed or fail and result in delayed operation (>24 hours).  Patients’ disease course was modeled over a 10-year time horizon using probabilities derived from 18 previously published studies.  Outcomes modeled included the total number of recurrences, complications, and bowel resections as well as the overall probability of an aSBO-related mortality associated with each treatment strategy.  Sensitivity analyses were performed to test the robustness of the model.

Results:
Over a 10-year time horizon, patients treated with EOM are less likely to experience a recurrence of aSBO than those treated with TCM (36% vs. 52%) and are 36% less likely to experience two or more recurrences.  Patients treated with EOM are more likely to undergo bowel resection (32% vs 16%) and are more likely to experience complications (34% vs. 24%).  A sensitivity analysis was performed to account for potential confounding by indication associated with the use of retrospective data.  When controlling for patients in the EOM arm who were likely assigned to this treatment due to signs of bowel ischemia, the two treatment strategies had similar complication rates (29% with EOM and 26% with TCM).  Peri-admission mortality over the 10-year time horizon was also similar between the two groups (0.06 vs 0.056).  

Conclusion:
Over a 10-year time horizon, EOM is associated with lower recurrence.  Complication rates are similar in the two treatment strategies when controlling for patients who likely had signs of bowel ischemia at pesentation.  EOM may be a suitable treatment strategy for patients with aSBO without signs of bowel ischemia. Future studies should focus on cost-effectiveness in order to further assess the impact of different treatment strategies on the healthcare system and to effect changes in clinical practice. 
 

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