52.11 A Comparitive Study Of Two Parathyroid Hormone Assays In Primary Hyperparathyroidism Patients

Posted on January 26, 2017

S. Joglekar1, J. C. Lee1,2, J. Serpell1,2, H. Schneider3  1The Alfred Hospital,Department Of General Surgery,Melbourne, VICTORIA, Australia 2Monash University,Endocrine Surgery Unit,Melbourne, VICTORIA, Australia 3The Alfred Hospital,Department Of Pathology (Clinical Biochemistry),Melbourne, VICTORIA, Australia

Introduction:
Inappropriately high serum parathyroid hormone (PTH) is a diagnostic criterion for primary hyperparathyroidism (pHPT). Recently hospital administrative records showed an increase in the diagnosis of pHPT during a 2-year (approx.) period when the Abbott assay was used instead of the usual Roche assay for our institution due to product unavailability. Therefore, we aimed to compare the clinical performance of these 2 2nd generation assays in patients undergoing parathyroidectomy for pHPT.

Methods:
All study patients underwent parathyroidectomy for pHPT at The Alfred Hospital. Those who were treated during the 20-month period (May 2012 to Feb 2014 inclusive) when the Abbott assay was in use were designated “Group A”; and those treated during the subsequent 20-month period (Mar 2014 to Dec 2015 inclusive) when the Roche assay was again in use were designated “Group R”. Comparisons were made of their biochemistry (serum calcium, PTH, vit D levels), as well as clinical outcomes (diagnostic accuracy and recurrence prognostication), using the Student’s t-test and Fisher’s exact test. Deviation of PTH from normal ranges are expressed as multiples of the upper limit of normal (xULN), as the 2 assays have different normal ranges. A biochemical diagnosis was classified as false positive (FP) when associated with a negative neck exploration. Post-operative PTH reduction was calculated from pre-operative and recovery room PTH levels. In this study, curative treatment was defined as normo-calcaemia lasting over 3 months. 

Results:
There were 79 patients in Group A and 64 in Group R. Mean ages and gender distribution were similar between the groups (63.3 ± 15.6 years vs 62 ± 12.9 years; 75% vs 70% female). The mean pre-operative PTH in Group A (2.25 ± 0.28 xULN) was significantly higher than in Group R (1.84 ± 0.25 xULN; p < 0.05); this was despite similar levels of hypercalcaemia (2.78 ± 0.17 mM vs 2.77 ± 0.18 mM respectively; p = 0.72). The FP rates were similar (p = 0.65), with each group only having 2 patients with a negative 4-gland exploration. Operative PTH reduction of > 50% was seen in the majority in both groups (Group A 92% vs Group R 93%), as was normo-calcaemia at 3 months (Group A 90% vs Group R 93%).

Conclusion:
This study confirmed that although the Abbott assay measured higher PTH levels in patients with pHPT compared to the Roche assay, this does not seem to affect the ability of these assays to make an accurate diagnosis. Furthermore, the comparable kinetics of post-operative PTH conferred similar medium term normo-calcaemia rates. 
 

52.10 A Prospective Study on Quality of Life after Laparoscopic and Open Inguinal Hernia Repairs

Posted on January 26, 2017

J. Horwitz1, F. Burbano1, R. Lingnurkar2, C. M. Divino1  1Icahn School Of Medicine At Mount Sinai,Department Of Surgery,New York, NEW YORK, USA 2Central Michigan University College Of Medicine,Mount Pleasant, MICHIGAN, USA

Introduction: Patient-reported quality-of-life (QOL) data is becoming an important component of modern surgical quality improvement initiatives. Using the Carolinas Comfort Scale (CCS), a validated QOL survey specific to patients undergoing hernia repairs with mesh, the aim of our study was to prospectively compare QOL outcomes for patients undergoing both laparoscopic and open inguinal hernia repairs.

Methods: Patients undergoing inguinal hernia repairs by a four surgeon group at The Mount Sinai Hospital from 2015-2016 were identified prospectively. The CCS survey was administered at the pre-operative visit, post-operative visit (<1 month from surgery), and follow-up visit (>1 month from surgery). These patients were stratified into operation specific groups: unilateral laparoscopic, bilateral laparoscopic, open with mesh plug-and-patch, open with mesh patch only. The primary outcomes were the CCS survey’s 1-5 point scale for mesh sensation, pain, and movement limitation in the pre-operative, post-operative, and follow-up settings. Secondary outcomes analyzed were blood loss, operative time, admission, re-admission, and recurrence.

Results: 92 patients, at this time, have completed the CCS surveys at all three visits. Mean follow-up time was 4.4 months. Within this group, 40 underwent laparoscopic repairs (31 bilateral and 9 unilateral) and 52 underwent open repairs (35 plug-and-patch, 17 patch only). Each operative group experienced a significant decrease in pain between the pre-operative and follow-up setting. There were no significant QOL differences between the laparoscopic and open groups, nor were QOL differences observed between the unilateral and bilateral laparoscopic groups. The open plug-and-patch group had a significantly higher pain and movement limitation score at follow-up compared to the open patch only group (p = 0.016 and p = 0.031, respectively); of note, no differences were observed at the baseline pre-operative visit. The unilateral laparoscopic group’s operative time was significantly longer than the unilateral open group, 74 vs 59 minutes (p <  0.001). There were no recurrences during the follow-up period.

Conclusion: Using prospective, patient-reported, QOL data with the CCS survey, we have demonstrated that all patients experienced lower pain scores after inguinal hernia repairs, regardless of operation type. There we no QOL differences between laparoscopic or open repairs; however, the open plug-and-patch repair group did experience increased pain and movement limitation at follow-up as compared to the open patch only repair group.

 

52.09 Risk Factor and Outcome Analysis of Patients with Bethesda Category III (AUS/FLUS) Thyroid Nodules

Posted on January 26, 2017

W. Ouyang1, O. Picado Roque1, S. Liu1, R. Teo1, A. Franco1, M. Gunder1, P. P. Parikh1, J. C. Farrá1, J. I. Lew1  1University Of Miami,Division Of Endocrine Surgery,Miami, FL, USA

Introduction:  With the Bethesda System for Reporting Thyroid Cytopathology (BSRTC), thyroid nodules designated as Bethesda Category III or atypia or follicular lesion of undetermined significance (AUS/FLUS) by fine needle aspiration (FNA) have an estimated risk of malignancy (ROM) ranging from 5% to 15%. Previous reports performed at other institutions suggest that the ROM for AUS/FLUS is highly variable. This surgical series determines the ROM and those clinical factors that may predict underlying malignancy in patients with thyroid nodules categorized as AUS/FLUS at a single institution.

Methods:  A retrospective review of prospectively collected data of 665 patients with index thyroid nodules who underwent FNA and thyroidectomy from April 2010 to June 2016 was performed. Patients with thyroid nodules classified as AUS/FLUS by FNA were divided into malignant or benign groups based on final pathology, noting whether malignancy was found in the index thyroid nodule or as an incidental lesion. Incidental cancers were defined as malignancy discovered outside the index nodule within the ipsilateral thyroid lobe or contralateral lobe. Such patients underwent initial thyroid lobectomy for definitive diagnosis unless there was a history of radiation exposure, familial thyroid cancer, obstructive symptoms, bilateral nodules and/or patient preference for which total thyroidectomy was performed. Groups were compared in terms of demographics, clinicopathologic factors, and surgeon performed ultrasound (SUS) features for malignancy.

Results: Among the 171 patients with AUS/FLUS nodules who underwent thyroidectomy, final pathology confirmed malignancy in 60% (103/171) of the patients compared to benign disease in 40% (68/171). Malignancy in the index thyroid nodule alone was found in 37% (64/171) of patients whereas incidental cancers were found in 9% (16/171) on final pathology. Twenty-three (14%, 23/171) patients were found to have both index nodule and incidental malignancy. The ROM for index thyroid nodule with AUS/FLUS overall is 51% (87/171). Papillary thyroid cancer (PTC) was the most common cancer, found in 86% (89/103) of patients with malignancy. The most common subtype among patients with PTC was the follicular variant in 71% (63/89), followed by the classic variant in 12% (11/89). Analysis of nodule features by SUS revealed solid texture more likely to be present in patients with a malignancy when compared to benign tumors (88.1% vs 73.5%, p<0.05).

Conclusion: In this surgical series, the malignancy rate of 51% in thyroid nodules with AUS/FLUS cytology is higher than the estimated ROM, but within range of other surgical reports in the literature. Furthermore, during SUS evaluation, solid features may help determine underlying malignancy in AUS/FLUS thyroid nodules. For appropriate treatment recommendations, surgeons should assess their ROM for AUS/FLUS nodules, which may vary in their everyday clinic practice and local institutional experience. 
 

52.08 Practical Adherence to the Step-Up Approach for Pancreatic Necrosis: An Institutional Review

Posted on January 26, 2017

V. Tam1, C. Umapathy4, M. Zenati3, S. Downs-Canner3, B. A. Boone1, J. Steve1, A. Zureikat1, K. K. Lee1, H. Zeh1, D. Yadav2, M. E. Hogg1  1University Of Pittsburgh,Surgical Oncology,Pittsburgh, PA, USA 2University Of Pittsburgh,Gastroenterology, Hepatology And Nutrition,Pittsburgh, PA, USA 3University Of Pittsburgh,Department Of Surgery,Pittsburgh, PA, USA 4University Of Pittsburgh,General Internal Medicine,Pittsburgh, PA, USA

Introduction:
Infected pancreatic necrosis is a highly morbid disease that was traditionally approached with an open necrosectomy. This approach was associated with rates of morbidity and mortality up to 95% and 39%, respectively. The multicenter randomized controlled PANTER trial published in 2010 in the New England Journal of Medicine proposed a “Step-Up” approach which demonstrated fewer major complications than conventional treatment, with comparable rates of mortality, and spared a major operation in one-third of patients. We sought to evaluate the practical adherence to the Step-Up approach at a single tertiary care institution, its temporal adoption into clinical practice, and impact on outcomes.

Methods:
This is a retrospective review of all patients treated at a tertiary care center with infected pancreatic necrosis between 2006 and 2014. Diagnosis was based on positive culture on pancreatic fine needle aspiration, or presence of an air filled necroma on computed tomography. “Modified Step-Up” (MSU) was defined as percutaneous or endoscopic drainage followed by additional percutaneous or endoscopic drainage, followed by any surgical intervention, including video-assisted retroperitoneal debridement and open necrosectomy. Patients were stratified into the “early” pre-PANTER (2006-2010) or ”late” post-PANTER (2010-2014) period. Rates of adherence to the MSU approach were compared as well as clinical outcomes. 

Results:
There were 130 patients with infected necrotizing pancreatitis in the overall cohort; 75(58%) and 55(42%) were treated in the early and late period. At baseline, patients admitted in the late period were more likely to have higher ASA scores (3-5 vs 1-2, 92% vs 39%, p<0.001). In the late period, adherence to MSU was 46%(n=25) vs. 27%(n=27) in the early period (p<0.05). Late period patients had a greater likelihood of percutaneous drainage (65% vs. 43%, p=0.012) and greater number of total median interventions (3 vs. 2, p<0.001), however had comparable rates of surgery (73% vs. 79%, p=0.432), including 34(85%) open necrosectomies in the late period vs. 55(93%) in the early period. There were no differences in length of hospital stay, rates of in-hospital mortality, long-term complications, or survival at 2-years following discharge. Patients in the late period were less likely to have a pancreatitis-related readmission (47% vs. 71%, p=0.007) or multiple readmissions (31% vs. 51%, p=0.024). 

Conclusion:
Overall, adherence to the MSU approach was 46% between 2010 and 2014. Patients treated during this period had lower rates of pancreatitis-related readmission and total readmissions, with similar rates of long-term complications and mortality compared to patients between 2006-2010. This study demonstrates that adoption of clinical guidelines can result in improved clinical outcomes. Barriers to implementation of the Step-Up approach should be identified to improve adherence rates. 

52.07 The role of simultaneous cystgastrostomy and necrosectomy for walled off pancreatic necrosis

Posted on January 26, 2017

M. R. Driedger1, F. R. Sutherland1, E. Dixon1, S. Gregg1, N. Zyromski2, C. G. Ball1  1University Of Calgary,General Surgery,Calgary, AB, Canada 2Indiana University School Of Medicine,Indianapolis, IN, USA

Introduction:  

Severe acute pancreatitis (SAP) occurs in 15% of patients with generalized pancreatitis. Walled off pancreatic necrosis (WOPN) is the most common end result of SAP.  When symptomatic, WOPN requires intervention. The aim of this study was to evaluate the role of simultaneous cystgastostomy and necrosectomy (CG/N) for WOPN.

Methods:

A retrospective review of patients with WOPN undergoing surgical management on a high volume pancreatic service over 11 years (2005-2016) was performed.  Outcomes included mortality, morbidity, intervention timing and symptom resolution. Statistics were descriptive.

Results:

Seventy-seven patients were analyzed (mean WOPN diameter=14.5 cm, 67.5% male, mean age=47 years). The majority were acutely ill, with an average preoperative length of stay of 28.7 days and 26% requiring preoperative support in the Intensive Care Unit (ICU). Preoperative complications were prevalent (42.9%), and included mesenteric vein thrombosis (37%), gastric outlet obstruction (19.2%), respiratory complications (19.2%), bacteremia (13.7%) and acute kidney injury (9.6%). Nearly all (93.5%) patients underwent an open trans-gastric CG/N while 6.5% received a cystjejunostomy. The median duration of time between the onset of SAP and operative intervention was 45.1 days. Forty-two percent of the cultured necrosum was infected with bacteria. Postoperative morbidity included infection (10.4%), bleeding (5.2%), fistula (5.2%) and re-operation (3.9%). Postoperative median hospital length of stay was 10 days (range 4-228) with 96.1% of patients discharged home. Mortality was 2.6% with 10.4% requiring postoperative ICU care. The mean length of follow up was 12 months with 87.7% of patients having complete clinical resolution of symptoms at an average of 7.3 weeks. Recurrent WOPN occurred in only 5.5% of patients at an average of 19 months after the index operation.

Conclusion:

Despite acutely ill and comorbid patients with large WOPN volumes, simultaneous CG/N offers a definitive single-stage solution in the vast majority of patients with minimal postoperative morbidity and rapid return to an asymptomatic state. Upon consideration of the minimal laparotomy required, this procedure represents the preferred approach for WOPN.

 

52.06 Prophylactic Antibiotic Use in Outpatient Anorectal Surgery for HIV Patients

Posted on January 26, 2017

S. A. Patel1, R. J. Kucejko1, J. L. Poggio1  1Drexel University College Of Medicine,Philadelphia, Pa, USA

Introduction:  Human immunodeficiency virus (HIV) has been a vexing challenge to healthcare providers since its discovery. As medical therapy increases survival among people with an HIV infection, surgeons have been seeing an increasing number of HIV-infected patients with anorectal pathologies, including anal dysplasia and cancer. There is, however, no data on the incidence and risk factors for postoperative complications, such as surgical site infections (SSIs), in HIV patients undergoing elective anorectal procedures, nor is there data to suggest the administration of prophylactic antibiotics. Regular antibiotics are costly and have side effects that urge for accurate targeting of use; the purpose of this study was to review a HIV-positive patient population that has undergone anorectal surgery for dysplasia and assess the need for antibiotic prophylaxis. 

Methods:  A retrospective chart review was performed of all HIV positive patients seen as an outpatient in the Colorectal Surgery Division from 2007 to 2014. Basic demographics and clinical data such as date(s) of surgery, follow-up visit(s), and antibiotic prophylaxis, as well as preoperative CD4 count and HIV viral load, were recorded for 229 patients and 362 procedures. Postoperative exam notes were reviewed to determine the presence of an SSI. To analyze the data, patients were stratified according to CD4 count and viral load. The proportion of patients who received prophylactic antibiotics was assessed and the SSI rate was calculated. A chi-squared analysis was performed to assess whether SSI risk was elevated in this population.

Results: SSIs occurred in two of 193 (1.04%) cases for which antibiotic prophylaxis was not administered and in none of the 36 cases with antibiotic prophylaxis and available post-operative reports. One SSI occurred in a 51-year-old male with a preoperative CD4 count of 612/μL and viral load of zero. The other SSI occurred in 57-year-old female with an unknown CD4 count and viral load. A chi squared analysis showed the incidence of SSIs in the groups with and without antibiotic prophylaxis was not significantly different (p=0.540). 

Conclusion: Our study found an SSI incidence of 1.04% in HIV-infected patients with CD4 counts above 50/μL, which does not suggest an elevated risk compared to the general population reported incidence of 3-11% for clean-contaminated wounds. Antibiotics are costly and have many side effects; based on our study, prophylactic antibiotics are not indicated for outpatient anorectal procedures in HIV patients with CD4 counts above 50/μL. 
 

52.05 Age is not associated with Readmission in Patients Undergoing Pancreatectomy or Colectomy Procedures

Posted on January 26, 2017

M. N. Mustian1, L. E. Goss1, D. Chu1, L. Theiss1, J. Christein1, C. Balentine1, M. S. Morris1  1University Of Alabama At Birmingham,Surgery,Birmingham, AL, USA

Introduction: More than one third of operations in the United States are performed on individuals aged 65 years or older. These patients are at high risk for unplanned readmission, prolonged hospitalization, and postoperative complications. This study analyzes the relationship between aging and perioperative outcomes for patients undergoing pancreatectomy and colectomy at a major academic medical center. We hypothesize that elderly patients would have higher rates of readmission and worse postoperative outcomes.

Methods: We used National Surgical Quality Improvement Project data from our institution to evaluate 1964 patients having colectomy or pancreatectomy between 2010 and 2016. We stratified by age: < 50, 50-59, 60-69, 70-79, and ≥80 years old. The primary endpoint was 30 day unplanned postoperative readmission.  Secondary endpoints included length of stay, mortality, postoperative readmission rates and NSQIP complications. Univariate and multivariate analysis were performed. We used stepwise backwards logistic regression analyses to identify risk factors for readmission.

Results: In our cohort of 1964 patients, 692 (35%) patients had pancreatectomies and 1272 (65%) colectomies.  The age distribution included:  23% age <50, 26% age 50-59, 28% age 60-69, 17% age 70-79 and 6% age 80 and older.  Median postoperative length of stay was 6 days and was similar across all age groups.  Median readmission rate was 13.6% and similar across age groups.  Major complications were observed in 216 patients and resulted in different rates of readmission based on age (<65 years 40% vs ≥65 years 27% p=0.03).  The risk of mortality increased steadily with age from <1% in the youngest group to 4.2% in the oldest group.  On multivariable analysis, there was no significant relationship between age and risk of readmission, but both minor (OR 1.76 CI 1.15-2.68) and major (OR 4.6 CI 3.2-6.5) complications were associated with increased odds of readmission.

Conclusion: Our data did not reveal an association between age and risk of readmission.  Postoperative complications are associated with readmission.  However, younger patients experiencing major complications were more likely to be readmitted when compared to older patients.  Reasons for readmission in elderly patients may differ from those of younger patients.  Further work is needed to understand the relationship between age and readmission to design programs to address the unique discharge needs of elderly patients.

52.04 Laparoscopic Partial Colectomy Reduces Length of Stay and Mortality in Patients with Ascites

Posted on January 26, 2017

D. T. Asuzu1, K. Y. Pei1  1Yale University School Of Medicine,Surgery,New Haven, CT, USA

Introduction:
Ascites increases perioperative complications and risk of death, but is not an absolute contra-indication for subtotal colectomy. It remains unclear whether this risk can be minimized using a laparoscopic versus open approach. We hypothesize that laparoscopic surgery reduces risk of complications and death in patients with ascites.

Methods:
Data was retrospectively analyzed from 2,419 patients with ascites who underwent laparoscopic or open colectomy from 2005 to 2013 using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Post-operative outcomes were compared using two-sample tests of proportions, or using two-sample T-tests after checking for variance equality with Welch’s approximation for degrees of freedom. Odds ratios (OR) and incidence rate ratios (IRR) for complications and death were calculated using univariable logistic regression or linear regression respectively. P values < 0.05 two-tailed were considered statistically significant. 

Results:
218 patients (9%) with ascites underwent laparoscopic colectomy. Laparoscopic surgery was associated with lower 30-day mortality (15.6% versus 24.3%, OR 0.58, 95% CI 0.39 – 0.84, P = 0.004) and shorter hospital length of stay (9 days versus 15 days, IRR 0.0046, 95% CI 6E-4 – 0.034, P < 0.001). There was no significant difference in operative time (145 minutes versus 146 minutes, P = 0.69) or superficial surgical site infections (7.3% versus 7.7%) between laparoscopic versus open surgery.

Conclusion:
Laparoscopic colectomy reduces 30-day mortality and hospital length of stay in patients with ascites. This surgical modality may help mitigate the additional risk associated with ascites in patients undergoing subtotal colectomy.
 

52.03 Trends in Utilizing Laparoscopic Colorectal Surgery Over Time in 2005-2014 Using the NSQIP Database

Posted on January 26, 2017

C. M. Hambleton Davis1,2, B. A. Shirkey3, L. W. Moore1, H. R. Bailey1, X. L. Du2, M. V. Cusick1  1Houston Methodist Hospital,Department Of Surgery,Houston, TX, USA 2The University Of Texas School Of Public Health,Department Of Epidemiology,Houston, TX, USA 3Oxford University,Oxford Clinical Trials Research Unit / Centre For Statistics In Medicine, NDORMS,Oxford, , United Kingdom

Introduction:  Laparoscopy, originally pioneered by gynecologists, was first adopted by general surgeons in the late 1980’s. Since then, laparoscopy has been adopted in the surgical specialties and colorectal surgery for treatment of benign and malignant disease. Formal laparoscopic training became a required component of surgery residency programs as validated by the Fundamentals of Laparoscopic Surgery (FLS) curriculum; however, some surgeons may be more apprehensive of widespread adoption of minimally invasive techniques. Although an overall increase in the use of laparoscopic techniques is anticipated over a ten-year period, it is unknown if a similar increase will be seen in higher risk or more acutely ill patients.

Methods:  Using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2014, colorectal procedures were identified by CPT codes and categorized to open or laparoscopic surgery. The proportion of colorectal surgeries performed laparoscopically was calculated for each year. Separate descriptive statistics were collected and categorized by age and BMI. ASA classification and emergency case status variables were added to the project to help assess complexity of cases.

Results: During the ten-year study period, the number of colorectal cases increased from 3,114 in 2005 to 51,611 in 2014 as more hospitals joined NSQIP. A total of 277,376 colorectal cases were identified, 114,359 (41.2%) of which were performed laparoscopically. The use of laparoscopy gradually increased each year, from 22.7% in 2005 to 41.2% in 2014. Laparoscopic procedures were most commonly performed in the youngest age group (18-49 years), overweight and obese patients (BMI 25-34.9), and in ASA Class 1-2 patients. Over the ten-year time period, there was a noted increase in the use of laparoscopy in every age, BMI, and ASA category, except ASA 5. The percent of emergency cases receiving laparoscopic surgery also doubled from 5.5% in 2005 to 11.5% in 2014.

Conclusion: Over a ten-year period, there was a gradual increase in the use of laparoscopy in colorectal surgery. Further, there was consistent increase of laparoscopic surgery in all age groups, including the elderly, in all BMI classes, including the obese and morbidly obese, and in most ASA classes, including ASA 3-4, as well as emergency surgeries. These trends suggest that minimally invasive colorectal surgery appears to be widely adopted and performed on more complex or higher risk patients. 

 

52.02 Incisional Hernia Risk after Prophylactic Mesh Augmentation: A Systematic Review and Meta-Analysis

Posted on January 26, 2017

S. Shakir1, Z. Borab2, M. A. Lanni1, M. G. Tecce1, J. MacDonald3, W. W. Hope4, J. M. Weissler1, M. J. Carney1, J. P. Fischer1  1University Of Pennsylvania,Plastic Surgery,Philadelphia, PA, USA 2Drexel University College Of Medicine,Philadelphia, Pa, USA 3University Of Western Ontario,London, ONTARIO, Canada 4New Hanover Regional Medical Center,Surgery,Wilmington, NC, USA

Introduction:  Incisional hernia (IH) is a morbid and challenging complication with an extraordinary financial burden to the healthcare system. With nearly 350,000 repairs and expenditures in excess of $3 billion annually, there is a clear need for reparative strategies to diminish hernia recurrence. As greater emphasis is being placed on disease prevention, and as surgical technique and mesh technology evolves, the surgical paradigm must transition from a reparative approach to preventative action. Restoration of tensile strength is paramount in reducing risk of IH, yet the optimal intervention is not known. This systematic review and meta-analysis reviews incidence of IH and complications after elective laparotomy using either PMA or conventional fascial repair.

Methods:  A systematic review of the literature was conducted in accordance with PRISMA guidelines to identify studies comparing PMA to primary suture closure (PSC) repair in elective, midline laparotomies during index operation. The primary outcome of interest was development of IH. Inclusion criteria included patients between the ages of 18-75 years and at least 1 IH risk factor (BMI ≥ 25 kg/m2, prior abdominal surgery, history of AAA, ≥45 years of age, and smoking or history of COPD). Exclusion criteria included prior hernia or existing abdominal mesh, non-elective cases, history of metastatic cancer, immunosuppression, active infection, life expectancy less than 24 months, and pre-existing pregnancy.

Results: Overall, 14 studies were included. Of the total 2114 patients, 1152 participants underwent PMA. PMA significantly decreased the risk of IH compared to PSC (RR=0.15, 95% CI 0.07-0.30). PMA reduced the risk of IH regardless of mesh location (i.e. onlay, retrorectus or preperitoneal), however, PMA use was associated with an increased rate of seroma (RR 1.95, 95% CI 1.31 to 2.91; 10 studies). PMA patients are at increased risk for chronic wound pain compared to PSC [RR=1.70, 95% CI 1.04 to 2.78).

Conclusion: The existing literature provides high level evidence demonstrating that prophylactic mesh lowers the rate of IH after elective, open intra-abdominal surgery. Risk stratification models in conjunction with an increased emphasis on preventative medicine, strategies such as PMA offer safe and efficacious risk reduction in high-risk laparotomy patients. Given the evidence gap, however, further study is undoubtedly warranted.  

 

52.01 Morbidity and mortality for patients with sinistral portal hypertension undergoing splenectomy

Posted on January 26, 2017

M. Neuwirth1, A. J. Sinnamon1, R. R. Kelz1, G. C. Karakousis1, M. K. Lee1  1Hospital Of The University Of Pennsylvania,Department Of Surgery,Philadelphia, PA, USA

Introduction: Patients with sinistral portal hypertension frequently develop gastric varices and are therefore at risk of life-threatening hemorrhage.  Splenectomy is the treatment of choice as it largely eliminates the bleeding risk, but these procedures likely carry increased risk relative to splenectomy performed for other reasons.   We sought to compare the specific morbidity and mortality of splenectomy performed for sinis-tral portal hypertension versus other indications using a national cohort.

Methods: The American College of Surgeons National Surgical Quality Improvement Program (ASC NSQIP) was accessed from the years 2005-2014 for patients undergoing open or laparoscopic splenectomy.  Patients with an operative diagnosis of gastric vari-ces were selected for inclusion in the case cohort.  These patients were compared to two separate control groups: hypersplenism or splenomegaly, and all other indi-cations (OI) for splenectomy with 25 or more cases (excluding trauma).  Pearson’s chi-squared or Wilcoxon rank-sum tests were applied to categorical variable com-parisons as indicated.

Results: Of the 7,522 splenectomies performed during the study period, we identified 28 performed for gastric varices, 1,186 performed for hypersplenism or splenomeg-aly, and 4,128 in the OI group.  Notably, patients in the gastric varices group had lower rates of thrombocytopenia and were similar to the comparison groups with respect to their total bilirubin and INR.  Compared to OI, patients with gastric vari-ces more often had dependent functional status (21.4 vs 5.9%, p < .001), ASA class > III (92.8 vs. 62.5%, p < .001), and albumin < 3 (57.1% vs 11.4%, p < 0.001).  There was no difference in mortality for the varices group as compared with the splenomegaly group (3.6% vs 2.4%; p = 0.678) or OI (3.6% vs 2.4%; p = 0.671).  As depicted in figure 1, serious morbidity was significantly increased in the varices group versus the control group (53.6% vs 19.7%; p < 0.001) and versus the sple-nomegaly group (53.6% vs 23.2%; p < 0.001).  Most major post-operative compli-cations in the varices group were due to respiratory (39.2%), bleeding (42.9%) and sepsis (25.0%) related events.

Conclusion:Patients that undergo splenectomy for sinistral portal hypertension are at substan-tially increased risk for morbidity but not mortality as compared with splenectomy for splenomegaly or other indications.  Most significant are risks of respiratory, renal, bleeding or sepsis-related events.  Careful patient selection must be employed in this cohort. 

 

51.20 Effects of Education and Health Literacy on Post-Operative Outcomes in Bariatric Surgery

Posted on January 26, 2017

S. Mahoney2, D. Tawfik-Sexton1, P. Strassle3, T. Farrell1, M. Duke1  1University Of North Carolina At Chapel Hill,Division Of Gastrointestinal Surgery,Chapel Hill, NC, USA 2University Of North Carolina At Chapel Hill,Dept. Of Surgery,Chapel Hill, NC, USA 3University Of North Carolina At Chapel Hill,Gillings School Of Global Public Health, Department Of Epidemiology,Chapel Hill, NC, USA

Introduction:
In bariatric surgery, strict adherence to diet and lifestyle modifications are necessary for a successful operative course. We hypothesize that lower levels of education and health literacy are associated with increased risks of nonadherence; thus leading to increased morbidity, emergency department (ED) visits, and preventable readmissions postoperatively. If so, pre-operative education and follow up care may be individualized to benefit those at-risk patients.

Methods:
Bariatric surgery patients were administered a pre-operative questionnaire which included education level and the Rapid Estimate of Adult Literacy in Medicine (REALM-SF) assessment. Patients were stratified by education level (≤12 years of education versus >12 years) and health literacy score (a score ≤6 [7th-8th grade or lower] versus 7 [high school]). Poisson regression was used to compare incidence rate of ED visits, readmission, and overall hospital visits. 

Results:
Of the 73 enrolled patients, 16 (22.2%) had ≤12th grade education and 5 (6.9%) scored ≤6 on the REALM-SF. Patients with lower education were significantly more likely to visit the hospital following surgery, 0.40/100 days (95% CI 0.19, 0.84) vs. 0.15/100 days (95% CI 0.08, 0.28), p=0.05. ED visits (0.18/100 days vs. 0.07/100 days, p=0.15) and readmissions (0.18/100 days vs. 0.07/100 days, p=0.16) were higher, but not significant, among patients with lower education.  No significant differences were seen in patients with lower health literacy in the rate of ED visits (0.09/100 days vs. 0.09/100 days, p=0.97), readmissions (0.11/100 days vs. 0.09/100 days, p=0.87), or overall hospital visits (0.22/100 days vs. 0.19/100 days, p=0.85).
 

Conclusion:
Lower level of education is associated with more than double the rate of post-operative hospital visits in our center’s bariatric surgery patients. Very few of our patients made less than a perfect score on the REALM-SF, limiting its effectiveness as a screening tool for risk stratification. A patient’s education level is quick and free to obtain and may identify patients at risk for costly post-operative hospital visits.  Further investigation is warranted in order to improve outcomes and unnecessary costs associated with bariatric surgery.  

51.17 30 States Physician Workforce Adversely Affected by Low Number of In-State Residencies and Residents

Posted on January 26, 2017

L. Chodroff1, W. H. Schwesinger1, R. E. Willis1, K. Sirinek1  1University Of Texas Health Science Center At San Antonio,General Surgery/Surgery,San Antonio, TX, USA

Introduction:
For 35 years, the # of graduating US medical students has dramatically ↑. Total annual enrollment ↑ 33% (65, 189 to 86,746) while the # of medical schools ↑ 25% (115 to 145). In contrast, the # of Medicare-funded residency positions has remained frozen at 1996 levels as a result of the Balanced Budget Act of 1997 (public law 105-33).  This study assesses the # of residencies and PGYI positions, and the # of medical students (MS) and residents (RES) per 105 population (pop) and their in-state retention patterns for 30 states below and 20 above the US x? for the # of physicians/surgeons per 105 pop.

Methods:

Data were obtained from the 2015 State Physician Workforce Data Book of the Association of American Medical Colleges for 2014 and the 2014 Main Residency Match.  Results were analyzed by t-Test (Significance P<0.05). Data for MS were calculated for 45 states with medical schools and RES for all 50 states.

Results:
30 states (x? 206, range 170.3 – 234.6) were below the US x? (235) and 20 were above it (x? 270, range 235.5 – 349.5) for the # of actively practicing physicians / surgeons per 105 pop. (206 vs 270, P<.05).  16 of 30 states below the US x? for physicians and surgeons per 105 pop were below the US x? and the 20 state x? (P<.05) for General Surgeons per 105 pop (6.3 vs 6.9, 8.5).  Compared to 20 states above the US x?, 30 states below the US x? had a statistically significant lower # of residences, PGYI residency positions, and residents per 105 pop but a higher MS in-state matriculation rate (Table). There was no statistical difference in-state physician retention rates between these two groups of states for those who completed either medical school, residency, or same state medical school + residency.  The highest in-state physician retention rate occurred for those who completed both medical school and residency in the same state (58.9%)

Conclusion:
High in-state matriculation rate for 30 states below the x? for number of physicians/surgeons per 105 pop (66%) was nullified by the fact that only 36% of them practiced in-state.  The root cause of this physician manpower exodus may in part be due to an insufficient number of both residencies and resident positions in those 30 states.  Since the highest retention rates occurred when MS completed a residency located in the same state as their medical school, it would seem prudent for states with a significant physician workforce shortage to start early and aggressive recruiting of their state MS.  At a national level, Congress should be encouraged to repeal that part of the Balanced Budget Act of 1997 which is inhibiting further growth in the # of Medicare-funded residents and residencies. 

51.16 Emergent Presentations of Colorectal Cancer in At Risk Populations: A Safety Net Hospital Experience

Posted on January 26, 2017

N. Ullman1, O. Prela1, P. Chung1, M. Smith1, R. Zhu1, H. Talus2, A. Alfonso1, G. Sugiyama1  1SUNY Downstate College Of Medicine,General Surgery,Brooklyn, NY, USA 2Kings County Hospital Center,Surgery,Brooklyn, NY, USA

Introduction:

Colorectal cancer is the second leading cause of cancer related deaths in the US. African Americans have a greater incidence, higher mortality rate and are more likely to present at an advanced stage when compared to their Caucasian counterparts. We explored the difference in African-American and Caribbean born (Afro-Caribbean) patients that underwent surgery for colorectal cancer at two urban safety-net hospitals. 

Methods:

We conducted a retrospective chart review of patients that underwent resection for colorectal cancer from 2007-2015. Patients were stratified by race and country of birth; 119 African American and 203 Afro-Caribbean patients were identified. We then compared rates of disease presentation requiring urgent or emergent surgical intervention and rates of presentation allowing for elective procedures. Emergent/urgent presentation was defined as surgical intervention to treat a tumor complication on the same hospital admission in which the diagnosis of colorectal cancer was made. Tumor complication rates between each group were also compared. Complications included obstruction, anemia requiring transfusion, colonic perforation and hemorrhage. Comparisons were performed using the Chi Square Test for emergent/urgent vs elective case presentations and the Fisher's Exact Test for tumor complication rates.

Results:

There was no significant difference in the rate of urgent/emergent cases of colorectal cancer when compared to elective procedures. We identified 30 (25.2%) African American patients compared to 55 (27.1%) Afro-Caribbean patients that required an urgent/emergent procedure (p = 0.7912). African American compared to Afro-Caribbean patients had no statistically significant differences in the rate of obstruction (9.24% vs 9.85%, p = 1.0), hemorrhage (7.56% vs 5.42% p = 0.4778), and perforation (3.36% vs 2.96% p = 1.0). However Afro-Caribbean patients were more likely to present with anemia requiring transfusion (7.88% vs 1.68%, p = 0.0221). 

Conclusion:

In this retrospective chart review of colorectal cancer in African American and Afro-Caribbean patients treated at two urban safety-net hospitals, there is little difference in the rates of emergent presentations of disease between the two cohorts. Of the tested disease complications, only one was shown to be significantly different. Despite this singular difference, we postulate that there may be a variance in the disease process found in these cohorts. We suspect that an underlying difference in tumor biology contributes to this discrepancy. A follow up study to examine the pathology of the specimens from each cohort may shed light onto this difference.

 

51.15 Regional Variation in Laparoscopic Resection For Diverticulitis in Academic and Non-Academic Centers

Posted on January 26, 2017

A. Talukder1, P. Martinez1, J. McKenzie1, R. Lassiter1, C. White1, D. Albo1  1Medical College Of Georgia,Department Of Surgery,Augusta, GA, USA

Introduction: Studies have demonstrated favorable outcomes for laparoscopic surgery over open surgery in the treatment of a variety of surgical diseases. In this study we analyzed regional differences in the use of laparoscopic surgery with respect to race in academic and non-academic centers in all geographic regions of the US, comparing to them our home state and our region.

Methods:   A retrospective analysis of elective admissions with a primary diagnosis of diverticulitis from 2009-12 was performed using data from the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality. Cases were selected based on diagnosis codes of Diverticulitis of colon with or without mention of hemorrhage and (ICD9 56.11, 562.13). All patients underwent a surgery as defined by non-endoscopic ICD-9-CM procedure codes for colorectal resection.

Results: At academic centers in the US, laparoscopic utilization rate was 44.5% for Whites, 29.5% for Blacks, and 39.4% for Hispanics and 38.2%, 29.6%, 38.0% respectively at non-academic centers. Odds of laparoscopic resection for Whites when compared to Blacks was 1.57 higher (95% CI: 1.45-1.71, p <0.01). At academic centers in the Southeast, the laparoscopic utilization rate was 44% for Whites, 35% for Blacks, and 60.1% at Hispanics academic centers, and 36.7%, 29%, and 57.9% respectively at non-academic centers. Odds of laparoscopic resection for Whites compared to Blacks was 1.45 higher (95% CI: 1.23-1.72, p <0.01). In academic centers in GA, the laparoscopic utilization rate was 48.9% for Whites, 21.4% for Blacks, and 0% for Hispanics and 47.5%, 47.9%, and 28.6% respectively at non-academic centers. Odds of laparoscopic resection for Whites compared to Blacks was 1.65 higher (95% CI: 1.93 – 3.20, p < 0.05). We have completed this analysis for all the Northeast, Mideast, Great Lakes, Plains, Southwest, Rocky Mountain, and Far West regions as well.

Conclusion: These results demonstrate significant disparities in the use of laparoscopic surgery to treat diverticulitis both at academic and non-academic centers at the national, regional, and state level.

 

51.14 Optimizing Colorectal Outcomes: Does Surgeon Specialty play a role?

Posted on January 26, 2017

Y. Alimi1, A. Asemota1, R. Stone3, B. Safar1, S. Fang1, S. Gearhart1, J. Efron1, E. Wick2  3Johns Hopkins University,Department Of Obstetrics And Gynecology,Baltimore, MD, USA 1Johns Hopkins University,Department Of Surgery,Baltimore, MARYLAND, USA 2UCSF,Department Of Surgery,San Francisco, CALIFORNIA, USA

Introduction: There is intense pressure to deliver high value surgical care by optimizing patient outcomes and reducing costs. Surgical site infections (SSIs) are the leading cause of morbidity after colorectal surgery. Most of the quality improvement efforts have focused on general surgeons but other surgical specialists, particularly gynecologic oncologists also perform colorectal resections as part of their practice. Therefore, the objective of this study is to assess the impact of surgeon specialty on morbidity after colorectal surgery to determine the potential impact of broader, transdisciplinary collaboration in colorectal quality improvement.

Methods: The American College of Surgeons National Surgical Quality Improvement Program (Jan 1, 2006 – Dec 31, 2013) was used to identify female patients undergoing colorectal surgery with a diagnosis of a solid organ malignancy. Logistic regression was used to analyze patient and procedure factors in cases with and without SSIs. The primary surgeon specialty was categorized as either general (general, colorectal or surgical oncologist) or gynecologic. Proportion odds ratio of any documented SSI (Superficial, Deep, Organ Space) and readmission occurrence; relative risk hospital length of stay. The National inpatient sample was used to project potential cost savings.

Results: Among the 108,415 patients identified undergoing colorectal surgery for solid organ malignancy, 106,130 were operated on by general surgeons and 2,285 by gynecologists. Patients operated on by gynecologists were, compared to those operated on by general surgeons: younger (64.1 vs 67.3 yrs, p<0.001), more likely to have contaminated/dirty wounds (12.2% vs 9.1%, p<0.001), be more complex (ASA 3/4 61.6% vs 57.5%, p<0.001), have longer mean operative time (264.0 vs 166.2 min, p<0.001), less likely to receive preoperative radiation (3.2% vs 0.57%, p = 0.002); but more likely to receive preoperative chemotherapy (1.9% vs 2.5%, p<0.001). The unadjusted rate of SSIs was higher for cases performed by gynecologists than for cases performed by general surgeons (17.3 vs 10.9, p <0.001). On multivariate analysis, patients operated on by gynecologists remained more likely to have SSIs than did their general surgery counterparts [any SSI: 1.15 (1.05 – 1.27), p <0.001]. 

Conclusion: Although gynecologists only perform a small subset of colorectal surgery procedures, their patients are at higher risk of developing an SSI. These elevated rates of infections results in a potential cost savings of $31,254,070. Further study is needed to understand if this difference is related to a gap in translating best practice evidence into practice, or to surgical technique.

51.13 Socioeconomic Disparities Among Bariatric Surgery Patients

Posted on January 26, 2017

U. Deonarine5, G. Ortega1, C. K. Zogg3, R. Altafi6, D. J. Taghipour6, N. Changoor2, D. D. Tran2, E. E. Cornwell2, T. M. Fullum1  1Howard University College Of Medicine,Division Of Minimally Invasive Surgery/ Department Of Surgery/ Howard University College Of Medicine,Washington, DC, USA 2Howard University College Of Medicine,Department Of Surgery,Washington, DC, USA 3Yale University School Of Medicine,New Haven, CT, USA 4Howard University College Of Medicine,Washington, DC, USA 5Howard University College Of Medicine,Department Of Medicine,Washington, DC, USA 6Howard University College Of Medicine,Outcomes Research Center, Department Of Surgery,Washington, DC, USA

Introduction:
Morbid obesity is a modifiable risk factor for many diseases that substantially impact the burden of care in the United States. Research has shown morbid obesity and obesity related complications to be more prevalent in minorities and lower socioeconomic classes. Bariatric surgery is an effective treatment for morbid obesity but continues to be underutilized in the population that may benefit the most. Our objective is to determine if the utilization of bariatric surgery differs by socioeconomic and demographic categorization among morbidly obese patients by analyzing data from a national database.  

Methods:
We conducted a retrospective review of the Nationwide Inpatient Sample (NIS) database from 2005 to 2013, selecting for patients with a diagnosis of morbid obesity. Data analyzed included patient characteristics such as demographics, co-morbid conditions, inpatient events, and post-operative morbidity and mortality. Cases were dichotomized into those who received bariatric surgery and those who did not. The two groups were compared utilizing t-test and chi-2 analysis when appropriate. A multivariate analysis was performed adjusting for patient characteristics and co-morbid conditions evaluating utilization by socioeconomic and demographic characteristics.

Results:

A total of 2,040,869 patients were morbidly obese. Of those the majority were White (68%), female (67%), and had a mean age of 53 years (SD+- 15). Overall, most patients had Medicare (39%), followed by private insurance (36%) and Medicaid (17%). Regarding median household income (MHI) the majority were in the lowest income quartile (32%), followed by second income quartile (28%), third income quartile (23%) and highest income quartile (17%). Nine percent of patients underwent bariatric surgery (n=184,615). Of the patients undergoing bariatric surgery most were White (72%, p<0.001), female (79%, p<0.001), were younger (45 vs. 54 years, p<0.001), in the third income quartile (27%, p<0.001) and had private insurance (70%, p<0.001). On adjusted analysis morbidly obese Black (OR 0.515, 95%CI: 0.506-0.525), Hispanic (OR 0.751, 95%CI: 0.736-0.768), Asian/ Pacific Islander (OR 0.645, 95%CI: 0.597-0.699) and Native American (OR 0.749, 95%CI: 0.695-0.807) were less likely to undergo bariatric surgery when compared to White patients. Regarding MHI, the second income quartile (OR 1.53, 95%CI: 1.49-1.55), the third (OR 1.85, 95%CI: 1.82-1.89) and fourth (OR 2.71, 95%CI: 2.66-2.76) were more likely to have bariatric surgery. Patients with private insurance were more likely to have bariatric surgery (OR 4.28, 95%CI: 4.19-4.36), while those with Medicaid insurance were less likely (OR 0.67, 95%CI: 0.65-0.69) when compared to Medicare insurance.

Conclusion:
Increased utilization of bariatric surgery may reduce the impact of the obesity epidemic. It is essential that the population most affected by morbid obesity has access to this life changing intervention. 

51.12 Uncovering Temporal Disparities in Outcomes for Patients Undergoing Elective, Weekend Surgery

Posted on January 26, 2017

S. P. Nassoiy1, B. A. Blanco1, E. M. Grindstaff1, Y. Azure1, P. C. Kuo1, A. N. Kothari1  1Loyola University Medical Center,Maywood, IL, USA

Introduction: Temporal disparities of care, including the “weekend effect”, can negatively impact surgical outcomes. Our objective was to determine if patients undergoing elective, weekend surgery were at increased risk for developing adverse postoperative events.

Methods: Patients >18 years old who underwent elective general surgery between 2009 and 2010 in California, Florida, Iowa, New York or Washington were identified using the Health Care and Utilization Project State Inpatient Database. General surgery was defined as procedures of the gastrointestinal, endocrine and integumentary system. The primary outcome was inpatient mortality or major morbidity. Propensity scores were assigned using patient comorbidity and surgical approach. Risk adjustment was performed at the hospital level using multivariable logistic regression.  

Results:489,516 patients at 757 hospitals met our inclusion criteria. Of these, 4,391 patients underwent surgery on the weekend at 541 hospitals. 3,683 were propensity matched (1:1) to patients who had weekday surgery and no difference in the primary outcome was observed (2.1% vs. 2.5%, p=0.212). However, significant outcome variation existed amongst hospitals routinely performing elective weekend surgery (top volume decile), with 17.6% having higher than expected event rates, 22.8% with as expected performance, and 59.6% performing better than expected.

Conclusion: Overall, no population-level temporal disparity was identified in patients undergoing elective general surgery on the weekend. Certain centers did have increased incidence of major adverse events on the weekend than during the week. Future studies will be directed at elucidating hospital characteristics that can reduce this disparity in surgical care.

 

51.11 Regional Variations in Cost and Outcomes of Appendicitis in the United States

Posted on January 26, 2017

R. P. Won1, S. Friedlander1, Y. Lu1, S. L. Lee1  1Harbor-UCLA Medical Center,Surgery And Pediatrics,Torrance, CA, USA

Introduction:
The study of regional variations in costs and outcomes of care has been used to identify areas of savings for several diseases and conditions. This study investigates similar potential regional differences in the cost and outcomes of adult appendicitis. We hypothesized that there would be no difference in rates of perforation, morbidity, length of stay (LOS), and cost among different regions of the US. 

Methods:
Data were obtained from the California (CA), New York (NY), and Florida (FL) State Inpatient Databases spanning 2005-2011. Patients between the ages of 18-70 who underwent non-incidental appendectomies were evaluated with hierarchical and multivariate negative binomial regression analyses. Our primary outcomes included perforation, negative appendectomy, morbidity, hospital cost, and LOS.

Results:

There were 371,354 appendectomies performed between 2005-2011 in CA, NY, FL. The univariate analysis is summarized in the table. Multi-variate analysis confirmed the differences between states. CA had a higher rate of perforation compared to NY (p<0.01). CA also had a higher rate of negative appendectomies compared to both NY and FL (p<0.01). Morbidity was lower in NY compared to CA and FL (p<0.01). The LOS was lowest in CA (p<0.01), despite having the highest median cost per patient when compared to NY and FL (p<0.01)

Conclusion:
Significant regional differences exist with the presentation, outcomes, and costs associated with acute appendicitis. A better understanding of these differences may result in significant cost savings. 

51.10 Racial Disparities in Surgical Outcomes Persist in Emergency General Surgery

Posted on January 26, 2017

M. D. Giglia1, A. A. Gullick1, P. L. Bosarge2, J. D. Kerby2, D. I. Chu1  1University Of Alabama At Birmingham,Gastrointestinal Surgery,Birmingham, AL, USA 2University Of Alabama At Birmingham,Acute Care Surgery,Birmingham, AL, USA

Introduction: Racial disparities have been well-studied in elective specialties. Less is understood about disparities in emergency general surgery. We aimed to determine the contribution of race to readmission rate, length of stay (LOS), and mortality in patients who required emergency general surgery in a contemporary surgical population.

Methods: We queried the 2011-2014 American College of Surgeons National Surgical Quality Improvement Program database for all patients who underwent emergency general surgery and stratified by race. Primary outcomes were readmission rate, LOS and mortality. Predictors of readmission rate, LOS, and mortality were identified with multivariate logistic regression and negative binomial models, from which Odds Ratios [OR] and Incident Rate Ratios [IRR] were obtained.

Results: Of 114,411 patients who underwent emergency general surgery, 69.6% were white, 13.3% were Hispanic, 12.1% were black and 4.9% were Asian. Compared to white, Hispanic and Asian patients, black patients had higher rates of heart failure (2.5% vs 1.8%,1.0% and 0.7%), end-stage renal disease on dialysis (4.9% vs 1.6%,1.8% and 2.3%), total functional dependence (2.6% vs 1.8%, 1.0% and 1.0%), hypertension (49.3% vs 40.3%, 23.9%, and 31.6%), smoking (26.5% vs 21.7%, 15.2%, and 10.9%), diabetes (18.2% vs 12.4%, 12.5%, and 12.8%), presentation with an open wound/wound infection (6.8% vs 4.4%, 3.0% and 1.9%), and  ASA Class 4-5 (20.3% vs 18.0%, 7.6% and 9.0%) (p<0.001), respectively. On unadjusted comparison, black patients had higher readmission rates (9.3% vs 8.5%, 5.9% and 5.5%, p<0.001), mean LOS (7.54 vs 6.43, 3.97, and 5.03 days, p<0.001) and median LOS (5 vs 4, 2, 2 days, p<0.001) than white, Hispanic and Asian patients, respectively. White patients had a higher unadjusted mortality rate compared to black, Hispanic and Asian patients (6.5% vs 5.5%, 2.5% and 3.3%, p<0.001). On adjusted comparison, black race was not independently associated with higher readmission rates compared to white patients (OR 1.01, 95%-Confidence Interval [CI] 0.95-1.08); however, Hispanic (OR 0.88, CI 0.81-0.95) and Asian (OR 0.78, CI 0.69-0.88) race was associated with lower risk for readmission. Black race remained independently associated with longer mean LOS (7.75 days vs 6.60, 4.09 and 5.12 days, p<0.001) and had longer LOS of 11%, 14% and 6% compared to white, Hispanic and Asian patients, respectively (IRR 1.11, 1.14 and 1.06, p<0.0001).  Compared to white patients, black (OR 0.80, CI 0.72-0.88), Hispanic (OR 0.99, CI 0.86-1.13) and Asian patients (OR 0.90, CI 0.74-1.09) had a lower risk of mortality.

Conclusion: Black patients who underwent emergency general surgery had significantly longer LOS than white, Hispanic and Asian patients. Mortality, however, was highest for white patients compared to all other groups. Further studies are needed to better understand these observations and to identify actionable opportunities to reduce these disparities.

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