15.12 Cost effectiveness of laparoscopic vs open appendectomy in developing nations, a Colombian analysis

Posted on January 25, 2017

S. Rey1, A. Ruiz Patino1, G. Molina1, S. Rugeles1  1Hospital Universitario San Ignacio,Department Of Surgery,Bogota, DC, Colombia

Introduction: Colombia is a developing nation in need for efficient resource administration in fields such as healthcare, were innovation is constant. Since the introduction of laparoscopic appendectomy, direct costs have been increasing without definitive results in terms of clinical outcomes. The objective of this study is to determine the cost effectiveness of open vs laparoscopic appendectomy and thereby help surgeons in clinical decision making in a limited resource setting.   

Methods: A retrospective cost effectiveness analysis comparing open (OA) vs multiport laparoscopic appendectomy (LA) during 2013 in a third level university hospital (Hospital Universitario San Ignacio) in Bogota, Colombia was performed. Effectiveness was determined as the number of days in additional length of stay due to complications saved. 377 clinical stories were collected by the authors and analyzed for the variables: surgery type, conversion to open laparotomy, complications (surgical site infection, reintervention, re admission), hospital length of stay (LOS) and total cost of hospitalization for initial surgery and subsequent complications related hospitalizations. The total accumulative costs and lengths of stay for OA and LA plus complications were estimated. The cost effectiveness threshold was set at US 46 (139,000 COP), the cost of an additional day in length of stay. An Incremental cost effectiveness ratio (ICER) was calculated for OA as the comparator and LA as the intervention. 

Results: The number of LA was 130 and for OA 247. The two groups were balanced in terms of population characteristics. Complication rate was 13.7 % for OA and 10.4% for LA (p <0.05) and LOS was 2 days for LA and OP (p=0.9). No conversions from LA to OA were recorded. The total costs for complications for OA were US 8,523 (25,569,220 COP) and US 3,385 (10,157,758 COP) for LA. Cumulative costs including cost of surgery and complications and length of stay for OA were US 65,753 (197,259,310 COP) and 297 respectively. For LA were US 66,425 (199,276,948 COP) and 271. The ICER was US 25.86 (77,601 COP) making LA a cost effective alternative with a difference of US 20.76 (62,299 COP) under the Cost-effectiveness threshold.

Conclusion: Laparoscopic appendectomy is a cost effective alternative over open appendectomy with an increasing cost of $25.85 per day of additional hospitalization due to complications saved. This is accounting the low cost of surgical interventions and complications in developing nations such as Colombia.

15.11 Patients with Benign Gallstone Disease Should Be Admitted to a Surgical Team

Posted on January 25, 2017

V. Sandoval1, J. T. Brady1, M. E. Kelly2, S. R. Steele1, V. P. Ho1  1University Hospitals Case Medical Center,Surgery,Cleveland, OH, USA 2Case Western Reserve University School Of Medicine,Cleveland, OH, USA

Introduction:  Benign gallstone disease is a common problem that becomes symptomatic in a minority of patients, but remains associated with significant health care utilization and costs. These patients can be admitted to a surgical or non-surgical (“medical”) team, but not much is known about the impact of this on patient outcomes in the current model of Acute Care Surgery (ACS) services.

Methods:  We performed a retrospective review of patients who underwent cholecystectomy by the ACS service at a tertiary care academic medical center from 7/2013 to 6/2015. Patient were identified by Current Procedural Terminology codes for open or laparoscopic cholecystectomy, percutaneous cholecystostomy or ERCP. Patients who underwent cholecystectomy during the index admission were grouped based on admitting service (ACS vs. medicine). Other data points collected included date of admission, date of surgery consult, diagnostic tests performed, and length of stay Continuous variables were compared using Student’s t test and categorical variables compared using Chi square or Fisher’s exact test where appropriate.

Results: We identified 85 patients during the study period who underwent cholecystectomy, of whom 51.8% (n=44) were admitted to the ACS service. The majority of the patients in the ACS and medicine groups were female (84.1% vs. 75.6%, respectively, P=0.33). Mean age was similar in both groups (ACS: 43.1±20.9 vs. medicine: 49.2±19.2, P=0.17). There were significantly more patients admitted to a medical service who were transferred from an outside facility (43.9% vs. 13.6%, P=0.002). The mean number of days from arrival at the hospital to surgery consult was  0.9±0.2 days in the medicine group. The mean number of days from ACS consult or admission to ACS to procedure date was similar (2.4±1.3 vs. 2.7±1.9, P=0.37). The number of diagnostic tests overall including CT, Ultrasound, HIDA scan and ERCP was similar between groups (ACS: 1.9±1.1 vs. medicine: 2.3±1.1, P=0.09). Significantly more patients in the medical admission group had acute pancreatitis on admission (51.2% vs. 9.1%, P=<0.001). There was no significant difference in the percentage of patients who underwent a laparoscopic approach between groups (ACS: 93.2% vs. medicine: 82.9%, P=0.14). There was an overall decreased length of stay by 1.2 days in the ACS group but it did not reach statistical significance (5.4±2.6 vs. 6.6±2.9, P=.052). 

Conclusion: This study suggests that patients who underwent cholecystectomy and were admitted to the ACS service had a 1 day shorter length of stay compared to patients admitted to a medical service and for which ACS was consulted. Implementing policies that favor admission to a surgery service could lead to decreased costs for patients.

 

15.01 Understanding the Financial Burden Associated with the Treatment of Colorectal Cancer

Posted on January 25, 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:  Colorectal cancer (CRC) represents the second leading cause of cancer, as well as the second most expensive cancer in the United States. While the implementation of a bundled care payment model has been proposed to curtail the increasing financial burden associated with the treatment of CRC, the distribution and determinants of payments among privately insured patients remain largely unknown. The current study sought to characterize and explain differences in payments received for the treatment of CRC using a cohort of commercially insured patients.

Methods:  Patients >18 years of age, who underwent a colorectal surgery with a primary diagnosis of colon or rectal cancer were identified using the Truven Health MarketScan Database for 2010-2014. Total payments associated with surgery, chemotherapy and / or radiation therapy were calculated. Nonparametric, multivariable linear regression analysis was used to calculate and compare risk-adjusted payments between patients.

Results: A total of 32,782 patients were identified who underwent a colorectal resection for cancer. The median age of the study population was 55 years (IQR: 49-60) with 54.4% (n=17,823) being male. Comorbidities were common as 49.1% (n=16,142) patients presented with preexisting comorbidity (Charlson comorbidity index (CCI)>2). The median risk-adjusted payment for surgery was $27,726 (IQR: $20,099-$40,013), ranging from $17,528 among patients in the lowest quartile of payments to $40,968 among patients included in the highest quartile of payments (+Δ $23,440, p<0.001). Greater preoperative comorbidity (CCI=2 vs. CCI>6: $36,082 vs. $40,944) and the development of a postoperative complication (no complication vs. complication: $35,823 vs. $44,858) were associated with higher payments (both p<0.001). Following surgery, 44.0% of patients received adjuvant therapy. Marked variations in payments received for adjuvant therapy were observed ranging from $366 / cycle of chemotherapy for patients in the lowest quartile of payments to $10,426 / cycle of chemotherapy among patients included in the highest quartile of payments (+Δ $10,060, p<0.001). Among patients included within the lowest quartile of payments chemotherapy accounted for 13.7% of all payments received; in contrast, among patients included in the highest quartile, chemotherapy related payments accounted for 63.4% of all payments received (+Δ 49.7%). Payments received for radiation therapy were comparable among all patients and accounted for <1% of all payments. 

Conclusion: Payments associated with the care of CRC varied significantly despite case-mix and geographical adjustment. Variations in payments were largely due to differences in chemotherapy, and less due to differences in payments for surgery. Episode-based bundle payments for surgery and chemotherapy may differentially impact reimbursement for CRC associated care.

 

14.20 Ultrasonographic Detection of Occult Inguinal Hernia

Posted on January 25, 2017

C. Shwaartz1, R. S. Lingnurkar2, B. Cohen1, M. Cohen1, H. K. Rosenberg1, C. M. Divino1  1Icahn School Of Medecine At Mount Sinai,General Surgery,New York, NY, USA 2Central Michigan University College Of Medicine,College Of Medicine,Mount Pleasant, MI, USA

Introduction:

In recent years, ultrasonography has gained popularity as an adjunct to physical examination, replacing the now abandoned contrast herniography to detect occult inguinal hernias. Despite pronounced heterogeneity in reported positive and negative predictive values for this modality, the integration of ultrasound in the diagnostic algorithm for inguinal discomfort has been advocated when physical examination alone is inconclusive. The aim of this study is to confirm this recommendation by assessing the diagnostic value of ultrasonography in detecting occult inguinal hernia, and appraise the limits of its detection rate across discrete populations. 

Methods:

We retrospectively reviewed the demography and the outcome of 137 patients presenting with inguinal discomfort between the years 2013 and 2016 in a single surgeon practice. Inclusion criteria were the following: (1) inconclusive physical examination by a single surgeon, and (2) ultrasound and interpretation by a single radiologist following physical examination. Follow up data were collected by either a clinic visit for inguinal hernia repair soon after inguinal ultrasound, or a telephone survey querying for both inguinal hernia repair during the follow up period, and eventual resolution of symptoms. Demographic factors affecting the accuracy of ultrasonography were analyzed.

Results:

137 patients were included in the study, with a median age of 49 years, of which 45% were females. 26 (19%) were tested positive and 111 (81%) were tested negative for occult inguinal hernia. A total of 18 (13%) patients underwent surgery soon after inguinal ultrasound. Of the remaining 119 patients, 101 (85%) were successfully called for follow up. 37 (31%) patients remained symptomatic on follow up, and 4 (3%) patients had undergone inguinal hernia repair during the follow up period. Positive and negative predictive values (PPV and NPV) for ultrasound in detecting occult inguinal hernia were determined to be 79.17%, and 61.05% respectively. Variance across cohort was noted: ultrasound accuracy was influenced by gender (PPV 90.91% in females vs. 69.2 in males), age (PPV 90.91% below 49 and 71.4 above 49), BMI, prior hernia surgery and comorbidities predisposing to hernia formation (lung disease, constipation, prostatism) (PPV of 85.7% with comorbidity vs. 76.4% without).

Conclusion:

Inguinal ultrasonography has a moderately high positive predictive value, but a relatively low negative predictive value for detecting occult inguinal hernia. Our study uniquely stratified these diagnostic values across discrete populations, revealing particularly high positive predictive values for females, patients aged ≤ 49, and patients with predisposing comorbidities.  These findings suggest that ultrasound may be most effective in detecting occult inguinal hernia in representative patients.

 

14.19 Patient-related and technical factors determining recovery after emergency appendicectomy

Posted on January 25, 2017

S. G. Thrumurthy1, R. Som1  1King’s College Hospital NHS Foundation Trust,Surgery,London, London, United Kingdom

Introduction:
Appendicectomy remains one of the most commonly performed emergency surgical operations, and postoperative recovery is influenced by various patient-related and technical factors. This prospective study aimed to identify how such factors affect the incidence of complications and the extent of symptom resolution after emergency appendicectomy.

Methods:
Patients who underwent emergency appendicectomy over a six month period were contacted by telephone. A standardised questionnaire was used to ascertain the duration of analgesia use, duration before return to normal physical activity, duration before return to work or school, surgical site infection rates, rates of re-presentation to community physicians or the emergency department, and rates of readmission to hospital. Patients were stratified into those who underwent laparoscopic versus open appendicectomy, smokers verses non-smokers, and body mass index (BMI) < 30 versus BMI > 30.

Results:
A total of 145 patients were included. Patients undergoing open surgery (versus laparoscopic surgery) required analgesia for significantly longer periods (22 days v. 6 days, p = 0.017), and a longer recovery period before full return to normal daily activities (48 days v. 17 days, p < 0.0001) and school/work (33 days v. 13 days, p < 0.0001). Compared to non-smokers, smokers required longer a recovery period before returning to school/work (24 days v. 17 days, p = 0.048), had a significantly higher risk of surgical site infection (relative risk [RR] 2.21, p = 0.029), and a higher risk of re-presenting to the emergency department (RR 3.21, p = 0.003) and being re-admitted to hospital within 3 months of surgery (RR 8.36, p = 0.002). Compared to patients with a BMI under 30, those with a BMI over 30 had a longer recovery period before full return to normal daily activities (49 days v. 24 days, p = 0.041) and school/work (26 days v. 17 days, p = 0.016), a higher rate of surgical site infection (RR 2.13, p = 0.044), and a higher risk of re-presenting to the emergency department (RR 3.09, p = 0.005) and being re-admitted to hospital within 3 months of surgery (RR 6.0, p = 0.008).

Conclusion:
When possible, the laparoscopic approach to appendicectomy should be adopted over open surgery to improve postoperative recovery. Patients who are smokers or obese (BMI > 30) should be warned of prolonged recovery times, and surgeons must be wary that such patients are at greater risk of surgical site infections and needing emergent or inpatient care for postoperative complications. Such patient groups may benefit from early postoperative outpatient follow-up.
 

14.18 Surgeon Attitudes Towards Prescribing Opioids

Posted on January 25, 2017

M. Alameddine1, O. Brown1, C. Hoban1, R. Kabeer1, H. Paulsen1, J. Silverberg1, B. VanWieren1, J. S. Lee1, M. J. Englebse1  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction:
Opioid-based pain management is contributing to an epidemic of opioid-related complications. The lack of clear guidelines in the prescription of opioid pharmaceuticals has encouraged inconsistent prescribing habits throughout the United States. Consequently, it is imperative to survey the current practice surrounding opioid-based pain management and identify detrimental trends that can be reversed via reforms in current practice guidelines. Establishing coherent protocols that unify providers in the individualized management of acute surgical pain will help to protect patients from the risk of chronic opioid dependence. The objective of this study is to characterize inconsistencies in perioperative pain management and thereby identify interventions that can most effectively encourage appropriate opioid prescribing practices. 

Methods:
A 26-question survey was constructed, piloted, and finalized through a collaboration of faculty input and student-led background research. The survey evaluated providers’ knowledge of opioid pharmacology, assessed their theoretical perioperative pain management practice in case scenarios, and surveyed their provider-specific approach to opioid prescriptive practices. All opioid-prescribing health professionals at the University of Michigan Health System were invited to participate in the study. The survey was hosted in Qualtrics and distributed via a standard email invitation and link.

Results:
Of the 66 health professionals that responded to the survey (n=201), 90% do not use a risk assessment questionnaire and 89% either rarely use, never use or are not familiar with the Michigan Automated Prescription System (MAPS). 70% of providers were confident answering questions on opioid prescribing practices in a case scenario describing an uncomplicated hernia repair, and of these 46 providers, 15 (33%) described that they would prescribe less than 30 pills for postoperative pain management, while 31 (67%) would prescribe greater than 30 pills. We then compared these subgroups using an unpaired T-test and both discussed pain management prior to surgery with, on average, only 25-50% of their patients.

Conclusion:
Despite clear evidence of an opioid epidemic in this country, our study demonstrates that health professionals are not fully utilizing available resources and prescribing practice strategies that may decrease the risk of opioid-related complications. We also saw that for the same surgical case, there is variation in the number of opioid pills that physicians would prescribe for patients post-operatively. Moving forward, the goal is to further investigate why current prescribing practices exist and try to identify potential areas for intervention and improvement. Specifically, encouraging the use of standardized prescription guidelines, risk assessment questionnaires, MAPS, and longitudinal discussions regarding postoperative pain management with patients could help to mitigate the current opioid epidemic.
 

14.17 Predicting Outcomes in Hospitalized Patients Requiring Emergency General Surgery

Posted on January 25, 2017

C. E. Sharoky1, E. A. Bailey1, M. M. Sellers1, A. J. Sinnamon1, C. Wirtalla1, D. N. Holena1, R. R. Kelz1  1Hospital Of The University Of Pennsylvania,Center For Surgery And Health Economics, Department Of Surgery,Philadelphia, PA, USA

Introduction: Acute care surgeons are charged with caring for a heterogeneous population, including patients who become acutely ill while hospitalized. Decision-making regarding these patients is often complicated, yet the majority of emergency general surgery (EGS) research has focused on the population operated on within the first two days of hospitalization. We examined outcomes of patients who had EGS at least three days after admission in order to identify preoperative and operative factors that predict mortality and postoperative length of stay >30d (LOS30) in this high risk cohort.

 

Methods: Patients >18y who had one of seven most common EGS operations (appendectomy, partial colectomy, small bowel resection, operative management of peptic ulcer disease, cholecystectomy, lysis of adhesions, exploratory laparotomy) after hospital day two on an emergent basis were identified in the ACS NSQIP registry (2011-2014). Exploratory laparotomy with no secondary procedure code was presumed non-therapeutic (NTEL). Descriptive statistics were performed. Multivariable logistic regression was used to identify predictors of 30 day mortality or LOS30 in independent models.

 

Results: Of 10,674 EGS patients who met inclusion criteria, the median age was 66 (IQR: 53-77) years. The majority of patients were white (65.5%), functionally independent (86.6%), and admitted from home (81.6%). Sepsis was the most common surgical indication (n=4,295; 40.2%). Median postoperative LOS was 8d (IQR 4-14d), and 719 (7.5%) patients experienced LOS30. Thirteen percent (n=1,424) of patients died within 30 days of operation (median time to death: 8d IQR 2-16d). Of those who died, 742 (52.1%) had a partial colectomy, 290 (20.4%) had a small bowel resection, and 600 (42.1%) failed extubation within 48 hours. Of patients who had NTEL, 171 (41.0%) died within 30 days. Factors most significantly associated with death were ASA class, age and procedure type. NTEL was the greatest operative predictor of death (OR 6.9 p<0.001). Factors most significantly associated with LOS30 were failure to extubate, ASA class and procedure type. Compared to patients whose index operation occurred during week 1, odds of death increased for each subsequent week prior to surgery (week 6 OR 2.6; CI: 1.8-3.9). Odds of LOS30 also increased weekly (week 6 OR 5.5 CI: 3.3-8.3). NTEL after week 3 had ≥50% risk of LOS30.

 

Conclusion: An important subset of patients require EGS after hospitalization. Although these patients are functionally independent on admission, mortality in this cohort is even higher than currently reported in published EGS literature. Risk of death and LOS30 increase as time from hospitalization to operation increases. Those who have NTEL are at particularly high risk of death or LOS30 following surgery. Patient and societal benefit versus risk of surgery in this cohort is complex and demands more attention from the research community.

14.16 Impact of Narcotic Analgesic Use on HIDA Scan-based Gallbladder Ejection Fractions

Posted on January 25, 2017

E. Wiesner1,2, L. Martin1,2, W. Peche1,2, J. Langell1,2  1VA Salt Lake City Health Care System,Center Of Innovation,Salt Lake City, UT, USA 2University Of Utah,Department Of Surgery,Salt Lake City, UT, USA

Introduction:  The use of gallbladder ejection fraction obtained by hepatobiliary iminodiacetic acid scan to diagnose Biliary Dyskinesia (BD) continues to be controversial. Cholescintigraphy or hepatobiliary iminodiacetic acid (HIDA) scan is a nuclear medicine imaging study that allows for the calculation of gallbladder ejection fraction (GBEF).  Patients with a clinical presentation consistent with BD and a low GBEF (<35%) are considered appropriate candidates for therapeutic cholecystectomy.  False positive HIDA-based GBEFs have been associated with the concomitant use of narcotic medications.  Narcotic analgesics are thought to reduce biliary smooth muscle motility and are typically therefore discontinued prior to conducting the HIDA scan. In this study we looked at the impact of narcotic use on HIDA scan-based GBEF in patients with suspected BD.

Methods:  We queried the Veterans Healthcare Administration National Corporate Data Warehouse from January 2005 to July 2016 for patients who underwent more than one HIDA scan. Patients undergoing HIDA for a suspected diagnosis of BD were included. Radiology reports were reviewed and the GBEF for each study was abstracted. We further categorized patients with abnormal GBEFs into those receiving concomitant narcotic analgesics during their initial HIDA scan and on subsequent HIDA scan.  A comparison was conducted to determine the impact of narcotic use on the reported GBEF in these populations.

Results: We identified 546 patients who underwent more than one HIDA scan for suspected BD during the study period.  Thirty-three percent (181) of all patients had an abnormal GBEF (average GBEF=17%) on their initial study.  Of these, 34 patients (19%) were on narcotic analgesics at the time of their initial HIDA scan (average GBEF=16%).  Of the 181 patients with a low GBEF, 45% were found to have a normal GBEF on repeat scan (average GBEF=41% and average time between studies 26.5 months), where as 100% of patients on narcotic analgesics demonstrated a normal GBEF on subsequent HIDA scan (average GBEF=74% and average time between studies 29.9 months) (p-value=0.005).  This finding was independent of continued narcotic use (26% of patients).

Conclusion: In this study, all patients who met diagnostic criteria for BD based on a low HIDA scan-based GBEF and were on narcotic analgesics at the time of the initial HIDA scan demonstrated a normal GBEF on subsequent scan.   This finding was independent of chronic long-term narcotic analgesic use.  Of the 26% of patients who remained on narcotic analgesics at the time of repeat scan, 100% were found to have a normal GBEF.  Although this study supports the discontinuation of narcotic analgesics prior to conducting a HIDA scan when possible, it also suggests that there may still be utility in conducting the repeat scan when patients who are chronic users of narcotics are unable to come off these medications. Further studies will need to be conducted to confirm these findings and determine if the effect of narcotic analgesics on biliary smooth muscle motility is lost with chronic narcotic exposure. 

 

14.15 ERAS: Eliminating the Length of Stay Differences between Open and Laparoscopic Colorectal Surgery

Posted on January 25, 2017

W. J. Farrington1, A. Gullick1, T. S. Wahl1, L. Goss1, M. Morris1, J. Cannon1, G. Kennedy1, D. I. Chu1  1University Of Alabama At Birmingham Medical Center,General Surgery,Birmingham, AL, USA

Introduction: The laparoscopic approach to colorectal surgery has several advantages compared to traditional open surgery including reduced length-of-stay (LOS). While the effectiveness of Enhanced Recovery After Surgery (ERAS) on reducing LOS is well-documented, it remains unclear whether ERAS equilibrates the LOS differences between open and laparoscopic surgery. We hypothesized that ERAS would reduce the LOS for both open and laparoscopic surgery and eliminate these differences.

Methods: A single-institution retrospective review of patients undergoing both laparoscopic and open colorectal surgery before and after the implementation of ERAS was conducted. Patient and procedure-specific variables were recorded. Primary outcome was post-operative LOS. Univariate and bivariate comparison were made. Chi-square and Wilcoxon Rank Sums tests were used to determine differences among categorical and continuous variables, respectively.

Results: Four hundred and twenty patients were included in this study. The pre-ERAS (n=210) patient groups included laparoscopic (n=68) and open (n=142) surgical approaches for both benign and malignant disease. The post-ERAS (n=210) group included laparoscopic (n=92) and open (n=118) surgeries. Patient gender, race, ASA class, smoking and insurance status did not differ by surgical approach among Pre-ERAS and ERAS patients (p>0.05). However, age, indication for surgery, procedure type, and operative time were significantly different by surgical approach in both pre-ERAS and ERAS groups (p<0.05). Prior to the initiation of ERAS, laparoscopic surgery exhibited an advantage in shorter LOS compared to open surgery (5 v. 6 days, p= 0.049). With ERAS, the LOS advantage of laparoscopic surgery was eliminated and LOS was similar between laparoscopic and open surgeries (4 v. 4 days, p= 0.12) (Figure 1).

Conclusion: ERAS reduces LOS for both laparoscopic and open colorectal surgery. Importantly, the LOS advantage of laparoscopic surgery was eliminated with ERAS. These data suggest that ERAS has positive effects on all approaches to colorectal surgery and should be used widely.

 

14.14 Concurrent PEH/Bariatric Surgery: Improved Outcomes of Sleeve Gastrectomy Compared to Gastric Bypass

Posted on January 25, 2017

A. Shada1, M. Stem2, L. Funk1, D. C. Jackson1, J. Greenberg1, A. Stroud1, A. O. Lidor1  1University Of Wisconsin,General Surgery, School Of Medicine And Public Health,Madison, WI, USA 2Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA

Introduction:
Nearly 200,000 bariatric operations are performed annually in the US. Paraesophageal hernia (PEH) is a relatively rare subset of hiatal hernia, but is associated with morbid obesity and is a fairly common condition that bariatric surgeons encounter. There is no consensus on the management of PEH at the time of bariatric surgery. We sought to examine short term outcomes following concomitant PEH repair at the time of bariatric surgery. We also investigated whether there were differences in 30 day outcomes between those who underwent a PEH repair and either a laparoscopic sleeve gastrectomy (LSG) or gastric roux-en-y bypass (LRGB).

Methods:
Using the American College of Surgeons National Surgical Quality Improvement Program database (2011-2014), patients who underwent bariatric surgery (laparoscopic gastric bypass or laparoscopic sleeve gastrectomy) with or without PEH repair were identified. A propensity score matching analysis was used to compare 30-day outcomes between these two groups. The primary outcome variable was overall morbidity; secondary outcome variables included mortality, readmissions, and reoperations. An additional propensity matched subgroup analysis compared LSG and LRGB in only those patients who received concurrent PEH repair.

Results:

Of the 76,343 bariatric surgery patients included in this study, 7.80%(n=5,958) underwent concurrent PEH repair. The proportion of bariatric cases that involved a concurrent PEH repair increased during the study period (2.14% in 2010 vs. 12.17% in 2014, p<0.001) with rate of concomitant PEH/LSG noted to be over 2.5 times higher than PEH/LRGB in 2014 (8.90% vs. 3.20%). After initial propensity score matching, 5,952 bariatric surgery patients who underwent a PEH repair were matched with 11,904 bariatric surgery patients who did not undergo a PEH repair. There were no significant differences in 30-day outcomes between the cohorts. However, the subgroup analysis demonstrated that among all patients with concurrent PEH repair, LRGB patients experienced greater rates of morbidity (6.20% vs. 2.69%, p<0.001), readmission (6.33% vs. 3.06%, p<0.001), and reoperation (3.00% vs. 1.05%, p<0.001) when compared to LSG patients.

Conclusion:
This study found that paraesophageal hernia repair at the time of bariatric surgery appears to be safe in the short-term and therefore strengthens the argument for a concurrent approach to the morbidly obese patient with PEH. In patients with PEH who are equivalent candidates for gastric bypass or sleeve gastrectomy, a sleeve gastrectomy may be preferable given that it is associated with a lower rate of postoperative morbidity.
 

14.13 Autonomous Detection and Grading of Post-Operative Complications Using Natural Language Processing

Posted on January 25, 2017

L. V. Selby1, W. R. Narain2, A. Russo1, H. McGowan1, V. E. Strong1, P. D. Stetson2  1Memorial Sloan-Kettering Cancer Center,Surgery,New York, NY, USA 2Memorial Sloan-Kettering Cancer Center,Health Informatics,New York, NY, USA

Introduction:  Natural language processing (NLP) is a computer science technique that allows interpretation of narrative text, but is infrequently used to identify surgical complications.  Our institution tracks post-operative complications using both the American College of Surgeons – National Surgical Quality Improvement Program (NSQIP) and our in-house surgical secondary events (SSE) database, which captures and grades complications for all surgical patients, but sub-optimally records lower-grade complications.  We attempted to use NLP to improve the entry of lower extremity deep venous thrombosis (DVT) and pulmonary embolisms (PE) (collectively: venous thromboembolism [VTE]) in the SSE database.

Methods:  In our 2011 – 2014 cohort of NSQIP patients all lower extremity duplex ultrasounds and computerized tomography angiographies (CTA) of the chest performed within 30 days of surgery were divided into training and validation datasets.   These studies were chosen as they represent the most frequent methods of detecting DVT and PE at our institution, and a bag-of-words-approach with a support vector machine (SVM) model was used for training.  Electronic health record data was used to classify the severity of the VTE according to our modification of the Clavien-Dindo classification.  Due to definition differences between NSQIP and the SSE database, we excluded cephalic and portal vein thromboses identified in NSQIP and compared NLP identified VTEs to VTEs identified by both NSQIP and our SSE database, and undertook a blinded review of all instances of discordance.

Results: Of the 10,295 NSQIP patients, 251 were used in our DVT validation cohort (273 total ultrasounds) and 506 in our PE cohort (552 total CTAs).  The SVM DVT model had a sensitivity of 85.1% and a specificity of 94.6%, while the PE model had a sensitivity of 90.0% and a specificity of 98.7% (Table 1).  The majority of discordances were due to identification of a VTE in studies other than duplex ultrasound or CTA of the chest (9/13; 69.2%), studies not in our original NLP dataset. The majority of DVTs (23 patients, 57.5%) and PEs (20 patients, 69.0%) in the validation set were grade 2 on our modified Clavien-Dindo classification, meaning they required administration of therapeutic intravenous or subcutaneous anticoagulation.  

Conclusion: NLP can reliably detect the presence and severity of post-operative lower extremity DVTs and PEs without requiring manual chart review from trained NSQIP surgical case reviewers. We are extending our NLP pilot to real-time identification and grading of all VTEs and to the detection of other post-operative complications, including wound infections.

 

14.12 A Nationwide Comparison of Laparoscopic Versus Open Appendectomy in Geriatric Patients

Posted on January 25, 2017

B. Zangbar1, L. Boudourakis2, V. Roudnitsky2, L. Dresner1  1State University Of New York Downstate Medical Center,General Surgery / Surgery / Medicine,Brooklyn, NY, USA 2Kings County Hospital Center,Trauma and Acute Care Surgery / Surgery / Medicine,Brooklyn, NY, USA

Introduction:  Acute appendicitis in elderly patients carries an increased risk of complications and mortality. The benefits of laparoscopic appendectomy (LA) remain undefined as compared to open appendectomy (OA) in elderly patients, particularly in cases of perforated appendicitis. The aim of our study was to evaluate the outcomes of LA versus OA in perforated and non-perforated appendicitis in elderly.

Methods:  Nationwide Inpatient Sample database was used to evaluate the clinical data of elderly patients (>65 years old) who underwent LA and OA over an 8-year period (2004-2011). Incidental and elective appendectomies were excluded. Univariate and Multivariate analysis was used.

Results: A total of 42,678 Elderly patients underwent urgent appendectomy in the United States during these years. The overall rate of perforated appendicitis was 28.4%, and 44.3% of all cases were performed laparoscopically. 21.4% of cases managed non-operatively. In non-perforated cases, LA was associated with lower overall complication rate (LA: 3.2% vs. OA: 7.9%; p < 0.001), shorter length of hospital stay (LOS, LA: 3.5 vs. OA: 6.7 days; p < 0.001), lower mortality (LA: 0.05% vs. OA: 1.9%; p < 0.001); and lower hospital charges (LA: $35,712 vs. OA: $46,345; p < 0.001) compared to OA. In perforated cases, LA had a lower overall complication rate (LA: 4.9% vs. OA: 10.4%; p < 0.001), shorter LOS (LA: 5.4 vs. OA: 7.7 days; p < 0.001), lower mortality (LA: 1.1% versus OA: 2.3%; p < 0.001), and lower hospital charges (LA: $42,823 versus OA: $51,393; p < 0.001) compared to OA.

Conclusion: LA has clear mortality and morbidity advantage in elderly patients with acute perforated and non-perforated appendicitis, and is associated with shorter hospital stay and lower hospital charges. Given their higher complication tendency and reduced physiological reserve, in elderly patients, laparoscopic appendectomy should be the standard of care.

 

14.11 Readability, Complexity, and Suitability of Online Resources for Mastectomy and Lumpectomy

Posted on January 25, 2017

B. N. Tran1, M. Singh1, B. T. Lee1  1Beth Israel Deaconess Medical Center,Plastic And Reconstructive Surgery/Surgery,Boston, MA, USA

Introduction:  Nearly half of American adults have low or marginal health literacy. This negatively affects patients’ participation, decision-making, satisfaction, and overall outcomes.   Previous studies in this area focus primarily on readability of online health information. This study compares online resources for mastectomy versus lumpectomy using expanded metrics including readability, complexity, and suitability.

Methods:  Ten most popular websites for mastectomy and lumpectomy were identified using the largest Internet engine (Google). Each website was assessed for readability (SMOG, Simple Measure of Gobbledygook), complexity (pMOSE/iKIRSCH), and suitability (SAM, Suitability Assessment of Materials). Scores were analyzed by each website and overall.

Results: Readability analysis showed average reading grade level of 15.38 and 13.80  (p=0.04) for mastectomy and lumpectomy literacy respectively.  Both exceeded the recommended sixth grade level. Complexity analysis via PMOSE/iKIRSCH revealed a mean score of 6.5 for mastectomy corresponding to a “low” complexity  and 8th-12th grade education. Lumpectomy literature had a lower PMOSE/iKIRSCH score of 5.8 corresponding to a “very low” complexity and 4th-8th grade education (p=0.05). Suitability assessment showed mean values of 41% and 46% (p=0.83) for mastectomy and lumpectomy literacy respectively, both are interpreted as “adequate” for the intended audience. Inter-rater agreement for PMOSE/iKIRSCH are 92% (k=0.73, p<0.001), and 96% (k=0.87, p<0.001) for mastectomy and lumpectomy literature respectively. Similarly, inter-rater agreement for suitability analysis are 94% (k-0.84, p<0.001), and 90% (k=0.73, p<0.001).

Conclusion: Online resources for breast cancer overall are above the recommended literacy level. When comparing mastectomy to lumpectomy, online resources for mastectomy have a higher reading grade level and tend to be more complex. 

14.08 The Safety and Feasibility of Early Discharge Following Ileostomy Closure: A NSQIP Analysis

Posted on January 25, 2017

A. I. Elnahas1, F. Quereshy1, R. Kelly2, T. Jackson1, A. Okrainec1, S. Chadi1, E. Le Souder1, U. David3  1Toronto Western Hospital,General Surgery,Toronto, ONTARIO, Canada 2University of Toronto,Surgery,Toronto, ONTARIO, Canada 3Women’s College Hospital,General Surgery,Toronto, ONTARIO, Canada

Introduction: The recent expansion of enhanced recovery programs after surgery has safely permitted early discharge for select patients following routine operations. As a result, more procedures are now being considered appropriate for outpatient surgery. The objective of this study is to determine if early discharge (i.e. less than 24 hours) following ileostomy closure is comparable to standard discharge (i.e. discharge on postoperative day 2 or 3) with respect to 30-day clinical outcomes.

 

Methods: Data was obtained from the American College of Surgeons’ National Surgery Quality Improvement Program participant use file to perform a retrospective cohort analysis. The study population consisted of patients discharged on postoperative day (POD) 0, 1, 2, or 3 who underwent elective ileostomy closure from 2005-2014. Patients were excluded if they had any concurrent procedure(s) or documented complications during admission. The primary outcome was the 30-day adverse event rate and the secondary outcome was the 30-day readmission rate. A multiple logistic regression analysis was performed to determine the adjusted effect of early discharge as well as the predictors of adverse events and readmissions.

 

Results: The study population consisted of 355 and 5798 patients in the early and standard discharge groups, respectively. There were no relevant clinical differences between the two groups. There were 19 (5.4%) 30-day adverse events in the early group and 341 (5.8%) in the standard group. The early group had 17 (4.8%) 30-day readmissions and the standard group had 294 (5.1%). Using a multiple logistic regression, an adjusted odds ratio (OR) estimate for 30-day adverse events and readmissions was determined for early discharge. The adjusted OR for 30-day adverse events was 0.95 (p=0.83) and for 30-day readmissions was 1.01 (p=0.96). Higher body mass index, longer operative time, ASA≥3, chronic steroid use along with a history of bleeding disorder and diabetes were significant predictors for adverse events and readmissions.

 

Conclusion: Using this large national surgical database, select patients discharged within 24 hours of ileostomy closure did not have a significantly higher rate of adverse events or readmissions compared to patients discharged on POD 2 or 3 following uncomplicated surgery. Predictors of adverse events and readmissions can help guide the selection of patients suitable for early discharge.

 

14.07 Delta-MELD and Outcomes in Emergency Surgery

Posted on January 25, 2017

M. L. Kueht1, E. Godfrey1, Z. Pallister1, S. Awad1  1Baylor College Of Medicine,Houston, TX, USA

Introduction:  The concept of delta MELD, the change in MELD score over a certain time period, has been shown to be a predictor of waitlist mortality, but not post-operative outcomes in liver transplantation. Liver transplantation is unique in that it improves liver function and transplant patients are generally free from significant cardiac disease; we sought to explore the effect of changing MELD scores on outcomes in non-transplant surgery.

Methods: We conducted a retrospective analysis of all emergency surgeries on patients with documented cirrhosis at the MEDVAMC between 2001 and 2012.  Delta MELD was calculated as the difference between MELD on the day of surgery (acute MELD) and a MELD calculated between 7 days and 9 months prior to the operation. Univariate analysis was used to identify predictors of 30-day mortality, intra- and post-operative complications, and disposition after discharge.

Results:Overall 30-day mortality was 15%.  Predictors of mortality were congestive heart failure (OR 5.57), serum creatinine on the day of surgery (OR 3.39), acute MELD (OR 1.43), and delta MELD (OR 1.34). The most common complication was the need for transfusion (39%).  Predictors of intraoperative complications were congestive heart failure (OR 9.32), coronary artery disease (OR 6.0), intra-abdominal surgery (OR 3.8), delta MELD (OR 1.23), and acute MELD (OR 1.19). Predictors of post-operative complications were intra-abdominal surgery (OR 3.92) and delta MELD (OR 1.22). 50% of patients needed transitional care.  Negative predictors of being discharged to home were INR on the day of surgery (OR 0.05), and acute MELD (OR 0.78).

Conclusion:Delta MELD and acute MELD performed equally well as predictors of intra-operative complications and 30-day mortality. However, only acute MELD was associated with the need for transitional care and only delta MELD was associated with post-operative complications.  The fact that the delta and acute MELD scores were predictive of different aspects of hospitalization suggests both may be of benefit in preparing for the logistics of emergency surgery in cirrhotic patients.

14.06 Should We Be Using More Home Health After Gastrointestinal Surgery?

Posted on January 25, 2017

C. Balentine1,2, G. Leverson3, D. J. Vanness3, S. J. Knight4, J. Turan5, C. J. Brown6,7, G. D. Kennedy1, H. Chen1, S. Bhatia2  1University Of Alabama At Birmingham,Surgery,Birmingham, AL, USA 2University Of Alabama At Birmingham,Institute For Cancer Outcomes And Survivorship,Birmingham, AL, USA 3University Of Wisconsin,Wisconsin Surgical Outcomes Research,Madison, WI, USA 4University Of Alabama At Birmingham,Department Of Preventive Medicine,Birmingham, AL, USA 5University Of Alabama At Birmingham,School Of Public Health,Birmingham, AL, USA 6University Of Alabama At Birmingham,Birmingham/Atlanta VA GRECC,Birmingham, AL, USA 7University Of Alabama At Birmingham,Department Of Medicine, Division Of Gerontology, Geriatrics & Palliative Care,Birmingham, AL, USA

Introduction: Post-acute care services such as home health, skilled nursing facilities, and inpatient rehabilitation play an important role in postoperative recovery.  Recent studies have questioned our ability to identify which setting best addresses each patient’s needs.  The purpose of this study is to evaluate whether patients discharged to skilled nursing facilities or inpatient rehabilitation could also be candidates for home health referral and vice versa, and to calculate potential savings from greater utilization of home health.  We hypothesized that a significant number of patients discharged to skilled nursing or rehabilitation would be similar to patients sent home with home health.

Methods: We analyzed 54,015 patients who were discharged with post-acute care after colectomy, pancreatectomy or hepatectomy from 2008-2011 in the Nationwide Inpatient Sample.  The primary endpoint was the proportion of patients discharged to skilled nursing facilities or inpatient rehabilitation who had an equivalent patient discharged home with home health.  This was determined by propensity score matching based on demographics, co-morbidity, postoperative complications, length of stay, predicted mortality, and insurance.  A secondary outcome was potential cost savings based on average Medicare costs.

Results: A total of 30,843 patients were discharged home with home health and 23,172 were discharged to skilled nursing facilities or inpatient rehabilitation. 66% of patients discharged home with home health were  ≥60 years old, compared to 90 % of the skilled nursing/rehabilitation group (p<0.001) and 70% of both groups were white.  14,163 (61%) patients discharged to skilled nursing or inpatient rehabilitation could be matched to an equivalent patient discharged home with home health. The matched populations did not show any differences in age, race, gender, insurance status, co-morbidity, postoperative complications, length of hospital stay, or predicted mortality (standardized difference <10%).  Potential cost savings from treating at home rather than in skilled nursing or inpatient rehabilitation facilities ranged from $2.5 million to $438 million annually. Potential savings varied based on a two-way sensitivity analysis varying the percentage of the 14,163 patients treated at home and estimated cost differences between home health and skilled nursing or inpatient rehabilitation.

Conclusion: Many gastrointestinal surgery patients discharged to skilled nursing facilities and inpatient rehabilitation are similar to patients treated at home with home health.  This may indicate the potential for significant cost savings by increasing use of home health, but it is also possible that patients sent home with home health might have benefited from discharge to skilled nursing facilities or rehabilitation.  There is an urgent need for evidence-based guidelines to help surgeons match patient needs to post-acute care setting after surgery.

 

14.05 Implications of IBD Status on Post-Colectomy Outcomes for the Value-Based Purchasing Program

Posted on January 25, 2017

Y. Chen1, R. Anand1, L. Ly1, J. Cedarbaum1, A. Hjelmaas1, S. Collins2, S. Regenbogen2  1University Of Michigan,Medical School,Ann Arbor, MI, USA 2University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction:
For Value-Based Purchasing (VBP) and public reporting of surgical outcomes to fairly reflect performance, hospital-based metrics of postoperative complications require balanced comparisons between hospitals. Colectomy is a central component of the Hospital Acquired Infections VBP metric, yet there is no attempt to account for differences in the indication for surgery. Using data from a population-based, statewide collaborative, we sought to understand what influence inflammatory bowel disease (IBD) might have on outcomes after colectomy, and how a greater share of IBD surgery might alter a hospital’s performance score. 

Methods:
This retrospective cohort study draws on data collected from the Michigan Surgical Quality Collaborative (MSQC), a network of 73 Michigan hospitals that prospectively collects data on surgical patient characteristics and outcomes. Among patients who underwent elective colectomy between 2012 and 2015, we compared rates of surgical site infection (SSI), bleeding, sepsis, and urinary tract infection (UTI) for those with IBD, compared with other indications, using chi-square tests for proportions.

Results:
Among the 7271 colectomy patients evaluated, the 297 with IBD had significantly higher rates of organ space SSI (6.7% vs. 2.6%, p<0.0001) and bleeding (8.4% vs. 5.7%, p=0.05). IBD patients also had higher, but not statistically different rates of superficial SSI (5.4% vs. 3.7%, p=0.15), deep SSI (2.0% vs. 1.1%, p=0.12), and sepsis (6.1% vs. 4.1%, p=0.11). There was no difference in the rate of UTI (p=0.97).

Conclusion:

Among patients in the MSQC who underwent non-emergent colectomy, those with IBD had significantly higher rates of organ space SSI and postoperative bleeding. Recognizing that organ space SSI is a core component of VBP metrics, and postoperative bleeding is an Agency for Healthcare Research and Quality endorsed Patient Safety Indicator, hospitals that specialize in the care of IBD may be unjustly identified as high outliers for these and other postoperative adverse events. These findings highlight the importance of detailed risk assessment in surgical outcomes evaluation, especially when it may determine reimbursement penalties.

14.04 Development of a Reference Population for Assessment of Surgical Patient Frailty and Fragility

Posted on January 25, 2017

R. L. Goulson1, C. M. Harbaugh1, P. E. Rabban1, A. R. Peltier1, N. C. Wang1, G. L. Su1, M. J. Englesbe1, B. A. Derstine1, S. C. Wang1  1University Of Michigan,Surgery,Ann Arbor, MI, USA

Introduction:  

Surgeons care for a highly variable patient population whose body composition has a very significant influence on their response to disease/injury and treatment.  Analytic morphomics measures very detailed geometry and material characteristics for tissues, organs and bones throughout the body using high-throughput automated processing of medical imaging scans.  We have previously reported that factors such as psoas muscle size are highly predictive of clinical outcomes following surgery (i.e. how frail patients are).  Analysis of real-world motor vehicle crash cases has demonstrated that morphomic characteristics are highly significant in whether an individual sustains injuries in a motor vehicle crash (i.e. how fragile patients are).  The objective of this research was to define the population distribution of morphomic factors that have been identified to be significantly predictive of patient fragility and frailty in surgical populations.

Methods:  

Chest, abdomen, and pelvis CT scans were collected from over 4700 patients, aged 16 to 91 years, who were scanned for trauma indications.  Customized software was used to perform automated processing of these CT scans and to measure detailed body geometry and composition data in an anatomically-indexed format.  Morphomic measures altered by injury were excluded.

Results: 

Quantile regression was performed to generate curves of morphomic factors corresponding to the 5th, 25th, 50th, 75th, and 95th percentiles from ages 16-91 for both men and women.  

Conclusion: 

We have curated and analyzed a large Reference Analytic Morphomic Population (RAMP) that serves as an excellent control population to determine the effect of body composition on clinical outcome.  Motor vehicle crashes affect a large and generally random portion of the population, including many individuals who are otherwise healthy.  We utilized the CT scans obtained during their trauma evaluation for morphomic analysis and determined the population distribution of body composition and geometry factors that have previously been shown to influence clinical outcome following surgery (frailty) as well as the severity of injuries an individual sustains in a motor vehicle crash (fragility). 

 

14.03 Trends in Emergency General Surgery Interhospital Transfers in the United States

Posted on January 25, 2017

C. E. Reinke1, M. Thomason1, L. Paton1, L. Schiffern1, N. Rozario2, B. D. Matthews1  1Carolinas Medical Center,Department Of Surgery,Charlotte, NC, USA 2Carolinas Medical Center,Dickson Advanced Analytics,Charlotte, NC, USA

Introduction: Emergency general surgery (EGS) admissions account for more than 3 million hospitalizations in the US annually. Patients who require surgery after transfer utilize additional resources and have higher acuity and worse outcomes. We aim to better understand the population of all transferred EGS patients and their subsequent care in a nationally representative sample.

 

Methods: Using the 2002-2011 Nationwide Inpatient Sample we identified patients age ≥18 years with an EGS non-cardiovascular principal diagnosis (AAST EGS DRG ICD-9 codes) who were transferred from another hospital with urgent or emergent admission status.  Patient demographics, hospitalization characteristics, rates of operation and mortality were identified.  Procedure codes were classified into surgery (broad) and procedures (narrow) based on the HCUP Surgery Flag definition.

 

Results: From 2002-2011 there were an estimated 525,913 EGS admissions that were transferred from another hospital. The mean age was 60 years, 51% were female, and over half of patients were Medicare patients. Over 10 years, EGS transfers increased from 1.2% of EGS admissions to 3.0% (Figure 1). More than half of the admissions were due to a HPB, Upper GI, or intestinal obstruction principal diagnosis. A surgery or procedure required for less than half of patients and remained steady over the time period (range 42-47%). Surgery was required for 33% of patients and a procedure for 21% of patients.  On average, there were 2.7 days from admission to first procedure.  The most common surgeries were laparoscopic cholecystectomy, lysis of adhesions and wound debridement.  The most common procedure was endoscopic sphincterotomy, endoscopic removal of bile stone and endoscopic control of gastric hemorrhage.  The median length of stay was 4.4 days.  Mortality was 4.0% in patients who did not have a procedure and 4.4% in those that did.

 

Conclusions: The percent of patients with an EGS diagnosis requiring interhospital transfer is on the rise, which may reflect a trend towards regionalization of EGS.  Transfers require significant resources and may delay care.  More than half of the EGS patients did not require surgical intervention.  Future studies to identify populations who most benefit from interhospital transfer and ideal timing of transfer can identify opportunities for optimizing resource utilization and patient outcomes.  

14.02 The Impact of Missed Ambulation Events After Abdominal Hernia Surgery on Length of Stay

Posted on January 25, 2017

Y. A. Ghazi3, T. W. Stethen2, R. E. Heidel4, B. J. Daley1, L. G. Barnes4, J. M. McLoughlin1  1University Of Tennessee Medical Center,Surgery,Knoxville, TN, USA 2University Of Tennessee Health Science Center,Graduate School Of Medicine,Memphis, TN, USA 3University Of Tennessee,Biology,Knoxville, TN, USA 4University Of Tennessee Graduate School Of Medicine,Knoxville, TN, USA

Introduction:  ~~Enhanced recovery after surgery (ERAS) principles have recently been introduced in abdominal ventral hernia surgery. Early ambulation after surgery has been demonstrated to reduce complications and decreases length of stay (LOS).  This study evaluated the impact of missed and refused ambulation attempts on LOS among those undergoing abdominal hernia repair. 

Methods:  ~~From January 2014–December 2015, all patients who had undergone elective abdominal hernia repair were assigned a dedicated ambulation team with the goal of ambulating three times per day. Clinical data was collected prospectively and compared to similar cohorts from 2010 – 2013.  Statistical analysis of ambulation frequency, percentage of sessions completed and overall LOS was performed using Mann-Whitney U and Spearman’s rho. 

Results: ~~A total of 79 patients were analyzed undergoing a total of 82 hernia repairs. The age range was from 20 to 85 with a mean age of 60. All patients were ambulatory prior to surgery.  There were 74 laparoscopic abdominal procedures and 8 open abdominal procedures. The overall median LOS for all patients was 1.9 days. When ambulation did not occur for 24 hours, the median LOS increased from 1.4 days to 4.0 days (p < .001).  When patients refused to ambulate, the median LOS increased from 1.3 days to 4.1 days (p < .001).  As missed ambulation events increased for any reason, LOS increased (r = 0.3, p = .008). 

Conclusion: ~~A dedicated ambulation team with three times a day ambulation reduced LOS for those undergoing abdominal hernia repairs. Failure to ambulate had a significant impact on increasing length of stay. Investment in a dedicated ambulation team as well as emphasis on a daily ambulation regimen is effective in reducing cost for ventral hernia surgery.

 

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