14.01 Perforated Appendicitis in Octogenarians: One-Year Operative Outcomes

Posted on January 25, 2017

M. M. Symer1, J. Abelson1, T. Sun2, A. Sedrakyan2, H. Yeo1,2  1Weill Cornell Medical College,Surgery,New York, NY, USA 2Weill Cornell Medical College,Healthcare Policy And Research,New York, NY, USA

Introduction:  Appendectomy is one of the most common surgical procedures in the U.S., with up to 30% of patients presenting with perforation. Despite this, there is no consensus on the optimal surgical management of perforated appendicitis. Older adults have increased operative risk and may represent a subgroup of patients for whom ideal management differs from the general population. In older adults, timing of intervention, as well as the use of laparoscopy may be especially beneficial. We performed a large database analysis of outcomes in early versus delayed surgery for perforated appendicitis in octogenarians.

Methods:  We analyzed the New York Statewide Planning and Research Cooperative database, an all-payer, in- and out-patient database which captures all admissions and surgeries in New York State. ICD-9 codes were used to identify all patients ≥80 years old undergoing appendectomy for perforated appendicitis from 2000 to 2013. Primary outcome was any complication within one year of follow up. Secondary outcomes included length of stay, hospital charges, utilization of laparoscopy, and readmission rate. Outcomes were compared in patients undergoing appendectomy before or after 48h from admission.

Results: 1691 patients were identified for analysis, 1407(83.2%) of whom underwent early appendectomy. Patients undergoing delayed appendectomy were more likely to have a complication (71.5% vs 59.8%, p<0.01). Rates of laparoscopy utilization were low overall, particularly in the late appendectomy group (27.1% vs 33.5%, p<0.01). After multivariate adjustment, patients undergoing delayed surgery were more likely to have complications (OR 1.62 95%CI 1.19-2.19), high hospital costs (OR 3.22 95%CI 2.23-4.65), and a prolonged length of stay (OR 5.06 95%CI 3.54-7.24). The only complication more common in the early group was a cardiac complication, and overall rates of cardiac complications were low (7.2% vs 3.9%, p=0.04).

Conclusion: We present a population-level study of early versus late appendectomy in octogenarians with perforated appendicitis. The nonoperative approach is associated with fewer cardiac complications, but is associated with having any complication, longer length of stay, and higher cost. Laparoscopy use is low in older adults with perforated appendicitis, regardless of timing of intervention.

13.20 The Bifid Recurrent Laryngeal Nerve – Anatomical Details & Operative Implications

Posted on January 25, 2017

J. C. Lee1,2, A. Kiu1, P. Chang1, J. Serpell1,2  1The Alfred Hospital,Department Of General Surgery,Melbourne, VICTORIA, Australia 2Monash University,Endocrine Surgery Unit,Melbourne, VICTORIA, Australia

Introduction:  The identification and preservation of the recurrent laryngeal nerve (RLN) is paramount during thyroid surgery. Due to the slenderness of the branches, a RLN with an extralaryngeal bifurcation is at higher risk of intraoperative injury. When bifid, the motor fibres of a bifid RLN are located mainly in the anterior branch, and the sensory fibres in the posterior branch. However, it has not been documented whether the motor or sensory branch is likely to be thinner and therefore more prone to injury. This study aimed to measure the widths of the bifid RLN trunk and its branches, and to determine their possible associations with demographic factors. 

Methods:  This is a prospective observational study over 18 months at The Alfred Hospital, Melbourne, Australia, in patients undergoing thyroid surgery. The widths of the RLN trunk and branches were measured with Vernier calipers to the nearest 0.1 mm. Demographic data including age, gender, height, weight, and body mass index (BMI) were collected. Nerve widths were compared using Student’s t-test, and RLN widths and demographic data were correlated with Spearman correlation co-efficient (Stata 13).

Results: A total of 150 RLNs were eligible for inclusion during the 12-month study period. Of those, 34 bifid RLNs were identified in 32 patients, and therefore included in the analysis. The main RLN trunk had a mean width of 2.37 (range 1.7 – 4.0) mm. Whereas the mean widths for the anterior and posterior branches were 1.55 (0.8 – 2.5) mm and 1.33 (0.5 – 2.9) mm respectively. Both the anterior and posterior branches were significantly smaller than the main trunk (both p < 0.01). However, the branches were not statistically different from each other in their widths. Body weight and BMI positively correlated to the widths of both the anterior branch (p = 0.003 & p = 0.01 respectively) and posterior branch  (p = 0.02 & p = 0.04 respectively). There was no correlation between age, height and either the main trunk or branches of the RLN.

Conclusion: As expected, the width of the RLN trunk is significantly greater than either of the branches of a bifid RLN. The knowledge of this may help alert the thyroid surgeon to the possibility of a bifid RLN during the process of dissecting along the RLN. More importantly, the similarity in the widths of the branches suggests that it is not possible to determine if a fine nerve branch is likely to be the anterior (motor) or posterior (sensory) branch. Low body weights or BMI may be a clue to possible delicate RLN branches.

 

 

13.19 Postoperative Complications in Patients with Inflammatory Bowel Disease

Posted on January 25, 2017

S. Stringfield1, S. Ramamoorthy1, L. Parry1, S. Eisenstein1  1University Of California,Surgery,San Diego, CA, USA

Introduction:  Patients with Inflammatory Bowel Disease (IBD) are at high risk for postoperative complications. Many patients will receive anti-TNF medications or other biologic medications prior to surgery. There is still controversy as to whether anti-TNFs are associated with complications. Many new biologic medications have not been studied in surgical patients. The purpose of this study is to identify rates and types of postoperative complications in patients with IBD who have undergone abdominal surgery, and identify predictors of these complications. 

Methods:  Retrospective review of patients with IBD who underwent abdominal surgery at our institution June 2014-June 2016. Preoperative, perioperative, and postoperative data was collected. Categorical variables were analyzed using Fisher’s exact test or Chi-square test and continuous variables were analyzed using two sided t-test for independent means. Univariate and multivariate analyses were performed using binary logistic regression. 

Results: We identified 155 abdominal operations performed on IBD patients. Overall complication rate was 40%, with infectious complications the most common with rate of 27% overall. Univariate analysis showed predictors of complications to be age (p=0.028, OR 0.98), BMI (p=0.02, OR 0.93), recent weight loss (p=0.029, OR 2.12), and intraoperative blood loss (p=0.006, OR 0.996). Current use of any biologic medication was not a significant predictor (p=0.144), however vedolizumab use was a predictor (p=0.041, OR 2.46). On multivariate analysis, age (p=0.014, OR 1.03), BMI (p=0.027, OR 1.09), weight loss (p=0.041, OR 2.14), emergent case (p=0.018, OR 2.74), and vedolizumab use (p=0.016, OR 3.27) remained significant predictors of complications. Forty-one percent of patients were on a biologic medication at time of surgery. These patients were more likely to have Crohn’s Disease (59% v 26%, p<0.001), lower preoperative hemoglobin (10.9 v 12.0, p=0.0004) and albumin (3.6 v 3.9, p=0.027), to be on thiopurines (31% v 11%, p=0.003) or steroids (55% v 14%, p<0.001) at the time of surgery, and undergo emergent surgery (36% v 16%, p=0.008). Patients on biologics had a 47% overall and 28% infectious complication rate. Patients not on biologic medications had a 35% overall and 25% infectious complication rate. Complication rates did not vary significantly, except risk of bleeding requiring a transfusion was higher in patients on biologic medications (23% v 11%, p=0.047). 

Conclusion: Patients with IBD have a high rate of postoperative complications. Predictors of complications include age, BMI, weight loss, intraoperative blood loss, and vedolizumab use. Only rates of hematologic complications varied significantly between patients on biologic medications and those not on biologics. 

 

13.18 Body Mass Index is Associated with Surgical Site Infection (SSI) In Patients with Ulcerative Colitis

Posted on January 25, 2017

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

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

Methods:
Using the 2012-2014 ACS-NSQIP Procedure Targeted Database, we identified all patients with UC who underwent colectomy between 2012-2014. Patients with UC were stratified by weight status to underweight, normal weight, overweight and BMI class I (30-34.9), II (35-39.9) and III (>40). Patient demographics, preoperative comorbidities and surgical characteristics were compared. Primary outcomes were wound complications (SSI, organ space SSI, anastomotic leaks) and secondary outcomes were other reported NSQIP-complications. Multivariate analysis was used to identify predictors for wound complications.

Results:
Of 1,487 patients with UC, 39.8% were classified as normal weight as compared to 25.4%, 14.9%, 6.59% and 3.43% for overweight, BMI class I, II and III, respectively. Overall, 10.96% of patients were smokers, 9% of patients were diabetic and 65.77% of patients were on steroids or other immunosuppressant. Patients with higher BMI class were more likely to have diabetes: 6.31% in class I, 10.2% in class II and 13.73% in class III (p value <0.001). At time of surgery, a larger percentage of class III obese patients (27.45%) were classified as ASA 4-5 (p value <0.001). Higher BMI was associated with greater rates of SSI: 7.25% in normal weight class, 8.7% in the overweight class, 9.01% in class I, 18.37% in class II and 27.45% in class III (p-value<0.001). There was no significant difference in organ space SSI (range: 3.92-7.94%) and anastomotic leaks (range: 1.35-6.12%) between the BMI classes (p>0.05). There was an increase in sepsis rate (33.3% vs 15.3%] and respiratory complication rates (23.5% vs 10.2%) with BMI class III vs BMI class II and  continued to decrease with the lower classes (p-value<0.001). On adjustment for covariate differences, BMI remained a significant predictor for SSI with the highest odds in class III (OR 5.0 CI 2.5-10.2) and Class II obesity (OR 3.5 CI 1.9-6.4) when compared to normal BMI individuals.

Conclusion:
Patients with UC and high BMI are at the highest risk for SSI but not for organ space SSI or anastomotic leak rates. Targeting BMI with weight-loss strategies may be one actionable opportunity to reduce post-operative SSI rates.  
 

13.17 Venous Thromboembolism After Incisional Hernia Repair

Posted on January 25, 2017

M. P. DeWane1, A. A. Maung1, K. A. Davis1, J. P. Geibel1, R. D. Becher1  1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA

Introduction: Repair of incisional hernias is one of the most common operations performed by general surgeons. However, outside of its classification as a “major” general surgery operation, little is known about the risk of venous thromboembolism (VTE) after this common procedure. This is concerning as VTE is a leading cause of death in surgical patients. We evaluated VTE rates after emergent and elective incisional hernia repairs to define risk factors, mortality, and determine time to VTE events. We hypothesized that emergent operations would put patients at an increased risk for VTE events.

Methods: Open and laparoscopic incisional hernia repairs were identified in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) participant user files (PUF) over a five year period, from 2010 to 2014. Patient demographics, perioperative variables, and well-established VTE risks were assessed. Logistic regression models determined the risks of VTE development, including the importance of emergent operative classification. Kaplan-Meier and Cox regression analyses determined timing to 30-day VTE events.

Results: A total of 30,372 patients were included in the analyses, 15.7% of whom underwent emergent hernia repair. Compared to elective procedures, incisional hernia operations performed emergently had significantly increased odds for developing VTE (2.16% vs 0.86%; Odds Ratio [OR] 2.51; p<0.0001). Emergent operative classification was found to be an independent predictor of VTE (OR 1.67; p=0.0007) after accounting for common VTE risks. Other VTE risk factors included: respiratory issues such as unexpected or prolonged post-operative intubation (OR 4.12, p<0.0001), need for reoperation (2.52, p<0.0001), and laparoscopic case (OR 1.54, p=0.0287). Variables which did not significantly predict risk of VTE included age, primary vs recurrent hernia, length of operation, need for bowel resection, and obesity. In patients who developed VTE, the risk of mortality was significantly increased (OR 2.57, p=0.0311). Patients presenting in extremis with pre-operative sepsis from incarcerated hernias who required prolonged postoperative ICU stays had a VTE risk 13 times greater than baseline (11.94% vs 0.86%; p<0.0001).

Conclusion: VTE events are significantly more likely to occur in patients undergoing emergent compared to elective incisional hernia repair. Even after controlling for the multiple reasons for this patient-population to develop VTE, emergent operative classification independently predicts VTE, and should be considered a high-risk characteristic. Emergent patients diagnosed with VTE had poorer survival. These findings highlight the importance of VTE prevention and prophylaxis in this high-risk patient population, and suggest that emergent operations may play a role as a thrombogenic stimulus.
 

13.16 Hyperglycemia Following Radical Cystectomy Associated With Shorter Lengths Of Stay And Lower Costs

Posted on January 25, 2017

M. B. Linskey1, D. Brunke-Reese1, E. B. Lehman2, D. I. Soybel1, M. G. Kaag1,3  1Penn State University College Of Medicine,Department Of Surgery,Hershey, PA, USA 2Penn State University College Of Medicine,Department Of Public Health Sciences,Hershey, PA, USA 3Penn State University College Of Medicine,Division Of Urology,Hershey, PA, USA

Introduction:  Post-operative hyperglycemia has been associated with adverse outcomes including increased length of stay (LOS) and increased costs of care. In the cardiac, vascular, general, and trauma surgery populations, post-operative hyperglycemia has also been linked to an increased risk of mortality. Patients without diabetes mellitus who develop acute hyperglycemia post-operatively are at an increased risk of complications compared to their counterparts with diabetes. Radical cystectomy for bladder cancer carries an inherent risk of post-operative morbidity due to the complexity of the procedure and the medical comorbidities of the patients. Morbidity of cystectomy includes frequent readmissions for renal failure, wound occurrences, ileus, failure to thrive, obstruction, and urinary tract infections. We investigate the impact of post-operative hyperglycemia on recovery following radical cystectomy (RC).
 

Methods: A retrospective chart review identified patients undergoing RC between May 2010 and December 2014 with at least one glucose level within 48 hours of surgery. Associations between post-operative hyperglycemia (defined as a first post-operative blood glucose >140mg/dL) and outcomes, including total hospital costs, LOS, and surgical site occurrences were determined.

Results: 176 patients underwent RC; 122 (69%) met our definition of post-operative hyperglycemia. 87 of 128 (68%) patients without diabetes, exhibited hyperglycemia postoperatively. 47 (54%) of these 87 patients required post-operative insulin, including 31 (36%) whose insulin requirement persisting beyond post-operative day 2. On univariate analysis, BMI classification predicted hyperglycemia (obese vs non-obese: Odds ratio (OR) 2.68, [95% Confidence Interval (CI) 1.25-5.75] p=0.01). This association was strong in patients without diabetes (OR 3.55 [95% CI 1.34-9.39] p=0.01), but not significant in those with diabetes. LOS (in days) was shorter in patients who were hyperglycemic post-RC regardless of prior diabetes diagnosis (Difference of medians (DOM) -2.0 [-3.5 to -0.5] p=0.01). This effect remained on multivariable analysis (DOM -2.19 [-3.54, -0.83] p=0.002) controlling for age, gender, race, Charlson score, ASA class, and BMI. Similarly, on multivariable analysis, hospital costs (in US dollars) were lower in patients with post-operative hyperglycemia (DOM -8,863.69 [-12,887.37, -4,840.17] p<0.001).

Conclusion: Post-operative hyperglycemia is common after RC and may occur in patients without diabetes. Contrary to results reported in the general surgery literature, hyperglycemia after RC was associated with shorter LOS and hospital costs. Whether this phenomenon is due to a protective effect associated with hyperglycemia, or is secondary to the aggressive post-operative management afforded these patients, is not yet clear.

 

13.14 Compliance After Bariatric Surgery: Patient-related Factors And Self-reported Barriers

Posted on January 25, 2017

B. Corey1,2, L. Goss1, A. Gullick1,2, D. Breland1, J. Richman1,2, J. Grams1,2  2Birmingham Veteran’s Affairs Medical Center,Surgery,Birmingham, ALABAMA, USA 1University Of Alabama At Birmingham,Surgery,Birmingham, ALABAMA, USA

Introduction:  Patient compliance with attendance at follow-up bariatric appointments is associated with increased weight loss, and reasons for low follow-up compliance are poorly understood. The purpose of this study was to investigate the association of patient-related factors with follow-up compliance after laparoscopic Roux-en-Y gastric bypass (LRYGB).

Methods:  Retrospective review was conducted of all adult patients who underwent LRYGB from 2005-2013 at a single institution. Patients were stratified by follow-up attendance at a total of 8 possible postoperative visits: low 0-2, intermediate 3-5, and high 6-8 visits. Socioeconomic status was determined using 6 measures compared to national census data to generate a neighborhood Summary Z-score. Patients who attended <50% of follow-up visits were mailed a survey to assess reasons for low compliance. Univariate and multivariate analyses were used to compare patient characteristics and compliance. Statistical significance was determined by p <0.05.

Results: Of 756 patients, there were 241 patients in the low, 327 in the intermediate, and 188 in the high compliance groups. The high compliance group was older (p=0.004), white (p=0.020), and had lower preoperative weight (p=0.008) and BMI (p=0.040). There were no differences in overall socioeconomic characteristics based on compliance. On adjusted multivariate analysis, patients were more likely to attend 1 year follow-up appointment if they were older (OR=1.04, CI 1.02-1.05), of lower socioeconomic status (OR=1.04, CI 1.00-1.08), white (OR=1.5, CI 1.03-2.2), had private insurance (OR=1.6, CI 1.02-2.5), and were present at their last appointment (OR=6.30, CI 4.41-8.95); while patients were more likely to attend 2 year follow-up appointment if they were successful at weight loss (OR=1.03, CI 1.00-1.05), if they had shorter driving distance (50-99 miles, OR=2.2, CI 1.4-3.5; <50 miles, OR=1.6, CI 1.0-2.4), or had attended their previous appointment (OR=4.49, CI 3.15-6.40). On survey, patients reported the primary reason they did not follow up was travel time to the clinic (44%), cost of the visits (28%), commitments at work/school (24%), and because of guilt for not following the diet and exercise plan and/or felt ashamed of regaining weight (24%).

Conclusion: Patient-related factors are predictive of follow-up compliance. Based on self-reported reasons, health behaviors and values influence attendance at postoperative bariatric appointments. Since patients self-report travel time and cost as the two primary reasons for failure to follow up, alternative methods of follow-up should be considered such as appointments using telemedicine technology, follow-up “apps” to self-report progress, or stronger collaboration with local primary care physicians. 

 

13.15 Preliminary Experience with Acellular Porcine Liver Matrix in Retrorectus Incisional Hernia Repairs

Posted on January 25, 2017

E. Vo1, C. Y. Chai1,2, D. S. Lee1,2, N. N. Massarweh1,2, K. Makris1,2, L. W. Chiu1,2, H. S. Tran Cao1,2, N. S. Becker1,2, S. S. Awad2  1Baylor College Of Medicine,Houston, TX, USA 2Michael E. DeBakey Veterans Affairs Medical Center,Houston, TX, USA

Introduction:
Acellular dermal matrices have been used since the 1990s for incisional hernia repairs in patients who are considered high risk for surgical site infections (SSI). Porcine dermal matrix is currently the most commonly used biologic mesh. Recently, an acellular matrix derived from decellularized whole porcine liver has been FDA-approved as a new biologic matrix alternative. No studies exist regarding its outcomes. Our objective was to describe our early experience and to compare the short-term outcomes of acellular porcine liver matrix (APLM) with acellular porcine dermal matrix (APDM).

Methods:
Patients undergoing retrorectus incisional hernia repairs were identified from Jan 2013 to Jul 2016 and case-matched in a 2:1 APDM to APLM ratio. Baseline demographics, comorbidities, ventral hernia working group (VHWG) grade, and outcomes such as seroma, hematoma, SSI, dehiscence, length of stay (LOS) were collected. Results were compared between APLM and APDM using univariate analysis with significance set at p<0.05.

Results:
Sixty patients were identified: 20 APLM and 40 APDM with an overall median follow-up of 13.9 months. Cohorts were well-matched in age (APLM 58.6±11.7 vs. APDM 61.5±7.7 years, p=0.26) and BMI (APLM 31.1±6.3 vs. APDM 30.3±5.9, p=0.56). Median VHWG grade (APLM 2.5 vs. APDM 2.0) and ASA (APLM 3 vs. APDM 3), were not statistically significant (both p>0.05). No significant differences in comorbidities were found. Thirty day follow-up demonstrated no difference in SSIs (25% vs. 25%, p=1.00) or readmissions (APLM 10% vs. APDM 17.5%, p=0.70). There was no clinically significant seroma requiring intervention in either cohort. Although LOS was shorter (median APLM 5 (IQR 3-10) days vs. APDM 7 (IQR 6-11) days, p=0.12] and hematoma rates lower (APLM 0% vs. APDM 5%, p=0.60) with the use of APLM, this was not statistically significant.

Conclusion:
There were no significant differences between APLM and APDM with respect to seroma, hematoma, SSI, and LOS. APLM appears to be a safe and feasible alternative for complex ventral hernia repairs. Further study on long-term outcomes is warranted.
 

13.12 Is the Surgical Apgar Score Reliable in Patients on Chronic Beta Blockers?

Posted on January 25, 2017

S. Amodeo1, A. Pinna1,2,3, A. Masi1,2, I. Hatzaras1, E. Newman1,2, S. M. Cohen1, R. S. Berman1, G. H. Ballantyne1,2, H. L. Pachter1, M. Melis1,2  1New York University School Of Medicine,Department Of Surgery,New York, NY, USA 2New York Harbor Healthcare System VAMC,Department Of Surgery,New York, NY, USA 3University Of Sassari,Department Of General Surgery,Sassari, , Italy

Introduction:  The lowest heart rate recorded during surgery is one of the 3 parameters required to calculate the Surgical Apgar Score (SAS), a 10-point prognostication score used to predict postoperative outcomes. We aimed to verify whether SAS maintains its validity in patients undergoing long-term treatment with beta blockers.

Methods:  We queried our institutional clinical database for patients undergoing general surgery procedures between October 2006 and September 2011. Patients on long-term beta blockers were identified and defined the study population. We divided our study population into 4 groups according to their SAS: ≤4, 5-6, 7-8, 9-10. Study end-points were overall morbidity and 30-day mortality. Differences between SAS groups were evaluated with Pearson’s chi-square or ANOVA, as appropriate.

Results: Of the 2125 patients who underwent general surgery over the study period, 568 (26.7%) were taking beta blockers at the time of their operation and represented our study population. They were distributed as follows: SAS ≤ 4: n= 10 (1.8%), SAS 5-6: n= 78 (13.7%), SAS 7-8: n= 181 (31.9%), SAS 9-10: n= 299 (52.6%). There were no differences in age, sex, race, history of smoking or alcohol abuse across SAS groups. Furthermore, no differences were seen in the incidence of diabetes, previous history of transient ischemic attacks, cerebrovascular accidents or peripheral vascular disease. A low SAS was associated with worse functional status (p<0.001), and increased incidence of certain preoperative conditions (congestive heart failure, dyspnea, acute renal failure, ascites: p<0.001; severe COPD: p=0.001; history of esophageal varices: p=0.002; hypertension, history of angina: p<0.05). Accordingly, a low SAS correlated with a higher American Society of Anesthesiologists score (p<0.001). The vast majority of patients with low SAS underwent major or extensive procedures (100% and 85.9% for score ≤ 4 and 5-6, respectively), while high SAS patients mostly underwent minor or intermediate surgery (77.3% for score 9-10). Post-operative morbidity was 60% for score ≤ 4, 46.2% for score 5-6, 27.6% for score 7-8, and 10.4% for score 9-10 (p<0.001). The mean number of complications for each group, respectively, was 1.40 ± 1.7, 1.00 ± 1.4, 0.56 ± 1.2, and 0.15 ± 0.5. Thirty-day mortality rate was 10% for score ≤ 4, 12.8% for score 5-6, 3.3% for score 7-8, and 0.7% for score 9-10 (p<0.001).

Conclusion: Correlation of SAS and risk of surgical complication is maintained in a population of general surgery patients treated with beta blockers. Correlation of SAS with pre-operative conditions and performance status was also confirmed in this patient group.

 

13.11 Duration of Preoperative Hospitalization is Associated With Mortality in Total Abdominal Colectomy

Posted on January 25, 2017

J. Zhang1, A. Lubitz1, M. Philp1, Z. Maher1, A. Pathak1, T. Santora1, L. Sjoholm1, A. J. Goldberg1, E. Dauer1  1Temple University,Department Of Surgery,Philadelpha, PA, USA

Introduction: Total abdominal colectomy (TAC) has been associated with morbidity and mortality rates as high as 62% and 28%, respectively. To date, varying findings regarding risk factors for postoperative complications after emergent colectomy have been reported in the literature. We sought to determine if preoperative length of stay impacts morbidity and mortality in patients undergoing emergent TAC.

Methods:  We conducted a retrospective cohort study of patients undergoing emergent TAC for any indication at our urban quaternary care institution from 2005-2015 (n=94).  Charts were reviewed for patient demographics, preoperative risk factors and Simplified Acute Physiology Score (SAPS), and discrete patient outcomes (leak, abscess, fascial dehiscence, wound infection, hospital length of stay, ventilator days, ICU length of stay and mortality). Patients were then divided into two groups based on whether they underwent TAC prior to hospital day 5 (HD<5) or on hospital day 5 or later (HD≥5). Student’s t-tests were used to compare means for categorical variables, and Chi-squared tests were used to analyze ordinal variables. Statistical analyses were performed using SPSS version 22.

Results: Patients who underwent TAC later in their hospital course had longer total hospital length of stay (Table 1, t=-2.45, df=92, p=0.016) and higher mortality (42.5% v 20.4%, Χ2=5.38, p=0.02). ICU length of stay and ventilator days trended toward being longer in the late group, though these did not reach statistical significance (t=-1.237, df=92, p=0.219 and t=-0.773, df=91, p=0.441, respectively). There was no difference between groups with respect to age, gender, coronary artery disease, hypertension, congestive heart failure, chronic obstructive pulmonary disease, diabetes, chronic kidney disease or stroke. When comparing the early and late operative groups, patient demographics and SAPS did not differ. Intraoperative findings of peritonitis or ischemia also did not differ, nor did postoperative rates of leak, abscess formation, fascial dehiscence or wound infection. Indications for TAC included Clostridium difficile colitis, lower gastrointestinal bleed, large bowel obstruction and inflammatory bowel disease, with more C. diff patients in the early group (Χ2=4.062, p=0.044).

Conclusion: Our data suggest that patients who undergo TAC later in their hospitalization incur longer lengths of stay and greater mortality rates. Age, gender, comorbidities and SAPS scores did not differ among the two groups, suggesting factors external to underlying illness and not reflected in commonly evaluated physiologic markers impact these outcomes. 

 

13.10 The Surgical Apgar Score Identifies Patients at Risk for Prolonged Post-Operative Hospital Stay.

Posted on January 25, 2017

S. Amodeo1, A. Masi1,2, A. Pinna1,2,3, I. Hatzaras1, E. Newman1,2, S. M. Cohen1, R. S. Berman1, G. H. Ballantyne1,2, H. L. Pachter1, M. Melis1,2  1New York University School Of Medicine,Department Of Surgery,New York, NY, USA 2New York Harbor Healthcare System VAMC,Department Of Surgery,New York, NY, USA 3University Of Sassari,Department Of General Surgery,Sassari, , Italy

Introduction:  The Surgical Apgar Score (SAS) is a 10-point score calculated on three intra-operative parameters (lowest heart rate, lowest mean arterial pressure, estimated blood loss), which has been demonstrated to be a reliable predictor of postoperative morbidity and mortality in several types of surgery. We aimed to investigate whether SAS could also predict length of post-operative hospital stay (LOS) in patients undergoing general surgical procedures.

Methods:  We retrospectively evaluated demographics, medical history, type of surgery, and postoperative data for patients undergoing general surgery between October 2006 and September 2011. We categorized our study population into 4 groups according to their SAS: ≤4, 5-6, 7-8, 9-10. The end-point of our study was the length of postoperative hospital stay. We used Pearson’s chi-square or ANOVA, as appropriate, to evaluate differences across SAS groups.

Results: Two thousand one hundred twenty-five patients underwent general surgery during the evaluated period. We excluded 711 patients who underwent outpatient surgery, and included in our analysis the 1414 patients who were admitted post-operatively to the hospital. There were 29 patients in the group SAS ≤ 4, 212 in SAS 5-6, 594 in SAS 7-8, 579 in SAS 9-10. No significant differences in age, sex, race, history of smoking or alcohol abuse among SAS groups were detected. Patients with lower SAS had a worse preoperative functional status (p<0.001) and worse American Society of Anesthesiologists score (p<0.001) than patients with a higher SAS. A low SAS was associated with a higher incidence of certain preoperative conditions (acute renal failure, ascites, history of myocardial infarction, congestive heart failure, severe COPD, dyspnea, history of dialysis: p<0.001; diabetes: p=0.001; history of angina, previous percutaneous coronary intervention, previous cardiac surgery: p<0.05). Most patients with low SAS underwent major or extensive procedures (89.7% and 75.5% for score ≤4 and 5-6, respectively), while high SAS patients mostly underwent minor or intermediate surgery (68.6% for score 9-10). LOS ranged from 0 to 193 days, with a median of 6 days (mean: 11.9 ± 18.8 days). LOS was 29.6 ± 26.5 for score ≤ 4, 24.2 ± 30.8 for score 5-6, 12.1 ± 16.0 for score 7-8, and 6.4 ± 10.9 for score 9-10 (p<0.001). 

Conclusion: In our retrospective analysis SAS correlated with post-operative LOS after general surgery. Moving forward, this information may be used to focus hospital resources (such as social workers and rehabilitation medicine) specifically on patients with low SAS, who are at higher risk for prolonged post-operative length of stay.

 

13.09 A Risk Model and Cost Analysis of Incisional Hernia Following 2,145 Open Hysterectomies

Posted on January 25, 2017

J. M. Weissler1, M. G. Tecce1, M. N. Basta2, V. Shubinets1, M. A. Lanni1, M. N. Mirzabeigi1, M. J. Carney1, L. Cooney1, S. Senapati1, A. F. Haggerty1, J. P. Fischer1  1University Of Pennsylvania,Plastic Surgery,Philadelphia, PA, USA 2Brown University School Of Medicine,Plastic Surgery,Providence, RI, USA

Introduction:  Incisional hernia (IH) is a pervasive complication across surgical specialties and presents a significant burden to both the patient and healthcare system. Morbidity associated with IH permeates all surgical specialties, including gynecologic surgery. Approximately 600,000 women undergo hysterectomy annually in the US and IH is estimated to complicate 8-16.9% of all abdominal hysterectomies. An open approach to abdominal hysterectomy portends increased risk for IH development, however there is a substantial knowledge gap regarding which procedure-specific factors govern risk. The purpose of this study is to assess the incidence and health care cost of surgically repaired IH after open abdominal hysterectomy, identify actionable, perioperative risk factors, and create a predictive risk mode to identify at-risk patients who could benefit from prevention strategies.

Methods:  We conduct a retrospective review of patients who underwent hysterectomy through an open abdominal approach between 1/2005 and 6/2013 at the University of Pennsylvania.  The primary outcome of interest was post-hysterectomy IH.  Univariate and multivariate cox proportional hazard analyses were performed to identify perioperative risk factors.  Patients with prior hernia, less than 1 year follow-up, or emergency surgeries were excluded.  Cox hazard regression modeling with bootstrapped validation, risk factor stratification, and assessment of model performance were performed.

Results: Overall, 2,145 patients underwent open abdominal hysterectomy during the study period. 76 patients developed IH, all of whom underwent hernia repair. 31.3% underwent further reoperation, generating significantly higher costs of care ($71,559 vs. $23,313, p<0.001).  8 risk factors were identified and included in the final adjusted risk model, the strongest of which were presence of a vertical incision (HR=3.73 [2.01-6.92]) and ascites (HR=2.39 [1.40-4.08]). Extreme risk patients experienced the highest incidence of IH after hysterectomy (22%), followed by the high-risk group (9.7%), moderate-risk group (2.7%), and low-risk group (0.8%) (C-statistic=0.82) (Figure 1).

Conclusion: This study presents an internally validated risk model of IH in patients undergoing open hysterectomy after a review of 2,145 cases. The model can serve to accurately stratify patients, facilitate pre-operative counseling, and potentially imply risk reductive techniques.

 

13.08 Financial Burden is Associated with Lower Quality of Life Scores in Adults with MEN-1

Posted on January 25, 2017

B. J. Peipert1, S. Goswami1, S. E. Yount2,3, C. Sturgeon1  1Northwestern University Feinberg School Of Medicine,Surgery,Chicago, IL, USA 2Northwestern University Feinberg School Of Medicine,Medical Social Sciences,Chicago, IL, USA 3Northwestern University Feinberg School Of Medicine,Psychiatry And Behavioral Sciences,Chicago, IL, USA

Introduction: Health-related quality of life (HRQOL) and financial burden among patients with multiple endocrine neoplasia type 1 (MEN-1) is poorly described. It is not known how the financial burden attributed to treatment and disease influences HRQOL in this population. We hypothesized that financial burden attributable to MEN-1 is associated with worse patient-reported outcomes (PROs) reflecting lower HRQOL.

Methods: Adults (≥18 years) recruited from an MEN-1 support group (n=174) completed an online survey that included questions regarding demographics, clinical characteristics, medical/surgical treatment, and various aspects of financial burden. PROMIS-29 was used to assess HRQOL. PROMIS-29 scores across 7 domains (physical function, fatigue, pain interference, anxiety, depression, sleep disturbance, social functioning) were converted to T Scores and compared to normative data for the United States (US) population using a one-sample T-Test. Data are presented as mean T scores ± standard deviation. Subgroup analysis was conducted using Mann-Whitney U for categorical variables and Pearson coefficients for continuous variables. Holms-Bonferroni Sequential Correction was used to control for multiple comparisons.

Results: Eighty-one percent of respondents reported financial burden associated with MEN-1. Respondents reported using up their savings (39%), being contacted by a collection agency (35%), borrowing money (27%), reaching their maximum credit limit (17%), taking out a new loan/mortgage (14%) or declaring bankruptcy (6%) due to the financial burden of MEN-1. Respondents who reported any financial burden due to MEN-1 had worse anxiety (62.9±9.6 vs 53.2±9.4, p<0.001), depression (58.7±10.3 vs 51.2±13.2, p<0.001), fatigue (62.9±10.2 vs 51.2±13.2, p<0.001), pain interference (57.2±11.0 vs 48.7±8.7, p<0.001), physical function (43.0±9.1 vs 52.2±7.6, p<0.001), sleep disturbance (58.3±8.6 vs 52.6±9.4, p<0.01) and social functioning (43.0±9.5 vs 53.2±11.5, p<0.001). Lower PRO scores were significantly associated with greater financial burden (r=0.34-0.52, p<0.001) and the number of negative financial events (r=0.34-0.45, p<0.001) across all domains, which was also true of respondents who were currently unemployed (14%), disabled (13%) or had a history of extended unemployment (37%) (p<0.05). An annual income <$50,000 (34%) was associated with worse anxiety, depression, pain, physical functioning, and social functioning (p<0.05). Monthly cost of prescription medication >$100 was associated with worse PROs across all domains (p<0.05). Skipping medications due to cost (19%) was associated with worse physical functioning and sleep disturbance (p<0.01).

Conclusions: This is the first PRO study to link worse HRQOL to financial burden attributed to the management of MEN-1. The number of negative financial events, unemployment, disability, monthly cost of prescription medicines, and low income were all associated with worse PRO scores in adults with MEN-1.

13.07 The Metabolic Benefit of Bariatric Surgery: Impact of Baseline Disease Status

Posted on January 25, 2017

L. A. Bayouth3, W. J. Pories3, M. B. Burruss3, K. Spaniolas3  3East Carolina University Brody School Of Medicine,Department Of Surgery, Minimally Invasive And Bariatric Surgery,Greenville, NC, USA

Introduction:  Bariatric surgery has been established as a treatment modality for the control and remission of metabolic syndrome. Multiple studies demonstrated that preoperative severity of type 2 diabetes (T2D) affects likelihood of remission postoperatively. Limited data is available for how the severity of other components of metabolic syndrome impact outcomes. The aim of this study is to identify how severity of metabolic syndrome preoperatively affects disease remission following bariatric surgery.

Methods:  We queried the BOLD database from 2005-2011 to identify patients undergoing gastric bypass or sleeve gastrectomy with available 12 month follow up information. Comorbidities at baseline and following surgery were recorded in a five-point Likert scale. A composite score was calculated for patients with all components of metabolic syndrome. Improvement and remission of components of metabolic syndrome (T2D, hypertension, and dyslipidemia) were assessed. Multivariable logistic regression models were built to determine effect of baseline disease, controlling for other baseline characteristics. Odds ratios (OR) with 95% confidence intervals are reported.

Results: Within a cohort of 51,081 patients who underwent bariatric surgery with 12 month follow up, we identified 20,089 (39.3%), 31,695 (62%), and 23,350 (45.7%) patients with T2D, hypertension and dyslipidemia, respectively; 11,075 (21.7%) patients had all three components of metabolic syndrome. Gastric bypass was performed in 46,381 (90.8%) patients. Mean age and BMI for the entire cohort were 47+11.6 and 47.7+8.5, respectively. Comorbidity remission significantly varied by baseline severity score (Fig 1 Comorbidity Remission for T2D, hypertension and dyslipidemia based on composite metabolic score. P<0.001 for all comparisons). After controlling for age, gender, BMI and procedure, the degree of baseline comorbidity independently associated with 12 month remission. In patients with metabolic syndrome, a composite score over 9 (median) was independently associated with lower rate of remission at 12 months (OR 0.46, 95% CI 0.41-0.51). Similarly, score over 9 was independently associated with 12 month remission of T2D (OR 0.37, 95% CI 0.34-0.4), hypertension (OR 0.59, 95% CI 0.54-0.65), and dyslipidemia (OR 0.68, 95% CI 0.63-0.74).

Conclusion: Bariatric surgery leads to remission of metabolic syndrome and individual components in a large percentage of patients. The remission rate at 12 months is significantly affected by preoperative severity of disease. This data proposes that early intervention would lead to significant benefit, improving remission rate. Bariatric surgery should not be reserved as last resort treatment of metabolic syndrome in the severely obese.

13.05 Appendicoliths Increase the Risk of Complications in Laparoscopic Appendectomy

Posted on January 25, 2017

M. Khan1, M. H. Siddiqui1, N. Shahzad1, M. B. Chaudhry2, M. Wajid1, R. Sultan1, W. A. Memon2, H. Zafar1, A. Alvi1  1Aga Khan University Medical College,Surgery,Karachi, Sindh, Pakistan 2Aga Khan University Medical College,Radiology,Karachi, Sindh, Pakistan

Introduction:
Appendicoliths are often found to be associated with perforated and gangrenous appendicitis. However, the relationship between appendicoliths and complications of laparoscopic appendectomy has not been studied. The objective was to determine if the presence of appendicolith/s increased the risk of infectious complications in laparoscopic appendectomy.

Methods:
A retrospective case-control study of patients who received a pre-operative abdominal Computed Tomographic (CT) scan and later underwent laparoscopic appendectomy from 01/2008-12/2015 was completed. Occurrence of post-operative infectious complications, namely surgical site infections and intra-abdominal abscesses were noted.  Patients were divided into two groups, those with appendicitis and appendicoliths (AA) and those who had appendicitis with no appendicoliths (NA) on CT scan.

Results:
In total, 453 patients who underwent laparoscopic appendectomy and had pre-operative CT scan were included. Of these, 123 (27%) patients were in the AA group while 330 (73%) patients were in the NA group. There were no significant differences between the mean age, gender and presence of comorbid conditions in both groups. Post-operative infectious complications were seen in 18 (4%) patients that were found in a significantly greater proportion of patients of the AA group than of the NA group. [AA vs. NA: 9 (7.3%) vs. 9 (2.7%); p value 0.03]. Odds ratio was calculated to be 2.8 (Confidence interval 1.1-7.2). On multivariable regression analysis, presence of appendicolith was significantly associated with the occurrence of post-operative infectious complications. 

Conclusion:
Appendicoliths increase the risk of post-operative infections in patients with appendicitis. For patients diagnosed to have appendicitis with appendicolith, steps to prevent postoperative complications, such as judicious use of post-operative antibiotics, should be considered.
 

13.06 Discordance in Hospital Quality Rank Using Traditional Vs. Patient-Preferred Outcomes After Colectomy

Posted on January 25, 2017

A. N. Kothari1, S. A. Brownlee1, E. C. He1, J. Rambo1, D. M. Hayden1, J. M. Eberhardt1, P. C. Kuo1, T. L. Saclarides1  1Loyola University Chicago Stritch School Of Medicine,Surgery,Maywood, IL, USA

Introduction:
Hospital quality is commonly measured using postoperative mortality rates. However, recent data demonstrate that patients may perceive several states of functional disability as worse than death. These include incontinence, ventilator dependence, being bed bound, confusion, and reliance on a feeding tube. The objective of this study was to compare how hospital performance would be ranked using traditional or patient-preferred outcomes for patients undergoing elective colon resections.

Methods:
The Healthcare Cost and Utilization Project State Inpatient Databases for California, Florida, Iowa, and New York were used to identify patients undergoing open colon resection. Traditional measures of postoperative outcomes included 1-year mortality. Patient-preferred measures of postoperative outcomes were based on prior study identifying states of functional disability that patients define as being as bad as or worse than death. Separate risk-adjustment models were constructed for each outcome using mixed-effects logistic regression models fit using patient-level covariates including diagnosis and procedure, and a random-effect term for the hospital. Expected event rates were derived from final models, with observed over expected ratios calculated for each hospital (with 95% confidence interval). 

Results:
A total of 42 116 patients at 663 hospitals met our inclusion criteria. Overall mortality of the study population was 11.0% at 1 year, while 3.5% of patients had functional disability at 1 year. At the hospital level, unadjusted rates of mortality ranged from 0.0 – 24.1% across hospitals, while rates of functional disability ranged from 0.0 – 11.8%. Following risk adjustment, hospitals were ranked based on observed over expected ratios for both mortality and functional disability. There was poor agreement between ranks assigned using each outcome (r=0.22, ICC=0.22 [0.14 – 0.29], kappa=0.006, p<0.001). A total of 69 hospitals were high performing for both outcomes (top quartile) and a total of 72 hospitals were low performing (bottom quartile) for both outcomes.

Conclusion:
Hospital rankings based on traditional outcomes, including mortality, may not adequately assess hospital performance for patient-preferred outcomes related to long-term postoperative functional disability. Transparency regarding the metrics used for publicly reported ranking systems and consideration of functional outcomes are important for adequately measuring the quality of a hospital’s surgical care. 
 

13.04 Can a Change in Surgical Technique Decrease Postoperative Hypocalcemia After Total Thyroidectomy?

Posted on January 25, 2017

D. S. Kim1, A. E. Barber1, R. C. Wang1  1University Of Nevada School Of Medicine,Department Of Surgery,Las Vegas, NV, USA

Introduction:

Hypocalcemia is the most common early postoperative complication of total thyroidectomy, with reported incidences up to 50% in some series, due to injury to or removal of parathyroid glands and/or compromise of parathyroid vascular supply. After observing an incidence of 20% transient hypocalcemia in our previous series, we adopted systematic changes in surgical technique in order to decrease postoperative hypocalcemia without routine calcium supplementation.  

Methods:

This was a prospective cohort study with chart review. 145 consecutive patients undergoing either total or completion thyroidectomy with or without central neck dissection at a tertiary academic center and a community hospital between May 2013 and June 2016 were included. Initial 70 patients underwent total thyroidectomy using standard techniques. Total thyroidectomy using a modified technique was performed on the subsequent 75 patients. This systematic approach consisted of the following sequential steps: mobilization of the medial and inferior thyroid lobe from the trachea to displace the inferior lobe away from the recurrent laryngeal nerve (RLN), exposure and transection of the attachments of the inferior parathyroid gland to the thyroid gland without compromising its blood supply from the inferior thyroid vessels, exposure of the RLN superiorly followed by completion of mobilization of the thyroid from the trachea and larynx, displacement of the thyroid lobe medially and inferiorly, exposure and transection of the attachments of the superior parathyroid gland to the thyroid gland without compromising the blood supply from either the superior or inferior thyroid vessels, and ligation of terminal superior thyroid vessels on one side and then on the contralateral side.  Blunt, blade shaped instruments instead of hemostats were used to dissect around the small parathyroid vessels. Harmonic scissors were used in all patients instead of ligatures whenever feasible. All patients were observed overnight without routine calcium supplementation. Significant biochemical hypocalcemia was defined as total serum Ca < 7.6 mg/dL 12 hours after surgery. Parathyroid hormone was measured in the preoperative, intraoperative and postoperative periods.

Results:

In the standard technique group, 14 of 70 patients (20.0%) developed transient hypocalcemia while 2 patients (2.9%) developed permanent hypoparathyroidism. Following the implementation of the new techniques, the incidence of transient hypocalcemia decreased to 2.7% (n=2/75; χ2=11.1, p<0.001), and there was no incidence of permanent hypoparathyroidism or hypocalcemia. No case of postoperative vocal cord palsy or paralysis was noted in both groups. The durations of surgeries were not significantly different between the two groups.

Conclusion:

The modified thyroidectomy techniques presented in this study improved the preservation of parathyroid gland function and reduced the incidence of postoperative hypocalcemia significantly.
 

13.03 Practice Variation in the Management of Uncomplicated Gastroschisis at U.S. Children’s Hospitals

Posted on January 25, 2017

S. M. Stokes1, S. S. Short1, D. C. Barnhart1, E. R. Scaife1, B. T. Bucher1  1University Of Utah School Of Medicine,Division Of Pediatric Surgery,Salt Lake City, UT, USA

Introduction:  The surgical management of infants with uncomplicated gastroschisis is not well defined. There remains a lack of strong evidence favoring primary versus delayed closure of the abdominal wall defect, and the decision is often based on surgeon preference. We proposed that institutional propensity for a particular closure method would help identify disparities in patient outcomes and resource utilization. 

Methods:  We performed a retrospective cohort analysis of infants with gastroschisis at children’s hospitals from 2010-2014 using the Pediatric Health Information Systems Database. Patients were excluded if they underwent an intestinal resection, had a significant cardiac or neurologic anomaly, or expired during the hospital admission. Patients were classified as either primary closure (≤ 24 hours from admission to closure) or delayed closure (> 24 hours from admission to closure).  The proportion of patients managed in a delayed fashion for each hospital was calculated as the hospital’s delayed closure rate. Primary outcomes included length of stay (LOS), total parental nutrition (TPN) days, and ventilator days. Multivariate hierarchical linear regression with random effects was used to determine the effect of hospital delayed closure rate on the primary outcomes after controlling for various patient and hospital level factors. 

Results: There were 1812 infants treated at 41 children’s hospitals during the study period and 1080 (60%) underwent delayed gastroschisis closure. Infants who underwent delayed closure were more likely to be lower birthweight (2451g vs 2567g, p<0.0001) and younger gestational age (35.9 weeks vs 36.1 weeks, p=0.03). Infants managed in a delayed fashion had longer LOS (43.2±24.1 vs. 35.3±19.6, p<0.001), greater TPN days (32.3±18.4 vs. 27.0±16.4, p<0.001) and greater ventilator days (7.7±10.1 vs. 4.5±3.6, p<0.0001).  The percentage of infants managed in a delayed fashion at each hospital is shown in the Figure and ranged from 27.5% to 100%.  There was no significant correlation between hospital delayed closure rate and average LOS (p=0.67), TPN days (p=0.33), or ventilator days (p=0.96).  After accounting for various patient and hospital level factors, hospital delayed closure rate was not significantly associated with LOS (p=0.09), TPN days (p=0.42) or ventilator days (p=0.84).

Conclusion: Significant practice variation exists in the management of gastroschisis in US children’s hospitals.  An institution’s propensity for a specific closure method is not significantly associated with adverse patient outcomes or increased resource utilization.

 

13.02 Safety and Efficacy of Revision Rouxeny Gastric Bypass after Gastric Banding for Weight Loss Failure

Posted on January 25, 2017

A. Wang1, S. Sprinkle1, M. Cox1, C. Park1, D. Portenier1, J. Yoo1, R. Sudan1, K. Seymour1  1Duke University Medical Center,Durham, NC, USA

Introduction:
The adjustable gastric banding (AGB) was popular as a primary weight loss procedure in the late 2000 but has decreased in popularity due to weight loss failure. With only approximately 50% of patients achieving adequate weight loss, patients may seek revision surgery to improve their outcome despite increased surgical risk. We thus aim to assess the safety and efficacy of revision roux-en-y gastric bypass (RGB) after AGB for weight loss failure. 

Methods:
After IRB approval, retrospective review from September 2004 to October 2014 at a single institution was performed.  Only those with at least 1 year follow up were included in the analysis (n=53). All surgeries were performed laparoscopically by 8 surgeons. Excess BMI loss was calculated as percent decrease in BMI compared to ideal BMI 25. Successful weight loss was defined as excess BMI loss greater than 50%. Continuous variables were compared with t-tests and categorical variables were compared with Wilcoxon rank-sum, Fisher’s exact test, or McNemar’s chi-squared test.

Results:
Average age was 46 +/- 10 years, 15% of patients were male and 64% were Caucasion race. Average length of time between AGB and RGB was 3.8 +/- 1.6 years.  Average length of stay during the revision operation was 2.7 +/- 3.3 days. At 30 days, there were 5 readmissions (3 for poor oral intake, 1 for obstruction, and 1 for cellulitis) and 3 reoperations (2 for obstruction and 1 for bleeding). There were no 30-day mortality, pulmonary embolism, or leak.  Patients did not experience a significant decrease in BMI between baseline BMI at primary AGB surgery and BMI at time of revision (45.3 vs 44.0, p=0.24, CI -0.9 – 3.7). Patients did experience a significant decrease in BMI after revision RGB (44.0 vs 38.12, p<0.0001, CI 3.4-8.4) and 30% (n=16) of patients experienced weight loss success at 1 year. There was no significant difference in medication controlled DMII at 1 year after revision (17% vs 9%, p=0.25, CI -5%-20%); however, the average number of HTN medications decreased at 1 year (0.83 vs. 0.62, p=0.033, 0.02-0.40). 

Conclusion:
In this cohort of patients who underwent AGB to RGB for weight loss failure, patients experienced improved weight loss at 1 year compared to their original operation. Overall, patients required fewer HTN medications at 1 year but had similar rates of medication controlled DMII.  Revisional RGB after AGB can be performed safely with improvement in co-morbidities at 1 year.
 

13.01 Impact of Surgical Site Infections on Recurrence and Quality of Life in Open Ventral Hernia Repair

Posted on January 25, 2017

K. Coakley1, S. Groene1, T. Prasad1, A. Lincourt1, K. Kercher1, V. Augenstein1, B. Heniford1, P. Colavita1  1Carolinas Medical Center,GI And Minimally Invasive Surgery,Charlotte, NC, USA

Introduction:
Surgical site infections (SSI) remain a common problem in the postoperative hernia patient.  These infections add to healthcare costs, however little is known on how SSI impact patient’s quality of life (QOL) following an open ventral hernia repair (OVHR).  Our aim was to assess the effects of SSI on surgical and QOL outcomes following OVHR.

Methods:
A query of a prospective, single-center, hernia-specific database was performed for adult OVHR.  Demographics, operative characteristics, and complications were analyzed using standard statistical methods.  Multivariate regression (MVR) was performed for outcomes controlling for BMI, defect size, and comorbidities. QOL was evaluated pre-operatively, at 2 and 4 weeks, as well as 6- and 12-months using the Carolinas Comfort Scale, a hernia specific assessment tool used to evaluate QOL outcomes. 

Results:
A total of 1,711 OVHR with 239 SSI (14%) were identified.  SSI were seen in patients with a larger BMI (37.0±9.1 vs 32.0±10.6kg/m2; p<0.001) and more comorbidities(3.2±2.2 vs 2.9±2.2;p=0.03).  Patients with SSI’s had larger hernia defects (241.6±242.4 vs 134.2±226.0cm2; p=<0.001), longer OR time (228.0±94.3 vs 150.4±92.0min; p<0.001), and greater EBL (217.3±286.7 vs 97.9±125.2mL; p<0.001).  Table 1 includes additional variables.  Patients with SSI overall had more postoperative complications beyond SSI (72.9 vs 34.9%; p<0.001), specifically mesh infection (9.3 vs 0.3%;p<0.001), unplanned return to the OR(25.1 vs 3.7%;p<0.001), wound breakdown(36.9 vs 6.1%;p<0.001), readmission in 30 days(41.6 vs 5.9%;p<0.001) and recurrence(18.8 vs 4.5%;p<0.001).  There was no difference in 30-day mortality.  MVR demonstrated SSI was an independent predictor of recurrence when controlling for BMI, defect size and comorbidities (Odds Ratio(OR) 4.82; 95% CI 2.725-8.55).  .  At 6 months, SSI was an independent predictor of worse mesh sensation (OR 2.831; 95% CI 1.421-5.640), movement limitation (OR 2.083; 95% CI 1.035-4.192) and overall QOL (OR 2.355; 95% CI 1.174- 4.724).  At 1 year, SSI was independently associated with overall decreased QOL (OR 2.284; 95% CI 1.134-4.600).  

Conclusion:
SSI is associated with recurrence and worse quality of life in univariate and multivariate analysis.  Consistently, OVHR patients who experienced an SSI reported worse QOL scores at all follow up time points, from 2 weeks to 12 months.  Efforts to reduce SSI should be strongly pursued to reduce hernia recurrence and improve patient quality of life.
 

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