12.20 Predictors of a Histopathologic Diagnosis of Complicated Appendicitis

Posted on January 25, 2017

J. B. Imran1, C. T. Minshall1, T. Madni1, A. El Mokdad1, M. Subramanian1, A. Clark1, H. Phelan1, M. Cripps1  1University Of Texas Southwestern Medical Center,Surgery,Dallas, TX, USA

Introduction: Complicated appendicitis (CA) is defined by the presence of perforation or abscess during appendectomy. This definition guides clinical assessment and has a profound impact on postoperative antibiotic use and hospital length of stay. Despite its utilization, the intraoperative (IO) assessment of CA is fraught with subjectivity. Although histopathologic (HP) diagnosis should be the gold standard in identifying patients with CA, it is not immediately available after an operation to guide postoperative management. Given the subjectivity in the IO assessment and delay in obtaining an HP diagnosis, the objective of this study was to identify predictors of an HP diagnosis of CA. 

Methods: A retrospective review was performed of all patients who underwent appendectomy at our institution from 2011 to 2013. Patients were divided into cohorts consisting of those with CA or uncomplicated appendicitis (UA) based on an HP diagnosis. CA was defined by finding evidence of macroscopic or microscopic perforation or abscess on pathology report. Clinical, IO, and postoperative data were compared using chi-square and Wilcoxon rank-sum tests. We evaluated predictors of an HP diagnosis of CA using a multivariable logistic regression model. 

Results: A total of 239 out of 1066 patients had CA based on IO assessment, while only 143 out of 239 patients (60%) had both an HP and IO diagnosis of CA. On univariate analysis, older patients, patients with type 2 diabetes mellitus, those with a longer duration of pain prior to presentation, the presence of an appendicolith, abscess and appendix size on preoperative computed tomography (CT) imaging, as well as higher median preoperative temperature and serum creatinine were found to have significant differences between complicated and uncomplicated cohorts diagnosed by HP (p < .05). Patients with an HP diagnosis of CA also had less focal right lower quadrant pain and an increased time from presentation to the operating room than those with UA (p < .05). Multivariate analysis revealed that an IO diagnosis of CA was found to be associated with an HP diagnosis of CA (OR 12.32; 95% CI, 8.2 – 18.5). Other risk factors were age (per 10 years; OR 1.25; 95% CI, 1.07 – 1.46), number of days of pain (OR 1.21; 95% CI, 1.07 – 1.37), appendix size (per millimeter; OR 1.10; 95% CI, 1.07 – 1.37), and the presence of an appendicolith (OR 1.65; 95% CI, 1.06 – 2.56) on preoperative CT imaging. 

Conclusion: Age, duration of pain, appendix size and the presence of an appendicolith on preoperative imaging are moderately associated with having an HP diagnosis of CA. The IO assessment is also associated with an HP diagnosis of CA; however 40% of patients were classified incorrectly at the time of surgery. These predictors in combination with improved intraoperative grading could be used to achieve a more timely and accurate diagnosis of CA.  

 

12.19 Judging a Book by its Cover? Effects of Clinic Location on Patient Satisfaction.

Posted on January 25, 2017

C. B. Matsen1, D. Ray1, M. O. Bishop2, A. P. Presson2, S. R. Finlayson1  1University Of Utah,Surgery/General Surgery,Salt Lake City, UT, USA 2University Of Utah,Epidemiology/Internal Medicine,Salt Lake City, UT, USA

Introduction: Patient satisfaction is an important quality metric used by many healthcare systems. Most large academic centers have multiple facilities with outpatient surgical clinics. For providers who see patients at multiple sites, we asked whether satisfaction scores may be affected by where the patient is seen.  We were specifically interested in how the site of the visit might impact satisfaction with the care provider.

Methods: We obtained patient satisfaction data from the Press-Ganey survey over one year for five providers who saw patients at both a university hospital clinic and a comprehensive cancer center in separate buildings on the same campus. Logistic regression models were used to estimate the odds of a perfect satisfaction score (100%) by clinic, adjusting for the patient’s age, gender and the care provider. Seven satisfaction outcomes were analyzed, including the total score and its 6 subdomains (overall assessment, access, moving through visit, nurse/assistant, care provider, personal issues).  All satisfaction measures were dichotomized due to the high rate of perfect satisfaction. We report odds ratios (ORs), 95% confidence intervals (CIs) and p-values. Statistical significance was evaluated at the 0.05 level and all tests were two-tailed.

Results: 424 patient experiences across the two sites (234 at the cancer center, 190 at the university clinic) were analyzed. After adjusting for patient age, sex and care provider, odds of satisfaction were lower in the university clinic relative to the cancer center for all measures, although moving through visit (which asked about delays and wait times) and care provider (which asked about the patient’s experience with the care provider) did not achieve statistical significance (Table 1).  The “personal issues” domain, which queried “the cleanliness of the practice”, had a 54% lower odds of satisfaction at the university clinic than the cancer center (OR=0.46, 95% CI: 0.26-0.8, p<0.001). There were also statistically significant differences in satisfaction among the providers for total satisfaction, moving through visit, nurse/assistant and care provider (all p<0.05).

Conclusion: In our single institution study, patient reported satisfaction was consistently associated with the site of the visit. Patient reported satisfaction with the provider appears to be influenced by both the provider and the site of the visit. The site-specific factors may include additional patient factors that were not adjusted for in our analysis, such as acuity and severity of illness, or other factors related to the setting.

 

12.18 Systematic Implementation of a Colon Bundle Significantly Decreases Surgical Site Infections

Posted on January 25, 2017

F. Gaunay1, T. Adegboyega1, C. Sanz1, M. Berrones1, D. Rivadeneira1  1North Shore University And Long Island Jewish Medical Center,Colon & Rectal Surgery,Manhasset, NY, USA

Introduction:

Surgical site infections (SSIs) represent significant morbidity and financial implications following colon surgery. The objective of this prospective study is to compare clinical outcomes pre- and post- implementation of a dedicated colon surgery bundle to reduce SSIs in our health system.

Methods:

A prospective study was conducted in which a dedicated colon surgery bundle and interdisciplinary team for its implementation was established.  The twenty-five components of the colon surgery bundle were divided into pre-hospital, pre, intra, and post-operative measures.  These included standardized pre-operative mechanical bowel preparation and oral antibiotics and body wash skin cleansing, alcohol-based skin preparation, intra- and peri-operative maintenance of normothermia, therapeutic levels of antimicrobial prophylaxis and optimal tissue oxygenation, glucose control, and the introduction of a clean standardized fascial closure process, and negative pressure wound therapy. Specific enhanced pre-operative patient education was also provided. Consecutive patients who underwent a colorectal procedure between January 2015 and January 2016.  SSIs were recorded and subdivided by surgical wound class.

Results:

SSIs were identified in 11/198 patients (7%) eligible for colon bundle implementation. When compared to the year prior to implementation of the colon bundle, SSIs where identified in 26/175 (15%).  Implementation of the colon bundle led to a significant decrease in SSIs 7% vs. 15%, (p <0.05).  Additionally, SSIs observed in clean-contaminated and contaminated procedures decreased from 34.6% to 14.3% and 38.5% to 14.3%, respectively (p<0.05%). 

Conclusion:

We demonstrate in this prospective study that the implementation of a specific colon bundle resulted in a 54% decrease in post-operative SSIs. The greatest reduction of SSIs was seen in wound classes II and III.  We also show a very high adoption and compliance of the colon bundle with a dedicated implementation of  an interdisciplinary team. This approach to incorporating an advanced surgery bundle for colon and rectal procedures can provide an effective strategy to reduce SSIs.
 

12.16 Using Patient Outcomes to Evaluate Residency Program Performance in Colorectal Surgery

Posted on January 25, 2017

M. M. Sellers1,2, R. L. Hoffman1, C. Wirtalla1, G. C. Karakousis1, R. R. Kelz1  1Hospital Of The University Of Pennsylvania,Center For Surgery And Health Economics Department Of Surgery,Philadelphia, PA, USA 2Mount Sinai School Of Medicine,Depar,New York, NY, USA

Introduction:  The feasibility of ranking residency programs based on the clinical outcomes of their graduates has previously been established. Colorectal resection is amongst the most common operations performed by general surgeons. Our objective was to assess general surgery residency program performance in colorectal surgery education using the objective clinical outcomes of patients operated on by program graduates.

Methods:  A retrospective cohort study was conducted of patients that underwent a colorectal resection in New York or Florida (2008-2011).  After linking with data from the American Medical Association, the cohort included 47,147 patients operated on at 343 hospitals, by 856 surgeons who trained at 74 distinct general surgery residency programs. A hierarchical generalized linear model, risk adjusted for patient, hospital and surgeon characteristics including surgeon specialty, was used to assess the independent association between residency program and adverse events (AE).

Results: The observed AE rates were 3.4% for death, 44.3% for any AE, 39.6% for colorectal-specific AE (CSAE), and 23.4% for prolonged length of stay (pLOS). Patients operated on by surgeons trained in residency programs ranked in the top tertile were significantly less likely to experience an AE than were patients operated on by surgeons trained in residency programs ranked in the bottom tertile (2.8% vs 5.4% for death, 41.6% vs 51.9% for any AE, 36.5% vs 46.3% for CSAE, and 22.9% vs 27.2% for prolonged length of stay (all P < .001)). Adjusted adverse event rates for patients operated on by surgeons trained in top tertile programs were marginally lower than those who were operated on by surgeons trained in bottom tertile programs (see Table). The model C statistics ranged from .76 to .87. The proportion of variation explained by the model ranged from 15.3% to 23.1%. 

Conclusion: Unadjusted outcomes of patients treated by surgeons who trained in programs ranked in the top and bottom tertiles differed significantly across all of the outcomes studied. The magnitude of the differences was small after risk adjustment. General surgery program performance is fairly homogeneous when compared by their graduates’ patients’ outcomes following colorectal surgery.

 

12.15 Laparoscopic Subtotal Cholecystectomy Compared to Total Cholecystectomy: A National Analysis

Posted on January 25, 2017

Y. Kim1, K. Wima1, B. T. Xia1, V. K. Dhar1, D. E. Go1, S. A. Shah1  1University Of Cincinnati,Surgery,Cincinnati, OH, USA

Introduction:  Laparoscopic subtotal cholecystectomy (LSC) is considered a safe alternative to laparoscopic cholecystectomy (LC) if dissection of biliary anatomy is obscured. Recent reports have shown that morbidity rates are similar between the two procedures, but the impact of conversion on resource utilization has not been defined.

Methods:  Using the University HealthSystem Consortium database, we identified 131,082 LC performed from 2009 to 2013, and 487 LSC performed during the same period. A 1:1 propensity score match was performed for 487 LSC procedures based on patient-level differences in clinical and demographic factors.

Results: Compared with LC, patients undergoing LSC were more likely to be male (54.2% vs. 32.3%), elderly (56 vs. 48 years), and have higher severity of illness (SOI) on admission (34.1% major or extreme SOI vs. 22.9%). LSC patients demonstrated a prolonged hospital length of stay (LOS, 4 days vs. 3 days), greater total direct cost ($9,053 vs. $6,398), higher readmission rates (11.9% vs 7.0%), and higher mortality rates (0.82% vs 0.28%, p<0.05 each). After matching, the difference in total direct cost persisted ($9,053 vs $7,581, p=0.0002), but there were no differences in hospital LOS, readmission rates, or overall mortality.

Conclusion: LSC is an important alternative to LC for difficult gall bladders in sicker patients. Our data demonstrate that patient-level factors are responsible for worse outcomes following conversion to LSC, and hospital outcomes are similar after adjusting for these factors.

12.14 Does Re-operative Bariatric Surgery Improve Glycemic Control and Cardiac Risk?

Posted on January 25, 2017

A. Mokhtari1, T. Mokhtari1, L. Voller1, J. Morton1  1Stanford University,Bariatric & Minimally Invasive Surgery,Palo Alto, CA, USA

Introduction:  Re-operative bariatric surgery following non-response to adjustable gastric banding (AGB) or sleeve gastrectomy (SG) is generally accepted and safe with conversion to laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB). While studies have reported reduced weight loss after re-operative procedures, the impact of revisional procedures on comorbidities has yet to be investigated.

Methods:  2,380 patients undergoing bariatric surgery at a single academic institution were prospectively followed in a defined data registry included 42 re-operative subjects with recorded data (13 AGB to SG; 20 AGB to RYGB; 9 SG to RYGB). Biomarkers for diabetes, cardiac risk, and inflammation including HbA1c, total cholesterol (TC), triglycerides (TG), LDL, TG/HDL ratio, and CRP were collected at preop and 6-months postop. 

Results: 

Demographic distribution for participants undergoing revisional surgery was 92% female, mean age 48 years, preop BMI 42.4 kg/m2.  Participants undergoing revisional SG after primary (1°) AGB lost significantly less weight than those undergoing primary SG (6-month percent excess weight loss, %EWL-6 38.0 vs 53.1%, p=0.03). Gastric bands  were present for 46 months with average BMI decrease of 3.3 points over this time and median time between band removal and subsequent re-operative SG was 4.7 months. Participants undergoing revisional RYGB after 1°AGB also lost significantly less weight than those undergoing 1° RYGB (%EWL-6, 47.0 vs 60.3%, p = 0.01); average band duration was 39 months prior to removal with mean BMI decreasing 4.1 points and median time between band removal and subsequent re-operative RYGB 3.7 months. For patients undergoing re-operative RYGB following SG, weight loss at 6 months was also significantly lower than those patients undergoing 1° RYGB (%EWL-6, 45.7 vs 60.3%, p=0.05). Participants experienced improved glycemic control upon bariatric re-operation following 1° AGB as evidenced by improved HbA1c 6-months following re-operative surgery (14.0% decrease after 2° SG and 17.2% following RYGB); there were no significant differences in these HbA1c values between 1° patients and those undergoing either 2° SG or RYGB after 1° AGB. Additionally, at the 6-month time point there was no significant difference in improvements for biochemical cardiac risk factors (including TC, TG, LDL, TG/HDL, and CRP) between re-operative SG and RYGB patients versus those undergoing the respective primary procedure (all p’s >0.05).

Conclusion: Re-operative bariatric surgery is effective with this study demonstrating that in addition to achieving significant weight loss (though less than the corresponding 1° surgery), re-operative bariatric patients experience improvements in glycemic control, biochemical cardiac risk factors, and inflammatory markers comparable to patients undergoing a primary procedure.
 

12.13 Roux-en-Y Gastric Bypass in Elderly Patients: Appropriate?

Posted on January 25, 2017

T. Hassinger1, J. Mehaffey1, L. Johnston1, G. Fasen1, B. Schirmer1, P. T. Hallowell1  1University Of Virginia,Department Of Surgery,Charlottesville, VIRGINIA, USA

Introduction: Numerous studies have established the effectiveness of Roux-en-Y Gastric Bypass (RYGB) for weight loss and comorbidity amelioration. This study evaluated outcomes in patients over the age of 60 with a propensity-matched group of controls. We hypothesized RYGB provides weight-loss benefits with no difference in overall survival.

Methods: All patients over the age of 60 undergoing RYGB at a single institution over a 30-year study period (1985-2015) were evaluated. Using a clinical data repository of all routine outpatient visits at our large academic medical center, we matched patients 4:1 on comorbidities, age, date of visit, and BMI to create our control population. Univariate analysis was performed, and Kaplan Meier survival curves were fitted for the two groups based on social security death data.

Results: Over the past 10 years 107 patients over the age of 60 underwent RYGB, and these were propensity matched with 428 controls. There was no difference in median BMI (45.6±5.3 vs. 47.1±4.3; p=0.45), age (61.6±2.1 vs. 62±2.0; p=0.15), or any other medical comorbidities between the groups. Kaplan Meier survival analysis with Log-Rank test demonstrated no difference in long-term survival (p=0.63) as seen below in Figure 1. Additionally, current BMI was evaluated based on medical record review demonstrating a significant percent excess BMI (%EBMI) reduction for the surgery group compared to the control group (81.8±35.8 vs. 10.3±28.0, p<0.001).

Conclusion: RYGB remains an excellent operation for weight reduction in patients over the age of 60 with no difference in long-term survival among comorbidity-matched controls. This study demonstrates major weight reduction benefit with surgery compared to an age- and comorbidity-matched control group. These data help to more clearly define the role for bariatric surgery in the elderly population and demonstrate outstanding %EBMI reduction.
 

12.12 Oncologic Adequacy of Resection in Elective Versus Emergent Cases of Colon Cancer

Posted on January 25, 2017

N. Tehrani1, S. Ganai1, M. Garfinkel1  1Southern Illinois University School Of Medicine,General Surgery,Springfield, IL, USA

Introduction: The practice of surgery is being increasingly subjected to quality improvement measures, including metrics for oncologic adequacy. The acute care surgeon often does not have the luxury of pre-operative optimization nor the ability to defer intervention but is still subject to these measures. The goal of our study was to evaluate oncologic adequacy as well as perioperative morbidity for resections done for colon cancers presenting electively versus emergently.  We hypothesized that emergent cancer operations will have decreased compliance with oncologic metrics.

Methods: A retrospective chart review was performed of a sample of patients who underwent colectomy for colon cancer at an academic-affiliated community hospital from 2010-2014. Cases of rectal cancer were excluded. Metrics related to oncologic adequacy of the resections, including margins and nodes sampled, as well as perioperative complication rates and blood loss were collected for the two populations.  Fisher’s exact and Student’s T-tests were used to make comparisons between groups with significance defined by p<0.05.

Results: Forty-four patients were identified with 19 emergent and 25 elective cancer resections. There was no difference in proportion of open cases among the two groups (94.7 vs 80%, p=0.21). Emergent and elective cases had no significant difference in presentation with pT3 or pT4 tumors (84.2 vs 56%, p=0.06). Adequate proximal and distal surgical margins—defined as greater than 5cm—were achieved in 94.7% of emergent colectomies and 84% of elective cases (p=0.37). Adequate node sampling (>12 lymph nodes) was achieved in 100% of emergent cases vs 94.7% in elective cases (p=1.00). Greater blood loss was seen in emergent cases (294 vs 167ml, p<0.05). Similarly, emergent cases demonstrated higher perioperative complication rates (78.6 vs 33.3%, p=0.02) as well as ICU admissions (57.1 vs 8.7%, p=0.002).

Conclusions: Contrary to our hypothesis, we demonstrated a similar rate of oncologically adequate resections for emergent colectomies, although this study may be underpowered to detect any clinically-important difference. The study will benefit from expanding our sample size to include all cases of colon cancer contained within local tumor registries for the same time period. Finally, an analysis of long-term recurrence rates controlled for cancer stage is warranted. 

12.11 Association Between Surgical Patient Satisfaction and Non-Modifiable Factors

Posted on January 25, 2017

L. Martin1, M. Gross1, A. Presson1, C. Zhang1, M. Hopkins1, D. Ray1, S. Finlayson1, R. Glasgow1  1University Of Utah,Salt Lake City, UT, USA

Introduction:  Patient satisfaction surveys have become an important tool in measuring physician performance in the area of patient experience.  We hypothesized that non-modifiable patient factors, such as age, gender and travel distance would be associated with outpatient satisfaction scores.

Methods:  Press Ganey Consumer Assessment of Health Providers and Systems (CHAPS) outpatient satisfaction scores from encounters at an academic department of surgery (1/2011-7/2015) were reviewed.  Completed surveys (18,373) from patients (10,652) over 18 years were included.  Data were collected on patient factors including age, gender, race, language, insurance status, travel distance, and marital status. Information about the specialty of the provider, the visit practice setting (ambulatory center clinic, referral center clinic, cancer center clinic) and whether it was the patient’s first visit were collected.  Patients were divided into groups based on the distribution of satisfaction scores—completely satisfied (score =100) or less satisfied (score ≤99).  Generalized estimating equation logistic regression analysis was performed to identify factors predictive of complete patient satisfaction.

Results: Older age was associated with being completely satisfied (OR 2.31; CI 1.43-3.71, p=0.001) [Figure]. Patients seeing their surgeon for the first time were less likely to be completely satisfied than those being seen in follow up (OR 0.83; CI 0.77-0.89, p<0.001).  Compared to patients seen at an ambulatory center clinic setting, there was no difference in complete satisfaction among those patients seen at the cancer center clinic (OR 0.92; CI 0.83-1.03, p=0.14); however, patients seen at the referral center clinic were less likely to be satisfied (OR 0.76; CI 0.69-0.84, p<0.001).  There was no difference in satisfaction among patients seen in General Surgery, Vascular Surgery or ENT clinics. Patients were less likely to be completely satisfied when seen in Urology clinic (OR 0.82; CI 0.74-0.91, p<0.001) and were more likely to be completely satisfied when seen in Plastic Surgery clinic (OR 1.16;  CI 1.03-1.32 p=0.02).  Gender, race, language, insurance status, travel distance, marital status, and a variety of interaction terms were not found to be predictive.

Conclusion: Utilizing satisfaction scores to evaluate providers should take into account non-modifiable factors of the underlying patient population, the specialty of the provider and the practice setting of the clinical visit. 

 

12.10 Monitoring the Skin Microbiota of Colorectal Surgery Patients to Predict Surgical Site Infections.

Posted on January 25, 2017

A. Yeh1, B. Firek1, J. Holder-Murray1, M. J. Morowitz1  1University Of Pittsburgh,Department Of Surgery,Pittsburgh, PA, USA

Introduction:
Wound infections after colorectal surgery occur at a rate of 5 to 30%. A potential contributor for which there is no published literature is the wound microbiome. This study will analyze the role of the skin microbiota in the development of wound infections after colorectal surgery. We will define the temporal and spatial changes of the skin microbiota in the peri-operative period and determine if specific bacterial populations or patterns of microbial diversity are predictive of wound infections.

Methods:
Peri-operative samples were obtained from adult patients undergoing colorectal surgery for cancer, diverticulitis, and IBD. Pre-operative samples included a skin swab at the anticipated site of the surgical incision. Intra-operative samples included skin swabs before and after skin preparation, subcutaneous fat of the extraction incision upon opening and prior to closing, and colon specimen contents. Post-operative samples included skin swabs and stool samples daily until discharge and at the post-operative clinic visit. Bacterial 16S rRNA gene sequences in each sample were amplified, sequenced on the Illumina MiSeq, and analyzed with QIIME. Healthy volunteer samples from the American Gut Project (AGP) were analyzed as a control.

Results:
A mean of 14.3 samples were collected from 9 patients. The average hospitalization was 5.1 days. Six, 1, and 2 patients underwent a left-sided resection, right-sided resection, and total colectomy, respectively. Species richness and evenness on the skin gradually decreased from the pre-operative clinic visit to the day of surgery after skin preparation and remained low in the post-operative period. Principal coordinates analysis comparing differences in microbial composition showed a clustering of pre-operative skin samples with healthy AGP volunteers signifying similar composition. Post-operatives skin swabs clustered distinctly from healthy samples signifying instability in microbial composition. Staphylococcus, a bacterium common in wound infections, was more abundant in the skin swabs post-operatively (see figure). Conversely, Corynebacterium, a common healthy bacterium, was decreased. One patient developed an Enterococcus wound infection. Ileostomy and skin samples prior to the wound infection showed dominance by Enterococcus, possibly signifying a predictive value of microbiota monitoring.

Conclusion:
In our preliminary results, the skin microbiota after colorectal surgery undergoes collapse of its microbial diversity and composition. During the post-operative period, pathogens such as Staphylococcus proliferate at the expense of healthy bacteria. Future work will require additional patient recruitment to determine whether these findings increase the risk of wound infections.

12.09 Outcomes of Intrathecal Analgesia as Part of an Enhanced Recovery Pathway in Colorectal Surgery

Posted on January 25, 2017

A. Merchea1, J. Lovely4, A. Jacob3, D. Colibaseanu1, S. Kelley2, K. Mathis2, G. Spears5, M. Huebner6, D. Larson2  1Mayo Clinic – Florida,Colon & Rectal Surgery,Jacksonville, FL, USA 2Mayo Clinic,Colon & Rectal Surgery,Rochester, MN, USA 3Mayo Clinic,Anesthesiology,Rochester, MN, USA 4Mayo Clinic,Hospital Pharmacy Services,Rochester, MN, USA 5Mayo Clinic,Biostatistics,Rochester, MN, USA 6Michigan State University,Statistics,Lansing, MI, USA

Introduction:  Multimodal analgesia is an essential component of an enhanced recovery pathway (ERP). An ERP that includes the use of single injection intrathecal analgesia (IA) has been shown to decrease morbidity, decrease cost, and shorten length of stay (LOS). Limited data exist on safety, feasibility, and the optimal intrathecal medication regimen in the setting of an ERP for patients undergoing colorectal surgery. Our objective was to characterize efficacy, safety, and feasibility of IA within an ERP program in a large cohort of colorectal surgical patients.

Methods:  A retrospective review was conducted to identify all consecutive patients age ≥ 18 years that underwent open or minimally-invasive colorectal surgery from October 2012 to December 2013. All patients were enrolled in an institutionally derived ERP that included the use of single-injection IA – consisting of opioid-only intrathecal (IA-O) or opioid with a local anesthetic (IA-L). Patient records were reviewed for demographic data, anesthetic management, analgesic efficacy (pain scores, opiate consumption), post-operative ileus (POI), adverse effects, and LOS.

Results: 601 patients were identified. The majority received opioid-only IA (91%, n=547) rather than a multimodal IA regimen. Median (IQR) LOS was 3 (2-5) days. Median (IQR) total oral morphine equivalents (OME) used was 24 (0-83). A greater proportion of patients receiving IA-O utilized zero OMEs compared to IA-L (30% vs. 15%, p=0.03).  Overall, 28% of patients required no additional narcotic other than that included with the intrathecal. There was no difference in LOS or POI based on intrathecal medication received or dose of intrathecal opioid. Pain scores were similar at all time intervals, however the median 48 hour maximum reported pain score was greater in those patients receiving IA-L (7 vs. 6, p=0.045). Overall, development of respiratory depression or pruritus was rare (0.2% and 1.2%, respectively). One patient required blood patch for post-dural headache.

Conclusion: Intrathecal analgesia is safe, feasible, and efficacious in the setting of ERP for colorectal surgery. All regimens and doses achieved a short LOS, low pain scores, and a low incidence of POI.

 

12.08 Shoulder Disability Affects Quality of Life After Thyroidectomy Even Without Lymph Node Dissection

Posted on January 25, 2017

H. Wong1, S. Kaplan1, M. G. White1, M. K. Applewhite2, P. Angelos1, B. Aschebrook-Kilfoy1, R. H. Grogan1  1University Of Chicago,Endocrine Surgery Research Group In The Department Of Surgery,Chicago, IL, USA 2Albany Medical College,Surgery,Albany, NY, USA

Introduction:  Shoulder disability after thyroid surgery without lymph node dissection (LND) is not a commonly appreciated morbidity.  Here we ask participants enrolled in the North American Thyroid Cancer Survivorship study (NATCSS) to define their shoulder disability after thyroid cancer operations and the impact of this impairment on quality of life (QoL).

Methods:  NATCSS participants were asked to self-report shoulder problems.  Those screening positive were provided the Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire, a validated instrument quantifying the severity of upper extremity disability. Responses were compared using t-test and ANOVA analyses.  Known risk factors for shoulder disability such as LND were studied using univariate and multivariate logistic regression.

Results: Of 1,019 respondents, 314 (31.0%) reported shoulder disability following their operations and 161/314 (51.3%) went on to complete the QuickDASH, scoring a mean QuickDASH score of 44.9±19.9, versus 13.0±17.4 in a healthy matched population (p<0.0001). One-hundred twenty (74.5%) of those with self-reported shoulder disability had a QuickDASH score >1 SD above the population mean, while 63(39.1%) had a score >2 SD above the population mean. Those patients with shoulder disability (QuickDASH >1 SD above matched population mean) had a mean age of 58.4±8.0 and are 92.4% female. Eighty-eight (55%) patients with shoulder disability reported a history of LND. Of these, 17 (18%) reported shoulder disability on the opposite side from their LND. In other words, those 73 (45%) patients who did not report a history of LND combined with the 17 patients who reported shoulder disability on the opposite side from their LND make up 90 (56%) patients whose shoulder disability were not explained by a history of LND. On multivariate analysis, female sex (p=0.033) and history of underactive thyroid function (p=0.017) were predictive of an increased QuickDASH score (p=0.036). Increased QuickDASH scores correlated with a decrease in a number of quality of life measurements (p<0.05).

Conclusion: In this retrospective study, 56% of post-operative thyroid cancer patients reported experiencing shoulder disability that did not correlate with having a LND. Elevated QuickDASH scores in these patients quantifies the functional impairment associated with this disability.  Our data also show an associated significant decrease in quality of life. While female gender, and hypothyroidism may be contributing factors, further prospective studies are required to better elucidate the reason for this phenomenon.

 

12.07 Modifiable Factors Related to Pre-Operative Psychosocial Distress Among Colorectal Cancer Patients

Posted on January 25, 2017

M. McLeod1, C. Veenstra1, S. K. Hendren1, P. H. Abrahamse1, D. Jomaa1, A. M. Morris1  1University Of Michigan,Ann Arbor, MI, USA

Introduction: Baseline psychosocial distress among cancer patients is associated with poor patient-provider communication, reduced treatment adherence, longer inpatient stays, and poorer clinical outcomes. We hypothesized that several factors would be independently associated with baseline patient-reported distress, which in turn would be associated with poorer clinical outcomes in the setting of colorectal cancer. 

Methods: Over one year, new colorectal cancer patients at the University of Michigan Comprehensive Cancer center were invited to complete the NCCN Distress Thermometer, Impact Thermometer and Problem List before their first visit. Additional clinical data were abstracted from the electronic medical record: age, sex, race, marital status, comorbidities, cancer stage and type, and clinical outcomes. We performed multivariable analysis to assess factors associated with patient-reported distress, and the association between distress and 30-day complications of surgery. We then conducted semi-structured interviews with patients selected based on quantitative analyses. We queried means of coping with the patient-reported physical, financial, practical, emotional and spiritual challenges posed by their cancer treatment. Interviews were recorded, transcribed, coded and discussed using rapid content analysis.

Results: Among 292 eligible patients with colorectal cancer who consented to participate, initial data abstraction was completed for 225. The average patient age was 61 years (range 27-91), and 58% were male. The mean Distress Thermometer score was 4.15 (range 0 – 10). Female sex (p<0.001), lack of a domestic partner (p<0.05), rectal cancer (p<0.01), and mental health comorbidities (p<0.001) were associated with greater distress in the multivariable analysis. 54% of patients had complications of surgery. Neither multivariable nor bivariate analyses demonstrated a correlation between distress and 30-day complications. In follow-up qualitative interviews, patients indicated that (1) a sense of their surgeon’s commitment to their physical and emotional well-being and (2) the presence of a trusted personal advocate enabled physical and emotional coping. Improved coping resulted in reduced psychosocial distress, and increased engagement in treatment.

Conclusions: These findings indicate the importance of the patient-surgeon relationship and the psychosocial benefit of a trusted personal advocate, usually a spouse, during cancer care. Although there was not a direct correlation between distress and surgical complications, these data support engaging the spouse or important others at the onset of multidisciplinary cancer care during the patient-surgeon interaction. Understanding the role that modifiable factors play in the progression of psychosocial distress provides a platform to facilitate patient coping, engagement, and satisfaction with care.
 

12.05 Concurrent Sleeve Gastrectomy and Hiatal Hernia Repair is Safe and Improves Weight Loss

Posted on January 25, 2017

A. Wang1, M. Turner1, S. Sprinkle1, A. D. Guerron1, D. Portenier1, C. Park1, R. Sudan1, J. Yoo1, K. Seymour1  1Duke University Medical Center,Surgery,Durham, NC, USA

Introduction:
Hiatal hernias are found in 40% of morbidly obese patients. For bariatric surgery candidates with hiatal hernias, the role of concurrent hiatal hernia repair (HHR) during laparoscopic sleeve gastrectomy (LSG) remains uncertain. We hypothesize that concomitant HHR during LSG is a safe procedure. 

Methods:
After IRB approval, retrospective review from August 2011 to December 2013 at a single institution resulted in 410 patients who underwent LSG. Isolated LSG was performed on 221 patients and LSG with HHR was performed on 188 patients. Six surgeons performed all cases with no open conversions. Excess BMI loss was calculated as percent decrease in BMI compared to ideal BMI 25. Continuous variables were compared with t-tests and categorical variables were compared with Wilcoxon rank-sum or Fisher’s exact test.

Results:
Baseline patient characteristic did not significantly differ between groups (Table). Intraoperative assessment revealed 105 patients with mild to moderate hiatal hernias, 52 with moderate sized, 7 with large sized, and 7 with paraesophageal. Intraoperative HHR used anterior approach in 9% of patients, anterior and posterior approach in 7%, and posterior approach in the remainder. Reinforcement with mesh was used in 47% of patients. Operative time was significantly longer in the HHR group (91 vs 76 min, p< 0.0001, CI: 9.9-19.4). When a single surgeon routinely performs HHR (n=147), however, there was no significant difference in operative time compared to sleeve alone (n=31) (88.9 vs 82.2 min, p=0.16, CI -2.7-16.4).  Between groups, there was no difference in estimated blood loss (22.7 vs 20.0 ml, p-0.23, CI -1.8-7.3) or length of stay (1.6 vs 1.8 days, p=0.07, CI -0.4-0.01). Neither group experienced a 30-day mortality, reoperation, pulmonary embolism, or leak and both groups had similar rates of 30-day readmission (n=4). Sleeve with HHR resulted in increased excess BMII loss at 3 months (40.1% vs 36.0%, p=0.003, CI 1.3-6.9) and 6 months (52.5% vs 45.9%, p=0.01, CI 1.6-11.6). 

Conclusion:
LSG with concurrent HHR is safe and does not result in increased short-term mortality or morbidity. When routinely performed, LSG with HHR does not result in increased operative time. In our cohort, LSG with HHR also resulted in increased weight loss, possibly due to improved mobilization and resection of the gastric fundus. 
 

12.04 Patient Reported Outcomes Following Splenectomy for Hematological Disorders

Posted on January 25, 2017

M. O. Mohamed1, D. Laan1, C. A. Thiels1, J. Bingener1  1Mayo Clinic,Surgery,Rochester, MN, USA

Introduction:
Splenectomy for hematologic malignancy is a high risk procedure, performed to improve patients’ quality of life (QOL). It is not well known which role underlying diseases play in the patient reported outcomes for these patients postoperatively.

Methods:
Patients who underwent elective splenectomy for hematological causes at our institute between the years 2009 and 2015 were identified retrospectively. Our institution routinely collects the validated LASA (Linear Analog Self-Assessment) to assess the patients’ fatigue, pain and overall QOL preoperatively (baseline) and at 1 month, 3 months, 6 months and 12 months after surgery. Demographic, operative approach, complications and one-year survival were abstracted. T-test and ANOVA were used to compare outcomes.

Results:

QOL data was available for 115 splenectomy patients including 82 patients with lymphoma, 16 patients with leukemia and 17 patients with myelofibrosis. Mean age was 62 years and 40 patients (31%) were women. Operative approach, spleen weight and complications are depicted in table 1. Thirty day mortality was zero, one year survival was 79% in the lymphoma group, 62%  in the leukemia group, and 65%  in patients with myelofibrosis.

Overall QOL did not markedly improve in general; only MF patients had improved QOL at one year postoperatively (0.55+3.35). Fatigue and pain showed clinically significant improvement from baseline for all groups during the follow-up period after splenectomy, more significantly for MF patients. 

Increased preoperative fatigue correlated with a decreased one year survival for the leukemia group p=0.023.

Conclusion:
Splenectomy significantly improved the fatigue for lymphoma and leukemia patients over the follow up duration, overall QOL did not change markedly. More PRO data are necessary to help patients and surgeons select the appropriate timing and indication for splenectomy in hematologic malignancies.

12.03 Patient Perceptions and Quality of Life after Colon and Rectal Surgery

Posted on January 25, 2017

S. M. Wrenn1, D. Ramos-Valadez2, A. Cepeda-Benito3, P. Cataldo1  1University Of Vermont College Of Medicine,Department Of Surgery,Burlington, VT, USA 2Sanford Health,Surgery,Thief River Falls, MINNESOTA, USA 3University Of Vermont,Department Of Psychological Sciences,Burlington, VT VERMONT, USA

Introduction: As healthcare payment models shift increasingly toward value-based incentives, it is imperative that postoperative outcomes are both accurately assessed and correctly aligned with patient priorities regarding their recovery and care. In particular, the assessment of patient quality of life as it pertains to both laparoscopic and open colorectal surgery remains understudied. 

Methods: Patients who underwent a colon or rectal surgical resection at a single academic medical center between 2009-2015 were identified and contacted via traditional mail.  Subjects were offered to complete a voluntary hand-written 36-question survey regarding their perioperative and postoperative quality of life. Responders who enrolled in the study were stratified into subcategories (including laparoscopic vs. open groups, benign vs. malignant groups). Analysis was performed via both subjective reported data and objective data from the electronic medical record regarding their clinical course. Statistical analysis was performed for categorical variables via chi squared test, and unpaired t test for interval variables. Statistical significance was defined as p<.05. 

Results:A total of 626 patients were queried, and 167 patients responded to the survey (27% response rate). 25% of patients reported their surgery was laparoscopic, 63.5% reported their surgery was open, and the rest did not respond or were unsure. 92.2% of responders were satisfied with their surgical recovery. Factors deemed most important to all responders included being cured of colorectal cancer (91%), not having a permanent ostomy or stoma (84%), and not having any complications after surgery (74%).  Patients who underwent laparoscopic surgery reported a shorter hospital length of stay (p<.001), quicker return to full strength (p<.05), and smaller incision (p<.001) with greater satisfaction with the appearance of their scar (p<0.05). 

Conclusion:Regardless of surgical technique or indication, patients in our study reported high levels of satisfaction with their surgical care. Laparoscopic colorectal resections do appear to have some significant advantages over traditional open procedures, however not in the categories deemed most important to patients.  This research helps elucidate the quality outcomes that are truly considered most valuable to patients during their perioperative and postoperative colorectal surgical care.   

 

12.02 A Critical Analysis of Feeding Jejunostomy Following Esophagectomy Versus Gastrectomy

Posted on January 25, 2017

R. E. Sargent1, A. M. Blakely1, T. Ng1, T. J. Miner1  1Brown University School Of Medicine,Department Of Surgery,Providence, RI, USA

Introduction:  Adequate nutrition following major upper gastrointestinal cancer resection is critical in order to achieve optimal recovery from the operation and to facilitate initiation of adjuvant therapy when indicated. Feeding jejunostomy tubes (FJT) are often placed at time of resection in order to secure enteral access. FJT utilization rates and need for parenteral nutrition (PN) were assessed.

Methods:  Retrospective review of prospectively-maintained database was performed of adult patients who underwent esophagectomy or gastrectomy (subtotal or total) for cancer with curative intent, January 2001 to June 2014. Esophagectomy approach, extent of gastrectomy, FJT placement and utilization at discharge, administration of PN, and complications were evaluated.

Results: 287 patients underwent resection, comprised of 182 esophagectomy (n=107 transhiatal, 58.7%; n=56 Ivor-Lewis, 30.7%) and 105 gastrectomy (n=63 subtotal [SG], 60.0%; n=42 total [TG], 40.0%). 181 of 182 esophagectomy patients underwent FJT, compared with 47 of 105 gastrectomy patients (99.5% vs. 44.8%, p<0.0001), of whom most had undergone TG (n=39, 92.9% vs. n=8 SG, 12.9%, p<0.0001). Median length of stay was similar between esophagectomy and gastrectomy groups (14.7 days vs. 17.1, p=0.076). Upon discharge, 81 esophagectomy patients (48.6%) were taking enteral feeds, with 53 (29.3%) fully and 28 (15.4%) partially dependent. Meanwhile, 20 of 39 TG patients (51.3%) were either fully (n=3, 15.0%) or partially (n=17, 85.0%) dependent on tube feeds, compared with 5 of 8 SG (62.5%) patients, all of whom were partially dependent. Gastrectomy patients were significantly less likely to be fully dependent on tube feeds at discharge compared to esophagectomy patients (6.4% vs. 29.3%, p=0.0006). PN was administered despite FJT placement more often following gastrectomy than esophagectomy (n=11, 23.4% vs. n=7, 3.9%, p=0.0001). Four esophagectomy patients required PN due to chylothorax. FJT-specific complications requiring reoperation within 30 days of resection occurred more commonly in the gastrectomy group (n=6), all after TG, compared to 1 esophagectomy patient (12.8% vs. 0.6%, p=0.0003). Six of 7 patients (85.7%) who experienced tube-related complications required PN.

Conclusion: Esophageal and gastric malignancies are distinct pathologies, and resection of each is associated with a unique complication profile. Such complications may preclude feeding jejunostomy use and therefore require parenteral nutrition. Reliance on tube feeds was more common following esophagectomy, while major tube-related complications occurred more frequently following gastrectomy. The type of upper gastrointestinal resection should inform the decision to place a feeding jejunostomy tube, considering potential resection- and tube-related complications, in order to optimize postoperative utilization rates. 

 

 

12.01 Outcomes Significantly Differ by Indication for Surgery in Elective Colectomies

Posted on January 25, 2017

A. A. Gullick1,2, L. E. Goss1,2, D. I. Chu1,2, C. Balentine1,2, M. S. Morris1,2  1University Of Alabama at Birmingham,Gastrointestinal Surgery,Birmingham, Alabama, USA 2VA AL Healthcare System,Surgery,Birmingham, AL, USA

Introduction:   Patients have high complication rates following Colorectal surgery and some of these outcomes are publically reported. Outcomes following colectomy are extensively reported but most studies fail to consider surgical indication or are performed on a cohort with a single indication such as colorectal cancer. We aim to examine our hypothesis that postoperative outcomes vary based on surgical indication in non-emergent colorectal procedures.

Methods:   We queried the 2011-2014 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) colectomy procedure targeted database for non-emergency cases and stratified patients by primary indication for surgery. Patient and operative characteristics were compared.  Primary outcomes are30 day all-cause readmission rates and post-surgical length of stay (poLOS). Secondary outcomes included post-operative complications. Chi-square and Wilcoxon Rank Sums tests were used to determine differences among categorical and continuous variables, respectively. Backwards linear regression was performed to identify risk factors for poLOS and backwards logistic regression was used to identify 30 day readmission risk factors.

Results: Of 52,617 patients who underwent elective colectomies, the indications included colorectal cancer (CRC)  (46.97%),diverticular disease (DV) (23.05%), other benign disease (OBD) (21.10%) and inflammatory bowel disease (IBD) (8.88%). Overall, 52.2% were female, the majority white (78.9%) and had a median age of 62.0 (52-72.0). IBD patients were more likely to be underweight, and most were on steroid medications, while those with diverticular disease were more likely to have diabetes, smoke and have hypertension When examining post-operative complications, IBD patients experienced the greatest proportion of organ space infections (6.65%), while those with colorectal cancer  experienced the greatest proportion of post-operative bleeding (11.37%).  30 day mortality was highest in those presenting with other benign disease (1.77%) and lowest in IBD patients (.30%). Readmission rates were significantly higher in those with IBD (13.97% vs  10.14%, 8.56% and 10.1% , p<0.001).  On adjusted comparisons, IBD patients had longer poLOS compared to other benign disease, diverticular disease and colorectal cancer (6.91 vs 6.86, 5.74 and 6.68, p<0.001) and was a significant predictor of readmission (OR: 1.18(1.03-1.36)).

Conclusion:  For patients undergoing colorectal surgery, the indication for surgery needs to be considered when reporting rates of readmission, surgical site infections and length of stay. Patients with IBD are at particular high-risk for post-operative complications including 30-day readmission and total number of complications. As financial penalties are tied to these outcomes, hospitals who serve higher proportions of IBD patients will be disproportionally affected.

10.15 Increased Rate of C. Difficile in Patients Following TPIAT. What are the Risk Factors?

Posted on January 25, 2017

J. E. Taylor1, K. A. Morgan1  1Medical University Of South Carolina,Gastrointestinal And Laparoscopic Surgery,Charleston, Sc, USA

Introduction: Patients with chronic pancreatitis often have associated medical comorbidities prior to total pancreatectomy with islet cell autotransplantation (TPIAT).  Predicting which patients may have an increased risk of certain complications is difficult.  Long-term outcomes evaluating insulin use and quality of life have been evaluated in these patients.  Little information has been published about the postoperative complications and the potential long-term implications.

Methods: A prospectively maintained database of 169 patients who underwent TPIAT at our institution from March 2009 to April 2016 was retrospectively reviewed.  Interest was given to development of Clostridium difficile infection (CDI) following surgery and the determination of time to diagnosis after surgery.  Pre-operative risk factors were analyzed.  Charts were reviewed for postoperative complications, including pneumonia, urinary tract infection (UTI), biliary leak, portal vein thrombosis, as well as long-term mortality. 

Results: A total of 17 patients (10.1%) developed C. difficile infection following TPIAT.  A binary logistic regression analysis of pre-operative factors was performed on the patients who developed C difficile infection.  Of the factors in the analysis, history of alcohol abuse (P = 0.025), diabetes (P = 0.016), previous emergency department visits (P = 0.004), previous hospitalizations (P = 0.009), enteral nutrition requirement (P = 0.046), and daily morphine use (P = 0.043) were found to be statistically significant (P < 0.05).  Postoperative complications found to be associated with the development of C. difficile infection include greater ICU length of stay and pneumonia. 

Conclusion: Following TPIAT at our institution, there is an increased rate of C. difficile infection compared to the overall rate of development within our hospital.  Several pre-operative risk factors in the patient population have been associated with the contraction of C. difficile postoperatively.  Knowledge of these factors may aid in the development of new protocols preoperatively to help minimize the risk that these elements have on this patient population.

 

07.12 Factors Associated with Burden of Anal Condyloma and Need for Operative Intervention

Posted on January 25, 2017

H. Foss1, C. Y. Peterson1, K. A. Ludwig1, T. J. Ridolfi1  1Medical College Of Wisconsin,Colorectal Surgery,Milwaukee, WI, USA

Introduction:  Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. An estimated 79 million Americans are currently infected with HPV, and approximately 14 million new infections occur each year. Known risk factors for contracting HPV include high number of lifetime sexual partners, failure to use condoms consistently, history of sexually transmitted infections, immunosuppression, and younger age. Many treatment modalities exist and are largely based on the extent of condyloma present. These treatments may range from simple office based procedures to major full thickness skin resections in those with large volume disease. The aim of this project is to identify risk factors associated with need for surgical intervention as well as extent of disease.

Methods:  A retrospective chart review was completed for patients seen at the Medical College of Wisconsin Anal Dysplasia Clinic from April 2014 to June 2016. Information including demographic information, smoking status, HPV subtype, immune condition, need for surgical intervention, and surgical specimen size was then extracted from the medical record. Descriptive statistics were employed to evaluate the patient population. Logistic regression was used to evaluate for statistically significant covariates in predicting need for surgical intervention. Multiple linear regression analysis was used to evaluate for statistically significant covariates in predicting a log transformation of surgical specimen size. Significance was determined using a p-value equal to or less than 0.05.

Results: 283 patients met inclusion criteria, of which 252 (89.05%) were male, 179 (63.25%) had a smoking history, 232 (81.98%) were HIV positive, and 108 (38.16%) had undergone surgical intervention for anal condyloma. HPV subtyping was completed in 236 (83.39%) patients, of which 76 (32.20%) tested positive for HPV 16, 25 (10.59%) tested positive for HPV 18, and 149 (63.40%) tested positive for other high risk HPV subtypes. Of six covariates analyzed with logistic regression, only male gender significantly predicted the need for surgical intervention (p-value 0.04). Of seven covariates analyzed with multiple linear regression, HPV 18 status (p-value 0.05), smoking history (p-value 0.005), and older age (p-value 0.04) significantly predicted larger specimen size.

Conclusion: 

Male gender is predictive of needing surgical intervention, while HPV subtype 18, smoking history, and older age are associated with greater burden of disease. The only modifiable risk factor in predicting burden of anal condyloma is smoking status with an average increase of 1 cm3 of condyloma burden in those who smoke. Smoking cessation should be strongly encouraged in those who are HPV positive.

 

 

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