73.06 Trauma Registries in Kenya: Improving Care with Mobile Technology

Posted on December 22, 2014

F. Paruk1, I. Botchey1, A. Hyder1, K. Stevens2  1Johns Hopkins University Bloomberg School Of Public Health,International Health / Health Systems,Baltimore, MD, USA 2Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA

Introduction:

An assessment of Kenya’s trauma care capacity highlighted the need for a better understanding of the burden of injury and a need for standardized, quality trauma care training for clinical staff. 

Trauma registries play an integral role in injury surveillance, identification of gaps in care, and in monitoring and evaluation of trauma care.  Success in establishing and maintaining trauma registries is limited in low-resource settings. Efforts are being made to establish hospital based trauma registries at multiple sites in Kenya. Challenges include: lack of clinical skills necessary for trauma care, missing data, errors in transcription, backlog of data entry, and lack of reliable software for data management and export. 

We aimed To educate clinical staff in trauma care skills while piloting a new mHealth injury surveillance tool.  Goals were to successfully train hospital staff to care for the injured, improve data quality, reduce feedback time, enable data sharing, identify immediate gaps in care, and improve efficiency of the entire process.  The data ultimately would highlight areas for immediate and long-term improvements in trauma care. 

An educational curriculum including trauma skills and injury surveillance skills was developed and implemented at 4 hospitals in Kenya in 2013 and 2014.  Using a free app-based program, a paper surveillance tool was adapted for mobile devices, and designed for real-time upload to a web-based database upon completion of each entry.

Methods:

Existing trauma care clinical skills and data collection methods in the Kenyan setting were assessed through literature review, focus group discussions, and site-visits.  Data collection software for trauma registry data was selected, taking into consideration cost, ease of programming, functionality and feedback to the end-user. 

Data is analyzed at regular intervals and feedback given to hospitals. 

Results:

Preliminary results of the training program demonstrated improvement in data quality: missing and erroneous data was decreased upon implementation of training and mobile data collection, and adherence to trauma care protocols has improved.  Vitals signs recorded on trauma patients at one site went from 29% pre-electronic data collection to 98%.  Feedback from end users was positive, with increased efficiency of the process from data collection to analysis. 

Conclusion:

In addition to expected outcomes, the use of mobile technology has decreased human resource requirements, while increasing interest and awareness for the program.  Electronic data collection has expanded from one site to four sites over the past year with further potential to scale-up to the injury surveillance and standardize trauma training in Kenya.

 

72.04 Hispanic NCDB Data & Adherence to Stage III Colon Cancer NCCN Guidelines: One Size Does Not Fit All

Posted on December 22, 2014

N. Saldana-Ruiz1, A. Becerra1, C. Probst1, C. Aquina1, A. Rickles1, K. Noyes1, F. Fleming1, J. R. Monson1  1University Of Rochester,Rochester, NY, USA

Introduction: Colorectal cancer is a leading cause of U.S. cancer death. Despite decreasing national colon cancer rates in recent decades, racial disparities continue widely documented. Hispanics constitute the largest growing ethnic group, yet their trends of colon cancer remain poorly characterized. We sought to determine factors associated with U.S. Hispanics and adherence to treatment guidelines for stageIII colon cancer, for which adherence to evidence-based treatment guidelines have been proposed as measure of cancer care quality.  

Methods: Patients from National Cancer Data Base (NCDB), a national registry of Commission on Cancer (CoC) accredited centers, with stageIII colon cancer patients 2003-2011 were identified(total 676,923). Adherence to National Comprehensive cancer network (NCCN) guidelines determined based on disease stage and excluded missing race and adjuvant chemotherapy data. Logistic regression analyses were preformed to identify factors predictive of receipt of adjuvant chemotherapy (p=0.05). To characterize the representativeness of our cohort we also compared colon cancer incidence in NCDB to national race-specific colon incidence rates from the Center Disease Control (CDC) utilizing census current population survey (CPS) race-specific population estimates and extrapolated absolute cancer rates for U.S. colon cancers between 1998 and 2011.

Results: We included 121,846 cases(66%) of whom were treated according to NCCN guidelines. Factors associated with receipt of adjuvant chemotherapy in logistic regression modeling included age, geographic region, race, rurality, income, education, comorbidity and facility type. Patients were less likely to receive guideline-based treatment if Black, and more likely if Asian, Cuban, or Central/South American (p<0.05). Mexicans, Puerto Ricans and Dominican Republicans, did not exhibit differences in guideline-based treatment compared to Whites (p<0.05). NCDB, CDC comparisons revealed that NCDB captures 50% of Hispanic compared to 70% cases of Whites and Blacks.

Conclusion: Our study highlights that NCDB data collected from CoC centers underrepresents Hispanics compared to Whites and Blacks. CoC-approved centers are associated with higher volume of operations and provide more cancer-related services associated with improved health outcomes, compared to non CoC-approved centers. While multivariate analyses of NCDB data demonstrates that significant U.S. variation exist in guideline-based treatment of stageIII colon cancer, our CDC rates comparison analyses highlight that NCDB underrepresents Hispanics. Lack of NCDB Hispanic data undermine information about the true state of health for this U.S. ethnic group and further study on Hispanic use of CoC centers is needed.

 

72.05 Obesity paradox in octogenarians after colorectal surgery: ACS-NSQIP Study

Posted on December 22, 2014

M. Perez1, R. Grim1, T. Bell1, J. Martin1, V. Ahuja1  1York Hospital,York, PA, USA

Introduction:  As lifespan increases, care for octogenarian patients will be paramount as living longer will result in more surgical procedures for this cohort. Colorectal resection in elderly patients has been associated with increased morbidity and mortality especially in non-elective cases. While obesity and higher mortality in older adults has not been observed consistently, some research indicates that mortality may be lower in older adults who are obese compared to non-obese – this is known as the obesity paradox. The purpose of this study was to 1) evaluate characteristics associated with octogenarians receiving colectomy, specifically in the obese population, 2) determine protective factors for all patients, and 3) assess mortality by body mass index (BMI) in octogenarians.

Methods:  Data were obtained from the ACS-NSQIP Participant User File (2011 and 2012) for CPT codes that included open partial colectomy, abdominoperineal resection, and total colectomy.  Age was categorized as 40-64, 65-79, and 80-89 (octogenarians). BMI was categorized as normal, overweight and obese. Variables of interest were gender, race, transfer status, residency supervision, wound infection, steroid use, bleeding disorder, transfusion, chemotherapy, radiotherapy, sepsis, prior operation, emergent case, wound classification, ASA, elective surgery, CPT, and mortality.

Results: 31,593 cases identified (40-64 = 49.5%; 65-79 = 36.4%; octogenarian = 14.1%).  Compared to younger cohorts, octogenarians were predominately white (79.7%), female (59.6%), normal BMI (44.6%), non-elective cases 27.4%, and had higher ASA classification of 3 (61.4%). They were less likely to be admitted from home 85.3%, with a high proportion from nursing or acute care home (10.8%). Octogenarians were more likely to die in the hospital (8.9%) than 40-64 (2.3%) and 65-79 (5%).  For all patients regardless of age, logistic regression indicated that transferred from home (OR 1.8) and obesity (OR 1.4) were predictive of living (all p<0.05). While obese people were more likely to die overall, obese octogenarians had the lowest mortality rate (21.4%) compared to obese 40-64 year olds (44.4) and 65- 79 year olds (40.6%), p<.001 (Graph 1). In addition, obese octogenarians had significantly fewer complications (M=2.67) than obese 40-64 year olds (M=3.05), p<.001. 

Conclusion: Octogenarians were more likely to die from colectomy, but mortality and complications were lower for obese octogenarians, which supports the obesity paradox; a phenomenon that has not been studied exclusively in colectomy patients. In the future with further research these independent factors can help surgeons stratify risks for octogenarians undergoing colectomies.

 

72.06 Breast Cancer Presentation Among Caribbean American Patients: Experience at an Urban Institution.

Posted on December 22, 2014

S. Ullrich2, R. Kaur2, J. Parks1, L. Dresner1, A. Alfonso1, G. Sugiyama1  1SUNY Downstate Medical Center,Surgery,Brooklyn, NY – NEW YORK, USA 2SUNY Downstate College Of Medicine,Brooklyn, NY – NEW YORK, USA

Introduction:  Disparity in the diagnosis, treatment, and outcome for women with Breast Cancer across ethnic and socioeconomic groups is growing in the United States. Black and Hispanic women present at higher stages and are twice as likely to die from the disease. Disparity has persisted despite improvement in access and quality of care. By identifying population based differences in tumor biology, we can tailor screening so that more effective, tumor specific treatment protocols can be designed. At our urban academic medical center, we treat a unique subset of the low-income Black population, 90.6% of whom are Caribbean-born. We hypothesize that Caribbean American Black patients treated at our urban medical center present with more aggressive disease that is biologically distinct from the Black population across the United States

Methods:  Data was obtained by retrospective chart review of all patients who underwent biopsy, lumpectomy, partial mastectomy or modified radical mastectomy at our academic medical center from 2007 through 2012. Average age at presentation, stage at presentation and tumor receptor characteristics were calculated and stratified by race and ethnicity, then compared with data from the Neighborhood and Breast Cancer (NABC) study and the California Cancer Registry (CCR).

Results: We identified 235 patients who underwent biopsy, lumpectomy, partial mastectomy or modified radical mastectomy for in situ or invasive breast carcinoma. Caribbean-American Black patients at our urban medical center presented at older ages than Black patients throughout the country and were more likely to present with more advanced disease (19.33% vs 8% presented at AJCC Stage III). Caribbean-American Black patients were also more than twice as likely to present with the Hormone Receptor negative Her2 positive subtype of invasive carcinoma than their African-American counterparts (17% vs 8%). 

Conclusion: Caribbean-American Black patients who received surgical treatment for breast cancer at our academic medical center presented with more advanced disease. In contrast with what has been shown in the literature, minority patients in our community do not present at an early age. In addition, the Caribbean-American Black population at our Central Brooklyn medical center also has a distinct pattern of receptor subtypes. This suggests that the underlying tumor biology of Caribbean-American Black patients is different from other Black patients, and that further investigation is necessary to tailor the therapy for our patient population.

72.07 Are We Actively Working to Reduce Disparities in Surgical Care? The Ground Reality.

Posted on December 22, 2014

B. Britton1, N. Nagarajan1, S. Selvarajah1, A. Schupper1, D. Efron1, A. Haider1  1Johns Hopkins University School Of Medicine,Baltimore, MD, USA

Introduction:

Minorities receive poorer quality of care and have worse outcomes than whites across a variety of surgical conditions. Despite these known inequities, it is unknown if efforts are being made by surgeons to rid the field of these disparities. The purpose of this study is to assess what surgeons are doing to address disparities in their practice settings.

Methods:

A computer-generated random sample of US general surgeon Fellows of the American College of Surgeons (ACS) were sent a 21-question online survey aimed at understanding any current efforts they or their organizations may have made towards reducing surgical disparities. Survey questions were previously validated using a series of cognitive interviews and pretests, and further reviewed by external researchers. Responses by surgeons who are affiliated with Academic Medical Centers (AMC) were compared with responses by non-AMC affiliated surgeons using descriptive statistics. 

Results:

Of the 536 surgeons contacted, 172 completed the survey (response rate = 32.1%). Surgeon demographics and practice characteristics included 68.6% male, 75.0% white, 64.0% practicing in urban settings, and 79.7% associated with an AMC. Only 19.8% of surgeons reported that their practice or hospital had made an effort to investigate the presence of racial disparities in their practice setting, and only 22.7% reported any initiatives to address racial disparities in their hospital or clinic in the past year. Significantly more AMC-affiliated surgeons reported that their practice setting had made an effort to determine if disparities existed compared with non-AMC affiliated surgeons. Similarly, compared to non-AMC affiliated surgeons, proportionally more AMC surgeons said their place of practice promoted initiatives to reduce disparities (Table).  

Conclusion:
Only 1/5th of surgeons responding to this study report initiatives aimed at reducing disparities in surgical care. Surgeons not affiliated with an AMC are making fewer efforts to eliminate disparities than AMC-affiliated surgeons.

72.08 Acute Appendicitis: Variation in Treatment and Outcomes by Insurance Status

Posted on December 22, 2014

T. L. Sutton4, E. E. Pracht3, J. M. Guido4, D. J. Ciesla2,4  2Tampa General Hospital,Tampa, FL, USA 3University Of South Florida,College Of Public Health,Tampa, FL, USA 4University Of South Florida College Of Medicine,Tampa, FL, USA

Introduction:

Acute appendicitis is a common condition in acute care surgery, and is often studied as a surrogate for the field. Appendicial perforation is associated with poorer outcomes, longer length of stay (LOS), and greater perioperative complication rates. Prior studies have shown that patients who are uninsured or of low socioeconomic status (SES) have greater likelihoods of presenting with appendicitis complicated by perforation. No comprehensive studies of the relationship between insurance status, treatment, outcomes, and hospital resource utilization in the setting of appendicitis were found in the literature.

Methods:

Patients with acute appendicitis were identified by ICD9 codes using the AHCA Florida Hospital Inpatient Discharge Datasets for 2002 to 2011. Five outcomes were examined: the probability of being admitted with complicated versus uncomplicated appendicitis, the probability of receiving laparoscopic versus open appendectomy, the probability of a perioperative complication, the length of stay in days, and the patient care cost associated with the hospitalization.  Data were analyzed using logistic, negative binomial, and least squares multivariate regression, depending on the dependent variable.  A p-value less than 0.05 was considered significant.  All equations controlled for patient demographics, comorbidities, and year and hospital fixed effects.

Results:

Upon admission, the uninsured had a significantly greater risk of presenting with complicated appendicitis, were less likely to receive a laparoscopic appendectomy, had longer lengths of stay, and greater cost of care. However, the uninsured did not experience significantly different odds of a perioperative surgical complication. These findings were preserved on progressive stratification for complicated or uncomplicated appendicitis and laparoscopic or open appendectomy.

Conclusion:

Patient insurance status is known to affect healthcare utilization. The uninsured may delay seeking medical assistance until later in the course of their disease, causing greater proportions of complicated and costlier to treat appendicitis. Decreasing the number of uninsured via the Affordable Care Act may improve patient outcomes and decrease hospital resource utilization related to acute appendicitis and other acute care surgery conditions.
 

72.09 Racial Disparities in Surgical Outcomes: Does the Level of Resident Surgeon Play a Role?

Posted on December 22, 2014

N. R. Changoor1, G. Ortega1, E. E. Cornwell1, A. H. Haider2  1Howard University Hospital,Department Of Surgery,Washington, DC, USA 2Center For Surgical Trials And Outcomes Research (CSTOR),Department Of Surgery,Baltimore, MD, USA

Introduction:  

Studies have demonstrated racial disparities among surgical outcomes. Contributing factors to these disparities have been evaluated at the system, provider and patient levels. Few studies have examined the role of surgical residents.  This study aims to elucidate if racial disparities exist in case selection and surgical outcomes by resident surgeons using a national database.

Methods:

A retrospective analysis of the ACS-NSQIP database from 2005-2010 was conducted. Procedures selected for analysis were laparoscopic cholecystectomy, laparoscopic appendectomy and open hernia repair. Demographic, pre-operative co-morbidities, level of resident surgeon, as well as post-operative complications were analyzed. Residents were grouped into junior level (PGY 1- 2), upper level/senior residents and attending alone (PGY 0). Descriptive statistics and multivariate analysis were conducted to assess case selection by level of training and surgical outcomes adjusting for age, gender, race, co-morbidities, and wound classification.

Results:

We identified 196,770 patients with a median age of 47, majority (51.3%) were females with the commonest procedure being laparoscopic cholecystectomy (47.4%). The majority were White patients at 74%, followed by Black, 9.2% and Hispanic 12.2%. Attendings alone performed 43% of cases, lower level residents 20.1%, then upper level residents 37.5%. Comparing Race and level of surgeon, attending alone operated on 44.1% White, 30.1% Black and 43.9% Hispanic; upper level/senior residents operated on 35.5% White, 48.7% Black and 41.34% Hispanic; lower level residents operated on 20.4%% White, 21.3% Black and 14.8% Hispanic. Black patients had a higher complication rate than white patients. (See Figure 1) On adjusted analysis, Black patients were more likely to have wound infections (OR 1.15, CI: 1.02-1.30), major complications (OR 1.39, CI: 1.27-1.53) and minor complications (OR 1.08, CI: 0.95 – 1.22). When compared to the attending alone, upper level/senior residents were more likely to operate on black patients (OR 2.02, CI: 1.95-2.09) and were more likely to have wound infections (OR 1.3, CI:1.19-1.39), major complications (OR 1.1, CI: 1.06-1.21) and minor complications (OR 1.2, CI:1.11-1.31).

Conclusion:

Our study demonstrates that there is an association between resident level training and surgical outcomes in minority patients. Upper level/senior residents were more likely to operate on Black  patients and these residents who may have a more active role in the operation were more likely to have wound infections, major and minor complications. These two findings suggest that black patients have worse outcomes as a result of more independent operating upper level/senior residents. 

72.10 Insurance Status Impacts Treatment and Survival in Early Stage Pancreatic Adenocarcinoma

Posted on December 22, 2014

E. A. Boevers1, A. M. Button1, B. McDowell1, C. F. Lynch1, S. Bhatia1, J. J. Mezhir1  1University Of Iowa,Surgical Oncology And Endocrine Surgery,Iowa City, IA, USA

Introduction: Previous population studies have shown that insurance status is a significant predictor of survival time for various cancers. This has not been studied in early stage pancreatic ductal adenocarcinoma (PDA), where due to the short survival times, diagnosis at an early stage offers the best chance of survival.  The objective of this study was to determine the impact of insurance status on 1) receipt of multimodality therapy including radiation and surgery and 2) overall survival in patients with early stage PDA.

Methods: Surveillance, Epidemiology and End Results Program data were evaluated for patients diagnosed in the years 2007-2011 with Stages I and II PDA.  Data were analyzed in a multivariate logistic regression model to examine variables associated with receiving either radiation or surgery, and for overall survival in patients with resectable PDA. 

Results:  Patients with Stage I (n = 2,104, 22%), IIA (n = 3,323, 34%), and IIB (n = 4,311, 44%) PDA were evaluated. Most patients (n = 8,231, 85%) were insured, while 1,257 (13%) patients were covered by a Medicaid program and 250 (3%) patients were uninsured. Overall, 32% received radiation therapy and 49% were treated with pancreatectomy.  After adjusting for age and stratifying by stage, a significant difference in the modes of treatment received by patients with differing insurance was found.  Medicaid patients with Stage I PDA were 47% less likely to receive radiation compared to insured patients (p=0.0002),and insured patients were 4.1 times more likely to receive radiation compared to uninsured patients (p=0.004).  A similar pattern was seen in patients with Stage II disease.  Medicaid patients with Stages I and II PDA were significantly less likely to undergo pancreatectomy compared to insured patients, and insured patients with Stage II PDA were 2.2 times as likely to receive surgery than uninsured patients (p<0.0001).

Median survival across types of insurance was significantly different (Medicaid=8 months, Insured=11 months, uninsured=12 months, p<0.0001).  Multivariate analysis with control for age, gender, race, radiation, and surgery showed the risk of death was 1.24 times greater (95% CI 1.2-1.3, p<0.0001) in Medicaid patients versus insured patients.

Conclusion: Treatment with multimodality therapy, including radiation and pancreatic resection, remain remarkably low in patients with early stage PDA.  In this study, insurance status had a measurable influence on the treatment patients received and on overall survival. These data provide initial evidence that certain patients and health care providers may require targeted education and improved access to multidisciplinary care.  More inquiry is needed to determine why this is affecting the Medicaid population, and how these disparities can be remedied in patients with this disease.

71.09 Central Venous Catheter-Associated Vascular injury in Children: A Survey of Venous Duplex Studies.

Posted on December 22, 2014

S. F. Rosati1, J. Brown1, L. Wolfe1, A. Shah1, N. Lee1, A. Maloney1, J. Haynes2, M. F. Amendola1,3  1Virginia Commonwealth University,Department Of General Surgery,Richmond, VA, USA 2Virginia Commonwealth University,Division Of Pediatric Surgery,Richmond, VA, USA 3Virginia Commonwealth University,Division Of Vascular Surgery,Richmond, VA, USA

Introduction:

Invasive lines central lines (CL) are sometimes a necessity in young children and neonates. These lines are known to come with the potential for serious complications, including deep venous thrombosis (DVT) as well as stenosis. Unlike in adults, consensus in the literature is lacking regarding the optimal management of these complications.

Methods:
We retrospectively reviewed all vascular lab studies performed in children younger than 5 years of age from September 2007 to December 2014. We queried our vascular laboratory database for venous studies obtained in the setting of central line placement. We reviewed medical records for subsequent management.

Results:
One hundred and ninety-five studies in 128 children were obtained over the study period. The average age was 1.62  ± 2.01 years for children greater than one year old, if less than one-year-old gestational age was 34.4 ± 6.91 weeks. 55.8% were male. 89.5% of patients reviewed (n=110) had a central venous access line present. Of the forty patients found to have DVT with (n=30) or without (n=10) CL there were several different services following finding with a variety of treatment modalities. The majority of children were evaluated by a Hematology-Oncology consulting service (50%; 20/40) and were being treated with subcutaneous low molecular weight heparin injections (52.5%; 21/40). Multiple linear regression models with step-wise selection of all variables identified presence of CL had an Odd’s Ratio of 2.812 (CI = 1.287 – 6.147; p=0.0095) as a significant predictor of DVT.

Conclusion:
Complications of indwelling central venous access lines are occasional in nature. Loss of pulse and extremity edema was predictive of DVT finding on exam. When present treatment options vary widely in our institution, as does the managing service. It has yet to be defined what the best course of treatment is for these complications and warrants further broader investigation.
 

71.10 Outcomes of Infrainguinal Lower Extremity Arterial Reconstruction: A Multi-Year NSQIP Review

Posted on December 22, 2014

D. K. Afflu1, G. Ortega1, K. Deonarine1, T. Obisesan2, D. Rose1, D. Tran1, E. Cornwell III1, K. Hughes1  1Howard University Hospital,Department Of Surgery,Washington, DC, USA 2Howard University Hospital,Department Of Medicine,Washington, DC, USA

Introduction:
Whereas several studies regarding the outcomes of infrainguinal arterial reconstruction abound in the literature, there are relatively few multi-year nationwide studies in contemporary times.  We sought to evaluate the multi-year outcomes of infrainguinal arterial bypass on a national level.

Methods:
The American College of Surgeons’ National Surgical Quality Improvement Program Database (ACS-NSQIP) was queried to identify all patients undergoing infrainguinal arterial reconstruction from 2005 to 2010. Outcomes including 30-day NSQIP-defined major complications were identified, and multivariate analyses were conducted to identify variables associated with adverse outcomes.

Results:
The study included 32,922 patients who underwent an infrainguinal lower extremity arterial reconstruction over a six-year period.  The mean age was 67 years, in a primarily male population (62%).  The majority of patients were non-Hispanic white (75%). The most common indication for a leg bypass was intermittent claudication (20%), followed by ischemic rest pain (12%). Median length of stay was 5 days.  Mortality following infrainguinal bypass was 3.2% and graft failure rate was 4.2%. The most common complication was surgical wound infection (10.4%). Additional postoperative complications included cardiac in 2.5%, pulmonary in 5.6% and renal in 3.7%. Overall, the rate of major complications was 27%.  Factors associated with an increased odds of mortality included renal comorbidity (OR 3.65, 95% CI 2.99 – 4.44) and pulmonary comorbidity (OR 2.09, 95% CI 1.77 – 2.47). Female gender was associated with a slight increase in mortality (OR 1.18, 95% CI 1.01 – 1.37). Cardiac comorbidity (OR 1.94, 95% CI 1.36 – 2.78), black ethnicity (OR 1.45, 95% CI 1.27 – 1.72) and smoking (OR 1.20, 95% CI 1.06 – 1.37) were associated with increased odds of graft failure.

Conclusion:
Although the mortality rate is relatively low for infrainguinal arterial reconstruction in contemporary times, the high overall complication rate suggests that rigorous indications be utilized when deciding to perform these operations.
 

71.12 Endovascular Versus Open Repair of Ruptured Abdominal Aortic Aneurysms in the Medicare Population

Posted on December 22, 2014

A. Cha1, V. Dombrovskiy1, N. Nassiri1, R. Shafritz1, S. Rahimi1  1Robert Wood Johnson – UMDNJ,Vascular Surgery,New Brunswick, NJ, USA

Introduction: There has been debate in the literature as to whether endovascular repair of ruptured abdominal aortic aneurysms has a survival advantage over open surgery. The purpose of this study was to evaluate a large subset of Medicare patients with ruptured abdominal aortic aneurysms who underwent endovascular repair or open surgery, and evaluate postoperative complications, survival and 30-day readmission rates.

Methods: Study population was selected from 2005-2009 MedPAR data with the appropriate ICD-9-CM diagnosis and procedure codes.  Statistics was performed with the Chi-square test, multivariable logistic regression analysis, Kaplan-Meier survival curves and Cox proportional hazards modelling

Results: 8,480 patients (1,939 with endovascular repair and 6,541 with open surgery) were identified. Patients with open surgery were younger than those with endovascular repair and had less comorbidities. However, patients with open surgery had more postoperative complications (OR[odds ratio]=2.1; 95%CI [confidence interval] 1.9-2.4), including cardiac (OR=1.4; 95%CI 1.2-1.6), respiratory (OR=2.2; 95%CI 1.9-2.4) and renal complications (OR=1.5; 95%CI 1.4-1.7). They had more infectious complications (OR=1.3; 95%CI 1.2-1.5) such as pneumonia (OR=1.6; 95%CI 1.3-1.8), sepsis and bloodstream infection (OR=1.4; 95%CI 1.2-1.7), clostridium difficile (OR=2.2; 95%CI 1.3-3.7). As a result, patients with open surgery had greater rates of hospital mortality (43% vs 28.4%; P<0.0001) and worse survival during 1 year after surgery (HR[hazard ratio]=1.4; 95%CI 1.3-1.5). At the same time, patients after endovascular repair compared to those with open surgery had greater 30-day readmission rates (22.5% vs 19.5%; P=0.02). However, readmissions for the repeated repair were rare in both groups: 0.14% after open surgery and 0.65% after endovascular repair.

Conclusion: Although there is a higher 30-day readmission rate to the hospital after endovascular repair compared to open surgery, patients after endovascular repair had significantly lower rates of postoperative complications and better survival. Endovascular repair of ruptured AAA should be first line therapy when technically feasible.

71.13 Insulin Use Leads to Worse Outcomes After Femoral to Popliteal Artery Bypass in Diabetics

Posted on December 22, 2014

K. Nagarsheth1, T. Dinitto1, J. Schor1, K. Singh1, J. Deitch1  1Staten Island University Hospital,Vascular And Endovascular Surgery,Staten Island, NY, USA

Introduction:

Diabetic patients are known to suffer from peripheral vascular disease. We sought to compare outcomes after femoral-to-popliteal artery bypass (FPB) in diabetic patients based on the use of oral medications (PO) versus insulin (INS) for glycemic control.

Methods:

The National Surgical Quality Improvement Program (NSQIP) database was searched, from the years 2005 to 2011, to identify diabetic patients who underwent FPB. There were a total of 5523 FPB procedures performed on diabetic patients. The patients were divided into groups based on what was used primarily to manage their diabetes, PO or INS. The search for FPB was performed using the following CPT codes; 35556, 35583 and 35656. Patient demographics, comorbidities, perioperative data, and outcomes were compared.

Results:

There were 13631 FPB identified in this database. Of those, 5523 were performed on diabetic patients. There were 2545 patients taking PO and 2978 who were treated with INS. The INS group had a higher incidence of pre-existing coronary artery disease, such as CHF (4.7% v. 2%, p<0.01), recent MI (2.6% v. 1.7%, p=0.01) and prior CABG (31.2 % v. 24.9%, p<0.01).  The INS group also presented with critical limb ischemia more frequently than the PO group (42.9% v. 36.2%, p<0.01). Intraoperatively, the INS group had a higher rate of cardiac arrest (0.2% v. 0.1%, p<0.01) and needed blood transfusions more frequently (10.4% v. 8.6%, p=0.02). Post-operatively, the INS group had a higher incidence of respiratory failure (2.6% v. 1.6%, p=0.01), cardiac arrest requiring CPR (1.6% v. 0.7%, p<0.01) and needed more blood transfusions (0.7% v. 0.3%, p=0.025). The INS group also had a higher incidence of postoperative complications like UTI (2.6% v. 1.3%, p<0.01) and deep SSI (4.1% v. 2.3%, p<0.01). The INS group also had a higher rate of 30 day mortality (2.7% v. 1.8%, p=0.03) than the PO group. There were no differences in operative time or hospital length of stay between these two groups.

Conclusion:

Patients who used insulin to manage their diabetes had more evidence of pre-existing heart disease, more post-operative complications and a higher 30 day mortality. Based on this data, when performing a FPB on an INS dependent diabetic patient, we advocate close peri-operative monitoring and pre-operative optimization, as they are more likely to have intra-operative and post-operative morbidity and mortality.

71.15 Latissimus Dorsi Reconstruction is Associated with Lower Complications vs. Pedicled TRAM.

Posted on December 22, 2014

D. J. Gerth1, J. Tashiro1, S. R. Thaller1  1University Of Miami,DIvision Of Plastic Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA

Introduction:  Pedicled breast reconstruction is the mainstay in the treatment algorithm for many plastic surgeons. While indications vary for each technique, there is considerable overlap in the type of defect each flap is used to reconstruct. This study aims to determine the impact that flap selection has on postoperative outcomes and resource utilization.

Methods:  We reviewed the Nationwide Inpatient Sample (NIS) database (2010-2011) for cases of latissimus dorsi (LD; ICD-9-CM 85.71) and pedicled transverse abdominis myocutaneous (pTRAM; 85.72) breast reconstruction. Males were excluded from the analysis. Demographic, socioeconomic, and clinical factors were assessed, along with postoperative complications (including reoperation, hemorrhage, hematoma, seroma, pulmonary embolus, wound infection, and flap loss), length of admission, and total charges. Chi-squared and multivariate analyses were performed to identify independent risk factors of increased resource utilization and complications following reconstructive surgery. Cases were weighted to represent national estimates.

Results: Our comparison was comprised of 29,074 cases, of which 17,670 (61%) were LD and 11,405 (39%) were pTRAM. In the cohort, 74% were Caucasian, 95% were insured, and 66% of patients were treated in a teaching hospital setting. There were 24 mortalities (15 LD, 9 pTRAM). Patients in the LD cohort were more likely to be obese (OR=1.3), and suffer from complications including flap loss (OR=1.4), wound infection (OR=1.6), wound dehiscence (OR=2.2) and hematoma (OR=1.3), p<0.05. Patients undergoing pTRAM were more likely to undergo surgical revision (OR=6.9), suffer from systemic infection (OR=1.8), pneumonia (OR=5.0), or pulmonary embolism (OR=29.2), p<0.05. There was no difference in postoperative hemorrhage. Total charges and length of stay were higher for pTRAM, p<0.001. A risk-adjusted multivariate analysis demonstrated that LD was an independent risk factor for postoperative complication (OR=1.4) and increased TC (OR=1.3), p<0.001. Conversely, undergoing pTRAM was an independent risk factor for increased length of stay (OR=6.3), p<0.001.

Conclusion: In an analysis of a large, population based database, patients undergoing LD breast reconstruction were found to have more costly hospitalizations and an increased risk for surgical site complications. Meanwhile, patients undergoing pTRAM had an increased risk for pulmonary complications and length of stay. Future procedure selection may be refined as additional characteristics are discovered using outcomes based research.

71.16 Predictors of Mastectomy Skin Necrosis in Autologous Breast Reconstruction

Posted on December 22, 2014

C. R. Vargas1, M. Paul1, P. G. Koolen1, K. E. Anderson1, B. T. Lee1  1Beth Israel Deaconess Medical Center,Surgery / Plastic And Reconstructive Surgery,Boston, MA, USA

Introduction:
Mastectomy skin flap necrosis represents a significant clinical morbidity following autologous breast reconstruction.  In addition to aesthetic deformity, necrosis of the native mastectomy skin may require debridement, additional reconstruction, and prolonged wound care, and can delay planned oncologic treatment.  This study aims to evaluate seven potential patient and procedural factors in order to identify predictors of mastectomy skin necrosis.

Methods:
A retrospective review was performed of all immediate autologous breast reconstruction procedures performed at a single academic center between January 2004 and December 2013.  Patient records were queried for age, mastectomy weight, pre-operative radiation therapy, pre-operative chemotherapy, diabetes, active smoking, previous breast surgery, and post-operative mastectomy skin flap necrosis.  Mastectomy weight was divided into quartiles for improved clinical interpretability. 

Results:
There were 698 immediate autologous microsurgical flaps performed by three surgeons at our institution during the study period; mean patient age was 49.3±8.3 years and average mastectomy weight was 769.3±413 grams.  The incidence of mastectomy skin flap necrosis was 13%.  Univariate analysis revealed a significantly higher incidence of mastectomy skin necrosis in patients with diabetes (p = 0.017) as well as those with higher mastectomy weight (p = 0.001).  No significant association was found for age, pre-operative radiation, pre-operative chemotherapy, active smoking, or previous breast surgery.  Multivariate analysis, adjusted for clustering related to bilateral reconstruction, demonstrated a statistically significant association between mastectomy skin necrosis and increasing mastectomy weight (OR 1.54, p < 0.001).  The association between diabetes and mastectomy skin necrosis was not significant after covariate adjustment.

Conclusion:
Increasing mastectomy weight is significantly associated with post-operative mastectomy skin necrosis following autologous reconstruction.  This factor should be considered during patient counseling, procedure selection, and operative planning.  Interestingly, patient age, pre-operative chemotherapy, radiation, active smoking, and previous breast surgery did not predict a significantly higher risk of mastectomy skin necrosis.

71.17 Comparing Outcomes & Costs in Body Contouring: Analyzing weekday v weekend admissions using the NIS

Posted on December 22, 2014

K. K. Tadisina1, K. Chopra2,3, D. P. Singh3  1University Of Illinois At Chicago,College Of Medicine,Chicago, IL, USA 2The Johns Hopkins Hospital,Department Of Plastic And Reconstructive Surgery,Baltimore, MD, USA 3University Of Maryland Medical Center,Division Of Plastic Surgery,Baltimore, MD, USA

Introduction:
Body contouring operations are a quickly becoming the most commonly performed operations by American plastic surgeons, mirroring the increase in bariatric surgery in the US over the last decade. Despite previous studies showing worse patient outcomes on weekend admissions for non-emergent cases (spine, breast, and hernia), there is no comparative data reported regarding body contouring procedures. This has implications especially now when physician handoffs are more frequent secondary to resident work hour restrictions. The authors’ aimed to determine whether body contouring surgery results in worse outcomes when performed on weekends versus weekdays.

Methods:
A serial cross-sectional study of body contouring patients was performed using the Nationwide Inpatient Sample (NIS) database from 2000-2010. Data were gathered using ICD-9 codes for reduction liposuction (86.83) for weekday and weekend admissions, including demographic, hospital charges, and patient outcomes were obtained.

Results:
A total of 49,706 hospital admission cases of inpatient body contouring admissions were examined over the 11 year period, 98% of which were on the weekday. 90% of patients were female, with admissions being elective in 85% of weekday cases versus 53% of weekend cases. When compared to weekday admissions, weekend admissions were associated with a statistically significant increase in hospital costs ($35,481, p<0.000) and increase in hospital length of stay (5.68 days, p<0.000). Mortality rates were found to be higher on weekend admission (3.7%) vs weekday (0.5%) as well.

Conclusion:
Although outcomes are multifactorial, in body contouring patients, weekday admission is associated with favorable outcomes in terms of LOS, mortality, and hospital charges.
 

71.18 Synovial White Cell Count For Diagnosis Of Septic Arthritis. Are Current Tests Appropriate?

Posted on December 22, 2014

K. Perera1, M. Armstrong1  1Eastern Health,Melbourne, VICTORIA, Australia

Introduction:

Septic arthritis is an emergency, potentially causing irreversible joint destruction and

disability. Synovial WCC and polymorphonuclear cell percentage is the best predictor of

septic arthritis likelihood. Yet, synovial WCC and differential are not routinely assessed.

We aim to investigate the incidence of this and develop correct synovial fluid analysis

practices.

Methods:

A retrospective analysis of native joints having had arthrocentesis for suspicion of septic

arthritis at Box Hill Hospital (BHH) between September 2011 and September 2013

inclusive. Recruitment was from the Eastern Health Decision Support Service (DSS), who

maintains a database compiled from all systems within Eastern Health; of which BHH is a

member.

The study was limited to large joints; this includes hip, knee and shoulder. All prosthetic

joints were excluded from the patient population.

All patient histories were examined for suspicion of septic arthritis and subsequent

arthrocentesis. Pathology records were accessed to determine incidence of cell count and

differential.

Results:

One hundred and thirty-six cases of joint aspirations were identified within the time frame,

of which sixty-seven fit our criteria for evaluation. All but two cases were delivered using

the DSS, which was limited to data compiled only until June 2013. The two remaining

cases were identified with a manual search of the radiology and pathology databases from

June to September 2013.

22 of the 67 joint aspirates studied did not have a cell count carried out. Four of these 22

cases had a diagnosis of septic arthritis. In five aspirates, there was a failure to confirm a

definite diagnosis and were thus conservatively treated as a septic joint. The remaining

acute joints in which no cell count was done were gout (7 cases), pseudogout (5 cases) and

rheumatoid arthritis (1 case).

Cell counts were not routinely detected for a variety of reasons. Eleven aspirates were

deemed too viscous, and in eight cases the sample had clotted prior to pathologist

assessment. Two cases had insufficient volume, and one sample was too bloodstained to

calculate a cell count and differential; likely due to traumatic aspiration.

Conclusion:

33% of acute monoarthritis’ evaluated over the study period failed to have a synovial fluid

WCC and differential. This may be due to inadequate samples, or lack of appropriate

collection tube. Better education is required for appropriate collection and test requesting

wherein a diagnosis of septic arthritis is in question.

71.19 Steroid Injections for Core Muscle Injuries in High-Performance Athletes

Posted on December 22, 2014

A. E. Poor1,2, T. A. Colangelo2, V. P. Bekerman2, B. K. Havens1, W. C. Meyers1,2,3,4  1Vincera Institute,Philadelphia, PA, USA 2Drexel University College Of Medicine,Department Of Surgery,Philadelphia, PA, USA 3Thomas Jefferson Univeristy,Department Of Surgery,Philadelphia, PA, USA 4Duke University School Of Medicine,Department Of Surgery,Durham, NC, USA

Introduction:  

In every season of every sport many different types of injuries occur in the musculoskeletal core.  In the literature, core muscle injuries have gone by terms such as sports hernia, athletic pubalgia, Gilmore’s groin, and pubic inguinal pain syndrome.  Coaches, management, and trainers continue to search for optimal temporizing solutions for these injuries. A number of treatments are currently in use, including prolotherapy and injections of platelet-rich plasma, bovine cartilage, and corticosteroids. However, there is little data available in regards to their effectiveness. We reviewed our experience with corticosteroid injection in highly competitive athletes over the course of an athletic season.

Methods:  

We selected patients who we were able to follow closely over a complete season during the past two years. The information was attained through direct patient interviews and from our database.The patients underwent clinical evaluation, MRI and plain x-ray imaging of the pelvis, and other diagnostic tests as indicated.  Full discussion occurred among the various involved parties (players, agents, trainers, etc) and steroid injection was selected as a minimum intervention.

We injected up to 400mg of triamcinolone acetonide mixed with bupivacaine directly into sites of elicitable pain and injury (sites of muscle tears and separation of the pubic fibrocartilage plate). We did not perform direct symphyseal joint injections.  It is our standard practice to put patients on indomethacin 25 mg three times daily with food for six weeks. Injections were complete upon elimination of pain with resistance testing. The patients returned to play within one day following injection, in accordance with our physical therapy protocols. 

Outcome measures include: a performance score (players’ assessment of their play following the injection, Table 1), days played after injection, and completion of season. We recognized that some patients were difficult to assess due to coaching/roster decisions and considered them separately.

Results: 

5 of 19 patients were considered non-assessable. One of the 5 was able to finish the season and the other 4 played for a mean of 27 days. The post-injection performance score for all non-assessable patients was 3.4 (range 3-4).

12 of the 14 (86%) assessable patients completed their seasons. One patient was still competing at the conclusion of this study. The remaining 2 patients that did not complete their season played for a mean of 37 days. The post-injection performance score for all assessable patients was 3.9 (range 3-5).

 

Conclusion:

Corticosteroid injection is a reasonable intervention to temporize a core muscle injury during a season, however performance scores are inferior to our experience following difinitive surgery. 

71.20 Risk Factors For Dislocation Following Revision Total Hip Arthroplasty

Posted on December 22, 2014

R. C. Stedman2, A. Husain1, D. Lim1, C. `. Nelson1  1University Of Pennsylvania Health System,Philadelphia, PA, USA 2Howard University College Of Medicine,Washington, DC, USA

Introduction: Dislocation occurs in more than 3% of revision total hip arthroplasty (THA) surgeries.  The most frequent complication of revision THA is dislocation. It is also the leading risk factor for patients that receive subsequent revision procedures. Risk factors for dislocation, are multivariate and not well understood. Patient variables as well as surgical variables all contribute to the overall risk of dislocation following a THA procedure. Patient variables include BMI, ASA score at time of surgery, age, and gender. Surgical variables include component exchange and components used during the revision procedure.

Methods: A retrospective analysis of 203 consecutive revision THA procedures performed by a single surgeon with a minimum two year follow up between June 2012 and May 2003 was performed through reviewing medical records and a phone survey. Five (2.4%) died and 76 (37.4%) were lost to follow-up leaving 122 revision procedures in 43 men (55 procedures) and 53 women (67 procedures). 

Results:About 5.8% of all patients reviewed experienced a dislocation episode. Of those, 43% had a history of recurrent dislocation that was the primary reason for having a subsequent revision THA. In our experience, 85% of the patients who dislocated after their revision THA had single component exchanges performed. About 20% of the traditional components failed and about 13% of those with a constrained liner failed.

Conclusion:Patient variables for dislocation are identified as well as surgical techniques that might be susceptible to instability and failure. Multiple risk factors contribute to the overall risk for dislocation and THA failure.  Other factors such as impingement, limited ROM, and faster wear on the components are considered in patients that may chronically dislocate. While all of these factor into the risk of dislocation, we found that single component exchanges present a significant risk for dislocation if a suboptimal component is accepted in hopes that it functions appropriately with its complement component. We propose a rational algorithm to determine whether or not a constrained liner is indicated in the setting of revision THA for patients with a history of dislocation.

 

72.01 Surgery for the Very Old: Are Nonagenarians Different?

Posted on December 22, 2014

C. N. Ochoa Chaar1, L. A. Skrip3, J. E. Indes1, R. J. Gusberg2, T. P. Sarac1, A. Dardik2  1Yale University School Of Medicine,Department Of Surgery, Division Of Vascular Surgery,New Haven, CT, USA 2VA Connecticut Healthcare System,Department Of Surgery, Division Of Vascular Surgery,West Haven, CT, USA 3Yale School Of Public Health,Department Of Epidemiology And Microbial Diseases,New Haven, CT, USA

Introduction: Octogenarians (OCT) and nonagenarians (NON) are considered the “very old” and are often viewed as one group.  Americans are aging, with the proportion of the very old expected to increase from 1.9% of the population to 4.3% in 2050. This study aims to underscore the differences in surgical trends, demographics and outcomes between OCT and NON.

Methods: The NSQIP data base (2007 – 2012) was used to derive the type of surgeries, demographics, comorbidities, and outcomes of OCT and NON undergoing non-emergent vascular, orthopedic, and general surgery procedures. Differences between OCT and NON were assessed using Chi-square tests or t-tests for categorical or continuous variables, respectively.   Risk ratios with their 95% confidence intervals were calculated to evaluate linear trends over time in the percentages of surgeries performed in NON and OCT. Statistical analyses were conducted using R Statistical Software version 3.0.1 or SAS version 9.3.

Results: Between 2007 and 2012, NON accounted for a steadily increasing percentage of surgeries recorded in NSQIP (85 to 121 per 10,000 surgeries, RR = 1.42; 95% CI: 1.30 – 1.54). This change is consistent across the surgical specialties studied: vascular surgery (RR= 1.22; 95% CI: 1.15 – 1.30), general surgery (RR= 1.18; 95% CI: 1.07 – 1.30), and orthopedic surgery (RR = 2.35; 95% CI: 2.19 – 2.51).  The percentage of OCT undergoing surgery remained unchanged during the same time period (RR = 1.02; 95% CI: 0.99 – 1.05). NON undergoing vascular surgery are more likely to be females (54.00% vs 41.16%, p<0.001) and less likely to live independently (68.49% vs 83.87%, p<0.001) compared to OCT. NON have a lower incidence of diabetes (15.05% vs 19.4%, p<0.001), smoking (3.41% vs 10.17%, p<0.001), and dialysis (3.77% vs 5.12%, p<0.001). OCT are more likely to previously have cardiac surgery (24.79% vs 16.43%, p<0.001) and previous percutaneous coronary interventions (16.87% vs 13.18%, p<0.001). There were significantly more patients with Do Not Resuscitate (DNR) order in NON (8.63% vs 2.29%, p<0.001) who underwent vascular surgery. NON have higher 30 day perioperative mortality (6.88% vs 3.4%, p<0.001), and longer hospital stay (4.97 ± 5.91 days vs 4.39 ± 6.20 days, p<0.001) than OCT after vascular surgery procedures. The same trends were found for NON undergoing orthopedic and general surgery procedures.

Conclusion: NON are a rapidly growing group of surgical patients with significantly higher perioperative mortality and longer postoperative hospital stay. The impact of surgery on the quality of life of NON needs to be studied to justify the increasing healthcare costs. 

72.02 Anal Cancer in an Urban Academic Institution

Posted on December 22, 2014

D. R. Bezzini1, G. Ortega2, N. Branch2, N. Changoor2, M. Sabtala1, D. H. Ford1,2  1Howard University College Of Medicine,Washington, DC, USA 2Howard University Hospital,Department Of Surgery,Washington, DC, USA

Introduction:
Anal cancer affects an estimated 7,200 patients nationally each year. Current literature suggests women make up 60% of all cases, but rates of diagnosis in males have increased nearly twice as fast as that of affected females. The aim of this study was to elucidate differences in demographics and outcomes of African Americans diagnosed with anal cancer at an urban institution in a city with high HIV infection rates.

Methods:
The study used a retrospective chart review of the institution’s cancer registry data from 1994 to 2014. Information was collected on gender, race, ethnicity, age of diagnosis, comorbidities including HIV status, primary lesion site, surgery type, pathology, histology, surgical margins, staging, radiation therapy status, chemotherapy status, and mortality. Descriptive statistics and multivariate analysis were adjusted for age, gender, race, morbidity, staging, radiation, and surgery. The primary outcome of interest was patient mortality. 

Results:
There were 63 patients that met inclusion criteria. Of those patients, 64% were male (n=40), 92% were black (n=58), and the mean age of diagnosis was 53 years of age, with men diagnosed earlier at 49.5 years of age and women later at 59.5 years of age. A total of 21% were HIV positive (n=13), with 8.7% of females (n=2) and 27.5% of males (n=11) affected. The most common histologic finding was squamous cell carcinoma at 48% (n=30), affecting 30% of females (n=7) and 57% of males (n=23). The most common American Joint Committee on Cancer stage was stage two anal cancer for 21% of women (n=5) and 25% of men (n=10). In terms of surgical intervention, 13% of the population underwent abdominoperineal resection (n= 8), made up of 17% of females (n=4) and 10% of males (n=10). Chemotherapy and Radiation therapy rates showed 60% of men receiving each treatment (n=24). Chemotherapy was given to 47% (n=11) of women and radiation therapy to 56% of women (n=13). Of the sample, 52% of males (n=21) and females (n=12) were deceased. On adjusted analysis, for each year after 53 years of age, there was a 12% more likelihood of mortality (OR 1.12, CI: 1.02-1.24).

Conclusion:
Current statistics suggest that anal cancer rates have a higher occurrence in females than males. However, analysis of the cancer registry points to a higher occurrence in men. There was no mortality difference based on radiation, chemotherapy, or surgery status. In addition, the age of diagnosis among African Americans was about eight years sooner than the national mean. This shift may suggest that African Americans are diagnosed at a younger age. Based on these findings, urban hospitals should spread awareness of anal cancer risk within their population and advise screening for male patients. More data collection from a larger sampling of cases is needed to understand the extent of possible shifts in the population at risk of developing anal cancer.

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