15.13 Early vs Late Hospital Readmission after Pancreaticoduodenectomy in Patients with Private Insurance

Posted on December 22, 2014

E. Schneider1, J. Canner1, F. Gani1, C. Wolfgang1, M. Makary1, M. Weiss1, G. Spolverato1, Y. Kim1, A. Ejaz1, T. Pawlik1  1Johns Hopkins University School Of Medicine,Surgical Oncology,Baltimore, MD, USA

Introduction:  Most studies on readmission report only data on the initial readmission to the index hospital within 30-days of surgery.  These data may underestimate the actual impact of readmission, as patients who undergo complex procedures may be readmitted beyond 30-days and/or at other hospitals.  We therefore sought to define the incidence of early versus late readmission of patients undergoing pancreaticoduodenectomy (PD) requiring re-hospitalization at any hospital.

Methods:  Patients discharged after PD (ICD-9-CM procedure code 52.7) between 2010-2012 were identified from the Truven Health Market Scan database, which is a large convenience sample of individuals covered by employer-provided healthcare.  Determinants of early (≤ 30 days) or late (31-90 days) readmission were identified and analyzed. 

Results: A total of 2,243 eligible patients underwent PD during the study period.  Mean (SD) patient age was 54.8 (8.4), 51.6% of the patients were male, and 85.0% had a Charlson Comorbidity Index of 2 or greater. The mean (SD) length-of-stay was 12.7 (11.6) days; 89.2% of patients were discharged home, 5.0% were transferred to another facility, and 1.6% died in hospital. Among 2,209 patients discharged alive, 450 (20.4%) had an early readmission while 165 (9.4%) had a late readmission.  Among patients who were readmitted, fewer than 11 patients (<1.8%) had multiple readmissions.  Common causes of readmission were similar among patients experiencing an early versus late readmission (post-op infection: 22.0% vs. 5.5%, P<0.001; dehydration: 5.6% vs. 4.9%, P=0.73).   Median length-of-stay was longer for early vs. late readmission (5 vs. 3 days, respectively, P=0.002) and no in-hospital mortality occurred among patients readmitted either early or late.   While early readmissions were more likely to occur at the index hospital (index hospital: 94.4% vs. non-index hospital: 5.6%), patients who had a late readmission tended to be re-admitted more often to a different hospital than where the PD had been performed (index hospital: 90.3% vs. non-index hospital: 9.7%)(P=0.06). 

Conclusion: One-in-three readmissions occurred beyond 30-days, with 10% of late readmissions occurring at non-index hospitals among patients undergoing PD.  Assessment of only 30-day same hospital readmissions may underestimate the true incidence of re-hospitalization following PD. 

 

15.14 Evaluation of a New Hospital Requirement to Report Participation in a Registry for General Surgery

Posted on December 22, 2014

C. V. Kinnier1,2, A. R. Dahlke1, J. W. Chung1, A. D. Yang1, M. H. Ju1, M. McHugh3,4, K. Y. Bilimoria1  1Northwestern University,Surgical Outcomes And Quality Improvement Center, Department Of Surgery And Center For Healthcare Studies,Chicago, IL, USA 2Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA 3Northwestern University,The Center For Healthcare Studies,Chicago, IL, USA 4Northwestern University,Department Of Emergency Medicine,Chicago, IL, USA

Introduction: The Centers for Medicare and Medicaid Services (CMS) is attempting to encourage participation in clinical registries to spur quality improvement. CMS now includes reporting of participation in a Systematic Clinical Database Registry (SCDR) for General Surgery as part of the Inpatient Quality Reporting Program (IQRP), and policy makers are considering tying registry participation to reimbursement. However, clinical registry participation is resource intensive and often costs upward of $100,000 annually. It is therefore unknown how many and what types of hospitals participate in an SCDR. Our objective was to examine the proportion and characteristics of hospitals participating in a General Surgery SCDR.

Methods: Hospitals performing inpatient surgery were identified from the CMS 2013 Inpatient Prospective Payment System (IPPS) Final Rule Impact File. SCDR-participating hospitals were identified through participation in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), the Michigan Surgical Quality Improvement Collaborative (MSQC), or the Surgical Clinical Outcomes Assessment Program (SCOAP). Structural characteristics were identified using the 2012 American Hospital Association Annual Survey. To measure hospital financial health, the 2011 and 2012 Healthcare Cost Report Information System was used to calculate hospital operating margin [(Total Operating Revenue – Total Operating Expenses)/Total Operating Revenue]. Baseline hospital quality was approximated with the CMS Value-Based Purchasing score. Multivariable hierarchical logistic regression models with state-level random intercepts were developed to examine hospital characteristics associated with SCDR participation.

Results: Of 2,998 hospitals, 429 (14.3%) participate in an SCDR. SCDR-participating hospitals accounted for 7,535,597 (31.4%) of all operations, 2,974,330 (34.0%) of inpatient operations, and 4,561,267 (30.0%) of outpatient operations. After adjustment, hospitals were more likely to participate in an SCDR if they were a teaching hospital (OR 5.14, 95%CI 3.88-6.80), were non-profit and non-government owned (OR 2.11, 95%CI 1.53-2.91), accredited by the Joint Commission (OR 1.71, 95%CI 1.11-2.63), were a large urban or other-urban facility (large urban: OR 2.71, 95%CI 1.80-4.07; other urban: OR 2.35, 95%CI 1.57-3.51), or had a greater financial operating margin (OR 1.47, 95%CI 1.02-2.13).

Conclusion: Only 14% of inpatient hospitals currently participate in a General Surgery SCDR. Large, teaching, urban, and financially-healthy hospitals are more likely to participate in registries. To further promote successful quality improvement endeavors, CMS may need to tie SCDR participation to payment incentives or provide grants to reduce the cost of SCDR participation to encourage the remaining 85% of US hospitals to participate in a Systematic Clinical Database Registry.

 

14.06 Variability of Surgical Mortality in Low and Middle Income Countries: Meta-Review of Published Data

Posted on December 22, 2014

T. Uribe-Leitz1, L. R. Maurer2, J. D. Jaramillo2, R. Fu3, M. M. Esquivel4, T. G. Weiser1,2  1Stanford University,Department Of Surgery, Section Of Trauma & Critical Care,STANFORD, CA, USA 2Stanford University,School Of Medicine,STANFORD, CA, USA 3Stanford University,School Of Engineering,STANFORD, CA, USA 4Stanford University,School Of Medicine/Division Of General Surgery,STANFORD, CA, USA

Introduction: WHO estimates that low income countries accounting for nearly 35% of the global population receive only 3.5% of all operations. Increased attention has focused on scaling up surgical services, yet post-operative mortality in these settings is unknown but likely to be high. Quantifying postoperative mortality is important to assess challenges in scaling up surgical services and improving care.

Methods: We performed a systematic literature review using Embase, Web of Science, Medline, SCOPUS and Google Scholar to identify articles reporting on mortality following cesarean section, appendectomy and groin hernia repair in low and middle income countries (LMICs) as defined by the World Bank. We included articles published since 2000 that reported mortality following one of these interventions, regardless of preoperative status, indication for intervention, or cause of death. We discarded duplicate analysis of the same data, reports on less than 10 operations, and laparoscopic-only studies. We aggregated studies by country to create larger data samples for analysis. 

Results: Our initial literature search identified 1255 citations. After exclusion criteria, 203 required full-text review and 129 contained data for extraction. Forty two out of 116 LMIC published data on at least one of the predefined operations. We calculated crude post-operative case fatality rates (CFR) per country for each intervention. CFR ranged from 0 to 51.7 (mean=11.4) per 1000 operations for cesarean section, 0 to 88.6 (mean=13.5), per 1000 operations for appendectomy, and 0 to 411.8 (mean=39.9) per 1000 operations for hernia repair. This represents a 20, 5 and 15 fold increase in mean postoperative mortality when compared to Netherlands, a country with historically low CFR (cesarean section 0.58, appendectomy 3.03, and hernia repair 2.78 per 1000 operations). 

Conclusion: Although these estimates do not control for comorbidities, demographics, or facility factors, our findings suggest tremendous variability in mortality following surgical intervention in LMIC. The excessive high death rates following essential surgical interventions indicate safety concerns that demand prompt attention. 
 

12.10 Predictors of Wound Hypergranulation in Pediatric Burns

Posted on December 22, 2014

K. B. Savoie1, M. Bachier-Rodriguez1, R. B. Interiano1, A. Rotenberry2, L. S. Herring2, J. W. Eubanks1,2, R. F. Williams1,2  1University Of Tennessee Health Science Center,General Surgery,Memphis, TN, USA 2Le Bonheur Children’s Hospital,Pediatric Surgery And Trauma,Memphis, TN, USA

Introduction:
The shift in treatment of pediatric burns with silver-impregnated dressings has led to an increase in outpatient therapy.  During these clinic visits, hypergranulation has been identified as a source of poor wound healing leading to increased clinic visits and the need for subsequent skin grafts.  Therefore, we examined all pediatric burn patients treated with silver-impregnated dressings to determine factors associated with severe hypergranulation.

Methods:
A review of all pediatric burn patients from an urban pediatric hospital was performed from 2011 to 2013. Our primary outcome was severe hypergranulation of the burn, defined as significant granulation tissue resulting in the need for treatment with silver nitrate.  Severe burns were classified as those requiring surgical consultation in the emergency room, admission, enteral nutrition, or central line placement.  A Chi-Square test was used to compare categorical variables and a Mann-Whitney U test was employed for continuous variables. Backwards elimination was used to build a model for multivariable analysis. 

Results:
A total of 597 patients were identified. The majority of patients were male, black, and had public insurance. Scald burns were the most common type of burn (59%). Thirty-two patients developed severe hypergranulation (5.4%). On bivariate analysis, thermal and chemical burns, lower extremity burns, and severe burns were associated with severe hypergranulation. In multivariable analysis, thermal and chemical burns and lower extremity burns remained significant predictors of severe hypergranulation (see table). Lower extremity burns remained significant when assessing for effect modification with total body surface area of the burns.

Conclusion:
In pediatric burn patients, thermal and chemical burns, as well as lower extremity burns, result in an increase likelihood of hypergranulation, which may lead to changes in therapy or additional surgical intervention.  These patients may require different initial therapy to decrease the rate of granulation tissue and thus increase burn wound healing.
 

12.11 Pediatric Papillary Thyroid Carcinoma: Outcomes and Survival Predictors in 2,566 Patients

Posted on December 22, 2014

S. Golpanian1, J. Tashiro1, J. I. Lew2, H. L. Neville1, J. E. Sola1, E. A. Perez1, A. R. Hogan1  1University Of Miami,Division Of Pediatric Surgery,Miami, FL, USA 2University Of Miami,Division Of Endocrine Surgery,Miami, FL, USA

Objective:   To evaluate and update outcomes and predictors of survival of pediatric thyroid carcinoma, specifically examining pediatric patients with papillary thyroid carcinoma.

Methods:   Surveillance, Epidemiology, and End Results database was searched for pediatric cases (<20 yrs old) of papillary thyroid carcinoma diagnosed between 1973 and 2011.  Demographics, clinical characteristics, and survival outcomes were analyzed using standard statistical methods.  All papillary types, including follicular variant were included in the data set.

Results: A total of 2,566 cases were identified.  Overall incidence was 0.483/100,000 persons per year with a significant annual percent change (APC) of 2.07% (p<0.05).  Mean age at diagnosis was 16 yrs old and highest incidence was found in white, female patients 15-19 yrs old.  Patients whose tumor sizes were ≤1cm were more likely to receive lobectomies and/or isthmectomy versus subtotal/total thyroidectomies (OR=3.03 [2.12, 4.32]; p<0.001).  When analyzed by propensity score matching by procedure, patients with larger tumors (≥1cm; p<0.001) and lymph node positive statuses (OR=99.0 [12.5, 783]; p<0.001) more likely underwent subtotal/total thyroidectomy compared to lobectomy and/or isthmetctomy.  Mortality did not differ between procedures. When matched by tumor size, larger tumors (≥1cm) tended to be lymph node positive (OR=39.4 [16.6, 93.7]; p<0.001). Subtotal/total thyroidectomy patients were more likely to have distant disease, lymph node sampling (>10), and radiation treatment compared to those who underwent lobectomies and/or isthmectomies (p<0.001).  Overall mean survival was 448 months and survival was highest in white females with regional disease.  Overall 30-yr survival ranged from 89%-100%, regardless of tumor size or procedure type.  Disease specific survival was highest in patients who received surgery, regardless of procedure type.  Lymph node sampling did not affect overall or disease-specific survival.  Multivariate analysis demonstrated that male gender was an independent predictor of poor prognosis (HR 8.074; p<0.0001). 

Conclusions:  The incidence of pediatric papillary thyroid cancer is increasing.  Females have a higher incidence but also a better prognosis with improved survival than males.  Tumors ≥1cm were highly likely to be lymph-node positive, but lymphadenectomy did not alter survival. Although larger tumors (≥1cm) were more likely to be resected by subtotal/total thyroidectomy, survival was high and did not differ based on procedure type.   

12.12 Epidural versus Patient-Controlled Analgesia for Pain Control after Pediatric Thoracotomy

Posted on December 22, 2014

K. W. Gonzalez1, B. G. Dalton1, P. Thomas1, S. W. Sharp1, S. D. St. Peter1  1Children’s Mercy Hospital- University Of Missouri Kansas City,Pediatric Surgery,Kansas City, MO, USA

Introduction:

Optimizing postoperative pain control in patients undergoing thoracotomy can be challenging and utilize substantial resources.  The use of thoracic epidural is standard in adult patients who undergo thoracotomy to facilitate earlier mobilization, deep breathing and minimize narcotic effects.  However, a recent randomized trial in pediatric patients who undergo repair of pectus excavatum suggests patient controlled analgesia (PCA) produces a similar post-operative course as epidural but is less costly, less time consuming and non-invasive.  Given thoracotomy is typically less painful than pectus bar placement, we compared the outcomes of epidural to PCA for pain management after pediatric thoracotomy.

Methods:

A retrospective review was conducted in patients who underwent thoracotomy at a children’s hospital between 2004 and 2013.  Data points included operative details, epidural or PCA use, urinary catheterization, days to regular diet, days to oral pain regimen, pain scores in the postoperative care unit and during admission, length of stay, and anesthesia charges.  Patients were excluded if they did not have epidural or PCA following thoracotomy.   Comparative analysis was performed utilizing 2-tailed Student t-tests.

Results:

There were 17 patients who underwent thoracotomy, of which 6 were treated with an epidural and 11 with a PCA.  Of the patients who received an epidural, 3 were opiate naïve, compared to 2 with a PCA.  The most common indication for thoracotomy was metastatic osteosarcoma (n=13).  When comparing epidural versus PCA, there was no significant difference in time to removal of foley catheter, days to regular diet, days to oral pain control, length of stay, or total operating room time.  Pain scores obtained in the postoperative care unit and during admission were also comparable.  The mean anesthesia charges were significantly higher in patients with an epidural versus PCA (Table 1).

Conclusion:

Epidural catheter and PCA provide comparable pain relief and objective recovery course in children who undergo thoracotomy, however, epidural catheter placement is associated with increased anesthesia charges suggesting PCA is a noninvasive, cost effective alternative.   

 

12.13 Long Term Outcome and State of Health After Fundoplication: Impact of Requiring a Redo Operation

Posted on December 22, 2014

E. Perrone1, J. Baerg1, R. Vannix1, D. Thorpe1, A. Gasior2, S. St Peter2  1Loma Linda University And Children’s Hospital,Pediatric Surgery,Loma Linda, CA, USA 2Children’s Mercy Hospital,Pediatric Surgery,Kansas City, MO, USA

Introduction:  To compare outcome and quality of life variables in children with one Nissen fundoplication to those with redo Nissen fundoplications  for gastroesophageal reflux disease (GERD).  

Methods:

After IRB approval (#5100277), children younger than 18 years, from two children’s hospitals, with Nissen fundoplications or redo fundoplications performed between January 1995 and March 2011 were retrospectively reviewed. 

Follow-up data were collected to December 2012. Phone calls were made to assess the current state of health for patients. Variables recorded included: hospital admissions for pneumonia, acute life threatening events (ALTEs), vomiting, retching, paraesophageal hernia on upper gastrointestinal (UGI) contrast study, need for esophageal dilations, operations for adhesive bowel obstruction, placement of gastro-jejunal (G-J) feeding tubes and administration of anti-GERD medications.

BMI z-scores at fundoplication, at one year after fundoplication, and at final follow-up evaluation were recorded.  Children with one fundoplication were compared to those with redos using t-tests for continuous and chi-square tests for categorical variables.   Means were expressed +/- standard deviation.  A p-value <0.05 was considered significant.

Results:

The families of 212 children were contacted, which included 53.8% males, and 181 had one fundoplication (85.4%) and 31 had redos (14.6%).  The median follow-up for the cohort was 3.4 years (range:  0.5-16 years) (mean: 4.1 +/- 2.9 years).  The median time to first redo was 17 months (range:  1-108 months) (mean:  31.5 +/- 34.4 months).  The median time to second redo after the 1st redo for 3/31(9.7%) was 32.5 months (range:  23-69 months) (mean:  41.5 +/- 24.3 months).  One had a third redo 5 years after the second redo complicated by incarceration of small bowel in a para-esophageal hernia.

Comparison of Variables- see table

 

Conclusion:

Children with redo fundoplications have significant difficulties compared to children with one fundoplication on follow-up evaluation.  They have significantly more admissions for pneumonia, vomiting, retching, paraesophageal hernias, and gastro-jejunal feeding tubes. 

 

12.14 Comparing Outcomes of Admission Patterns in Pediatric Trauma Patients with Isolated Injuries

Posted on December 22, 2014

S. M. Farach1, P. D. Danielson1, E. Amankwah2, N. M. Chandler1  1All Children’s Hospital Johns Hopkins Medicine,Pediatric Surgery,Saint Petersburg, FLORIDA, USA 2All Children’s Hospital Johns Hopkins Medicine,Clinical And Translational Research Organization,Saint Petersburg, FLORIDA, USA

Introduction:  Pediatric trauma patients presenting with stable, isolated injuries are often admitted to the trauma service for initial management. The purpose of this study was to evaluate admission patterns in trauma patients with isolated injuries and to compare outcomes based on admitting service.

Methods:  After Institutional Review Board approval, the institutional trauma registry was retrospectively reviewed for patients presenting from January 2007 to December 2012. A total of 3417 patients were admitted to a surgical service and were further reviewed. Patients were grouped by isolated or non-isolated injuries and further stratified into trauma service (TS) versus non-trauma service (NTS) admission. Significance was defined as p ≤ 0.05.

Results: Table 1 describes select demographic and outcomes data between the groups. Patients with isolated injuries admitted to a NTS were significantly younger, were more likely to present with Injury Severity Scores (ISS) ranging from 9-14, Glasgow Coma Scale (GCS) ≥ 13, had a shorter emergency room length of stay, were more likely to undergo surgery within 24 hours, and had significantly fewer computed tomography scans performed. Patients with isolated injuries admitted to the TS had a significantly lower GCS (3-12), were more likely to present with ISS ranging from 1-8, had longer emergency room length of stay, and were less likely to undergo surgery within 24 hours. There was no significant difference between the groups for ISS ≥ 15. Patients with isolated injuries following falls or sports related injuries were more likely to be admitted to NTS, while those presenting after motorized trauma were more likely to be admitted to the TS. Patients with isolated injuries admitted to NTS included: 54.4% orthopedic, 38.3% neurosurgery, and 7.3% other. There were no missed injuries noted in patients with isolated injuries admitted to NTS with 5% having a TS consult. Patients with isolated injuries admitted to a NTS were found to have significantly lower complication rates.

Conclusion: Pediatric trauma patients presenting with stable, isolated injuries may be efficiently and safety managed by non-trauma services without an increase in missed injuries or complications.
 

12.15 Post-operative analgesia after laparoscopic appendectomy in children

Posted on December 22, 2014

R. Baird1, R. Mujallid2, P. Ingelmo2, S. Emil1  1McGill University,Pediatric Surgery,Montreal, QC, Canada 2McGill University,Pediatric Anesthesia,Montreal, QC, Canada

Introduction: Appendicitis is the most common pediatric general surgery emergency procedure. The optimal analgesic strategy to minimize patient discomfort and adverse events while maximizing patient throughput has yet to be defined. Furthermore, the utility of ketorolac to minimize narcotic use has not previously been investigated.

Methods: A single-institution, retrospective review of a random sample of pediatric patients undergoing laparoscopic appendectomy for simple appendicitis (no evidence of perforation or gangrene) was performed over a two-year period. Analgesia administration was non-standardized. Demographics, analgesia use and outcomes were evaluated; pain was assessed using age appropriate Likert scores. Categorical and continuous variables were compared using the Fisher’s Exact and Student T test, respectively, with p=0.05 considered significant.

Results: One hundred and forty seven patients were included for analysis with a mean age of 11.7 years; 86 (58.5%) patients were male.  The median length of stay was 0.7 days (25%-75%ile: 0.54-1.18). Median pain score at ward admission was 2/10 (25%-75%ile: 0 – 5.5), which worsened during admission (median 5/10; 25%-75%ile: 3.75- 7). Patients received a median of 2 doses of 10 mg/kg of oral/rectal acetaminophen, and a median of 0.16mg/kg of intravenous morphine during admission.

Thirty-one patients received ketorolac after surgery. Compared to patients not receiving ketorolac, there was no difference in the number of individuals receiving opioids (13 [41.9%] vs. 51 [43.9%], p=1), nor in the overall morphine dose administered to each group (0.12 v 0.11mg/kg, p=0.82). The median maximal pain score with ketorolac was similar to without ketorolac: (5 [25%-75%ile: 3-7] vs. 5 [25%-75%ile: 4-7]).

Conclusion: Pain after laparoscopic appendectomy may worsen during hospital admission without a protocolized approach to post-operative analgesia. Ketorolac does not improve pain control in this patient population, likely due to the lack of associated inflammation and peritonitis associated with simple appendicitis alone. Efforts to optimize post-operative pain control through protocolized care appear warranted.
 

12.16 Parental & Volunteer Perception of Pyloric Scars: Comparing Lap, Open, & Non-Surgical Volunteers

Posted on December 22, 2014

S. R. Shah1, C. Archer2, D. J. Ostlie2, S. W. Sharp1, S. D. St. Peter1  1Children’s Mercy Hospital / University Of Missouri – Kansas City,Section Of Pediatric General And Thoracic Surgery,Kansas City, MO, USA 2American Family Children’s Hospital / University Of Wisconsin,Division Of Pediatric Surgery,Madison, WI, USA

Introduction:
Despite prospective trials and meta-analyses supporting laparoscopic pyloromyotomy (LP), the open technique (OP) is still utilized on the premise that there is minimal benefit to LP over OP. Despite the fact that the potential cosmetic benefit of LP over OP is often cited in reports, it has never been objectively evaluated.

Methods:
After IRB approval, the parents of patients from a previous prospective trial that had undergone LP (n=10) and OP (n=10) were contacted. After assent was obtained, the parents were asked to complete a validated scar scoring questionnaire which was compared between groups. Standardized photos were taken of study subjects and 5 controls with no abdominal procedures.  Blinded volunteers were recruited to view the photos, identify if scars were present, and complete questions if scar(s) was seen. Volunteers were also asked about degree of satisfaction if their child had this result on a 4 point scale from happy to unacceptable.

Results:
Mean age was 7 years in both groups. Parental scar assessment scores were superior in the LP group in every category (Table 1).  Blinded volunteers detected abdominal scars significantly more often in the OP group (98%) vs. the LP group (28%) (P<0.001).  The volunteers detected a scar in 16% of the controls, comparable to the 28% detected in the LP group (P=0.17). The degree of satisfaction estimate by volunteers was 1.78 for OP and 1.02 for LP and controls generating a Cohen’s d effect size of 5.1 standard deviation units comparing OP to either LP or controls (very large > 1.3).

Conclusion:
Parents of children scored LP scars superior to OP scars.  Scars are almost always identifiable with OP while the LP scars approach invisibility to the casual observer appearing similar to patients with no prior operation. 
 

12.17 Management of Appendiceal Carcinoid Tumors in Children

Posted on December 22, 2014

S. C. Fallon1, M. J. Hicks2, J. L. Beer1, S. A. Vasudevan1, J. G. Nuchtern1, D. L. Cass1  1Texas Children’s Hospital,Division Of Pediatric Surgery, Michael E. DeBakey Department Of Surgery, Baylor College Of Medicine,Houston, TX, USA 2Texas Children’s Hospital,Department Of Pathology,Houston, TX, USA

Introduction:

Appendiceal carcinoid tumors are rare lesions detected incidentally following appendectomy in children. There are limited data about the natural history of these tumors, and guidelines regarding family counseling and need for additional surgery or follow-up imaging are not established in the pediatric age group.  The purpose of this study was to review our institutional experience with appendiceal carcinoid tumors to provide data that might improve management.

Methods:

After IRB approval, the charts of all patients treated at our institution for an appendiceal carcinoid tumor between 2002 and 2014 were reviewed.  Data collected included patient demographics, pathologic details, postoperative management, and follow-up information.  Descriptive analyses were performed.

Results:

Twenty-eight patients were identified, which represents an incidence of 0.2% of children undergoing appendectomy during that time interval. The mean age at surgery was 13.8+2.1 years; 54% were females. Two patients had symptoms suspicious for carcinoid syndrome at presentation, though none had evidence of metastatic disease.  The mean tumor size was 0.8 (+0.4) cm.   Five patients (18%) underwent subsequent ileocecectomy or right hemicolectomy due to pathologic findings of invasion of the mesoappendix (n=4) or lymphovascular invasion and subserosal extension (n=1).  One child was found to have positive lymph nodes on pathologic examination. No recurrences have been detected at mean follow-up of 1.2 yrs.

Conclusion:

Appendiceal carcinoid tumors are discovered incidentally in about 0.2% of children undergoing appendectomy.  Based on findings from the largest series to date, we can conclude that these tumors are generally small, and demonstrate lymphovascular invasion or mesenteric extension in fewer than 20% of cases.  Prospective, multi-center studies are necessary to better define the indication for ileocecectomy and follow-up imaging protocols.

12.18 Management and Outcomes in Earlobe Keloids in Children

Posted on December 22, 2014

N. Drucker1, D. W. Kays1, S. D. Larson1, J. A. Taylor1, S. Islam1  1University Of Florida,Surgery,Gainesville, FL, USA

Introduction:  Earlobe keloids are challenging conditions to manage in children due to high recurrence rates.  There are a number of therapeutic alternatives available to treat these, which have not been reported in children.  The purpose of this study is to investigate the management and outcomes of keloids in a large cohort and attempt to understand the optimal way of treating them.

Methods:  We retrospectively analyzed all children who underwent surgical therapy for earlobe keloids over a 10-year period (2004-2014).  Clinical data including etiology, demographics, treatment, and outcome were collected. A follow up phone survey was attempted on all patients to assess for long term recurrence and satisfaction. Data was analyzed using student’s t test and Fischer’s exact test as appropriate. 

Results: A total of 95 patients with 135 keloids were identified.  Mean age was 14.0 years, 54.3% were female, and a majority (85%) were African American (AA).  The most common etiology was secondary to pierced earrings (88.4%).  Mean keloid size was 2.4 cm (0.25-11 cm) and they were more common on the left earlobe (73.7% including bilateral). Excision with (n=56) or without (n=24) steroid was the most common surgical management, with some cases also having compression earrings, and others radiation therapy(n=8).  Mean follow up of the entire cohort was 27 months. Recurrences were noted in 20 cases (21.1%), a majority of which were managed operatively (70%). The highest rate of recurrence was with those treated with radiation therapy (37.5%), while we found no difference in recurrence between excision alone vs. with steroid (20.8% vs. 19.6%). There have been 5 re recurrences as well. We found age less than 10 at surgery (p=0.015) to be a risk factor for recurrence, and all recurrences were in AA patients. Size of the lesion, gender, side, and nodular vs. pedunculated shape did not have any effect on recurrence. Phone follow up was achieved in 56% cases. 

Conclusion: This is the largest series of earlobe keloid treatment reported in children. Younger age at excision and AA race are associated with increased risk of recurrent keloid. Intraoperative administration of steroids did not seem to influence recurrence rates, and radiation therapy was associated with a higher recurrence. Longer duration follow up is needed for establishing true recurrence rates, and a larger multi center study would help in answering these questions.

 

12.20 Pediatric Non-Papillary Thyroid Carcinoma

Posted on December 22, 2014

E. A. Perez1, J. Tashiro1, S. Golpanian1, J. I. Lew2, H. I. Neville1, A. R. Hogan1, J. E. Sola1  1University Of Miami Miller School Of Medicine,DeWitt Daughtry Family, Department Of Surgery, Division Of Pediatric Surgery,Miami, FL, USA 2University Of Miami,Division Of Endocrine Surgery, DeWitt Daughtry Family, Department Of Surgery,,Miami, FL, USA

Introduction:   To update outcomes and predictors of survival on pediatric thyroid carcinoma, specifically examining pediatric patients with non-papillary thyroid carcinoma.

Methods:   Surveillance, Epidemiology, and End Results database was searched for pediatric cases (<20 yrs old) of non-papillary thyroid carcinoma diagnosed between 1973 and 2011.  Demographics, clinical characteristics, and survival outcomes were analyzed using standard statistical methods.   All follicular, medullary, Hurthle cell, and nonencapsulated sclerosing carcinoma types were included in the data set.

Results: A total of 504 cases were identified.  Overall incidence was 0.096/100,000 persons per year.  Mean age at diagnosis was 15 yrs old and highest incidence was found in white, female patients 15-19 yrs old. Most patients had regional (60%) or localized disease (35%) treated with surgery (98%) and less commonly radiation (38%). Of the surgical patients, subtotal/total thyroidectomy (83%) was the most common procedure performed and 47% had lymph node sampling. The most common histologies were follicular (54%) and medullary (28%) and most tumors were > 2 cm in size (63%). Overall 30 year survival was 91% but higher for females (94%, p=0.02) and for local disease (92%). Disease specific survival was highest for those with no lymph node sampling, and negative lymph nodes. On multivariate analysis only subtotal/total thyroidectomy was an independent prognostic indicator of survival. Neither gender, age, tumor size, histology, nor extent of disease were associated with increased risk of mortality.

Conclusions:  The incidence of non-pediatric papillary thyroid cancer is low.  Females have a higher incidence but similar survival to males. Subtotal/total thyroidectomy is the only independent prognostic indicator of survival. 

 

13.01 The Impact of Electronic Medical Record Implementation on Operating Room Efficiency

Posted on December 22, 2014

R. C. Frazee1, A. Carnes1, Y. Munoz Maldonado1, T. Bittenbinder1, H. Papaconstantinou1  1Scott & White Healthcare,Departments Of Surgery And Anesthesia,Temple, Texas, USA

Introduction:   First start delays in the operating room have a downstream effect on operating room efficiency and patient satisfaction.  In accordance with the American Recovery and Reinvestment Act, in February 2014, our institution adopted EPIC ™ as our electronic medical record (EMR) system.  The impact of the transition from paper to electronic documentation on operating room efficiency is not known.  This study analyzed first start data as a measure of overall operative suite efficiency, looking at the initial impact and the learning curve to return to baseline parameters.

 

Methods:   A retrospective review of on time start data was reviewed for three months prior and 4 months after implementation of the EMR.  A start was considered delayed if the patient arrived to the room after the 7:30 start time.  Patients transported from the intensive care unit were excluded from analysis.  Data was analyzed using control charts for the percentages, and comparisons of the average percentage of on time starts before EPIC implementation against each month percentage using Dunnet’s method.  Confidence intervals were calculated at 0.05 and 0.01 for significance.

 

Results:  On time starts for the three months leading into EPIC implementation averaged 64.1%.  After EPIC implementation, there was an initial drop in on time starts from to 41% (p<0.01).  There was a gradual return to baseline levels over the ensuing 4 months.

Conclusions:  Implementation of an EMR produced decreased efficiency in on time first starts in the operative suite, but the learning curve was brief, returning to baseline values in 4 months.  These findings can serve as a guide for other institutions that are undergoing transition from a paper to an electronic medical record.

 

 

 

13.02 Benefit of Hepatic Resection Versus Intra-Arterial Therapies for Neuro-Endocrine Liver Metastases

Posted on December 22, 2014

G. Spolverato1, A. Vitale1, A. Ejaz1, Y. Kim1, J. Geschwind1, C. Wolfgang1, M. Weiss1, T. M. Pawlik1  1Johns Hopkins University School Of Medicine,Baltimore, MD, USA

Introduction:  Management of patients with neuroendocrine liver metastasis (NELM) remains controversial. We sought to compare the survival benefit of hepatic resection (HR) versus intra-arterial therapy (IAT) among patients with NELM. 

Methods:  A decision analytic Markov model was created to estimate and compare life expectancy associated with different management strategies (HR vs. IAT) for a simulated cohort of patients with NELM. The primary (base-case) analysis was calculated based on a 57-year old male patient with metachronous, symptomatic NELM that involved < 25% of the liver in the absence of extrahepatic disease. A Monte Carlo simulation was performed to assess the effect on outcomes with variation in model/disease parameters.  

Results: In the base-case analysis, HR was strongly favored over IAT providing a survival benefit of 52 months. On the Monte Carlo simulation, the greatest survival benefit for HR was among patients with a smaller volume of disease (<25%) and functioning/symptomatic NELM.  While patients with large volume symptomatic disease (≥ 25%) benefited from HR over IAT, the effect was less pronounced (34 months).  In contrast, patients with large volume non-functioning/asymptomatic NELM did not seemingly derive a benefit from HR; instead, this cohort of patients had an anticipated 23 months better survival with IAT rather than HR. 

Conclusion: A Markov decision model demonstrated that HR was the preferred strategy among patients with symptomatic NELM, regardless of hepatic disease burden.  In contrast, IAT was associated with better outcomes among patients with large volume disease, especially among those patients with non-functioning/asymptomatic NELM.

 

13.03 Preventable Comorbidities (PCm) Effect on Open Ventral Hernia Repair (OVHR)

Posted on December 22, 2014

T. C. Cox1, L. J. Blair1, C. R. Huntington1, P. D. Colavita1, A. E. Lincourt1, B. T. Heniford1, V. A. Augenstein1  1Carolinas Medical Center,Division Of Gastrointestinal And Minimally Invasive Surgery,Charlotte, NC, USA

Introduction: Many patients with complex ventral hernias have comorbidities.  This study compared patients with PCm to those patients without such risks to evaluate the financial impact of PCm during elective surgery.

Methods: In this prospective study of OVHR at a single institution from 2007-2011, total hospital costs and outcomes for patients with PCm—diabetes, tobacco use, and obesity—were compared to patients without such risks.  Outcomes included total wound complications, wound infections, and mesh infections.  Cost evaluation included all hernia-related visits, interventions, or readmissions within one year. 

Results: The 249 OVHR patients were categorized into four groups: No PCm without complications(n=85), No PCm with complications(n=33), two or more PCm without complications(n=50), and two or more PCm with complications(n=81).  The majority were female(55.8%); mean age was 56.6 years, average defect size 202.01cm2.  BMI of the PCm group with complications was 40kg/m2 compared to 36kg/m2 in the PCm without complications(p<0.05).  There was no difference in BMI in the no PCm groups(p>0.05).  For all patients with wound complications, total hospital costs were $80,660 with PCm compared to $55,444 in those without PCm (p<0.05).  There was no difference in hospital costs in those with PCm without complications compared to no PCm with complications($65,453 vs$55,444, p>0.05). Even when no complications occurred, patients with PCm had higher costs than those without PCm for inpatient($61,269 vs$31,236, p<0.05), outpatient($4,185 vs$552, p<0.05), and total hospital costs($65,453 vs$31,788, p≤0.001). PCm vs no PCm did not impact number of office visits comparing the groups without complications(2.18 vs2.54, p>0.05) or those with complications(5.15 vs5.89, p>0.05). For all patients with wound complications, readmission in the PCm group was 37% compared to 21% in the no PCm group.

Conclusion: OVHR patients with PCm have higher hospital costs than those without PCm even when no complications occurred.  Furthermore, patients with PCm and no complications showed no difference in total hospital costs than those with no PCm that had complications.  Aggressive risk reduction can translate into saving tens of thousands of dollars in hospital care costs.  Novel tactics for preoperative optimization of patients prior to elective surgery are indicated.

 

13.04 Operating Room Material Costs: What Do Attending Surgeons and Surgical Residents Know?

Posted on December 22, 2014

A. D. Newton1, G. Savulionyte1, K. R. Dumon1, J. Anderson1, V. Salasky1, D. T. Dempsey1  1Hospital Of The University Of Pennsylvania,Surgery,Pennsylvania, PA, USA

Introduction: The American College of Surgeons’ 2009 Statement on Health Care Reform called for a reduction of health care costs and implementation of cost-effective care. Operating room (OR) materials are an important component of surgical health care costs. The purpose of this project was to measure surgeons’ knowledge of the cost of ten commonly used OR materials.

Methods: A questionnaire was designed to determine knowledge of actual (not billed) cost to the hospital of 10 common OR materials (Ligasure, Endoclip, Endodissect, Lap irrigator, GIA 60 Stapler, Endo GIA, Harmonic ACE, Marlex Mesh, Permacol, and packed red blood cells). It was completed by surgical attendings (n=12) and residents (n=44). All were familiar with all 10 OR items. Each multiple-choice question (1 per OR item) contained four distinct price range options, one of which contained the actual cost of the item. Differences were assessed by Chi Square.

Results: Attending surgeons scored significantly better on the overall survey than surgical residents (45% vs. 31% correct answers, p<0.05). On 6 out of 10 items, at least 50% of attendings and residents were wrong about the cost (Table 1).

Conclusion: Surgical attendings and residents demonstrate a lack of knowledge of the actual cost to the hospital of basic operating room materials. In an era of increased focus on cost-effectiveness and value in healthcare, medical centers and  residency programs should improve education to both attending and resident surgeons regarding the cost of OR supplies. 

 

13.05 Outpatient Versus Inpatient Thyroidectomy: A Cost minimization Analysis

Posted on December 22, 2014

E. Y. Cabrera Riascos1, A. E. Sanabria Quiroga1, L. C. Dominguez Torres1, P. A. Cifuentes Grillo1, A. E. Sanabria Quiroga1  1Universidad De La Sabana,General Surgery/Head And Neck Surgery,Chia, CUNDINAMARCA, Colombia

Introduction:

Traditionally, Patients Undergoing To Thyroidectomy Are Admitted Overnight To Monitor The Potential Complications As Hemorrhage, Airway Compromise And Severe Hypocalcemia. However, Current Evidence Has Shown That Outpatient Thyroidectomy Is Safe, And May Be More Cost-effective.  The Aim Of This Study Was To Determine The Costs And Safety Of Outpatient Versus Inpatient Thyroidectomy, Performed Routine In Low-risk Patients.

Methods:  

Patients Undergoing Thyroidectomy Between July 2013 And January 2014 Was Abstracted From The Surgical Department Databases From A Tertiary Care Center, Noting The Patient’s Age, Sex, American Society Of Anesthesiologists (Asa) Classification, Type Of Thyroidectomy, Indication, Operative Time, Hospital Stay, Postoperative Emergency Room Visit And Complications. The Main Factor Evaluated Were The Direct Costs Of The Intervention, So A Cost-minimization Analysis Was Designed From The Perspective Of The Payer. A Projection Of The Impact On The Budget Of The Health System Was Performed Taking Into Account The Number Approximate Thyroidectomies Per Year Performed.

Results:

A Total Of 44 Patients Were Included, Where 52.3% (N=23) Were Outpatients (Group 1) And 47.7% (N=21) Hospital Thyroidectomy (Group 2). There Were Not Statistically Significant Differences In Age, Type Of Thyroidectomy, Indication For Surgery, Asa And Surgical Time. The Overall Rate Of Complications Was Not Different Between The Groups (P = 0.82). The Overall Difference In Cost Was Usd$ 200.51 (Usd$ 1407.49 +- 247.48 In The Group 1 Versus Usd$ 1608.40 +- 1570.79 In The Group 2) (P <0.01). When Adjusted For Variables Of Resource Use, Implementation Of Ambulatory Thyroidectomy Guidelines, Can Decrease The Value Of The Procedure In 12.5%. 

Conclusion:

Outpatient Thyroidectomy Is A Feasible Option, That In Selected Patients Can Minimize The Costs Of The Procedure Safely.

 

Keywords: Thyroidectomy, Outpatient Surgery, Costs, Complications.

 

13.06 The Diagnostic Dilemma of Identifying Perforated Appendicitis

Posted on December 22, 2014

Z. Farzal1,2, Z. Farzal1,2, N. Khan2, A. Fischer3  1University Of Texas Southwestern Medical Center,Pediatric Surgery,Dallas, TX, USA 2Children’s Medical Center,Pediatric Surgery,Dallas, TX, USA 3Beaumont Children’s Hospital,Pediatric Surgery,Royal Oak, MI, USA

Introduction:  Despite decades of research, a best clinical pathway for classifying perforated versus nonperforated appendicitis remains undefined. The lack of accuracy in the classification of appendicitis can affect the therapeutic course and associated costs with the average cost per case of complicated appendicitis often being twice as much as that of a case of uncomplicated appendicitis. We hypothesized that there is variability in identification of perforated and nonperforated appendicitis across specialties due to lack of standardized criteria.

Methods:
An IRB-approved retrospective review of appendectomies (N=1311) allowed a comparison of classification as perforated appendicitis (PA) or nonperforated appendicitis (NPA) based on radiology (R), operative (O), and pathology (P) reports. For the radiology arm (R), only cases in which CTs were performed were included to use the most definitive radiologic diagnosis. Three groups: P+O (N=1241), P+R (N=516), O+R (N=512), were compared to identify the inter-group discordance in classification of appendicitis. The length of stay (LOS) served as a metric of clinical behavior and was compared to the designated classification of the case of appendicitis to test if the diagnosis was consistent with being clinically nonperforated (NPA) with a LOS less than or equal to 48 (LOS≤48) hours or perforated (PA) with a length of stay greater than 48 (LOS>48) hours.

Results:
The subsets P+O, P+R, O+R revealed a discordance of 11%, 15.7% and 16.6%, respectively. Operative and radiology (O+R) reports were the most discordant. In the O+R group, 35% of the cases that were operatively designated as perforated appendicitis (PA) were discordant with their radiologic diagnosis of nonperforated appendicitis (NPA). Cases designated as perforated appendicitis (PA) in all subsets (P+O, P+R, O+R) clinically behaved as perforated with an average LOS>48 hours (97, 95, 95, respectively), whereas the cases designated as nonperforated appendicitis (NPA) displayed greater variation from the expected LOS≤48 hours, with means of 35, 83, and 52 hours, respectively.

Conclusion:
There is significant variability in classifying perforated versus nonperforated appendicitis. With up to 16.6% discordance between operative and imaging findings, the absence of standardized classification criteria results in a continued lack of diagnostic accuracy, as confirmed by variation in clinical behavior. Standardizing the criteria for the classification of the type of appendicitis across specialties may improve diagnostic accuracy needed for meaningful clinical trials and to identify best practices for optimal use of hospital resources and health care costs.
 

13.07 Variation in Individual Surgeon Practice in the Treatment of Appendicitis

Posted on December 22, 2014

S. C. Fallon1, W. Zhang1, M. E. Lopez1, M. L. Brandt1, M. E. Kim1, J. R. Rodriguez1, M. V. Mazziotti1, D. E. Wesson1, J. G. Nuchtern1, E. S. Kim1  1Baylor College Of Medicine,Division Of Pediatric Surgery,Houston, TX, USA

Introduction:

Previous literature has shown that decreasing variation in medical care often leads to improved value by optimizing outcomes and decreasing cost. The purpose of this study was to determine variation between individual surgeons caring for children with appendicitis in a large, tertiary children’s hospital. 

Methods:

The records of all patients who underwent appendectomy during 2012 were retrospectively reviewed. Since 2011, patients in our institution have been managed using a standardized perioperative protocol, with >80% adherence to the protocol.  The primary outcome evaluated was variable direct cost of the patient’s initial hospitalization. Secondary outcomes included operating time, intra-abdominal abscess (IAA) rate, and LOS. Results were stratified by surgeon, and by simple and complex disease. Final diagnosis was based on intra-operative findings. Linear, logistic, and Poisson regression models, adjusting for patient age, gender, and simple vs. complex appendicitis, were used to analyze the differences between surgeons with respect to these outcomes.

Results:
1,089 appendectomies were performed by 15 surgeons. The average number of cases per surgeon was 71.8(+5.5). There were significant differences between surgeons for operative time (p=0.001), cost of treatment (p=0.001), and LOS (p=0.005) for simple appendicitis. For complex appendicitis, there were significant differences between surgeons for operative time (p=0.001), cost of treatment (p=0.045), and IAA rate (p=0.005), but not LOS (p=0.979). (Figure 1)

Conclusion:

Significant differences in operating time, cost, LOS, and IAA rates in pediatric appendicitis exist between surgeons at a single, high volume, tertiary hospital despite the use of a standardized pre and post-operative evidence-based protocol.  Future study to identify factors leading to these differences may allow further improvement in outcome while decreasing the cost of care. 

« Previous Page
Next Page »