13.08 The Cost of Gastroschisis: Has Anything Changed ?

Posted on December 22, 2014

D. M. Hook-Dufresne1, X. Yu3, V. Bandla2, E. Imseis2, S. D. Moore-Olufemi1  1The University Of Texas Health Science Center Houston,Pediatric Surgery,Houston, TX, USA 2The University Of Texas Health Science Center Houston,Pediatric Gastroenterology,Houston, TEXAS, USA 3Baylor College Of Medicine,Pediatric Epidemiology,Houston, TEXAS, USA

Introduction:  Gastroschisis (GS) is a common, congenital abdominal wall defect that can cause significant morbidity associated with the development of intestinal dysfunction and feeding intolerance. The purpose of this study was to provide an update on the economic impact of pediatric patients diagnosed with gastroschisis on a national and state level.

Methods:  The Healthcare Cost and Utilization Project (HCUP) database was queried from 2007 -2011 for the following data: number of discharges, length of stay (LOS), costs and charges for all national pediatric (age < 1) hospital stays and all national pediatric (age < 1) hospital stays with the procedure code 54.71, designating repair of GS. The same data was collected for the state of Texas. The variation of differences in mean outcome between GS and normal infants over the years was negligible, thus we calculated the overall effect of having GS on LOS, cost and charges by the weighted average of the differences, where the weight was the reciprocal of the variance of the mean for each year. This value is represented by the combined estimate of difference (CED) and its standard error (SE). We performed a one-sample z test to compare the state CED against the national population CED.

Results: Pediatric patients under the age of 1 represent, on average, 11.86% of all national discharges. Pediatric patients with GS represent only 0.04% of all national pediatric discharges. Nationally, infants with GS had a significantly longer LOS (CED 38.5±0.9 days, p <0.0001). Infants with GS had significantly increased costs (CED $79,733±2,119, p <0.0001) and significantly increased charges (CED $249,999±9,652, p< 0.0001) for the national data. Data for the state of Texas reflected that of the national data. LOS was significantly longer for GS infants in the state of Texas (CED 41.6±2.5 days, p < 0.001). Texas infants with GS had significantly higher costs (CED $79,431±6,056, p <0.0001) and significantly higher charges (CED $252,611±27,752, p < 0.0001) when compared to non-GS infants. There were no significant differences between the state of Texas and the nation for LOS (p-value 0.22), costs (p-value 0.96), or charges (p-value 0.92).

Conclusion: While infants with GS represent a very small minority of both the national and Texas pediatric discharges, their LOS and costs greatly exceed their non-GS counterparts. Our findings reflect those of studies conducted more than 10 years ago, but interestingly, even when adjusting for the rate of inflation, the costs of caring for infants with GS continues to rise despite improved treatment strategies. Further investigation into the factors that promote the development of intestinal dysfunction and feeding intolerance in these patients is needed to significantly impact the economic burden of GS.

 

13.09 Bariatric Surgery and its Cost-Effectiveness in an Adolescent Population

Posted on December 22, 2014

S. Bairdain1, M. Samnaliev2  1Boston Children’s Hospital,Department Of Pediatric Surgery,Boston, MA, USA 2Boston Children’s Hospital,Harvard Medical School,Boston, MA, USA

Introduction:  The current estimates of the prevalence adolescent morbid obesity and severe morbid obesity are 21% and 6.6%, respectively.  Obesity, if left untreated, may result in a variety of comorbid conditions and earlier mortality. Adolescent bariatric surgery is expensive, but may be an effective means to ameliorate these conditions, and risk of earlier mortality.  We aimed to develop a model that can be used to evaluate the long term cost-effectiveness of bariatric surgery.

Methods:  All adolescents, who participated in our bariatric surgery multidisciplinary program from January 2010 to December of 2013 were included if they had at least 12 months follow-up following their surgery. A Markov cohort model was used to project costs, BMI and QALYs over a lifetime starting at age 18. Intervention costs included all operative as well as pre, and 12 month post-operative care costs. We estimated reductions in BMI after surgery and linked that information with the Medical Expenditures Panel Survey (MEPS) to estimate future savings from reduced medical care use. We used MEPS and other external data sources to estimate the association between BMI and health-related quality of life (HRQL). We linked BMI reductions with changes in life expectancy using publicly available data from the CDC. Incremental costs and quality-adjusted life years (QALYs) of surgery (vs. no surgery) were then estimated over different time periods. 

Results: From January 2010 to December 2013, data from 11 patients were analyzed. Ninety percent (n=10) were female. Median age at surgery was 17 (1.3) years. Median preoperative body mass index (BMI) was 48.7 (6.6) kg/m2.  All patients underwent a laparoscopic Roux-en-Y Gastric Bypass (RYGB) and 45% (n=5) had a concomitant hiatal hernia repair. Median length of stay was 3 days (range: 2-4 days). There were no complications. At 1 year follow-up, mean weight loss was 37.5 (13.5) kg and the corresponding BMI was 35.4(reduction of 13.2, p<0.01). Mean total intervention costs/person were $25,854 (sd=2,044). A unit change in BMI was associated with future medical care savings of $157 / year and with an increase in both quality of life and life expectancy. Bariatric surgery was not cost-effective in the first 3 years after surgery, but became cost-effective after that (e.g., $74,328/QALY in year 4 and 32,453/QALY and lower in year 7 and afterwards). 

Conclusion: Our results suggest that bariatric surgery among adolescents may be cost-effective when evaluated over a long period of time (e.g. 4 years). Future studies on a large scale are needed to show a continued improvement in QALYS and to evaluate earlier cost-effectiveness of the procedure.
 

13.10 DIEP Flaps Offer Lower Complication Rates, Shorter Hospitalizations at Higher Cost.

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:  Abdominal based breast reconstruction may be performed using several techniques, including pedicled transverse rectus abdominis myocutaneous (TRAM), free TRAM, and deep inferior epigastric perforator (DIEP) free flaps. DIEP flaps have the advantage of complete rectus abdominis sparing during the procedure, thus decreasing donor site morbidity. The aim of this study is to determine whether the surgical advantages of the DIEP flap impact postoperative outcomes vs. the free TRAM flap (fTRAM).

Methods:  We identified cases of DIEP (ICD-9-CM 85.74) and fTRAM (85.73) breast reconstruction within the Nationwide Inpatient Sample (NIS) database (2010-2011). Males were excluded from the analysis. Demographic and socioeconomic characteristics, comorbidities, postoperative complications (reoperation, hemorrhage, hematoma, seroma, pulmonary embolus, wound infection, and flap loss) were examined, along with endpoints of length of stay (LOS) and total charges (TC). Standard statistical methods and risk-adjusted multivariate analyses were used; all cases were weighted to project national estimates.

Results: Overall, 15,836 cases were identified, with 9,699 (61%) DIEP and 6,137 (39%) fTRAM reconstructions. Within the cohort, 70% were Caucasian, 97% were insured, and 83% of patients were treated in a teaching hospital setting. LOS was longer among fTRAM patients, whereas TC were lower, p<0.001. There were no in-hospital mortalities during the study period. DIEP patients were more likely to be obese (OR=1.2), p<0.001. The fTRAM cohort was more likely to suffer pneumonia (OR=3.7), wound infection (OR=1.7), and wound dehiscence (OR=4.3), p<0.001. Type of reconstruction did not affect risk of revision, hemorrhage, hematoma, seroma, or flap loss on bivariate analysis. Risk-adjusted multivariate analysis demonstrated that fTRAM was an independent risk factor for increased length of stay (OR=1.6) and postoperative complications (OR=1.3), p<0.001. DIEP was an independent risk factor for increased total charges (OR=1.5), p=0.001.

Conclusion: Patients undergoing fTRAM breast reconstruction were more likely to suffer postoperative complications and an increased length of stay; total charges however, were higher for the DIEP cohort. Additional research is necessary to elucidate patterns of technique availability to improve cost-utilization.

13.11 Free TRAM Flaps Have Higher Resource Utilization, More Complications vs. Pedicled Flaps.

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:  Conventionally, free transverse rectus abdominis myocutaneous (fTRAM) flap breast reconstruction has been associated with decreased donor site morbidity and improved flap inset, at the expense of higher requirements for technical expertise and advanced facilities. This study aims to characterize postoperative outcomes and their differences in patients undergoing free vs. pedicled TRAM (pTRAM) flap breast reconstruction.

Methods:  The Nationwide Inpatient Sample (NIS) database (2008-2011) was reviewed for cases of fTRAM (ICD-9-CM 85.73) and pTRAM (85.72) breast reconstruction. Inclusion criteria were female patients undergoing pTRAM or fTRAM total breast reconstruction; males were excluded from the analysis. We examined demographic characteristics, hospital setting, insurance information, patient income, comorbidities, with clinical endpoints of postoperative complications (including reoperation, hemorrhage, hematoma, seroma, myocardial infarction, pulmonary embolus, wound infection, and flap loss), length of stay (LOS), and total charges (TC). Bivariate and Multivariate analyses were performed to identify independent risk factors associated with increased complications and resource utilization. Cases were weighted to project national estimates.

Results: Overall, 21,655 cases were captured. Of the entire cohort, 70% were Caucasian, 95% were insured, and 72% of patients were treated in an urban teaching hospital. Of the 11,331 pTRAM and 10,328 (48%) fTRAM cases, there were 9 pTRAM and 6 fTRAM in-hospital mortalities. On bivariate analysis, the fTRAM cohort was more likely to be obese (OR=1.2), undergo revision (OR=5.9), require hemorrhage control (OR=5.7), suffer complications from a hematoma (OR=1.9), or wound infection (OR=1.8), p<0.003. The pTRAM cohort was more likely to suffer pneumonia (OR=1.6) and pulmonary embolism (OR=2.0), p<0.004. Type of reconstruction did not affect risk of flap loss or seroma. TC were higher in the fTRAM group (p<0.001), while LOS was not affected by procedure type. On a risk-adjusted multivariate analysis, fTRAM was found to be an independent risk factor for increased LOS (OR=1.6), TC (OR=1.8), and postoperative complication rate (OR=1.3), p<0.001.

Conclusion: Free TRAM breast reconstruction was found to have an increased risk of postoperative complications and resource utilization vs. pedicled TRAM on the largest risk-adjusted analysis to date. Further analyses are required to elucidate additional factors influencing outcomes following fTRAM and pTRAM reconstruction.

13.12 Financial Implications of Managing Penetrating Trauma Patients to an Acute Care Surgery Service

Posted on December 22, 2014

B. C. Branco1, P. Rhee1, B. Joseph1, A. L. Tang1, G. Vercruysse1, T. O’Keeffe1  1University Of Arizona,Trauma,Tucson, AZ, USA

Introduction:  Trauma centers often report unfavorable financial performance by caring for injured patients Penetrating trauma in particular has a significant impact on health care systems, with up to one third of these patients reported as uninsured. The financial impact on trauma surgery practice is unknown. The purpose of this study was to evaluate the financial implications of managing penetrating trauma patients in a level I trauma center.

Methods: All trauma patients admitted to a level I trauma center over a fiscal year (July 2011 to June 2012) were retrospectively identified. Demographics, clinical data and outcomes were extracted. Hospital and trauma surgeon financial data were also extracted. Outcomes were total charges, costs, net margin and reimbursements. Patients were compared according to injury mechanism. What stats did you use?

Results: 3,343 trauma patients were admitted of which 513 (15.3%) sustained penetrating trauma (51.3% GSW and 48.7% SW) and 2,830 (84.7%) blunt. Penetrating trauma patients had lower overall ISS (8.4 ± 11.3 vs. 9.2 ± 9.4, p<0.001) but were more likely to undergo an intra-cavitary procedure (39.3% vs. 26.7%, p<0.001). Patients who sustained penetrating trauma were more often uninsured (19.4% vs. 9.1%, p<0.001) and had Medicaid (55.8% vs. 36.9%, p<0.001). There were no significant differences in hospital LOS (penetrating: 4.2 ± 6.5 days vs. blunt: 4.7 ± 6.8 days, p=0.271). Overall, hospital net margin was $1.2 ± 1.3 k per trauma patient (1.9 ± 1.3 k for blunt vs. -2.4 ± 1.3 for penetrating, p<0.001). The average % hospital reimbursement was 25 ± 23% for blunt and 15 ± 18% for penetrating trauma (p<0.001). There were no differences in total hospital costs (10.4  ± 2.9 k vs. 10.1  ± 1.9 k, p=0.841) or patient charges (40.8 ± 8.1 k vs. 44.9 ± 7.4 k, p=0.302). Nevertheless, trauma surgeon professional charges were significantly higher for penetrating trauma (3.9 ± 7.3 k vs. 1.6 ± 3.2 k, p<0.001), in particular after GSWs (4.7 ± 8.9 k vs. 1.7 ± 3.4 k, p<0.001), as were surgeon’s reimbursement (1.4 ± 1.9 k vs. 0.6 ± 1.0 k, p<0.001.

Conclusions: Penetrating trauma was found to be a significant source of revenue loss for hospitals. This data may help inform mission support efforts in critical access hospitals that have high rates of penetrating trauma. Trauma surgeon reimbursement were however significantly higher after penetrating trauma, in particular after gunshot wounds, due to the associated operative interventions.

 

13.13 Do Healthcare Professionals Practice Evidence Based Medicine?

Posted on December 22, 2014

R. Kaur1, E. Chang1, P. Chung1, S. Hahn1, D. Chang1, A. Alfonso1, G. Sugiyama1  1SUNY Downstate,BROOKLYN, NY – NEW YORK, USA

Introduction:  Healthcare professionals (HCPs) have a duty to provide service for patients based on the best possible evidence available. However there is often little data available when novel approaches are first introduced. We conducted a survey of HCPs preferences for minimally invasive cholecystectomies with robotic cholecystectomy being the most recently introduced in available mainstream options for the procedure.   

Methods:  Non-surgical HCPs (attending and resident physicians, nurse practitioners, physician assistants and registered nurses) at our academic medical center were surveyed on their preferences for the following: multiport laparoscopic cholecystectomy (MLC), single incision laparoscopic cholecystectomy (SILC), single incision robotic cholecystectomy (SIRC), or no preference. HCPs were then provided educational material providing images of post-operative wounds, and expected outcomes based on currently available data. Only known parameters of patient outcomes in regards to SIRC were reported in the survey due to lack of currently available outcomes data.

Results: 100 HCPs completed the survey study. Prior to image and data presentation, reported preferences were SILC (48%), SIRC (21%), no preference (20%), and MLC (11%). After image and data presentation, preferences were SIRC (45%), SILC (33%), MLC 12%, and no preference (10%). The Stuart-Maxwell test showed a significant change (p < 0.0001) in preference for surgical approach between the paired groups. 

Conclusion:The plasticity displayed in HCPs’ preferences for surgical approach before and after data presentation shows the effects of information on HCPs’ choices. These results were surprising. Despite being provided incomplete outcomes data for SIRC, many HCPs chose SIRC over the more familiar options of MLC and SILC. These results suggest that HCPs are comfortable making decisions based on incomplete data. Further studies to explore the magnitude of the effects of marketing in the absence of concrete outcomes data as applied to robotic surgery is necessary.

 

13.14 Resource Utilization in Pediatric Skin and Soft Tissue Infections

Posted on December 22, 2014

M. Veenstra1,2, A. Hartner2, B. Kumar2, P. Mahajan2, B. Asmar2, M. Klein1,2  1Detroit Medical Center,Detroit, MI, USA 2Children’s Hospital Of Michigan,Pediatric Surgery,Detroit, MI, USA

Introduction:
Skin and soft tissue infections (SSTIs) have increased in the past 2 decades and are associated with increasing health care costs. We convened a multispecialty group of physicians from the departments of surgery, pediatrics, emergency medicine, and infectious disease to evaluate our experience and costs related to evaluation of pediatric SSTIs. 

Methods:
Patients (682) who presented to our ED with SSTIs during 6 consecutive months (July-December 2012) were reviewed for resource utilization and costs. This data was compared to current recommendations in the literature to identify evaluation tools that add resource consumption without benefit to the patient. ANOVA was used for statistical analysis.

Results:
Of the 682 patients presenting with a pediatric SSTI, 331 (49%) underwent incision and drainage for an abscess. Wound cultures were completed in 38% of patients, blood cultures in 29%, US in 16%, antibiotics prescribed to 97%, and 208 patients (30%) were admitted to the hospital. The mean direct cost per patient was $792.66 and mean length of stay was 15 hours. The total direct cost of care for 6 months was $540,593.  The use of ultrasound, wound culture, and blood culture increased the length of stay (p<0.01) and all resources increased cost for patients (p<0.01). Patients admitted to a surgical service had a shorter length of stay and lower cost than those admitted to a non-surgical service (p<0.01).

Conclusion:
We noted many resources that are being overutilized in the evaluation of pediatric patients with SSTI that are contributing to unnecessary costs when compared to recommendations in the literature. The include blood cultures, wound cultures, and the use of utrasound.
 

13.15 Indications And Outcomes For Nissen Fundoplication In Infants Less than 6 Months Of Age

Posted on December 22, 2014

J. Yoon1, J. Gross1, S. Burjonrappa1  1St.Jospeh’s Regional Medical Center,Surgery/Pediatric Surgery,Patterson, NJ, USA

Introduction:  Anti-reflux surgery is offered only to those who fail medical management for gastro-esophageal reflux (GERD) in the pediatric population. The general consensus is that most infants would grow out of their reflux with medical management only. A handful of studies show that those with neurologic impairment have benefited from these procedures; however, there are few studies that document the outcomes for infants less than 6 months of age.  This study investigates the short-term outcomes of Nissen Fundoplication (NF) in this population.

Methods:  We performed a retrospective analysis of children less than 6 months of age who underwent Nissen Fundoplication at our institution from December 2006 – June 2013.  The following factors were analyzed: surgical indications, co-morbidities, hospital course data, weight gain, length of stay, and complications.

Results: 23 patients were studied in this analysis (average age: 95.8 days, median 90 days).  Pre-surgery, these patients on average were in the 9.88 percentile for weight (median 0.9 percentile) and 21/23 (91.3%) patients were under the 50th percentile.  19/23 (82%) patients underwent NF for GERD and 16/23 (69%) patients had poor feeding prior to the surgery.  All patients had concomitant gastrostomy tube creation.  All patients had co-morbidities other than GERD/ poor feeding.    18/23 (78%) had anatomic or genetic abnormalities.  11/24 (45.8%) patients underwent an upper gastrointestinal contrast study that was positive for reflux.  Diet was advanced on average post-operative day 2.39 and the patients were tolerating their goal diet by post-operative day 6.45 (median 5.5).  All but 3 patients were discharged on diets more substantial (by volume) than their highest pre-operative diet. On average, these patients were on 1.9 GERD related medications before surgery (Pepcid most common), but decreased to 0.7 GERD related medications after surgery. Of the 15 patients who were still on GERD medications after surgery, only 2 were discharged with medications. Patients who were observed for longer than 2 weeks in an inpatient setting (10/23 patients) had an improvement in weight percentile (average 9.79 to 14.97 percentile; median 1.4 to 3.2). 7/24 (29.2%) patients had complications related to their g-tube, the main complaint being leakage around the tube.

Conclusion:Infants undergoing NF under the age of 6 months are very sick patients with multiple co-morbidities.  They have exhausted all options for weight gain due to excessive reflux and/or poor feeding.  Our study shows that NF in these patients improves their ability to gain weight and also decreases the overall need for GERD related medications.  
 

13.17 Temporal Variation of Non-Perforated and Perforated Appendicitis in the United States

Posted on December 22, 2014

A. A. Desai1, K. W. Schnell1, B. G. Dalton1, S. D. St. Peter1, C. L. Snyder1  1Children’s Mercy Hospital- University Of Missouri Kansas City,Kansas City, MO, USA

Introduction:   Seasonal variation in the incidence of acute appendicitis has been recognized.  The aim of this study was to determine whether children with non-perforated and perforated appendicitis were more likely to present during specific days of the week or seasons of the year in the United States.   Previously reported data demonstrates increased likelihood of presentation of perforated appendicitis on Mondays and increased rates of presentation during the fall and winter.

Methods:   A retrospective population-based study of patients was performed by querying The Pediatric Health Information System (PHIS) database over a 9-year period for de-identified patients with both ICD-9 code for appendicitis and procedure code for appendectomy.  Patients greater than 18 years of age were excluded.  Demographics and temporal data regarding day, quarter, and month were based on day of operation.  Chi square and odds ratio were performed where appropriate.

Results:  A total of 139,499 children were admitted during the study interval of which 34.1% were perforated.  The greatest incidence for non-perforated appendicitis was Tuesday (15.9%), and the greatest incidence for perforated appendicitis was Monday (15.8%).  Although the greatest incidence of perforated appendicitis was on Monday, this was not significant (p=0.72).  The weekends however were at higher odds (OR: 1.13; 95% CI1.102-1.16) for perforation.  Peak incidence of non-perforated appendicitis occurs in the summer (spring 25.9%, summer 27.1%, autumn: 23.8%, winter: 23.1%).  Peak presentation of perforated appendicitis occurs in the summer as well (spring: 8.8%, summer: 9.2%, autumn: 8.1%, winter: 7.9%)  However, the odds of perforated appendicitis during summer months (OR: 1, CI: 0.97-1.02) or winter months (OR 1.0, CI: 0.99-1.05) was not significant.

Conclusion:  Presentation with perforated appendicitis is more likely to occur on the weekends.  Seasonal variation supports previously reported data demonstrating peak presentation of non-perforated and perforated appendicitis in the summer, however increased odds of perforation in fall and winter months was not noted in this study.

 

13.18 Pediatric Ulcerative Colitis: Comparison of 30-day outcomes for laparoscopic and open colectomy

Posted on December 22, 2014

J. B. Mahida1,2, L. Asti1, P. C. Minneci1,2, K. J. Deans1,2, B. C. Nwomeh2  1Nationwide Children’s Hospital,Center For Surgical Outcomes Research,Columbus, OH, USA 2Nationwide Children’s Hospital,Division Of Pediatric Surgery,Columbus, OH, USA

Introduction:
For patients with ulcerative colitis, colectomy is considered curative treatment. Colectomy can resolve frequent disease flares and minimize the risk of colon cancer in patients with ulcerative colitis. The objective of this study was to compare 30-day outcomes between laparoscopic and open colectomy performed on pediatric patients with ulcerative colitis using a validated national database.

Methods:
We identified all total colectomies performed on patients with ulcerative colitis in the 2012 National Surgical Quality Improvement Program Pediatric (NSQIP Pediatric) database and compared demographic, clinical, and 30-day outcome characteristics between patients who underwent an open or laparoscopic resection. Minor complications included superficial and deep surgical site infections and urinary tract infections, whereas major complications included ventilator dependence for > 48 hours, unplanned reoperation within 30 days, and all other NSQIP Pediatric predefined 30-day complications.

Results:
Of the 69 patients who underwent colectomy, 21 (30%) were performed open and 48 (70%) laparoscopically. There were no significant differences in baseline characteristics between the groups with the exception of patients undergoing open procedures having  lower white blood cell counts (9,800 vs. 10,900 cells/mm3, p=0.041) and platelet counts (302,000 vs. 361,000 cells/mm3, p=0.026). There was no significant difference in the proportion of patients undergoing operations longer than 3 hours (open vs. laparoscopic, p-value) (67% vs. 81%, p=0.187), in postoperative length of stay (8 vs. 6 days, p=0.074), or in the rates of major and minor complications (Table).

Conclusion:
The majority of colectomies for pediatric ulcerative colitis are being performed laparoscopically with similar operative times, postoperative lengths of stay, and 30 day outcomes to open procedures. Additional patient accrual within NSQIP-Pediatric will allow for future risk-adjusted analyses to determine differences in outcomes.
 

13.19 Increased height associated with patients with pectus excavatum and pectus carinatum

Posted on December 22, 2014

A. A. Desai1, H. Alemayehu1, B. G. Dalton1, K. W. Schnell1, S. D. St. Peter1, C. L. Snyder1  1Children’s Mercy Hospital- University Of Missouri Kansas City,Kansas City, MO, USA

Introduction:   The underlying cause of most chest wall deformities is not clearly understood. A small fraction are associated with connective tissue diseases, with associated systemic skeletal abnormalities. Other than scoliosis, no other skeletal abnormalities are commonly associated with congenital chest wall deformities. We investigated the clinical observation that children with pectus defects appeared to be, on average, taller than unaffected children.

Methods:  A retrospective institutional review board approved review was conducted of all patients with pectus excavatum and pectus carinatum seen in our outpatient congenital wall deformity clinic from January 2011 to June 2013.   Demographic data including age at presentation, weight, height, body mass index (BMI) and gender were collected and compared to national cohort as published by the Center for Disease Control Clinical Growth Charts.  Two-tailed t-test was used for statistical analysis.   

Results:   A total of 360 patients (280 males and 80 females) were identified in the study period.   The mean and median percentile for height among males was 70.9 and 80.3, and the mean and median percentile for height among females was 67 and 69.5.  The mean and median percentile for weight among males was 56.6 and 54, and for females was 46 and 50 (Figure 1).  There was no significant difference between mean percentile height (p=0.1) or weight (p=0.12) between genders.  There was no significant difference in percentile of height (p=0.12) or weight (p=0.75) in patients with pectus carinatum and pectus excavatum.

Conclusions:  Patients with congenital chest wall deformity do have increased height when compared to the national cohort. The average weight of patients with congenital chest wall defects is similar to the national cohort, accounting for the lower BMI. The increased height and decreased BMI may be associated with general growth abnormalities seen with chest wall deformities.

14.01 Partnerships in Global Surgery: Do Short-Term Surgical Teams Increase Operative Volume?

Posted on December 22, 2014

S. R. Addington1, A. Matousek1,3, C. Exe2, R. R. Jean-Louis2, H. Sannon2, J. G. Meara3, R. Riviello1,3  1Brigham And Women’s Hospital,The Center Of Surgery And Public Health,Boston, MA, USA 2Hospital Albert Schweitzer,Surgery,Deschapelles, ARTIBONITE, Haiti 3Harvard Medical School,The Program In Global Surgery And Social Change, Department Of Global Health And Social Medicine,Boston, MA, USA

Introduction:  Short-term surgical teams (STSTs) offer the potential to increase surgical capacity, provide specialty services and create educational opportunities for local staff. They also often gain exposure to advanced pathology, improved physical examination skills and practice patterns with limited resources from experienced local providers.  In the absence of outcome data, STSTs often use productivity as a metric of impact.  We set out to determine whether STSTs increase operative volume at an NGO hospital in rural Haiti.

Methods:  We retrospectively reviewed the operative log at an NGO hospital in rural Haiti from Jan 1st, 2013 through July 1st, 2014. We compared the mean number of operations performed on weekdays when STSTs were present and absent. We also analyzed the relative contributions of STSTs and local staff surgeons to the operative volume.

Results: The sample included 1976 operations completed over 399 weekdays. During the study period, 53 individuals comprising 22 STSTs were present for 118 of the 399 weekdays (29.6%).  STSTs were associated with a modest increase in operative volume (5.83 vs. 4.58 operations/day, p= 0.0024) that accounted for approximately 100 additional procedures per year. STSTs did not perform as many operations as the local staff did during their stays (2.11 vs. 3.72 operations/day, p=0.0001). STSTs were also associated with a decrease in local staff productivity (3.72 vs. 4.58 operations/day, p=0.025).  

Conclusion: STSTs were associated with a modest increase in operative volume partially mitigated by a decrease in local staff productivity. STSTs offer many benefits to hospitals in LMICs, but must be well coordinated and integrated into existing systems to maximize potential benefits.

 

14.02 Measuring Surgical Outcomes in Rural Haiti: Choosing a Target for Quality Improvement

Posted on December 22, 2014

A. C. Matousek1,3, S. Addington1, C. Exe2, R. R. Jean-Louis2, J. G. Meara3,4, R. Riviello1,3  1The Center For Surgery And Public Health, Brigham And Women’s Hospital,Surgery,Boston, MA, USA 2Hospital Albert Schweitzer,Deschapelles, ARTIBONITE, Haiti 3Harvard Medical School,Program in Global Surgery And Social Change, Department Of Global Health And Social Medicine,Boston, MA, USA

Introduction:  The lack of outcome data is a barrier to quality improvement efforts in resource poor settings.  Most hospitals in LMICs endure several resource constraints and do not include outcome measurement in routine data collection.  We set out to systematically record inpatient surgical outcomes for an eight-month time period at a typical rural NGO hospital in rural Haiti to inform future quality improvement efforts.

Methods: A single data collector used a standard set of definitions to prospectively record outcomes during any admission or readmission for adult and pediatric general and orthopedic surgical patients from Sept 16th, 2013 to May 16th, 2014. Primary outcomes included all cause mortality, post-operative mortality, surgical site infection, and unplanned re-operation.  Secondary outcomes included length of stay and reasons for re-admission.

Results:  The cohort included 1088 patients and 1165 admissions.  The surgical caseload consisted of 1022 operations performed on 864 patients. All-cause mortality occurred in 1.52%, post-operative mortality in 1.45%, SSIs in 2.47%, and unplanned repeat operations in 1.40% of cases.  The 30-day readmission rate was 7.1%. Median Length of stay (LOS) for all patients was 4 days.  Median LOS for patients with diabetic foot ulcers was 30 days.  Readmissions were due to complications in 50% of cases.

Conclusions:  Measuring outcomes should precede attempts at quality improvement in order to identify the most relevant interventions.  For this hospital, we identify inpatient wound care as a target for quality improvement and encourage the development of outpatient metrics to more fully characterize surgical quality.

 

14.03 Estimating Global Access to Surgical Care with Geospatial Mapping of Surgical Providers

Posted on December 22, 2014

N. P. Raykar1,2,3, A. N. Bowder3,4, M. P. Vega3, J. Kim3,5, G. N. Boye2, S. L. Greenberg2,3,6, J. N. Riesel2,3,7, R. D. Gillies3, J. G. Meara2,3, N. Roy8  1Beth Israel Deaconess Medical Center,Boston, MA, USA 2Children’s Hospital Boston,Boston, MA, USA 3Harvard School Of Medicine,Program In Global Surgery And Social Change,Brookline, MA, USA 4University Of Nebraska College Of Medicine,Omaha, NE, USA 5Tufts Medical Center,Boston, MA, USA 6Medical College Of Wisconsin,Milwaukee, WI, USA 7Massachusetts General Hospital,Boston, MA, USA 8BARC Hospital,Mumbai, MH, India

Introduction: The Lancet Commission on Global Surgery calls for universal access to safe, affordable and timely surgical care.  Unfortunately, billions of people currently lack access to such care due to myriad factors including severe deficits in the surgical workforce.  Little is known, though, about the distribution of surgeons and their accessibility to patients in low-resource settings — this makes allocation of human and physical resources challenging.  Geospatial mapping can be used to (1) identify populations that lack timely access to surgical care (defined as living within two hours of a surgical provider) and (2) understand variations in surgeon-to-population density that can impact service availability.

Methods: The number and practice location of surgeons was obtained from Ministries of Health, professional societies, registration databases, personnel with in-country knowledge of surgeon distribution, and the published literature.  Spatial distribution of providers was mapped using online mapping software.  Two-hour driving zones were constructed around each provider location through analysis of roads and driving times calculated from Google Maps. The number of people living within these zones was estimated using the Socioeconomic Data and Applications Center Population Estimation Service.

Results:Analysis was completed on data from nine countries: Mongolia, Namibia, Papa New Guinea, Sierra Leone, Somaliland, Zimbabwe, nine states in Nigeria, six states in India, and one state in Ecuador.  Percentages of populations living within two hours of a surgical provider vary dramatically, ranging from 4.7% (Chhattisgarh state, India) to 88.6% (Ogun state, Nigeria).  Surgeon-to-population ratios ranged from 1:10,500 (Mongolia) to 1:1,360,000 (rural Kerala state, India).  Surgeon-to-population ratios also vary dramatically within the same country. In Sierra Leone, for example, the urban surgeon-to-population ratio was 1:80,900 compared to the rural surgeon-to-population ratio of 1:383,000.

Conclusion:Access to surgical care in the resource-limited setting is contingent upon multiple factors. The most fundamental of these is availability of and access to a surgeon. Geospatial mapping of surgical providers shows that regardless of national surgical numbers, many populations in the world still lack access to timely surgical care.  Wide variability in timely and available access exists between and within countries.  Geospatial mapping has the unique ability to illustrate coverage gaps in a meaningful way.  Understanding these access patterns can prove useful in addressing national deficits in surgical care. 

 

14.04 Improving Surgical Capacity in a Low Resource Setting: the Rwanda Human Resources for Health Program

Posted on December 22, 2014

A. Costas1,2,4, J. Kreshak2,3,4, G. Ntakiyiruta4, P. Kyamanywa4, R. Riviello2,3,4  1Children’s Hospital Boston,Department Of Plastic Surgery,Boston, MA, USA 2Harvard School Of Medicine,Brookline, MA, USA 3Brigham And Women’s Hospital,Surgery,Boston, MA, USA 4National University Of Rwanda,Surgery,Kigali, NONE, Rwanda

Introduction: There is an estimated shortage of approximately 7.2 million health care workers worldwide, with critical shortages in sub-Saharan Africa. These shortages are largely due to lack of sufficient quality medical education programs, limited faculty and infrastructure, and difficulty retaining trained professionals. This deficit is particularly noticeable in surgery, which is often forgotten in global health discussions. Surgical missions, isolated trainings by surgical volunteers, and task shifting have played important roles as short-term solutions. However, these vertical programs are unable to fill the workforce gap in resource-limited countries. For these countries to sustainably manage the volume of their unmet surgical need, an emphasis needs to be placed on capacity building.

Methods: Instead of small-scale cooperative efforts between stand-alone academic institutions or isolated individuals, the Human Resources for Health (HRH) program was created in Rwanda in 2012 as a long term plan to increase the quality and quantity of health care professionals in the country.  The HRH program is a seven-year partnership between the Rwandan Ministry of Health, the United States federal government, and a consortium of 23 US institutions (USI) dedicated to building sustainable health care capacity. USI faculty are recruited to work full-time for one year in Rwanda and are partnered directly with Rwandese colleagues. Since August 2012, 10 USI surgeons a year (including general, plastics, orthopedic and pediatric surgery) have been active participants in surgical clinical and didactic teaching, curriculum and residency program development, research support and trainee mentorship.

Results:The HRH program is unique in many ways but perhaps none more so than its attention to surgical education as a critical component of a thriving health care delivery system. The HRH faculty have been instrumental in the improvement of education practices including clinical bedside and operative teaching, establishing protected didactic time, regular educational lectures and conferences such as morbidity and mortality, and research mentoring.  Greater appreciation has developed as well for surgery as a complex system and the importance of the many components needed to run a successful surgical program. HRH surgeons have thus assisted in the creation of separate specialty surgical services, streamlining operating room efficiency, procuring necessary and adequate instruments, providing teaching to ancillary staff, and highlighting the importance of having adequate radiology and pathology services.

Conclusion:The HRH Program surgical faculty, in partnership with their Rwandan colleagues, have provided formal surgical instruction and mentoring in Rwanda since 2012. In doing so, they are helping to improve the quality and capacity of the Rwandese surgical workforce so that it may comprehensively and sustainably meet the country’s future healthcare needs.

 

14.05 A Nationwide Survey of Access to Surgical Facilities, Poverty, and Deaths from Acute Abdomen in India

Posted on December 22, 2014

J. S. Ng-Kamstra1,2, S. Fu1, A. J. Dare1, M. M. Hsiao1,2, P. Rodriguez1, J. Patra1, N. Correa1, P. Jha1  1University of Toronto,Centre For Global Health Research, Li Ka Shing Knowledge Institute, St Michael’s Hospital,Toronto, Ontario, Canada 2University of Toronto,Department Of Surgery,Toronto, Ontario, Canada

Introduction: Acute abdominal conditions, including appendicitis, peptic ulcer disease, and incarcerated hernias are associated with high mortality in the absence of timely surgical care. In India, limited country-specific data exists to quantify the burden and distribution of deaths from acute abdomen (DAA) and to guide the development of surgical services. In this study, we describe the spatial and socioeconomic distributions of DAA and quantify potential access to surgical facilities in relation to such deaths.

Methods: Data on DAA throughout India in 2001-2003 were obtained from the Million Death Study (MDS), a nationally representative, population-based mortality survey of 1.1 million Indian households using verbal autopsy methodology. We created a national spatial database of abdominal mortality by integrating data from the MDS with surgical provider and facility data from the District-Level Household and Facility Survey and household socioeconomic data from the Special Fertility and Mortality Survey. The spatial distribution of DAA was calculated using ordinary kriging, and cluster analysis was performed using the Getis-Ord Gi* statistic. This provided ‘hot’ and ‘cold’ clusters of DAA at the postal (PIN) code level. Spatial metrics of access and socioeconomic indicators were then evaluated to compare hot and cold spots of DAA.

Results: 923 of 85388 study deaths in those aged 0-69 years were identified as DAA, representing an estimated 1.1% proportional mortality. The majority of deaths occurred at home (71%) and in rural areas (87%). The mean age-standardized DAA mortality rate was 8.6 times higher in hot than in cold PIN codes. Hot spots were associated with poorer access to district-level hospitals (DH) with a full complement of surgical resources. The median distance to the nearest such hospital was 53 km [IQR 32-85] in hot spots versus 27 km [IQR 17-43] in cold spots. Poverty indicators were also associated with mortality. Median monthly total household expenditure was significantly lower in hot spots versus cold spots, as were adult literacy rates. The proportion of households belonging to a scheduled caste or tribe was significantly higher in hot versus cold spots.

Conclusions: DAA were concentrated in rural India and predominantly occurred outside of a health facility. Mortality was associated with poor geographic access to surgical care, poverty, and belonging to a scheduled caste or tribe. These findings support the need to improve timely access to well-resourced surgical facilities in India to prevent avertable mortality from common surgical conditions. Policies must also address the significant socioeconomic barriers to surgical care, especially for the rural poor in India.

11.06 Efficacy of a Single PTH Measurement Protocol for Prediction of Hypocalcaemia after Thyroidectomy

Posted on December 22, 2014

J. Y. Liu1, C. J. Weber1, M. McCullough1, J. Sharma1  1Emory University School Of Medicine,General Surgery,Atlanta, GA, USA

Introduction:  
The management of hypocalcaemia after total thyroidectomy (TTx) is a challenge as TTx is transitioned into a same-day surgery. Measurement of the parathyroid hormone (PTH) level following TTx allows for prediction of postoperative hypocalcaemia, defined as symptomatic hypocalcaemia or requiring intravenous calcium (IV Ca) supplementation, and may decrease the need for routine serum calcium (Ca) monitoring and lead to shorter hospital stays. 

Methods:
After implementing a standardized calcium management protocol based on PTH measurement and routine oral Ca supplementation, a retrospective database was queried to evaluate protocol efficacy and compliance for 169 patients undergoing TTx between 2012 and 2014. This was compared to a previous time period between 2010 and 2012 where 67 patients underwent TTx.  Patient demographics, extent of surgery, post-operative laboratory values, complications, IV Ca, and length of stay were analyzed. 

Results:
Of the 169 patients undergoing TTx, transient hypocalcaemia (TH) and permanent hypocalcaemia (PH) was reported in 17 and 0 patients respectively (10.1%, 0%). PTH was recorded in 81.7% (n=138) patients with 64.5% (n=89) >10 pg/ml and 35.5% (n=49) <10 pg/ml. In 2012-2014, there was a decrease in length of stay in the PTH<10 group compared to 2010-2012 (Table 1). However, in the PTH>10 group no significant change was observed between the two time periods (Table 1). From 2012-2014, patients with PTH<10 also had fewer calcium lab draws compared to 2010-2012 (Table 1). In the PTH>10 group, 3.4% (n=3) of patients had TH. However, in the PTH<10 group, 34.69% (n=17) of patients had TH. There were three readmissions for TH and all were in patients with PTH<10. 

Conclusion:
A PTH<10 can serve as a predictor for TH and readmissions in TTx. The implementation of a single PTH measurement protocol with a standardized calcium regimen has decreased the length of stay and the number of calcium draws for patients undergoing TTx and will make TTx a more cost effective procedure. 
 

11.07 High Volume of Emergency General Surgery Cases Is Associated With Better Outcomes.

Posted on December 22, 2014

V. Pandit1, P. Rhee1, B. Zangbar1, N. Kulvatunyou1, M. Khalil1, T. O’Keeffe1, A. Tang1, D. J. Green1, G. Vercruysse1, R. S. Friese1, B. Joseph1  1University Of Arizona,Trauma/Surgery/Medicine,Tucson, AZ, USA

Introduction:
The impact of trauma center volume on patient outcomes is well established. With regionalization of emergency general surgical (EGS) care, the association between EGS case volume and patient outcomes remains unknown. The aim of this study was to evaluate the association between EGS case volume and outcomes across the centers in the United States.

Methods:
We abstracted the national estimates for EGS procedures from the National Inpatient Sample database 2011 (representing 20% of all in-patient admissions).  Patients undergoing emergent procedures (appendectomy, cholecystectomy, hernia repair, small and large bowel resections) were included. Centers were divided into two groups based on the number of EGS cases performed per year: High volume (> 350 cases) centers (HVC) and low volume (<350 cases) centers (LVC). Outcome measures were: in-hospital complications, hospital length of stay, failure to rescue rate, and mortality.  Regression analysis was performed controlling for age, gender, Charlson comorbidity index, and type of surgical procedure.

Results:
A total of 167,698 patients that underwent EGS procedures across 825 centers were included.  22.8% (n=188) centers were HVC. Patients managed in HVC had a lower complication rate (16.8% vs.17.2%; OR [95%CI]: 0.96 [0.91- 0.97], p=0.032) and a shorter hospital length of stay (5.8±4.1 vs. 6.2±5.4; OR [95%CI]: 0.95 [0.89- 0.96], p=0.041) compared to patients managed in LVC. On sub-analysis of patients with major complications (n= 4,516), HVC had a lower failure to rescue rate compared to LVC (24.8% vs.36.1%; OR [95%CI]: 0.91 [0.85- 0.96], p=0.021). There was no difference in overall mortality rate between the two groups. (2.5% vs. 2.4%; OR [95%CI]: 1.13 [0.05- 1.21], p=0.71).

Conclusion:
A volume effect relationship exists among centers managing EGS patients. High volume EGS centers have a lower complications rate and a lower failure to rescue rate compared to low volume EGS centers. Understanding the reasoning behind the volume impact in EGS cases is critical as we move forward with expanding the acute care surgery model.

11.08 Do Probiotics/Synbiotics Reduce Postoperative Sepsis in Abdominal Surgery? – A Meta-analysis

Posted on December 22, 2014

S. Arumugam1, K. Mahendraraj1, R. S. Chamberlain1  1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA

Introduction: The gastrointestinal (GI) tract is intimately linked to the development of systemic anti-inflammatory response and sepsis following surgery. GI surgery significantly disrupts the natural microbiome environment by altering nutrient metabolism and deregulating immune function. The health benefits of probiotics and synbiotics is well established in healthy adults, but their role in preventing postoperative complications including sepsis remains controversial. This meta-analysis assesses the impact of probiotics and synbiotic preparations on the incidence of postoperative sepsis in GI surgical patients.

Methods: A comprehensive search of Pub Med, Google Scholar, and Cochrane Review (1966-2014) was performed seeking all published randomized controlled clinical trials (RCTs) assessing the impact of perioperative probiotics or synbiotics in elective GI surgery. Studies were included if patients underwent GI surgery with the addition of adjunct prebiotic, probiotic, or a synbiotic therapy and a control group receiving placebo or no therapy.16 potentially eligible studies were identified, of which 4 were excluded for lack of randomization, inadequate blinding and incomplete outcome data. Only RCTs which were completed and analyzed as level 1 studies were included. The primary outcome measured was postoperative sepsis within 1 month of surgery.

Results:12 RCTs involving 815 patients were included. 327 patients received synbiotics and 83 received probiotics, while 405 patients received placebo or no therapy. Overall, there was a 41% reduction in postoperative sepsis for patients treated with either a synbiotic or probiotic compared to the control group (RR 0.59; 95% CI=0.45-0.77; p<0.001). When assessing specific treatment, there was 76% reduction in the incidence of postoperative sepsis in the probiotic group (RR-0.24 ;95% CI=0.12-0.50; p  <0.001) and a 32% reduction in sepsis in the synbiotic group compared to the control group. (RR-0.68; 95% CI, 0.51-0.92 p = 0.014).

Conclusion:
Perioperative probiotic and synbiotic therapy significantly reduces the likelihood of post-operative sepsis in elective GI surgical patients. The adoption of this strategy is encouraged to optimize gut microbiota modulation after elective GI surgery. Additional studies are required to optimize duration, dose, and types of pro- and prebiotic regimens which yield the greatest benefit.
 

11.09 Disparities In Mangement Of Patients With Colorectal Disease: Impact Of Urbanization And Specialised Care

Posted on December 22, 2014

V. Pandit1, B. Joseph1, H. Aziz1, M. Iyoob1, V. Nfonsam1  1University Of Arizona,Surgical Oncology/Surgery/Medicine,Tucson, AZ, USA

Introduction:

Disparities in the management of patients with various medical conditions is well established. Colorectal diseases continue to remain one of the most common causes for surgical intervention. The aim of this study was to assess disparities (rural versus urban) in the surgical management of patients with colorectal diseases. We hypothesized that there is no difference among rural versus urban centers in the surgical management for colorectal diseases. 

Methods:

We abstracted the national estimates for colorectal procedures from the National Inpatient Sample database 2011 (representing 20% of all in-patient admissions).  Patients undergoing procedures (abscess drainage, hemmoroidectomy, fistulectomy, and bowel resections) were included. Patients with colon cancer were excluded. Patients were divided into two groups based on location: Urban and rural. Outcome measures were: in-hospital complications, mortality, and hospital costs.  Sub-analysis of urban centers was preformed: centers with colorectal surgeons and centers without colorectal surgeons. Regression analysis was performed.

Results:

A total of 20,617 patients that underwent colorectal surgery intervention across 496 (Urban: 342, Rural: 154) centers were included. Of the urban centers, 38.3% centers had colorectal surgeons.  Patients managed in urban centers had lower complication rate (7.6% vs. 10.2%, p=0.042), shorter hospital length of stay (4.7±3.1 days vs. 5.9±3.6 days, p=0.037) with higher hospital costs (56,820±27,691 vs. 49,341±2,598, p=0.046).  On sub-analysis, patients managed in centers with colorectal surgeons had a 11% lower incidence of in-hospital complications (OR: 0.90, 95%CI: 0.74-0.94) and 7.2% (OR: 0.072, 95%CI: 0.65-0.81) shorter hospital length of stay in comparison to patients managed in urban centers without colorectal specialization. 

Conclusion:

Disparities exit in patient outcomes managed in urban verses rural centers for colorectal surgery. Specialized care with colorectal surgeons at urban centers helps to reduce adverse patient outcomes. Steps to provide effective and safe surgical care in a cost effective manner across rural as well as urban centers is warranted.

 

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