11.10 Is Patient Satisfaction an Accurate Predictor of Patient Outcomes?

Posted on December 22, 2014

M. Garg1, K. Hu1, C. Davian1, D. Polk1, A. Sugiyama1, E. Chin1, S. Nguyen1, S. Nguyen1, L. Zhang1, C. M. Divino1  1Icahn School Of Medicine At Mount Sinai,General Surgery,New York, NY, USA

Introduction:

Medical insurance companies and healthcare systems are increasingly adopting value-based purchasing. This practice involves shifting patient care towards high-quality providers and away from practitioners and systems with poor clinical outcomes. Patient satisfaction is commonly utilized as a metric to determine clinical quality for value-based purchasing assessments. However, the validity of patient satisfaction as a measure of clinical outcomes has yet to be properly investigated. Our study aims to find a correlation between patient outcomes and satisfaction after commonly performed general surgical procedures.

Methods:
After receiving institutional review board approval, we conducted a retrospective chart review on patients that underwent commonly performed general surgical procedures. We then collected patient satisfaction data using Short Form 12 (SF12) and Surgical Satisfaction surveys (SSQ). Using SPSS we conducted, receiver operating curves (ROCs) to see how patient satisfaction can be used to predict clinical outcomes. We used the presence of any complication to the total satisfaction scores.

Results:

A total of 80 surveys were completed. Our patient population consists of 37 (46.3%) females, 53 (66.3%) Caucasians, and 10 (12.5%) African Americans with an average age of 54.12 ± 15.5 years. Most common religious preference was Christians 24 (30%), and English is the primary language for 69 (86.3%). Median ASA is 2, average body mass index 28.16 ±9.29, 28.16 % patients suffered from hypertension. Other comorbidities in our patient population included Diabetes Mellitus 5 (6.3%), Asthma/COPD 11(13.8%), and documented psychiatric issues in 12 (15%) patients. The average length of stay in this patient population was 1.29 days ± 2.29. On ROCs we found that area under the curve for SSQ survey was 0.465 (p= 0.722), and for SF12 was 0.467 (p= 0.738). 

Conclusion:

Using two validated surveys our study found no correlation between patient satisfaction and surgical outcomes.

 

11.11 Predictors of Morbidity and Mortality in Ambulatory Surgery

Posted on December 22, 2014

D. R. Cummings1, M. Garg1, C. Divino1  1Icahn School Of Medicine At Mount Sinai,Department Of Surgery,New York, NY, USA

Introduction:

The volume of ambulatory surgical procedures is increasing on a yearly basis in the United States, exceeding an estimated 34 million outpatient surgeries in the year 2006. As the US population continues to age, the burden of surgical illness will continue to fall upon an older cohort, with an increase in attendant comorbidities and perioperative morbidity and mortality. This study seeks to elucidate patient specific risk factors for perioperative morbidity and mortality in the outpatient setting.

Methods:
A retrospective analysis of the 2011 NSQIP data was used for this study. The most frequent general surgical procedures categorized as outpatient were analyzed. Univariate analysis of demographic information, comorbidities and complications were calculated.  The outcome variables of interest were 30-day morbidity and mortality. Multivariable logistic regression analyses were performed to identify predictors of the outcome variables.

Results:
Out of 442,149 surgical procedures registered in the NSQIP 2011 database, 88,256 were included in this study.  40% of the population was male (n=35,852) and 77% Caucasian (n=67,598). The most frequently represented cases were laparoscopic cholecystectomy (n=11,451), inguinal hernia repair (n=9,936), partial mastectomy (n=5,957), umbilical hernia repair (n=5,753) and laparoscopic appendectomy (n=5,714). There were 1,924 cases with a morbid outcome and 48 deaths. The most significant predictors of morbidity were ASA class, operative time in hours, female gender, BMI (mean 29.4), and dialysis dependence (p<0.0001).  The most significant predictors of mortality were ASA class (p<0.0001), functional status (p=0.0125), male gender (0.0131), and emphysema (0.0213).

Conclusion:

This study highlights several risk factors for perioperative morbidity and mortality in the outpatient surgical setting.  More investigation is necessary to identify ways to optimize these patients for surgery. 

 

11.12 Who's Ordering the CT Anyway? Frequency of CT Scan Use in Suspected Acute Appendicitis

Posted on December 22, 2014

W. Boyan1, A. Dinallo1, B. Protyniak1, M. Farr2, M. Goldfarb1  1Monmouth Medical Center,Surgery,Long Branch, NJ, USA 2Saint George’s University,Grenada, Grenada, Grenada

Introduction: Historically, acute appendicitis has been a clinical diagnosis made primarily on the basis of history and physical findings. The typical history is onset of abdominal pain followed by anorexia and nausea. Physical exam findings include right lower quadrant tenderness. Using solely clinical and laboratory variables, the rate of negative appendectomies has been approximately 20%. With the advent of the high resolution multi-slice computed tomography (CT), the aforementioned rate is now reported to be 6-13%. However, this has led to a liberal use of imaging regardless of a convincing clinical exam. The implications of additional radiation exposure are still unclear. We sought to quantify the number of CTs obtained for patients with suspected acute appendicitis and to identify the ordering physician group.

Methods: This is a single institution retrospective chart review of all patients presenting to the emergency department with a working diagnosis of acute appendicitis between January 2011 and December 2012. Patient demographics, history of presenting illness, physical exam, whether or not a CT was obtained, and CT ordering physician were identified. CT ordering physicians were grouped into three categories: emergency medicine, surgery, and primary care. All positive CT findings were confirmed by final pathology.

Results: Two thousand five hundred patients comprised the study group. A CT was obtained in 2400 patients (96%), confirming acute appendicitis in 440 (18%). CT findings other than acute appendicitis were responsible for abdominal pain in 200 patients (8%). One thousand seven hundred and sixty patients (73%) with a negative CT for appendicitis were either discharged or admitted for supportive care.  Emergency medicine physicians accounted for the majority (75%) of those ordering CT scans.

Conclusion: Emergency medicine physicians, primary care practitioners and even surgeons have become dependent on CT scanning to diagnose acute appendicitis. Recent literature states that diagnostic imaging can significantly increase an individual’s risk of developing cancer. The majority of patients in our study with a suspected diagnosis of appendicitis underwent a CT scan and did not have appendicitis. Although CT scans may prevent unnecessary surgery, their liberal use has potentially worrisome implications of developing future malignancy

11.13 Mini-Lap With Adjunctive Care Vs. Laparoscopy for Placement of Gastric Electrical Stimulation

Posted on December 22, 2014

M. G. Hughes1, B. Cacchione1, E. Miller2, L. McElmurray2, R. Allen3, A. Stocker2, T. L. Abell2  1University Of Louisville,Surgery,Louisville, KY, USA 2University Of Louisville,Medicine,Louisville, KY, USA 3KentuckyOne Health,Anesthesiology,Louisville, KY, USA

Introduction:  We have previously shown that implant hospital length of stay (LOS) for gastric electrical stimulation (GES) implantation varies with type of surgery and peri-operative care (JSLS. 2005; 9:305-310).  We now compare outcomes for GES via mini-laparotomy with adjuctive care (MLAC) vs. laparoscopy alone (LAPA) to measure equivalency. 

Methods:  Patients were evaluated with baseline solid gastric emptying tests (GET) and underwent pre-operative temporary endoscopic GES (Am Surg 79(5):457-64) in both groups prior to permanent implant. Patients with MLAC had pre-operative transvere abdominus plane (TAP) block with bupivacaine liposome of the lower abdomen to cover the area of generator placement.  Laparotomy was typically performed through a 2.5 – 3.0 cm midline incision above the area covered by TAP block.  Retraction was provided by disposable wound protector (Alexis Wound Protractor/Retractor, Applied Medical, Racho Santa Margarita, CA) that typically lengthened the wound to approximately 4 – 5 cm.  Pain control system was placed in the pre-peritoneal abdominal wall to both sides of midline wound (On-Q Pain Buster Post-Op Pain Relief System, I-Flow LLC, Irvine, CA).  This delivered 750 cc of 0.2% ropivacaine at 10 cc/hour (approximately 3 days) and then was removed and discarded by patients after discharge.  Patients with LAPA were treated with a similar post-operative oral and intravenous analgesia regimen but no adjunctive care (TAP or pain control system). Health related quality of life (HRQOL) was measured by IDIOMS (NGM  2005; 17: 35-43) at baseline. Follow up GI symptoms were recorded at last follow up. Results were reported as median or mean ± standard deviation and were compared by Wilcoxon rank-sum test or students t-test, respectively.

Results:  39 patients (87% female, mean age 43 years) with the symptoms of gastroparesis underwent MLAC and were compared with 36 patients (92% f, mean 42 years) who had LAPA. We aimed to compare the equivalency of MLAC to LAPA approach in terms of baseline and outcome measures. Baseline GI symptom scores (for nausea, vomiting, anorexia/early satiety, bloating/distention, and abdominal pain), solid GET and HRQOL were similar between the 2 groups (p>0.05). Median implant length of stay was significantly shorter in MLAC (2.0 days) than LAPA (3.0 days; p=0.02).  Follow up GI symptoms (were equivalent in the two groups (p>0.05).  

Conclusion:  For implantation of gastric electrical stimulators in this group of patients with gastroparesis, mini-laparotomy is as effective in improving symptoms as laparoscopic implantation and can result in shorter lengths of stay when coupled with adjunctive measures to limit incision size and relieve pain.

 

11.14 Continuous versus interrupted fascial closure of midline laparotomy incisions. A meta-analysis

Posted on December 22, 2014

V. Chakravorty1,2, R. S. Chamberlain1,2,3  1Saint Barnabas Medical Center,Department Of Surgery,Livingston, NJ, USA 2St. George’s University School Of Medicine,St. George’s, St. George’s, Grenada 3New Jersey Medical School,Department Of Surgery,Newark, NJ, USA

Introduction: Although fascial closure of a midline incision is a part of nearly all abdominal operations, the “ideal” or “best” method remains controversial. Numerous randomized controlled trials (RCT) have evaluated different methods of fascial closure with regards to time required and complications, but lack of consensus leads most surgeons to be guided by experience, anecdote, and training. This meta-analysis critically analyzes all existing RCTs to establish an evidence based approach to fascial closure which limits complications (dehiscence, surgical site infection, and incisional hernia).

Method: A comprehensive search of PubMed, Google Scholar, and the Cochrane and NIH registry of clinical trials assessing continuous or interrupted fascial suture closure of a midline laparotomy was performed. Outcomes analyzed were fascial dehiscence, surgical site infection, incisional hernia development, and time required for closure.

Results: 15 studies involving 9,539 patients were identified. No significant difference in fascial dehiscence (p=0.801) or incisional hernia rates (p=0.407) were observed between continuous and interrupted fascial closure. Wound infection rates were significantly higher with continuous compared to interrupted technique (RR 1.248, CI 1.074 to1.45; p=0.004). Time required for wound closure was significantly lower with continuous (14.1 min) compared to interrupted closure (22.3 min) (Z=-4.119; p<0.001). Subgroup analysis identified that a significantly lower rate of fascial dehiscence occurred with non-absorbable suture placed in a continuous fashion (1.37%) than with interrupted absorbable suture (5.18%) (p=0.02). Subgroup analysis of wound infection and incisional hernia rates showed no significant difference between the 4 different suture techniques (absorbable/non-absorbable and continuous and interrupted).

Conclusion: Continuous fascial closure required significantly less time than interrupted suture technique. Dehiscence and incisional hernia rates were not significantly affected by suturing technique; however analysis of different suture material identified a clear advantage for continuous non-absorbable closure over interrupted absorbable closure. Delayed or non-absorbable suture material placed in a continuous fashion offers significant advantages in terms of time, dehiscence rate, and a slightly lower incisional hernia rate  (7.3% vs. 8.82%, p=NS), but a slightly higher wound infection rate (8.1% vs. 6.36%, p=NS) compared to absorbable interrupted suture. Additional studies controlling for wound classification, # of prior laparotomies, suture type/size, ASA class, and co-morbidities are required for more precise recommendations on optimal laparotomy fascial closure technique.

11.15 Preoperative Biliary Drainage for Obstructive Jaundice Does Not Improve Outcomes: A Meta-Analysis

Posted on December 22, 2014

K. Mahendraraj1, R. S. Chamberlain1,2,3  1Saint Barnabas Medical Center,Department Of Surgery,Livingston, NJ, USA 2New Jersey Medical School,Department Of Surgery,Newark, NJ, USA 3Saint George’s University,Department Of Surgery,Grenada, Grenada, Grenada

Introduction:
Preoperative biliary drainage (PBD) was initially introduced to improve the postoperative outcome in patients with obstructive jaundice caused by pancreatic head and periampullary tumors, yet its benefits remain uncertain.This meta-analysis aimed to assess the benefits and risks of routine PBD in patients with obstructive jaundice compared to immediate surgery. 

Methods:
A comprehensive search of PUBMED, Embase, and both the Cochrane and NIH Registry of Clinical Trials was conducted using the keywords ‘preoperative biliary drainage’, ‘obstructive jaundice’ and ‘randomized controlled trial (RCT)’. Citations of relevant review articles were examined. 25 potentially eligible studies were identified, of which 18 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. Data on patient recruitment, intervention and complications were extracted from the included trials and analyzed. ‘Overall’ complications were defined as those associated with PBD (including pancreatitis, bleeding and bowel perforation) in addition to postoperative complications (which included reoperation, readmissions, technical, infectious and hepatobiliary complications). The risk ratio (RR) was calculated with 95% confidence intervals. 

Results:
7 RCTs involving 548 patients with obstructive jaundice were analyzed. 279 patients (50.9%) were randomized to receive PBD while 269 patients (49.1%) proceeded directly to surgery. Overall morbidity was 30% higher in the PBD group, although this difference was not statistically significant (RR 1.3, 95% CI 0.97-1.75; p=0.08). Overall postoperative morbidity was 6% lower with PBD, but not statistically significant (RR 0.94, 95% CI 0.74-1.20; p=0.62). Overall mortality was 10% higher in the preoperative biliary drainage group, but this finding was not significant (RR 1.1, 95% CI 0.72-1.68; p=0.65). Significant heterogeneity was found among the identified trials with regard to the definition and severity of complications, as well as the precise timing of PBD.

Conclusion:
The routine use of PBD in patients with obstructive jaundice did not significantly reduce overall complication rates or perioperative mortality. Current evidence suggests routine PBD does not improve patient outcomes. Further clarification of the effects of PBD is required in large, adequately powered randomized trials with low risk of bias.
 

11.16 Identifying Risk Factors for Complications Following Ventral Hernia Repair in the Elderly Patient

Posted on December 22, 2014

E. Ohlrogge1, K. O’Connell1, T. Webb1  1Medical College Of Wisconsin,Trauma/Critical Care,Milwaukee, WI, USA

Introduction: The aging population is on the rise in the United States, and general surgeons are increasingly operating on geriatric patients for repair of ventral hernias. This study investigates the risk factors associated with complications following both laparoscopic and open ventral hernia repairs in elderly patients. Specifically, we were interested if frailty markers predicted poorer outcomes.

Methods: This is a retrospective review of patients 65 years and older who underwent ventral hernia repair at a single institution from July 1 2004 to June 1, 2014. Patient demographics, comorbidities, frailty markers, and perioperative factors were analyzed. 

Results:The cohort consisted of seventy-three patients, of which 32 (43%) were performed laparoscopically and 41 (56%) were open ventral hernia repairs. 8 (11%) were emergent cases, and only 2 (25%) of these were completed laparoscopically. Overall, 23 (31%) patients developed post-operative complications, 11 (47%) following laparoscopic repairs and 12 (52%) following open repairs. The most common complications were urinary tract infections, wound complications, and early post-operative small bowel obstructions. Frailty markers were not associated with post operative complications; however, a history of heart disease (p=0.04), obesity (p=0.04), and prior percutaneous coronary intervention PCI (p=0.05) did predict complications. There were no deaths in the post-operative period.

Conclusion:This study suggests that laparoscopic ventral hernia repair in elderly patients is at least as safe as the traditional open approach and complications are common with either approach. Furthermore, history of heart disease, obesity, and PCI, but not currently used frailty markers predispose aging patients to post-operative complications following either laparoscopic or open ventral hernia repair. 

 

11.17 Pre-operative Oral Carbohydrate Supplementation Improves Clinical Outcomes: A Meta-analysis.

Posted on December 22, 2014

T. K. Woleston1,3, R. S. Chamberlain1,2,3  1Saint Barnabas Medical Center,Department Of Surgery,Livingston, NJ, USA 2Rutgers Univsersity,Department Of Surgery,Newark, NJ, USA 3St. George’s University School Of Medicine,St. George’s, ST. GEORGE’S, Grenada

Introduction: Preoperative fasting is an accepted precaution for patients undergoing surgery and is intended to prevent aspiration of gastric contents while under anesthesia. Surgery while in a fasting state can lead to increased metabolic stress and increased morbidity and mortality. Preoperative oral carbohydrate (OCH) supplementation has been proposed to decrease postoperative complications and improve clinical outcomes, however studies to date have produced inconsistent findings. This meta-analysis critically analyzes existing randomized controlled trials (RCTs) to establish an evidence-based perspective on preoperative OCH supplementation and its effect on length of stay, postoperative nausea/vomiting, insulin resistance, and post-operative complications.

Methods: A comprehensive search of PubMed, Google Scholar, and both the Cochrane and NIH Central Registry of Controlled Trials was completed (1990 – 2014). 15 RCTs were identified involving non-diabetic adult subjects undergoing elective surgery receiving a preoperative OCH dose greater than 25g or placebo/no therapy. Length of stay (LOS), postoperative nausea/vomiting, insulin resistance, and postoperative complications (including infection, wound dehiscence, anastomotic leak, atrial fibrillation, pneumonia, and ileus) were the outcomes assessed.

Results: 15 RCTs involving 1,380 patients were included in this meta-analysis. 605 subjects received preoperative OCH supplementation and 775 received traditional preoperative fasting or calorie-free placebo. OCH use decreased LOS by 1.8 days (6.9 vs. 8.7 days, p=0.026).  There was no significant decrease in the risk of postoperative complications (p=0.157), or postoperative nausea/vomiting (p=0.485).  The homeostatic model assessment for insulin resistance (HOMA-IR) value was 4.8% higher (2.44 vs. 2.30, p=0.009) in the OCH group than the control group preoperatively, however the postoperative day 1 values were not significantly different (p=0.6665).

Conclusions: Preoperative OCH supplementation is associated with a significant decrease in LOS when compared to fasting, and is comparable regarding postoperative complications. Preoperative caloric loading should be considered in all patients undergoing prolonged surgical procedures and may be superior to current practice. Additional well-designed large scale RCTs are required to evaluate ideal dose and timing of OCH, associated risks, and which procedures are most likely to benefit from OCH loading.

 

11.18 OBESITY IS A PREDICTOR OF BILE DUCT INJURIES

Posted on December 22, 2014

H. Aziz1, T. Jie1, V. Nfonsam1  1University Of Arizona,Tucson, AZ, USA

INTRODUCTION

Iatrogenic bile duct injury is a serious complication of cholecystectomy. The aim of this study was to assess predictors of bile duct injury using a national database.

METHODS

The Nationwide Inpatient Sample (2010-2012) was queried for cholecystectomy. We used a) diagnoses for bile duct injury and b) bile duct injury repair procedure codes as a surrogate marker for bile duct injuries.

RESULTS

A total of 316 patients had bile duct injury. The mean age was 58.2 ± 19.7 years, 53.5% were males, and median Charlson co-morbidity score was 2 [2-3]. Univariate analysis revealed age (p- < 0.001), male gender (p- 0.004), morbid obesity (p- 0.001), and teaching hospital status (p-0.021) to be associated with CBD injury. Multivariate analysis revealed morbid obesity (2.8[2.1-4.3]; p-0.03) as the independent predictors for bile duct injury in patients undergoing cholecystectomy.

CONCLUSION

Our study finds a new association between obesity and bile duct injuries which has never been reported in literature before. The effect of obesity on outcomes in biliary surgery needs prospective evaluation.

11.19 Study of routine upper gastrointestinal study to evaluate for leak after roux-en-Y gastric bypass

Posted on December 22, 2014

S. Gambhir1, P. Yenumula1, C. Moon1, P. Haan1, S. Kavuturu1  1Michigan State University,Surgery,Lansign, MI, USA

Introduction:  Routine Upper Gastrointestinal (UGI) x-ray use after laparoscopic Roux-en-y gastric bypass (LRYGB) is still practiced by many bariatric surgeons in order to investigate for anastomotic leaks.We present our experience with a large retrospective review of gastric bypass surgeries studying the usefulness of a routine drain placement. 

Methods:  Retrospective record of all patients undergoing LRYGB from September 2006 to November 2011 was performed. As we changed our practice in December 2009, we have two comparable groups; one with a routine UGI x-ray completed after surgery and one UGI was done selectively based on clinical suspicion and patient symptoms. A total of 613 LRYGBs were performed during the study period, the first 301 were routine UGI x-ray and the subsequent 312 without routine UGI x-ray. Demographics were statistically similar between the two groups.  

Results:There were 3 leaks in the routine UGI group (1%) and 5 leaks in the selective UGI group (1.6%)  (p >0.05). In the Routine UGI group, the sensitivity and specificity of the UGI to detect a leak are 25% and 99.7% respectively. Where as in the selective UGI group, the sensitivity and specificity of the UGI to detect a leak are 50% and 99.7% respectively. Clinical suspicion has a sensitivity and specificity of 100% and 99.3% in the routine UGI group, and 100% and 97.4% in the selective UGI group.

Conclusion: There is no difference in the leak rate or morbidity with routine use of UGI after a laparoscopic gastric bypass. Change in clinical parameters can accurately diagnose a patient with ongoing anastomotic leak. Selective use of UGI based on clinical suspicion for a leak is prudent and economically efficient.
 

11.20 Nutritional And Psychiatric Weight Loss Predictors Following Bariatric Surgery

Posted on December 22, 2014

B. T. Fox1, E. Y. Chen1, A. Suzo2, S. A. Jolles1, J. A. Greenberg1, G. M. Campos1, M. J. Garren1, C. I. Voils3,4, L. M. Funk1  3Center For Health Services Research In Primary Care,Department Of Veterans Affairs,Durham, NC, USA 4Duke University Medical Center,Department Of Medicine,Durham, NC, USA 1University Of Wisconsin,Department Of Surgery,Madison, WI, USA 2Ohio State University,Department Of Surgery,Columbus, OH, USA

Introduction

Identifying morbidly obese patients who will succeed following bariatric surgery remains challenging. While numerous studies have focused on preoperative factors associated with weight loss following bariatric surgery, the critical nutritional and psychological characteristics remain unclear. The purpose of this study was to measure the association between preoperative nutritional and psychological characteristics and the likelihood of successful weight loss among bariatric patients.

Methods

Our study is a retrospective cohort study of all patients who underwent primary laparoscopic Roux-en-Y gastric bypass from September 1, 2011 to June 1, 2013 at the University of Wisconsin Hospital and Clinics (124 patients). Patient demographics, comorbidities, nutritional and psychological factors, and excess weight loss were collected from the electronic medical record. “Successful” weight loss was defined as loss of ≥ 50% of excess body weight one year after surgery.  To evaluate bivariate associations between predictors and successful weight loss, Fisher’s exact and student’s T-tests were used for categorical and continuous variables, respectively. Variables significant (p<.05) in bivariate analyses were included in a multivariable logistic regression model with successful weight loss as the outcome.

Results

78% (n=97) of patients had at least one year of follow-up data and were included in analyses. Of those, 69% (67) experienced successful weight loss. Mean excess body weight loss was 69.0% (+/- 16.6%) for these patients vs. 39.0% (+/- 9.4%) for patients with suboptimal weight loss (p=0.01). In bivariate analyses, successful weight loss was associated with lower preoperative weight (268.1 vs. 301.4 lbs, p=0.02), a lower maximum past weight loss attempt (40.0 vs. 65.6 lbs, p=0.01), no diabetes history (81.4% of non-diabetics vs. 59.3% of diabetics were successful, p=0.03), being able to quit soda consumption before surgery (81.8% who quit vs. 59.3% with unchanged drinking habits were successful, p=0.04) and greater autonomy (mean percentile rank of 68.7% in successful vs. 38.8% in unsuccessful patients, p=0.01). On multivariate analysis, diabetes and a past weight loss > 50 lbs were inversely associated with success (Table 1).

Conclusion

Dietary habits and psychological characteristics were not associated with weight loss success after adjusting for measurable confounders. Identification of predictive dietary and psychological variables for patients in our program remains elusive. Diabetic patients warrant especially close follow-up after surgery given their propensity to experience suboptimal weight loss.

12.01 Variability In Same Day Discharge For Pediatric Appendicitis: An Analysis Of The KID database

Posted on December 22, 2014

T. A. Oyetunji1, E. M. Knott1, A. Desai1, B. Dalton1, K. W. Schnell1, J. J. Dehmer1, P. Aguayo1, B. C. Nwomeh2  1Children’s Mercy Hospital- University Of Missouri Kansas City,Surgery,Kansas City, MO, USA 2Nationwide Children’s Hospital,Columbus, OH, USA

Introduction:
Recent single institutional data point to the feasibility of same day discharge (SDD) after appendectomy for non-perforated appendicitis and its potential as a quality indicator of care. Also the opportunities for SDD are greatest the sooner the appendectomy is performed after admission.  We examine a national database to assess the pattern of utilization of SDD among children that had an appendectomy on the same day.

Methods:
The 2009 Kids Inpatient Database (KID) was queried for children with a diagnosis of acute appendicitis. All perforated appendicitis and those with no procedure code for open or laparoscopic appendectomy were excluded.  Day from admission to procedure day and total length of stay (LOS) were then analyzed by demographics, type of procedure (laparoscopic vs. open), children’s hospital designation and hospital region. After stratifying all patients udergoing appendectomy on day of admission into 2 groups by LOS (<=1 day vs. >1 day), a multivariate analysis was this subset to determine the predictors of prolonged LOS (>1day).

Results:
A total of 51,133 records, representing a weighed estimate of 73,956 patients with a diagnosis of non perforated appendicitis were analyzed of which 76% met the inclusion criteria of admission day appendectomy. Median age was 14 yrs with inter-quartile range (IQR) of 10- 17yrs. Median LOS was 1 day (IQR  1-2 days) and the majority (71.8%), had laparoscopic appendectomy. On adjusted analysis, laparoscopic cases were 50% less likely to be discharged later compared to their open counterparts (OR 0.50, 95% CI 0.47-0.53).  Compared to Whites, significantly more Hispanics (OR 1.44, 95% CI 1.36-1.56) and African Americans (OR 1.57, 95% CI 1.42-1.73) had a LOS > 1 day.  Table 1 shows the SDD rates based on children’s hospital designation and hospital region. 

Conclusion:
SDD is increasingly utilized for children with non-perforated appendicitis, but there is significant variability in the utilization of SDD for different ethnicities and hospital regions. Also, these data demonstrate that SDD is more likely to occur the sooner an appendectomy is performed after admission for non-perforated appendicitis. Further research is still required.
 

12.02 Pediatric Lung Malformations: Resource Utilization and Outcomes following Resection.

Posted on December 22, 2014

J. Tashiro1, J. E. Sola1, H. L. Neville1, A. R. Hogan1, E. A. Perez1  1University Of Miami,Division Of Pediatric Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA

Introduction: Congenital Cystic Adenomatoid Malformation (CCAM) and Pulmonary Hypoplasia/Sequestration (H/S) are rare lung malformations.

Methods: Kids’ Inpatient Database (1997-2009) was used to identify all CCAM and H/S patients undergoing resection. Cases were analyzed using standard and multivariate regression methods. Open and thoracoscopic CCAM resections were compared using propensity score-matched analysis (PSMA).

Results: Overall, 1,548 cases comprised the cohort (CCAM 56%, H/S 40%, both 4%). Survival was 97%. Average length of stay (LOS) decreased, while total charges (TC) increased during the study period (p<0.001). Mean age at admission was 2.2 years. CCAM had 1.4% mortality with self-pay, lowest income quartile patients, and small bedsize hospitals having higher mortality (p<0.05). H/S had 4.6% mortality with rural hospitals having higher mortality vs urban teaching hospitals, p=0.027. When pooled, survival, pneumothorax (PTX), and thoracoscopic procedure rates were higher in children having resection at ≥3 vs <3 months of age (p<0.001). Transfusion rates and LOS however, were lower in patients ≥3 vs <3 months of age (p<0.001), whereas lobectomy rates were unchanged. Analysis for ≥6 vs <6 months of age produced similar results. On multivariate analysis of the cohort, LOS was shorter in children’s general hospitals (CGH) and non-children’s hospitals (NCH) vs children’s units in general hospitals (CUGH), p<0.05. LOS was longer for older patients, those with Medicaid, and those admitted in Midwestern and Southern U.S. (all p<0.001) and for CCAM (p=0.006). TC were lower for the 2nd/3rd income quartile, but higher for Western U.S. (p<0.004) and Medicaid patients (p=0.015). Small and medium bedsize hospitals had higher mortality vs large hospitals, p<0.005. NCH and CGH had higher survival vs CUGH, p<0.04. Segmentectomy and lobectomy patients had improved survival (p<0.02), while pneumonectomy patients had higher mortality (p<0.025). PSMA for thoracoscopy vs thoracotomy in CCAM patients showed no difference in LOS, disposition, TC, resection type, or transfusion / PTX rates.

Conclusion: Surgery for CCAM and H/S has high associated survival. When analyzed by age at resection, children <3 months of age had higher mortality, thoracotomy, and transfusion rates vs those ≥3 months, though PTX were more common ≥3 months. Socioeconomic status, age, diagnosis, hospital type, and region were independent indicators for resource utilization. Hospital bed size, type, and extent of resection were independent prognostic indicators for survival. On PSMA thoracoscopic resection does not affect resource utilization, disposition, or transfusion / PTX rates.

12.03 Cost and Utilization Varies with Procedure Type in Pediatric Gastrointestinal Foreign Bodies.

Posted on December 22, 2014

J. Tashiro1, R. S. Kennedy1, E. A. Perez1, F. Mendoza2, J. E. Sola1  1University Of Miami,Division Of Pediatric Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA 2Baptist Children’s Hospital,Children’s Emergency Center,Miami, FL, USA

Introduction: In the pediatric population, ingested foreign bodies are a common cause for emergency department visits. While esophageal foreign bodies may require immediate intervention, gastrointestinal foreign bodies (GIFB) have distinct factors contributing to longer and more costly hospitalizations.

Methods: Patients with ingested foreign bodies were identified using ICD-9-CM 935.2, 936, 937, 938 within the Kids’ Inpatient Database (1997-2009). Ordinal logistic regression models were used to identify predictors of resource utilization. Esophageal ingested foreign bodies (935.1) were excluded from this cohort. Cases were weighted to project national estimates.

Results: Overall, 7,480 cases were identified. Most GIFB patients were ≥5 years of age (56%), male (54%), and Caucasian (57%) with a median (IQR) length of stay (LOS) 2 (3) days, and total charges (TC) 9,295 (14,049). A total of 2,506 procedures were performed, most commonly GI surgery (56%) followed by GI endoscopy (24%), esophagoscopy (11%), and bronchoscopy (9%). A total of 5,110 patients (68% of the cohort) did not have surgery or endoscopy and were not transferred. Psychiatric/cognitive disorders (18%) and self-inflicted/suicidal (5%) were the most common diagnoses. Intestinal perforation (1%) was rare, but intestinal obstruction (5%) was more common.

On multivariate analysis, LOS increased when cases were associated with psychiatric/cognitive disorder (OR=1.9), self-inflicted/suicidal (OR=1.6), intestinal obstruction (OR=1.7), esophageal perforation (OR=40.0), intestinal perforation (OR=4.4), exploratory laparotomy (OR=1.9), and gastric (OR=2.9), small bowel (OR=1.5), or colon surgery (OR=2.5), all p<0.02. Children admitted to hospitals in the Western U.S. had the lowest LOS vs. all other regions, while small bedsize hospitals had higher LOS (OR=1.4), p<0.05.

Higher TC were associated with intestinal obstruction (OR=2.0), endoscopy of esophagus (OR=1.8), stomach (OR=2.1), or colon (OR=3.3), and exploratory laparotomy (OR=3.6) or surgery of stomach (OR=5.6), small bowel (OR=6.4), or colon (OR=3.4), all p<0.001. Hospital mortality was 0.06% (n=5). Western U.S. hospitals had the highest TC vs. all other regions, while small bedsize hospitals had lower TC (OR=0.7), p<0.001.

Conclusion: GIFB affect older children and most do not require surgery or endoscopy. Associated psychiatric disorder or intent to self-harm is seen in over 20% GIFB patients, and surgical or endoscopic procedures are needed in one third of cases. Nevertheless, resource utilization is determined heavily by associated diagnoses and treatment procedures.

12.04 Helicopter Transport in Pediatric Trauma Patients: Are There Improved Outcomes?

Posted on December 22, 2014

S. M. Farach1, L. Bendure1, P. D. Danielson1, E. Amankwah2, N. M. Chandler1, N. E. Walford1  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:  Studies have shown that survival after trauma is improved by the timely transfer of injured patients to a trauma center. There is conflicting data to support the routine use of helicopter transport for trauma patients. The purpose of this study is to evaluate outcomes for trauma patients transported via helicopter to a regional pediatric trauma center.

Methods:  The institutional trauma registry was queried for all trauma patients presenting from January 2000 through March 2012. Of 9119 patients, 1709 patients who presented from the scene were selected for further evaluation. This cohort was stratified into helicopter transport (HT) versus ground transport (GT) for analysis. Significance was defined at p ≤ 0.05.

Results: Table 1 describes select demographic and outcomes data between the groups. There were no differences between the groups with regards to age or gender. Patients arriving by HT had a higher injury severity score (ISS), lower Glasgow Coma Scale (GCS), were less likely to undergo surgery within 24 hours, were more likely to present after motorized trauma, and had longer intensive care unit (ICU) and hospital length of stay.  When controlled for ISS, patients arriving by HT had a higher rate of pre-hospital intubation, had significantly higher ICU admissions, and longer hospital length of stay. There was no difference in 30 day mortality compared to patients arriving by GT. Patients presenting from less than 20 miles were more likely to arrive by GT while those presenting from distances greater than 20 miles were more likely to arrive by HT. When controlled for ISS, there was no significant difference noted from time of injury to hospital arrival between the two transport groups at distances less than 40 miles. 

Conclusion: In distances less than 40 miles, transport to the trauma center was not improved by HT. While patients arriving by helicopter are more severely injured and arrive from greater distances, when controlling for ISS, there is no difference in mortality when compared to patients arriving by ground transport.

 

12.05 Timing of Post-Op CT Scans for Abscess in Children with Complicated Appendicitis

Posted on December 22, 2014

J. W. Nielsen1, K. Kurtovic1, B. Kenney1, K. Diefenbach1  1Nationwide Children’s Hospital,Division Of Pediatric Surgery,Columbus, OH, USA

Introduction:   Appendicitis is a common surgical problem in pediatric patients.  Many pediatric patients present to the hospital with gangrenous or ruptured appendicitis and despite surgical and medical management they form intra-abdominal abscesses with associated morbidity.  Although some have suggested that imaging for patients with suspected abscess be delayed until one week the optimal timing is a subject of debate.

Methods:   Our institutional pediatric appendicitis database was reviewed for all complex appendicitis patients (ruptured or gangrenous) who were not discharged before post-op day (POD) #5 from April 2012 to February 2014.  Patients were stratified into 2 groups: those who had a CT scan before POD #7 (Group 1, n=23) and those who did not (Group 2, n=109).   Patients who did not have a CT scan before POD #7 were further stratified into those who were afebrile (<37.5° Celsius)(Group 2a, n=68) or febrile (Group 2b, n=41) at POD #5.  Outcomes including abscess formation, number of additional CT scans, and culture data were compared.

Results: A total of 133 patients were identified who were not discharged before POD #5.  The majority of patients were male (54%) with a mean age of 10.1 years.  The drainage rate was higher for patients who underwent early CT scans: Group 1, 69.6% vs. Group 2b 42.1%, p=0.07.  No difference was found in the rate of culture positivity between Group 1 and Group 2b (73.3% vs. 72.7%, p=1.0).  Of the 23 patients in Group 1 who underwent CT scanning early, 5 patients ended up getting 2 additional CT scans compared to only 4 patients in Group 2b who got 1 additional scan each.  Twenty one of the 41 (51.2%) patients who were still febrile after POD #5 in Group 2b had a resolution of symptoms with antibiotics alone and did not need scanning or drainage.  The 68 patients in Group 2a who were afebrile but still admitted to the hospital due to other symptoms were all discharged with a resolution of symptoms without CT scanning.  In total, 89 of the 109 (81.6%) patients in Group 2 had a resolution of symptoms prior to discharge without needing a CT scan or drainage procedure with readmission of only 3 patients (3.4%) for subsequent abscess development.

Conclusions: CT scanning post-operative appendectomy patients earlier than POD #7 was associated with a higher number of repeat CT scans and an increased number of drainage procedures.  The vast majority of complex appendicitis patients who were still admitted at POD #5 had a resolution of fevers or other symptoms without CT scanning or drainage procedures and they had a low readmission rate.  Our results suggest important patient benefits in decreased CT scans and avoidance of unnecessary procedures from waiting until POD #7 or later before performing a CT scan to look for an abscess.

12.06 Histrelin Implant Treatment of Central Precocious Puberty: A Single Center Experience

Posted on December 22, 2014

S. F. Rosati1, D. Parrish1, J. Haynes2, K. Brown3, M. Poppe3, D. Lanning2  2Virginia Commonwealth University,Division Of Pediatric Surgery,Richmond, VA, USA 3Virginia Commonwealth University,School Of Medicine,Richmond, VA, USA 1Virginia Commonwealth University,Department Of General Surgery,Richmond, VA, USA

Introduction:
 

Precocious puberty is defined as the onset of secondary sexual characteristics before the age of 8 in girls and the age of 9 in boys and is associated with an increase in linear growth velocity, acceleration of bone maturation, and  can result in early epiphyseal closure if untreated. The most common cause of precocious puberty is idiopathic central precocious puberty (CPP), traditionally treated with monthly injections of depot parenteral preparations of gonadotropin-releasing hormone agonists (GnRHa). An alternative treatment is a subcutaneous implant that contains histrelin acetate, which is continuously released over one year; it is then removed or replaced with a new implant.  The aim of this study was to conduct a retrospective review of one surgeon’s experience with the histrelin implant and to examine patient satisfaction in follow-up.    

Methods:
 

After obtaining IRB approval, we conducted a retrospective review of one surgeon’s patients with CPP treated with the histrelin implant. Additionally, parents were contacted by telephone to gather satisfaction with respect to post-operative pain, cosmesis, preference to depot injections, and effectiveness.

Results:
 

Fifty-eight children, average age 8.4 years old (range 7-14) underwent at least one histrelin implant insertion for treatment of CPP. Telephone follow was achieved in 44. All 44 children received local analgesia at implantation; 32 also received conscious sedation.    Thirty-nine children (89%) had at least one implant replacement. Eight children (18%) received injections before undergoing implant insertion; the majority of the parents (88%) preferred the implant.   On average, parents’ satisfaction with the insertion of the implant rated 9.5 on a scale of 1-10 with 10 being most satisfied; parents’ satisfaction with replacement of the implant was also rated highly at 9.5.   The patients’ discomfort after initial surgical insertion was rated on average 3.9 with 10 being the most discomfort (range 1-6); discomfort after replacement and removal was even lower at 2.3 and 2.7, respectively.   Almost all of the parents (95%) stated that they would agree to have their child undergo surgical implantation again, and the majority of children (93%) returned to baseline function within 24 hours.   Parents rated the cosmetic appearance of the scar after surgery on average at 9.1.  There were no surgical complications with the placement, replacement, or removal of the implant.

Conclusion:
 

This study suggests that the using a histrelin subcutaneous implant for control of CPP provides a safe and effective method that, according to parents, is associated with minimal discomfort, allows for a quick return to normal function and activity, and is a preferred method of treating CPP when compared to depot injections in our limited subset analysis.
 

12.07 Surgical Management of Bronchopulmonary Malformations: Comparing Thoracoscopic and Open Approaches.

Posted on December 22, 2014

J. Tashiro1, A. Wagenaar1, A. C. Hirzel2, L. I. Rodriguez3, E. A. Perez1, A. R. Hogan1, H. L. Neville1, J. E. Sola1  1University Of Miami,Division Of Pediatric Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA 2University Of Miami,Department Of Pathology,Miami, FL, USA 3University Of Miami,Department Of Anesthesiology,Miami, FL, USA

Introduction: Bronchopulmonary Malformations (BPM) are rare conditions affecting the pediatric population. The spectrum of BPM encompasses congenital cystic adenomatoid malformation (CCAM), pulmonary sequestration (PS), congenital lobar emphysema (CLE), bronchogenic cyst (BC), and hybrid lesions. These focal anatomic anomalies typically arise below the carina and can result in significant morbidity (infection/hemorrhage) and mortality (respiratory failure).

Methods: After IRB approval, all children with BPM surgically treated from 2001-2014 at a tertiary care children’s hospital were identified. Patient demographics, surgical indications, procedure type, estimated blood loss (EBL), pathology, perioperative complications, length of stay (LOS), and outcomes were analyzed using standard statistical methods.

Results: Overall, 41 patients with BPM had surgery (39 thoracic/ 2 abdominal) over the study period (CCAM 19, PS 8, CCAM/PS hybrid 6, CLE 6, BC 5). Our cohort was 51% male with a median age (IQR) at resection of 11 (19) months, weight of 9.1 (5.1) kg. Overall survival was 98% (one CDH/ECMO abdominal BPM expired) but 100% for thoracic lesions. Analysis of thoracic lesions revealed a median (IQR) operative time of 140 (45) minutes, EBL 1.47 (1.90) ml/kg, chest tube (CT) days 4 (4), LOS 5 (5) days, and a complication rate of 26% (21% pulmonary). The left and right lower lobes were most commonly resected (39% and 24%, respectively) and 27% of lesions had a systemic artery. Resections were performed thoracoscopically (38%), thoracoscopy converted to open (23%), and via thoracotomy (38%). Conversions to thoracotomy were due to poor visualization (66%) or inability to tolerate single lung ventilation (33%). There were no conversions due to hemorrhage or blood transfusions in thoracoscopy patients. Patients undergoing thoracoscopic surgery were more likely to have a prenatally diagnosed BPM (OR: 18.2) v. open/converted, p=0.002. Open/converted surgery patients had longer CT days (6.2) vs. thoracoscopic (2.9), p=0.048. BPM with a systemic artery (PS/hybrid) were more commonly resected thoracoscopically (OR: 6.1) than open, p=0.047. Additionally, respiratory distress was a more common indication in patients <4 months old (OR: 28.0) vs. ≥4 months, and patients weighing <6 kg (OR: 40.5) vs. ≥6 kg, p<0.05. Similarly, procedures were started as open resections at a higher rate in patients <4 months old (OR: 8.8) and weighing <6 kg (OR: 24.0) vs. ≥4 months and ≥6 kg, respectively, p<0.05. Operative time was lower for <6 kg vs. ≥6 kg, p=0.035.

Conclusion: BPM resections are procedures with high overall survival over a 14-year experience at a large tertiary care children’s hospital. Chest tube days are shorter among thoracoscopic patients but conversion to thoracotomy for poor visualization avoids hemorrhage and need for transfusion. Size and respiratory distress limit use of thoracoscopy in young infants with BPM.

12.08 Pectus Excavatum-To Randomize or Not To Randomize

Posted on December 22, 2014

B. G. Dalton1, K. W. Schnell1, A. A. Desai1, S. W. Sharp1, S. D. St. Peter1  1Children’s Mercy Hospital- University Of Missouri Kansas City,Pediatric Surgery,Kansas City, MO, USA

Introduction:  Minimally invasive bar repair for pectus patients produces substantial pain which dictates the post-operative hospital course.  We conducted a randomized trial comparing epidural catheter placement to patient controlled analgesia and second trial comparing these 2 strategies is under way.  The purpose of this study was to compare the outcomes of patients who were enrolled in the trials to those did not participate in the trials. 

Methods:  A retrospective chart review was performed on patients not enrolled in the trials to compare to the prospective datasets from October 2006 to June 2014.  Perioperative outcomes including length of stay (LOS), pain scores, time to PO diet, operative time and complication rate were examined.  Pain scores were calculated with a visual analog system (VAS).  Findings are reported in mean ± standard deviations.  Comparative analysis was performed using student t test

Results: There were 135 patients in a study protocol (IS) and 195 patients that were not enrolled in a study (OS).  Of the IS patients, 23.4% (n=15 of 64) had epidural failure for pain control compared to 45.9% (n=17 of 37) of OS patients (p<0.01).  In the PCA groups LOS was less in the IS group vs OS group (4.5d vs 4.1d, p=0.02).  Comparing the entire IS and OS groups, LOS was less in the IS group, as was time to PO diet. Average pain scores, operative time and complication rates, including bar malposition, bar infection and wound infection, were not significantly different between the groups (table).

Conclusion: 

There are clear clinical benefits derived from participating in our randomized trials comparing epidural to patient controlled analgesia after bar placement for pectus excavatum regardless of which arm is utilized.  

 

12.09 Same Day Discharge of Pediatric Laparoscopic Cholecystectomy Patients

Posted on December 22, 2014

B. G. Dalton1, K. W. Schnell1, E. M. Knott1, S. D. St. Peter1, P. Aguayo1  1Children’s Mercy Hospital- University Of Missouri Kansas City,Pediatric Surgery,Kansas City, MO, USA

Introduction:  Although historically thought to be a fairly uncommon problem in the pediatric population, gallbladder disease, symptomatic cholelithiasis (SC) and biliary dyskinesia (BD) in particular, is being increasingly diagnosed in the pediatric population.  In the United States, the accepted surgical approach for symptomatic gallbladder disease in both adults and in children has been laparoscopy.  While the safety of same day discharge (SDD) after laparoscopic cholecystectomy (LC) in adults has been well documented in the literature, the same data in the pediatric population is lacking.  We have recently instituted a protocol for SDD after LC for SC and BD and this study is an analysis of our initial experience.  

Methods:  A retrospective chart review of all patients who underwent laparoscopic cholecystectomy for BD and SC in our institution from January 2011 to July 2014 was performed. Time from operation to discharge, reason for overnight stay, complications, readmissions, and follow-up prior to scheduled appointment were analyzed. The Student t test was used for statistical analysis. 

Results: A total of 227 laparoscopic cholecystectomies were performed for SC and BD during the study period.  Approximately 25% (n=57) of patients were discharged on the day of surgery.  The remaining 75% (n=170) of patients were admitted at least one night for the following reasons:  medical 16.5% (n=28), surgery ending too late 4.1% (n=7) or clinical care habits 79.4% (n=135).   Comparing patients that were discharged the same day with patients that stayed overnight, no differences were found in complication rate (3.5% vs 5.8%, P=0.44), readmissions (5.3% vs 1%, P=0.12) or follow up prior to scheduled appointment (3.5% vs 2.9%, P=0.84).  Length of stay was significantly less for the SDD group than the inpatient group (4.1h vs 26.8h, p<.01).   A trend for more SDDs was observed as time elapsed from initiation of the protocol.  From January 2013 (the month of the first SDD) through September 2013, 34% (18/53) of pts undergoing LC  were discharged the same day.  October 2013 through July 2014, 55% (36/69) of patients were sent home the same day.  Also, earlier completion of surgery trended toward SDD (figure).

Conclusion:  Same day discharge appears safe for pediatric patients undergoing laparoscopic cholecystectomy for BD or SC.  The main obstacles to discharge were time of surgery completion and clinical care habits, both of which improved as comfort level with SDD grew among the staff.

 

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