6.16 Continous Non-Invasive Assessment of Hemoglobin and Fluid Responsiveness in Obesity and Laparoscopy

Posted on December 22, 2014

M. D. DeBarros1, M. W. Causey1, P. Chesley1, M. Martin1,2  1Madigan Army Medical Center,Department Of General Surgery,Tacoma, WA, USA 2Oregon Health And Science University,Department Of Trauma And Critical Care,Portland, OR, USA

Introduction: During surgery, proper fluid resuscitation and hemostatic control is critical.  Pleth variability index (PVI) is advocated as an accurate means of optimizing intraoperative fluid resuscitation.  PVI is a measure of dynamic change in perfusion index during a complete respiratory cycle.  Non-invasive monitoring of total hemoglobin could provide an accurate means to determine the need for transfusion. We analyzed the impact of insufflation and obesity on non-invasive measurements of hemoglobin and PVI in laparoscopic procedures to validate its usefulness in assessing fluid responsiveness and hemoglobin levels.

Methods: A non-invasive hemoglobin and PVI monitoring device was prospectively analyzed in patients undergoing abdominal operations.   Patients were stratified by open and laparoscopic approach and obesity (BMI≥35).  PVI and hemoglobin values were assessed before, during, and after abdominal insufflation and compared to control patients undergoing open surgery.

Results: 63 patients were enrolled (mean age 42 years; 71% female; mean BMI 36) with 24 patients being laparoscopic non-obese (LN), 20 being laparoscopic obese (LO), and 19 undergoing open operations.  There was no significant blood loss in any case.  Hemoglobin did not change significantly before or after insufflation (Figure 1a). There was false elevation of PVI with insufflation and more pronounced in obese patients (Figure 1b).

Conclusion: Insufflation or obesity was not associated with significant variations in hemoglobin.  Non-invasive monitoring of hemoglobin is useful in laparoscopic procedures in obese and non-obese patients. PVI values should be used cautiously during laparoscopic procedures, particularly in obese patients.

 

6.17 Fluorescent Cholangiography during Robotic Cholecystectomy: Early Experiences at an Urban Hospital

Posted on December 22, 2014

L. Policastro1, R. Huang1, P. J. Chung2, H. Patel2, A. Schwartzman2, R. Lee2, G. Sugiyama2  1SUNY Downstate College Of Medicine,Brooklyn, NY, USA 2SUNY Downstate Medical Center,Department Of Surgery,Brooklyn, NY, USA

Introduction:
Intraoperative cholangiography using contrast fluid is traditionally a useful visual aid during laparoscopic cholecystectomy, but its disadvantages include increased operative time and exposure to radiation. Recently, near-infrared fluorescent cholangiography using indocyanine green (ICG) dye became available to users of the da Vinci surgical platform. It provides a real-time, 3D endoscopic view highlighting the bile ducts. ICG imaging has been utilized safely and effectively during robotic cholecystectomy. Adequate visualization of biliary structures is paramount in patients presenting with advanced gallbladder disease. This study compares operative results in robotic cholecystectomy with and without the use of ICG at an inner-city academic medical center.

Methods:
Eighty-six patients underwent robotic cholecystectomy between June 2013 and July 2014. Use of fluorescent cholangiography began in November 2013 after FDA approval was obtained. Patients were administered 5 mg of ICG on induction of anesthesia. If there was a failure to visualize biliary anatomy, another 2.5 mg was administered. Both single-site and multiport techniques were used. Patient records were compiled retrospectively.

Results:
There were 46 patients in the non-ICG group and 40 in the ICG group. The groups were similar, except that single-site was utilized more frequently with ICG (73% vs. 48%; p=.02), and chronic cholecystitis was slightly more prevalent in the ICG group (88% vs. 83%; p=.07). Overall, the mean BMI was 30.4 ± 6.5, and the rate of acute cholecystitis was 21%. Use of ICG neither lengthened nor shortened operation time (120 min with, 133 min without; p=.22) or robot time (58 min with, 57 min without; p=.85). The rate of conversion to either open or laparoscopic cholecystectomy was favorable (3% with, 13% without), but to qualify this result, logistic regression was used to account for age, sex, BMI, use of single-site, acute and chronic cholecystitis, tobacco use, and alcohol use. While marginally significant (p=.079), the use of ICG was associated with fewer conversions (OR 0.10, 95% CI 0.008−1.30). There was no difference in post-op length of stay (p=.91).

Conclusion:
ICG fluorescent cholangiography during robotic cholecystectomy enables confident identification of biliary structures without impacting operation time. It is helpful in the training of residents and fellows. It is safe for routine use and may reduce conversions, though its overall cost-effectiveness cannot be concretely established without a large randomized study.
 

6.18 The ‘Inside-out’ Technique for Ventral Hernia Repair with Mesh Underlay

Posted on December 22, 2014

A. E. Berhanu1,2, S. G. Talbot1,2  1Brigham And Women’s Hospital,Division Of Plastic Surgery,Boston, MA, USA 2Harvard School Of Medicine,Boston, MA, USA

Introduction: Techniques for mesh installation in hernia repair are varied and can be improved by preventing recurrent herniation, reducing intraoperative visceral injury, and increasing procedural efficiency. We present a method of securing mesh (either prosthetic or biologic) as an underlay concurrent with component separation, with pre-placed sutures on the material, to the overlying fascia through an ‘inside-out’ technique using a Carter-Thomason suture passer. The Carter-Thomason is a sharp, narrow trocar (3mm diameter) with the ability to grasp a suture at the distal end. It was originally designed to aid with closure of laparoscopic ports by facilitating the placement of sutures through fascia around port sites.

Methods:  The ‘inside-out’ technique was performed on 23 patients at a single tertiary academic medical center from November, 2011 to February, 2014.  We have followed these patients for a median of 12.5 months to assess for post-operative complications and hernia recurrence.  The innovative steps in this technique include (1) the preplacement of sutures on the mesh and removal of needles, (2) placement of mesh into the abdomen, and (3) retrieval of each end of the sutures with the Carter-Thomason for safe passage through the fascia from within the abdomen under direct visualization (Figure).

Results: There have been two recurrences (2/23=8.7%), one in a patient at 383 days post-operatively and the other at 311 days post-operatively.  The former recurrence occurred in a patient who underwent repair for a recurrent ventral hernia and the latter patient had significant loss of domain requiring an inlay mesh.  There were no hernia recurrences in patients who underwent repair of a primary ventral hernia with an underlay technique.

Conclusion: The ‘inside-out’ technique for ventral hernia repair with a mesh underlay after component separation using a Carter-Thomason suture passer is easy, safe, and reliable.  We have observed no hernia recurrence in patients who underwent repair for a primary ventral hernia with an underlay technique.  By pre-placing the sutures in the mesh, these can be evenly spread, giving the surgeon better control over the distribution of tension across the repair.  The technique described here seemingly reduces the risk of bowel injury by allowing direct visualization of the entire path of the sharp instrument, the tip of the Carter-Thomason, as it passes through the rectus. Additionally, pre-placed sutures lie between the mesh and posterior rectus fascia, allowing the mesh to shield the viscera from the path of the Carter-Thomason.

6.19 Robotic TAPP Inguinal Hernia Repair: Early Experiences at an Inner-City Academic Medical Center

Posted on December 22, 2014

R. Huang1, L. Policastro1, P. J. Chung2, H. Patel2, A. Schwartzman2, R. Lee2, G. Sugiyama2  1SUNY Downstate College Of Medicine,Brooklyn, NEW YORK, USA 2SUNY Downstate Medical Center,Department Of Surgery,Brooklyn, NEW YORK, USA

Introduction: Laparoscopic inguinal hernia repair was introduced in the 1990s and has been widely adopted. Many studies have shown that the transabdominal pre-peritoneal (TAPP) and totally extra-peritoneal (TEP) approaches to inguinal hernia repair have low recurrence rates and allow for early return to activity due to decreased pain. The robotic surgical platform improves upon standard laparoscopic approaches, providing enhanced dexterity and 3D viewing. Robotic inguinal hernia repair has been previously reported en-passant with prostatectomy, but has not been studied as a stand-alone procedure. We report one of the first case series of stand-alone robotic TAPP inguinal hernia repair at an inner-city academic medical center.

Methods: From December 2013 to June 2014, 26 robotic TAPP inguinal hernia repairs were performed at a single institution. We employed a three port approach, with a camera port at the umbilicus and two 8 mm lateral ports roughly 2 cm above the umbilicus. Patient characteristics, operative times, complications, and hernia recurrence were assessed. Data were compiled retrospectively.

Results: Twenty-six robotic TAPP inguinal hernia repairs were performed, of which seven were bilateral. Twenty-four patients were male and two were female. The mean age of the patients was 59.6 ± 11.2 years. The mean BMI of the patients was 26.3 ± 3.4. The mean incision-to-closure time was 127 ± 42 minutes. The mean robotic operation time was 82 ± 37 minutes. The mean robot docking time was 6 ± 3 minutes. Seven patients had scrotal hernias, three presented with incarcerated inguinal hernias, and an additional two had large hernia sacs. On follow-up, 4 of 26 patients (15%) had postoperative hematomas, while 3 patients (12%) had postoperative urinary retention. One patient (4%) returned with a recurrent hernia. No scrotal hernia patients presented with recurrence.

Conclusion: We present a case series of robotic TAPP inguinal hernia repairs at an inner-city institution and conclude that the procedure is feasible and safe for both routine herniorrhaphy and in advanced scrotal cases. Recurrence and morbidity were low during the early learning curve. Large scrotal and incarcerated inguinal hernias were repairable using the robotic approach. Further prospective study is needed to determine whether robotic inguinal hernia repair should be broadly adopted.
 

6.20 Difficult Laparoscopic Cholecystectomy: Conversion to Open versus Laparoscopic Subtotal Cholecystectomy

Posted on December 22, 2014

K. Leick1, D. Ring1, A. Bhama1, H. Chong1  1Universisty Of Iowa,Gastrointestinal-Minimally Invasive Surgery,Iowa City, IA, USA

Introduction: As laparoscopic cholecystectomy is now the gold standard for removal of the gallbladder, trainees and newly graduated surgeons are more experienced and comfortable with laparoscopic cholecystectomy (LC) as compared to open cholecystectomy (OC).  Laparoscopic subtotal cholecystectomy (LSC) is a safe alternative to conversion to OC (COC) in difficult cholecystectomy cases. To our knowledge, no current literature exists comparing complications between these two procedures.

Methods: A single-institution retrospective chart review was performed on patients who underwent attempted LC over a 4-year period from July 2009 to July 2013. LC patients with common bile duct injury prior to conversion to open cholecystectomy were excluded from the study. Demographic characteristics and postoperative outcomes were analyzed. Statistics were performed using paired t-tests and χ2 in Microsoft Excel®, and a p value of <0.05 was considered significant.

Results: A total of 2646 patients underwent LC. Of these, 95% (n=2518) were completed laparoscopically,  2% (n=47) underwent COC and 3% (n=81) underwent LSC.  Demographic characteristics were equivalent between COC and LSC group, except for age, as the COC group was significant older than the LSC group (58 ±17 vs. 49 ± 18, p=0.009). Intraoperative records demonstrated longer operative time with COC as compared to LSC (160 ± 90 minutes vs. 130 ± 37 minutes, p < 0.001). There was a significantly longer length of hospital stay in the COC group as compared to the LSC group (5.3 ± 2.3 days vs. 2.1 ± 2.5 days, p < 0.05). Overall, total complication rate was significantly higher with COC as compared to LSC (22.2% vs. 45.8%, p<0.02). These complications included: bile leak, retained common bile duct stone, acute kidney injury, urinary complications surgical site infection, small bowel obstruction or ileus, and postoperative arrhythmias. There was no significant difference in need for postoperative ERCP between the two groups.

Conclusion: LSC is associated with shorter length of hospital stay, shorter operative time, fewer complications and lower morbidity when compared to COC. Additionally, LSC is associated with decreased morbidity when compared to COC. In situations where standard laparoscopic cholecystectomy is not possible, performing LSC instead of COC should be considered as the next alternative.

 

6.02 Risk Factors for Conversion of Laparoscopic to Open Cholecystectomy in Acute Cholecystitis

Posted on December 22, 2014

M. Sippey1, A. Mozer1, M. Grzybowski1, M. Manwaring1, J. Pender IV1, W. Chapman1, W. Pofahl1, W. Pories1, K. Spaniolas1  1East Carolina University Brody School Of Medicine,General Surgery,Greenville, NC, USA

Introduction:   Laparoscopic cholecystectomy is one of the most common general surgical procedures performed.  Conversion to an open procedure (CTO) is associated with increased morbidity and length of stay. Patients presenting with acute cholecystitis (AC) are at higher risk for CTO. Studies have attempted to examine risk factors for CTO in patients who undergo laparoscopic cholecystectomy for AC, but are limited by small sample size.  The aim of this study was to identify pre-operative variables that predict higher risk for CTO in patients presenting with AC.

Methods:   Patients undergoing laparoscopic cholecystectomy for AC from 2005 to 2011 were identified from the ACS-NSQIP database. Patients who underwent successful laparoscopic surgery were compared with those who required CTO.  Demographics, co-morbidities, and 30-day outcomes were analyzed. Multivariable logistic regression was used for variables with p-value <0.1, with CTO used as the dependent variable.

Results:  A total of 7,242 patients underwent laparoscopic cholecystectomy for AC.  CTO was reported in 436 (6.0%) patients.  Those who required conversion were older (60.7 ± 16.2 vs 51.6 ± 18.0, p = 0.0001) and mean BMI was greater (30.8 ± 7.55 vs 30.0 ± 7.31, p = 0.028) compared to those whose procedure was completed laparoscopically.  Vascular, cardiac, renal, pulmonary, hepatic disease, diabetes and bleeding disorders were more prevalent in CTO patients.  Mortality (2.1% vs 0.7%, p = 0.001), overall morbidity (21.2% vs 6.0%, p<0.0001), serious morbidity (14.4% vs 3.8%, p<0.0001), reoperation (3.2% vs 1.4%, p = 0.002), and SSI (9.1% vs 1.8%, p<0.0001) rates, as well as LOS (8.52 ± 12.58 vs 3.41 ± 5.60, p<0.0001) were greater in those requiring CTO.  Our model showed the following factors were independently associated with CTO: age (OR 1.01, p = 0.015), male gender (OR 1.77, p = 0.005), BMI (OR 1.04, p<0.0001), pre-operative alkaline phosphatase (OR 1.01, p = 0.0005), WBC count (OR 1.06, p = 0.0001), and albumin (OR 0.52, p = 0.0001).  The overall model had a strong ability to discriminate between patients who did and did not require CTO (c=0.74, p<0.0001).

Conclusion:  CTO for AC remains low, but not clinically negligible.  After controlling for confounding baseline characteristics, for each unit increase in BMI, risk of CTO increases by 4%.  The identified risk factors can potentially guide management and patient selection for delayed intervention for AC.

 

6.03 Enterocutaneous Fistula Treatment (ECF) with Fibrin Glue Injection – Does it work?

Posted on December 22, 2014

J. S. Merkow1, A. Paniccia1, M. Gipson1, J. Durham1, L. Wilson1, J. Vogel1  1University Of Colorado Denver,Aurora, CO, USA

Introduction:  ECF is a challenging problem that often requires complex surgery for resolution.  A reliable nonsurgical cure for ECF would be welcome.  Fibrin glue treatment of anal fistula tract is an accepted and commonly used therapy with several studies demonstrating its efficacy.  The value of fibrin glue treatment for ECF has been relatively poorly evaluated.  The PURPOSE of this study was to describe our experience with fibrin glue therapy of ECF and determine characteristics associated with therapeutic success or failure. 

Methods:  Clinical data was extracted from a chart review of patients with ECF who underwent fibrin glue injection at the University of Colorado Hospital from 2003 to 2014.  Eligible patients had clinical and radiologic evidence of a fistula originating from the small or large intestine, between the ligament of Trietz and the upper rectum. Low output vs. high output fistula were <200 cc/day vs. >200cc/day.  Complete success was defined as 100% closure of the ECF.  Partial success was defined as decreased output reported by patient or physician after the gluing and during follow up.  Demographic and clinical data were recorded. 

Results: There were 38 patients with a median age of 55 years (IQR 45-62) with 22 (58%) male and 16 (42%) female patients. The median BMI was 24 (IQR 22-29), albumin 2.5 g/dL (IQR 1.9-2.9), and hemoglobin 9.9 g/dL (IQR 8.6-11).  Average ECF duration was 5 months (IQR 2-19).  20 (52%) patients had low output fistulas compared to 1 (3%) with a high output fistula. ECF origin was 17 (45%) small bowel, 16 (42%) colon, and 1(13%) rectum.  Etiology of fistula formation was iatrogenic in 21 (55%) patients, of which 18 (47%) occurred after a surgical procedure.  Other causes of fistula formation were infection/abscess (9, 24%) and pancreatitis (8, 21%).  The median number of gluing procedures was 1 (IQR 1-2).  Median follow-up after glue therapy was 17 months (IQR 5-52). Complete success occurred in 12 (34%) patients and partial success in 6 (17%).  Complete and partial therapeutic success was 23% and 18% for small bowel and 50% and 12% for colorectal fistula.  Of patients with complete success, 83% closed within 1 week of therapy and 75% required only a single fibrin treatment.  There were no complications associated with the use of fibrin therapy.  Analysis of factors including immunosuppression, albumin, obesity, IBD, cancer, output volume, repeated gluing procedures and fistula duration did not predict successful fibrin glue therapy.  

Conclusion: Fibrin glue therapy was a complete success in one-third of patients with an ECF that originated from the small or large bowel.  There were no complications associated with this therapy.  Further studies on a larger sample will be required to identify factors associated with successful fibrin glue therapy of ECF.  In the meantime, with little to lose and much to gain, we advocate a trial of fibrin glue therapy for ECF prior to surgical intervention. 
 

6.04 Laparoscopic Appendectomy: Who Falls Through the Cracks?

Posted on December 22, 2014

K. N. Marley1, A. M. Fecher1, B. L. Zarzaur1, G. A. Gomez1  1Indiana University School Of Medicine,Department Of Surgery,Indianapolis, IN, USA

Introduction:  Laparoscopic appendectomy (LA) is well accepted as a standard treatment for patients with acute appendicitis.  However, the types of complications and the patients likely to suffer them are not well characterized.  The purpose of this study was to characterize the types of complications that occur after LA and to determine factors for complication occurrence.  

Methods:  A retrospective review was performed to include patients 15 years and older undergoing a LA (CPT code 44970) between January 1, 2009 and April 1, 2014 at a single institution.  Demographic data, imaging, pathology, operative reports, length of stay, complications, and relevant history were obtained. Bivariate and multivariable analyses were used to determine risk factors for complications.  

Results: 625 patients met inclusion criteria.  Complications occurred in 14.6% (n=91) of patients. The 3 most common complications were organ space infections (n=45, 7.2%), superficial surgical site infection (n=23, 3.7%) and ileus (n=15, 2.4%). After bivariate and multivariable analysis, age (45-54yrs vs 15-24yrs – OR 4.14 95%CI 1.83, 9.37), perforated appendix (OR 6.85, 95% CI 3.99, 11.80), and pain prior to surgery (5-7 days vs ≤1 day OR 4.37 95%CI 1.46, 13.14) were associated with complications.  Of all LA only one procedure related complication was noted (0.2%) due to a trocar placement injury, but no further complications occurred.  

Conclusion: Despite being considered minimally invasive and perceived as safe, LA is associated with complications in nearly 15% of patients undergoing the procedure.  Patients who are of middle age, with history of prolonged pain and perforation are at increased risk of suffering complications.  Earlier recognition of the signs and symptoms of acute appendicitis in this atypical age range could result in fewer complications overall for LA.  Future research should focus on possible areas of intervention in this vulnerable patient population.

 

6.05 Surgical Frailty in elderly patients undergoing urgent abdominal surgery

Posted on December 22, 2014

H. H. Garzon1, C. Restrepo1, E. L. Espitia1, L. Torregrosa1, L. C. Dominguez1  1Pontificia Universidad Javeriana – Hospital Universitario San Ignacio,Surgery,Bogota, , Colombia

Introduction: The association between frailty and worse outcomes in urgent abdominal surgery has not been completely evaluated. There is no information in Colombia. The objective of this study is to establish the relation between frailty, mortality, morbidity and readmission rates confined to the first 30th postoperative days, in a prospective cohort of elderly patients undergoing urgent abdominal surgery.   

Methods: The Canadian Study of Health and Aging Frailty Scale (CSHA) was applied at admission to the emergency room to elderly patients (>65 years). We determinate the association between CHSA frailty scale, demographic, clinical and surgical factors with the probability of complications, death and readmission by Chi-square and Fisher’s exact tests. Multivariate analyses were conducted to identify the independent association of previous significant factors with major outcomes. Survival analysis was performed by Kaplan-Meier analysis with a log-rank test.

Results:A total of 300 consecutive patients fulfilled the inclusion criteria and were included. The global mortality rate was 14% (42 patients), the morbidity rate was 27.6% (83 patients) and the readmission rate was 15.67% (47 patients). Fifteen percent presented a frailty degree (CSHA Frailty Scale>5). The main independent factor associated to mortality was the CSHA Frailty Scale>5 (OR:4,49 p<0,001). The main independent factors associated with morbidity were the CSHA Frailty Scale>5 (OR:2,78 p<0,014) and LoS>12 days (OR:6,83 p<0,001). The independent factors associated to readmission were malnutrition (OR:1.97 p<0,04) and previous major surgery (OR:2.27 p<0,04).

Conclusion:Surgical frailty is associated to postoperative morbidity and mortality in urgent abdominal surgery in the elderly population. This association was not demonstrated with the readmission. Additional interventions are needed to control this factor in the perioperative period, which must be evaluated in new studies.  

 

6.06 Costly Complications: Readmissions in Elderly Following Appendectomy

Posted on December 22, 2014

L. A. Bliss1, C. J. Yang1, Z. Chau2, E. Witkowski2, S. Ng1, W. Al-Refaie3, J. F. Tseng1  1Beth Israel Deaconess Medical Center,Surgical Outcomes Analysis & Research,Boston, MA, USA 2University Of Massachusetts Medical School,Department Of Surgery,Worcester, MA, USA 3Georgetown University Medical Center,Department Of Surgery,Washington, DC, USA

Introduction:  Elderly patients (65 years of age or older) may be at risk after routine surgical procedures given underlying co-morbidities, frailty, and decreased physiologic reserve. Research regarding readmissions in the elderly population following appendectomy for acute appendicitis is limited. This study examines rates, risk factors, and costs for readmission among elderly patients undergoing appendectomies for acute appendicitis.

Methods:  The Healthcare Cost and Utilization Project (HCUP) Florida State Inpatient Database and State Emergency Department Database with HCUP supplemental files for revisit analysis were used to identify inpatient admissions between 2007 and 2011 for patients age 65 years or older who underwent appendectomy for acute appendicitis.  Readmission was defined as emergency department (ED) visit or inpatient admission within 30 days of discharge. Demographic data included sex, age, Elixhauser co-morbidity score, and race.  Index admission information included procedure, length of stay (LOS), and complications. Total costs were determined using HCUP Cost-to-Charge Ratio Files. Univariate and multivariate analysis performed by chi-square and logistic regression. For all, p-values <0.05 were considered statistically significant.

Results: Within this large, racially diverse state, 8,669 elderly patients underwent appendectomy for acute appendicitis from 2007 to 2011. Appendectomy median LOS was 3 days (interquartile range (IQR) 2-6 days) and median cost was $9,384 (IQR $7,211-$13,009). 12.94% experienced inpatient complications. 13.39% (1,161) were readmitted within 30 days, of whom 39.19% (455) experienced an ED visit only and 60.81% (706) underwent inpatient readmission. After adjustment, readmission was more likely among males (p=0.0147) discharged to skilled nursing or other facilities (p<0.0001) with 3 or more co-morbidities (p<0.0001) and with select inpatient complications. On the other hand, within-elderly age and prolonged LOS did not predict re-admission. Of those readmitted, 16.37% had more than one readmission and median total cost of care was $16,624 (IQR $11,419-$25,244).

Conclusion: Appendicitis is not uncommon in elderly patients, who are at risk for both ED visits and inpatient admissions after appendectomy. Readmissions are more common among those discharged to facilities or with select complications during index admission. The financial impact of readmission is significant. Identifying elderly at risk of post-operative readmission may offer significant cost and resource savings.

6.07 Pneumatosis Intestinalis: Considerations for this Clinical Conundrum

Posted on December 22, 2014

E. Insley1, B. Braslow1, Z. Maher1, S. Allen1  1Hospital Of The University Of Pennsylvania,Philadelphia, PA, USA

Introduction: The radiographic finding of pneumatosis intestinalis (PI) raises the concern for ischemic bowel and possible need for urgent surgical intervention.   Lactic acidosis, peritonitis, and the systemic inflammatory response have been show to be predictors of surgical pathology in patients with PI, but how immunosuppressant may impact on the reliability of these findings is not well characterized. We hypothesized that the use of immunosuppressants and their effect on physical exam findings in patients with PI would lead one to rely on physiologic and metabolic derangements to base operative decision making.

Methods: The institutional radiology database from our urban academic medical center was queried over a 5 year period for patients with CT scans that had the presence of PI as determined by board-certified radiologists.  Radiology reports containing the words “pneumatosis intestinalis” were obtained and the scans were reviewed to confirm the presence of PI.  Only the index CT scan of each patient was included.  Demographics, comorbidities, laboratory values, physiologic data, and operative findings were abstracted by chart review for these patients.  Patients were stratified by immunosupression (defined as steroids, transplant immunosuppressants or recent chemotherapeutic agents) and univariate logistic regression was used to determine the association of these factors with the outcomes of interest including need for operation, therapeutic laparotomy (Ther lap) and in-hospital survival. 

Results:A total of 124 patients met inclusion criteria. Demographics were similar between the 2 groups. Statistically more patients in the immunosuppression group presented with > 2 SIRS criteria while lactic acid levels were similar. Other laboratory markers of acid/base status were also similar. There was no difference in the percentage of patients that underwent an operation with over 80% in each group receiving a therapeutic intervention (bowel resection). Those in the immunosuppression group without abdominal pain demonstrated the lowest proportion of a ther lap (Table).

Conclusion:The association between abdominal examination and positive operative findings appears to be similar in immunocompromised and immunocompetent hosts.  Additionally, patients taking immune suppressing medications demonstrated the ability to mount an inflammatory response based on defined SIRS criteria. The decision to operate in patients with PI should be based on SIRS criteria, acid base status and abdominal exam in both immunocompetent and immunocompromised patients.
 

6.08 Anxiolytic Medication is an Independent Risk Factor for Short-Term Major Morbidity after Surgery

Posted on December 22, 2014

D. L. Davenport1, J. S. Roth1, N. Ward3, L. Mutiso4, C. C. Lester2, K. M. Lommel2, D. L. Davenport1  1University Of Kentucky,Dept. Of Surgery,Lexington, KY, USA 2University Of Kentucky,Dept. Of Psychiatry,Lexington, KY, USA 3University Of Kentucky,College Of Medicine,Lexington, KY, USA 4University Of Kentucky,College Of Nursing,Lexington, KY, USA

Introduction: The incidence of psychiatric illness is increasing in the United States as is treatment with psychotropic medication. The area of the country in which this study was conducted also has a known high incidence of prescription drug abuse. There have been several reports of the effects of depression and antidepressants on cardiac surgery outcomes, but chronic anxiety and anxiolytics have been understudied.  This study aimed to determine the relationship, if any, between preoperative anxiolytic medication and morbidity after a broad range of non-cardiac surgeries.

Methods: A retrospective review of the American College of Surgeons National Surgery Quality Improvement Program data at a single large academic medical center was performed with the addition of anxiolytic prescription medication (AXM, benzodiazepines or hydroxyzine HCL) identified at admission from the patients’ active medication list. The data reflected a prospective, 100% sample of 20 major general, vascular, urologic and plastic surgical procedures performed at our hospital between October 1, 2011 and September 30, 2012. The data included demographics, >30 comorbid clinical risks, procedural variables and 21 specific complications and death for up to 30 days after major surgery. Major morbidity (MM) was defined as a patient having one or more of the complications or death.

Results: We reviewed a total of 1847 surgical patients of whom 289 (15.6%)  were taking AXM at admission. AXM use varied significantly by type of procedure (p <.001) with breast reconstruction patients having >25% AXM use while appendectomy and prostatectomy <7% AXM use. Operative duration was ½ hour longer on average in AXM patients (p <.001) who were also more likely to be smokers, suffer from COPD, dyspnea and hypertension (all p <.001). They had higher MM (24.3% vs 14.9%, p <.001), particularly infections (16.3% vs. 9.4%, p =.001) and 1 day longer median hospital stay (3 vs 2 days, p <.001).  In multivariable logistic regression, AXM was an independent predictor of MM (odds ratio 1.73, 95% CI 1.09-2.75, p=.021) after adjustment for the procedure performed, clinical and demographic risk factors. Conclusion: We found that 15.6% of our non-cardiac surgery patients were actively taking anxiolytics at admission and that these patients had significantly worse risk-adjusted short-term surgical outcomes, particularly infection.  Future studies are needed to study mechanism; particularly whether the observed outcomes were caused by physiologic changes due to chronic anxiety or to the medications themselves.

 

6.09 Impact of Health Literacy on Post-Operative Outcomes in Patients Undergoing Major Abdominal Surgery

Posted on December 22, 2014

G. C. Edwards1, K. M. Goggins2, J. Ehrenfeld3, H. R. Mir4, A. A. Parikh1, N. B. Merchant1, S. B. Kripalani2, K. Idrees1  2Vanderbilt University Medical Center,Center For Health Services Research,Nashville, TN, USA 3Vanderbilt University Medical Center,Department Of Anesthesiology, Vanderbilt Anesthesiology & Perioperative Informatics Research (VAPIR) Division,Nashville, TN, USA 4Vanderbilt University Medical Center,Department Of Orthopaedics & Rehabilitation,Nashville, TN, USA 1Vanderbilt University Medical Center,Department Of Surgery, Division Of Surgical Oncology,Nashville, TN, USA

Introduction:  

Health literacy (HL) is broadly defined as an individual’s ability to obtain, process, and understand health information in order to make informed health care decisions. Low HL status adversely affects health outcomes in patients living with chronic diseases such as diabetes, hypertension, and congestive heart failure. However, the link between HL and post-operative outcomes has not been evaluated in the surgical population. The aim of this study is to evaluate the influence of HL on post-operative outcomes in patients undergoing major abdominal surgery.

Methods:  

From 2010 to 2013, 1,376 patients undergoing elective gastric, colorectal and hepato-pancreatico-biliary resections at a single academic institution were assessed. Patient demographics, education and insurance status, procedure type, American Society of Anesthesiologists (ASA) status, Charlson comorbidity index (CCI), and post-operative outcomes [complications, length of stay (LOS), 30- and 90-day emergency department (ED) visits, and 30- and 90-day unplanned hospital readmissions] were obtained from the electronic medical records.  HL was assessed using the Brief Health Literacy Screen (BHLS), a validated tool administered by nursing staff upon hospital admission. This tool is scored 3-15 and divided into four HL categories [low (3-8), intermediate (9-11), intermediate-high (12-14), and high (15)].  Multivariable logistic regression modeling was utilized to determine the association of HL and other covariates on post-operative outcomes.

Results: 

In this cohort, there was a median HL score of 15.0 and a median educational attainment of 13.0 years. Hospital readmission and re-presentation to the ED within 30 days were 16% and 13.5%, respectively, and within 90 days were 19% and 16%, respectively. ASA status, pancreatic and gastric resections, and postoperative complications were independently associated with increased LOS [p<0.05], while post-operative complications [OR 3.482, CI 2.4-5.1, p<0.001], increased LOS [OR 0.972, CI 0.953-0.992, p=0.007], and higher CCI [OR 0.949, CI 0.905-0.992, p=0.030] were associated with increased rates of readmission within 90 days. After controlling for all factors, patients with a higher HL score had a shorter LOS [p=0.016]. However, low HL was not significantly associated with increased rates of complications [OR 0.994, CI 0.935-1.056], 30- or 90-day hospital readmission [OR 0.972, CI 0.921-1.026], or 90-day ED visits [OR 0.991, CI 0.935-1.050]. 

Conclusion: 

Higher HL status is independently associated with shorter LOS in patients undergoing major abdominal surgery. In contrast, lower HL status is not associated with increased complication rates or 30- and 90-day hospital readmissions or ED visits. Decreased LOS results in decreased hospital cost and improved overall patient satisfaction. Therefore, the role of health literacy should be considered within surgical practice to improve health care utilization. 

6.10 Laparoscopic Inguinal Herniorrhaphy: Comparing Outcomes Between Self-adhering Versus Tacked Mesh

Posted on December 22, 2014

I. S. Pourladian1, A. W. Lois1, M. J. Frelich1, A. S. Kastenmeier1, J. R. Wallace1, J. C. Gould1, M. I. Goldblatt1  1Medical College Of Wisconsin,General Surgery,Milwaukee, WI, USA

Introduction:  Inguinal herniorrhaphy is one of the most common surgical procedures performed annually. Several synthetic meshes are available to reinforce the inguinal region following laparoscopic hernia reduction. Historically, most surgeons secure mesh with tacks; however, self-adhering mesh now allows the elimination of fixating tacks. We sought to compare postoperative outcomes of patients who underwent laparoscopic inguinal herniorrhaphy using self-adhering polyester mesh to those who had non-adhering, synthetic mesh implanted using absorbable tacks.

Methods:  This study is a retrospective review of patients who underwent primary laparoscopic inguinal herniorrhaphy at the Medical College of Wisconsin between October 2012 and July 2014. Procedures were performed by four surgeons. Clinical information and perioperative outcomes were collected up to one year following surgery when available. The Surgical Pain Scale (SPS) was used to evaluate pain preoperatively, at two weeks, six weeks, six months, and one year after surgery.

Results: One hundred and four patients (94 male) underwent laparoscopic inguinal herniorrhaphy during the study interval. Forty-two patients received the self-adhering mesh and 62 patients received a mesh adhered with tacks. Patient demographics and comorbidities did not differ significantly between the two groups. The mean patient age was 51.5 (±14.3) years with a mean BMI of 26.5 (±4.0).  Complications, which included seroma, hematoma, urinary retention, emesis, and constipation, did not differ between groups perioperatively or post-discharge (p=0.7 and p=0.06, respectively).  No hernias recurred in either group during the study interval.

Conclusion: Postoperative complications did not occur more frequently in patients undergoing laparoscopic inguinal herniorrhaphy receiving non-adhering mesh implanted using absorbable tacks versus self-adhering mesh.  SPS responses differed significantly at six weeks suggesting that patients receiving self-adhering mesh may experience less postoperative pain in the short term compared to tacked, non-adhering mesh, but this advantage goes away as the tacks dissolve.  We will continue to follow patients to evaluate for risk of recurrence and other postoperative complications.

 

6.11 Elective versus Non-elective Ventral Hernia Repairs utilizing the Nationwide Inpatient Sample

Posted on December 22, 2014

K. Simon1, M. Frelich1, J. Gould1, H. Zhao1, T. Chelius1, M. Goldblatt1  1Medical College Of Wisconsin,Milwaukee, WI, USA

Introduction: Ventral hernia (VH) repair remains one of the most common general surgery procedures.  The majority of hernia repairs are performed electively.  Patients who present emergently with hernia related concerns may experience increased morbidity with repair when compared those repaired electively.  Patients who undergo elective surgery may also be different than those who opt to undergo elective surgery.  We sought to characterize the outcomes of patients who undergo elective and non-elective VH repair using a large population-based data set.

Methods: The Nationwide Inpatient Sample (NIS) was queried for primary ICD-9 codes associated with VH repair (years 2008-2011). Outcomes were in-hospital mortality and the occurrence of a pre-identified complication.  Multivariate analysis was performed to determine the risk factors for complications and mortality following both elective and non-elective VH repair.

Results: We identified 74,151 VH repairs performed during the study interval. Of these procedures, 67.3% were elective and 21.6% were performed laparoscopically.  The overall complication rate was 20.0% and overall mortality was 0.95%. Non-elective repair was associated with a significantly higher rate of morbidity (22.5% vs. 18.8%, p<<0.01) and mortality (1.8% vs. 0.52, p<<0.01) than elective repair.  Elective repairs were more likely to occur in younger patients, Caucasians, and were more likely to be performed laparoscopically.  Logistic modeling revealed that female gender, Caucasian race, elective case status, and laparoscopic approach were independently associated with a lower probability of complications and mortality. Minority status and Medicaid payer status ware associated with increased probability of non-elective admission.

Conclusion: Patients undergoing elective ventral hernia repair in the United States tend to be younger, Caucasian and more likely to have a laparoscopic repair. The need for non-elective VH is associated with a substantial increase in morbidity and mortality.  Minority status and Medicaid payer status were associated with increased probability of non-elective admission. Considering the above, we recommend that patients consider elective repair of ventral hernias when possible, to avoid the increased risk of complications associated with non-elective repair.

6.12 Abdominal Wall Reconstruction: A Comparison of Totally Extraperitoneal and Intraperitoneal Approaches

Posted on December 22, 2014

J. S. Roth1, M. T. Miller1, K. Johnson1, M. Plymale1, S. Levy1, D. Davenport1, J. Roth1  1University Of Kentucky,General Surgery/Surgery/College Of Medicine,Lexington, KENTUCKY, USA

Introduction: Abdominal wall reconstruction for complex hernia repairs are challenging with significant complications.  The retro-rectus approach typically involves creation of submuscular flaps from an intraperitoneal approach following adhesiolysis, potentially resulting in visceral injuries.  A totally extraperitoneal approach to abdominal wall reconstruction is feasible in most hernia repairs and may minimize visceral injuries without impacting outcomes.  This study compares outcomes following abdominal wall reconstructions by means of an extraperitoneal and intraperitoneal approach.

Methods: An IRB approved review of a prospective hernia database was performed for all abdominal wall reconstructions between 2009 and 2013. Pre-operative patient characteristics including demographics and comorbidities; operative variables including surgical technique (intraperitoneal vs. extraperitoneal), operative duration, type, size and location of mesh, concomitant procedures, and incidence of inadvertent injury; and patient outcomes in terms of length of stay, wound and non-wound complications, readmissions and return to the operating room were obtained. Cases were evaluated based surgical approach. Groups were compared using t-tests, Mann-Whitney U tests, chi-square and Fisher’s Exact tests as appropriate. Significance was set at p < .05.

Results: Patient groups were compared based upon surgical approach; intraperitoneal (n=121) vs. extraperitoneal (n=54). Pre-operative patient characteristics were similar between the two groups including age, BMI, gender, comorbidities, smoking status, and prior hernia repairs. Hernia defect sizes were similar; mesh size was larger in the extraperitoneal group (675 ±317 vs. 440 ± 185 cm2; p<.001); Operative time was less in the extraperitoneal group (172 ±46 vs. 217 ±52 minutes; p<.001). An extraperitoneal approach resulted in fewer inadvertent bowel injuries ( 0 vs 9.1%, p = .02). Readmissions, reoperations, recurrences and other patient outcomes were similar between the two groups.  Among patients undergoing mesh placement in the retrorectus space (extraperitoneal n=47; transabdominal preperitoneal n=74) operative time was less in the extraperitoneal group while other outcomes were similar.

Conclusion: Abdominal wall reconstruction may be performed in a totally extraperitoneal fashion.  The extraperitoneal approach results in fewer enterotomies, shorter operative duration and similar readmissions, reoperations and recurrences when compared to an intraperitoneal approach.  
 

6.13 Does Preoperative Opioid Use Affect Bariatric Surgery Outcomes?

Posted on December 22, 2014

T. Mokharti1, A. Nair1, D. Azagury1, H. Rivas1, J. Morton1  1Stanford University,Bariatric And Minimally Invasive Surgery,Stanford, CALIFORNIA, USA

Introduction:
Long-term opioid use has recently increased. However, the interaction of opioid use as it relates to obese populations remains understudied. This study aims to investigate the effect of pre-operative use of opioid analgesics on weight loss outcomes, reoperation rates, readmission rates, and complication rates for patients undergoing laparoscopic Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG) and gastric banding (LB).

Methods:

A prospective cohort of 1139 patients undergoing bariatric surgery at a single academic institution was analyzed preoperatively, three-months, six-months, and twelve-months postoperatively. Patients were stratified into opioid analgesic users and non-opioid users based on narcotic questioning at the consult or preoperative visit. The effect of pre-operative opioid use on bariatric surgical outcomes was analyzed using Student t-test for continuous variables and chi-squared analysis for dichotomous variables. All data was analyzed using Stata/SE, 12.1.

 

Results:

Within the cohort of 1139 patients, 77.81% underwent RYGB (n = 866) 9.34% underwent LB (n=104) and 12.85% underwent SG (n= 143). Of the patient population, 105 patients were reported as having preoperative use of opioid medications. Patients on opioid medications had a 4.7% lower percent excess weight loss (%EWL) 12-months postoperatively compared to those not on opioid medications (70.35 %EWL vs. 65.69 %EWL, p = 0.035). However by surgical type, no statistically significant difference was found among RYGB and SG patients. LB patients on preoperative opioid analgesic medication were found to have a 16.6% decreased excess weight loss as compared to non-opioid users (44.04 %EWL vs. 27.44 %EWL, p = 0.021). No statistically significant differences between opioid analgesic users and non-users were found collectively or for the individual procedures for changes in BMI, reoperation incidence, readmission incidence, or incidence of post-surgical complications.

 

Conclusion:

Preoperative opioid analgesic use is a negative predictor for 12-month excess weight loss, particularly for patients undergoing laparoscopic adjustable gastric banding. These results indicate the need for thoughtful preoperative management of pain and opioid analgesics in bariatric patients to optimize surgical weight loss.

 

 

6.14 Analytic Morphomics Predicts Body Composition Associated with Diabetes

Posted on December 22, 2014

O. C. Juntila1, J. Friedman1, D. Cron1, M. Terjimanian1, M. Lindquist1, A. Hammoud1, M. Alameddine1, J. Claflin1, M. Englesbe1, S. Wang1, C. Sonnenday1  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction:

Risk stratification for surgical procedures is traditionally done using demographic factors, such as: age, BMI, and comorbid disease. Better methods are needed to measure body composition and assess risk in surgical patients with chronic disease. BMI, for example, is limited in describing characteristics associated with diabetes, a chronic disease with profound impact on overall health and surgical outcomes. This study aims to use analytic morphomics to describe differences in fat distribution and trunk muscle size among patients with and without diabetes.

 

Methods:
A retrospective cohort study was established using CT scans and associated clinical profiles of trauma patients at the University of Michigan between 2000 and 2013. The visceral fat area and lean psoas area were measured at the L4 level using established analytic morphomic techniques.  Patients were stratified by gender and BMI weight categories: obese (BMI >30 kg/m²), overweight (25<BMI<30 kg/m²), and normal weight (BMI <25 kg/m²). Statistical analysis was performed to determine differences between morphomic measurements within each weight category. 

Results:

We identified 1178 patients (66.7% male) with an overall presence of Type II diabetes of 9.2%. Across all male weight categories diabetics consistently had significantly greater visceral fat area than non-diabetics (obese: P=<0.001, overweight: P=0.074, normal weight: P=<0.001) and displayed significantly smaller lean psoas area when compared to non-diabetics within the same weight category (obese P=0.001, overweight P=<0.001, normal weight P=0.0056). Similarly, female diabetics showed greater visceral fat area (obese P=0.0035, overweight P=0.043, normal weight P=<0.001), and smaller lean psoas area (obese P=0.031, overweight P=0.003, normal weight P=0.18) when compared to non-diabetic females. Figure 1 compares lean psoas and visceral fat areas of diabetic and non-diabetic males across weight categories.

 

Conclusion:

Diabetics have greater visceral fat and smaller lean trunk muscle mass than non-diabetics. Analytic morphomics appears to offer greater characterization of body composition than that offered by BMI. Future study is needed to identify morphomic phenotypes associated with chronic disease and adverse health outcomes.

 

5.03 Tumors and Wounds Compete for Circulating Progenitor Cells In Vivo

Posted on December 22, 2014

M. S. Hu1, Z. Maan1, W. Hong1, G. Walmsley1, R. Rennert1, T. Zhu1, M. Esquivel1, D. Atashroo1, D. Duscher1, R. Tevlin1, A. Zimmermann1, M. Chung1, A. McArdle1, G. Gurtner1, H. P. Lorenz1, A. Giaccia3, M. Longaker1  1Stanford University,Surgery,Palo Alto, CA, USA 2University Of Hawaii,Surgery,Honolulu, HI, USA 3Stanford University,Radiation Oncology,Palo Alto, CA, USA

Introduction:
Tumors have been described as wounds that do not heal based upon similarities in stromal composition, angiogenesis, and gene expression. However, the interactions between the two processes have yet to be clearly examined. We previously developed a novel in vivo tumor wound competition model to examine the interactions between wound healing and tumor growth. Prior studies demonstrate that the placement of a full thickness excisional wound will inhibit tumor growth as the wound is healing. Herein, we study the role of circulating progenitor/stem cells in this phenomenon.

Methods:
Parabiosis was performed with NOD-SCID-gamma (NSG) and NSG-GFP mice. After cross circulation was confirmed at 2 weeks, head and neck squamous cell carcinoma (HNSCC) SAS cells were injected subcutaneously and a splinted full thickness excisional wound was created on the dorsum of the NSG parabiont. After 10 days, the tumor and wound were harvested, digested, and analyzed via fluorescence-activated cell sorting.

Results:
Identification of circulating cells by GFP fluorescence show wounds recruit more circulating cells than tumors (8.63% vs. 3.9%; *p<0.05). Furthermore, progenitor cells (GFP+ Lin-) had better recruitment by wounds versus tumors (0.7% and 0.28%; *p<0.05). Using subset analysis, the ability of wounds to recruit hematopoietic progenitor cells (GFP+ Lin- c-Kit+) and putative endothelial cells (GFP+ Lin- VEGFR2+) were demonstrated (13.1% vs. 4.01%; p<0.05 and 7.24% vs. 3.11% ; p<0.05, respectively).

Conclusion:
We conclude that wounds recruit more circulating progenitor cells than tumors using a parabiosis model. This may explain how wounds can inhibit tumor growth when placed adjacently in vivo. With further studies, insight into this mechanism may offer a deeper understanding of both tumor growth and wound healing.
 

5.04 Activation of Notch Signaling in Human Biliary Atresia and Experimental Cholestasis

Posted on December 22, 2014

J. A. Zagory1,2, N. Mavila1,2, S. Utley1,2, D. James1,2, K. S. Wang1,2  1Children’s Hospital Los Angeles,Pediatric Surgery,Los Angeles, CA, USA 2Saban Research Institute,Developmental Biology And Regenerative Medicine Program,Los Angeles, CA, USA

Introduction:  Biliary atresia (BA) is a congenital progressive fibro-obliterative disease of the extrahepatic biliary tree and is the most common cause of end-stage liver disease in children. BA is characterized by extensive intrahepatic proliferating ductular reaction and biliary fibrosis. The expansion of COLLAGEN-1-expressing cells expressing the stem cell marker PROMININ-1 (PROM1) within the biliary fibrosis is associated with the experimental model of BA induced Rhesus rotavirus (Mavila et al, Hepatology, 2014). However the molecular mechanisms regulating ductular reaction and biliary fibrosis are unclear. Given the role of Notch signaling in biliary development (Kodama et al, Gastroenterology, 2004), we hypothesize that activated Notch signaling is associated with ductular proliferation and biliary fibrosis in cholestatic liver diseases such as BA.

Methods:  Statistical analyses were performed on normalized human BA microarray data acquired from http://genet.cchmc.org using Statview software (BA n=66, normal n=7). Liver from mice with experimental cholestasis/biliary fibrosis induced using 3% 3,5-diethoxycarbonyl-1,4-dihydrocollidine (DDC) diet for 2 weeks, human BA collected at the time of Kasai portoenterostomy, and age-matched control liver samples were analyzed histologically using immunofluorescence (IF)/immunohistochemistry (IHC) for the expression of biliary marker Cytokeratin (CK)-19, activated Notch receptors (Notch Intracellular Domain (NICD))-1 & 2, and Notch ligand JAG1. Fibrosis was assessed by Sirius red staining. Gene expression analysis was performed by quantitative Polymerase Chain Reaction (qPCR).

Results: Analysis of human BA microarray data demonstrated significant increases in the expression of JAG1 (2.54 fold, p< 0.001) and its receptor NOTCH2 (1.5-fold, p<0.001). CK19 immunostaining and Sirius red staining confirmed the presence of ductular reactions and fibrosis in both BA and DDC-treated livers compared to normal livers. IHC/IF analysis demonstrated increased expression of activated NICD1 and JAG1 proteins in BA and DDC-treated livers compared to controls. qPCR analysis of DDC-treated livers demonstrated a significant increase in the expression level of Notch-1, Notch-2  and Notch ligands Jag1, Dll1 and Dll4 (p<0.05).

Conclusion: NOTCH signaling is activated in human BA and experimental model of cholestasis and may contribute to the ductular reaction and biliary fibrosis associated with cholestatic liver diseases.

 

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