75TH ANNUAL MEETING
ANNIVERSARY
annual meeting
CENTRAL SURGICAL ASSOCIATION
FINAL PROGRAM
March 15–17, 2018 Columbus, OH Hilton Columbus Downtown
CSA_2018_FinalProgram.indd 1 3/6/18 8:49 PM THE CSA THANKS OUR INDUSTRY PARTNERS
The Central Surgical Association would like to thank the following organizations for their marketing support of the 2018 Annual Meeting: Legally Mine USA | Gold Sponsor
The Central Surgical Association would like to thank the following companies for their generous support as Exhibitors:
Bard Davol Ethicon, Johnson & Johnson Gore & Associates Hitachi Healthcare Integra LifeSciences Legally Mine USA Teleflex, Inc. U.S. Army Healthcare
A
CSA_2018_FinalProgram.indd 2 3/6/18 8:49 PM SAVE THE DATE
CSA 2019 Annual Meeting
March 7-9, 2019 Innisbrook Palm Harbor, Florida
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CSA_2018_FinalProgram.indd 1 3/6/18 8:49 PM TABLE OF CONTENTS
3 Special Notes 5 Officers and Councilors, Society Representatives, Committees 7 Educational Objectives 9 Schedule-at-a-Glance 13 Scientific Program 35 Abstracts 137 Best Paper by a New Member 140 New Members 141 Membership List 143 Past Presidents 147 Past Officers 151 Central Surgical Association Foundation Board of Directors and Committee Members 153 CSA Capital Campaign 156 Enrichment Awards 156 Turcotte Award
163 Past Annual Meeting Locations
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CSA_2018_FinalProgram.indd 2 3/6/18 8:49 PM SPECIAL NOTES
The Hilton Columbus Downtown Hotel will serve as the headquarters for the 2018 CSA Annual Meeting. Registration is located in the Bellows Foyer and is open:
Wednesday 3:00pm – 6:00pm Thursday 7:00am – 4:30pm Friday 7:00am – 5:30pm Saturday 7:30am – 11:30am
All scientific sessions will be held in the Bellows Ballroom DEF and a parallel session in the Robert King Room.
Continental breakfast will be available for physicians on Thursday – Saturday mornings, and registered spouses and companions can enjoy breakfast Thursday and Friday mornings from 8:00am – 10:00am and on Saturday morning they can join the physicians for breakfast. Meeting registrants are encouraged to visit our industry partners in the exhibit hall during breakfasts and refreshment breaks on Thursday and Friday.
A Welcome Reception will be held on Thursday, March 15th in the Lamp Room from 5:30pm – 7:30pm. Support the CSA Foundation and register for the CSA Foundation Dinner that evening at the Hyde Park Steakhouse.
The Nonie Lowry Dinner Dance will be held on Friday, March 16th in the Bellows Ballroom DEF from 7:00pm – 10:00pm. Members and registered guests are cordially invited and encouraged to attend. Attire is black tie optional.
Business attire is recommended for the Welcome Reception.
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CSA_2018_FinalProgram.indd 3 3/6/18 8:49 PM CSA Staff Marjorie Malia Director, Association Management Jill Willhite Director, Association Management Tracy Brown Membership, Publications & Events Laura Fitzgerald Manager, Finance Corinne Hornsey Manager, Meetings & Events Deborah East Manager, Exhibits & Sponsorship Mary Kawulok Coordinator, Registration & Membership Dues Shayla Concannon Manager, CME & Communications Nora Barrett Onsite Regsitration
CSA Headquarters 2625 W. 51st Terrace Westwood, KS 66205 t: 913.402.7102 [email protected] www.centralsurg.org
Please mail any registration or dues payments to: Central Surgical Association PO Box 219191 Kansas City, MO 64121-9191
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CSA_2018_FinalProgram.indd 4 3/6/18 8:49 PM OFFICERS AND COUNCILORS 2018 – 2019
President Fred A. Luchette, MD, MSc
President-Elect Margo C. Shoup, MD
Secretary L. Michael Brunt, MD
Treasurer Timothy A. Pritts, MD, PhD
Recorder Ronald J. Weigel, MD, PhD
Immediate Past President W. Scott Melvin, MD
Councilors Jeffrey M. Hardacre, MD C. Max Schmidt, MD, PhD, MBA Tara M. Breslin, MD
American Board of Surgery Christopher R. McHenry, MD
Board of Governors - American College of Surgeons Jon C. Gould, MD
Advisory Council for Surgery - American College of Surgeons Tina W. F. Yen, MD, MS
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CSA_2018_FinalProgram.indd 5 3/6/18 8:49 PM OFFICERS AND COUNCILORS 2018 – 2019 (continued)
CSA Foundation President Nathaniel J. Soper, MD
Local Arrangements Chair Steven M. Steinberg, MD
Program Committee Peter Angelos (Chair) L. Michael Brunt (Ex Officio) Ronald Weigel (Ex Officio) Stephen Barnes Timothy Pawlik Shimul Shah Wendy Wahl Matthew Walsh Linwah Yip
Membership Advisory Committee Daniel Eiferman (Chair) L. Michael Brunt (Ex Officio) Heather Dolman Lorenzo Ferri Peter Hallowell Craig Miller Jason Smith Michael Ujiki Vic Velanovich
Auditing Committee Paul Kuo (Chair) Ashraf Mansour
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CSA_2018_FinalProgram.indd 6 3/6/18 8:49 PM EDUCATIONAL OBJECTIVES
LEARNING OBJECTIVES This program has been constructed by the Program Committee of the Central Surgical Association and has been selected from abstracts submitted by the membership of the Association. The subject matter selected is a cross-section of the cutting edge of surgical practice today. At the conclusion of this activity participants will: 1. Possess an increased basic knowledge and understanding of surgical disease 2. Be able to analyze the result of new approaches or techniques for managing disease 3. Have increased ability to examine new concepts and techniques in surgical science 4. Have an understanding of the importance of early genetic counseling and testing of asymptomatic carriers of hereditary diffuse gastric cancer. 5. Learn how a schedule change in postoperative opioid dosing can reduce the numbers of opioids patients leave the hospital with. 6. Learn management options for abdominal wall reconstruction in the setting of a contaminated wound.
DISCLOSURE INFORMATION In compliance with the ACCME Accreditation Criteria, the American College of Surgeons, as the accredited provider of this activity, must ensure that anyone in a position to control the content of the educational activity has disclosed all relevant financial relationships with any commercial interest. All reported conflicts are managed by a designated official to ensure a bias-free presentation. Please see the insert to this program for the complete disclosure list.
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CSA_2018_FinalProgram.indd 7 3/6/18 8:49 PM EDUCATIONAL OBJECTIVES (continued)
CONTINUING MEDICAL EDUCATION CREDIT INFORMATION
Accreditation This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the American College of Surgeons and the Central Surgical Association. The American College of Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
AMA PRA Category 1 Credits™ The American College of Surgeons designates this live activity for a maximum of 17.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Of the AMA PRA Category 1 Credits™ listed above, a maximum of 13 credits meet the requirements for Self-Assessment.
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CSA_2018_FinalProgram.indd 8 3/6/18 8:49 PM SCHEDULE AT A GLANCE
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CSA_2018_FinalProgram.indd 9 3/6/18 8:49 PM SCHEDULE AT A GLANCE Wednesday, March 14 2:30pm - 3:30pm CSAF Meeting | Robert King Room 3:30pm - 5:30pm Council Meeting | Robert King Room 3:00pm - 6:00pm Registration Open
Thursday, March 15 7:00am - 4:30pm Registration Open 7:00am - 9:00am Continental Breakfast for Physicians Bellows Balllroom ABC 7:30am - 8:00am Quick Shot Session 1 Bellows Ballroom DEF 8:00am - 10:00am Spouse & Companion Breakfast Private Dining Room 8:00am - 9:00am Local Program | Bellows Ballroom DEF 9:00am - 9:30am Debate | POEM vs Heller for Achalasia Bellows Ballroom DEF 9:30am - 10:00am Refreshment Break & Exhibits Bellows Ballroom ABC 10:00am - 11:40am Scientific Session 1 | Bellows Ballroom DEF 11:40am – 12:40pm Industry Sponsored Luncheon - Thank You Legally Mine USA! Private Dining Room 11:40am - 12:40pm Lunch Break - on own 12:40pm - 2:40pm Scientific Session 2 - New Member Papers Bellows Ballroom DEF 1:00pm Spouse/Guest Program Franklin Park Conservatory
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CSA_2018_FinalProgram.indd 10 3/6/18 8:49 PM SCHEDULE AT A GLANCE (continued) Thursday, March 15 2:40pm - 3:00pm Refreshment Break & Exhibits Bellows Ballroom ABC 3:00pm - 4:00pm Scientific Session 3 | Bellows Ballroom DEF 4:00pm - 4:30pm Quick Shot Session 2 Bellows Ballroom DEF 5:30pm - 7:30pm Welcome Reception | Lamp 7:30pm CSAF Dinner | Hyde Park Steakhouse
Friday, March 16 7:00am - 5:30pm Registration Open 7:00am - 8:30am Continental Breakfast for Physicians Bellows Ballroom ABC 7:30am - 8:30am Leadership That Gets Results Bellows Ballroom DEF 8:00am - 10:00am Spouse & Companion Breakfast Private Dining Room 8:30am - 9:00am Quick Shot Session 3 Bellows Ballroom DEF 9:00am - 9:20am Refreshment Break & Exhibits Introductions | Bellows Ballroom ABC 9:20am - 11:00am Scientific Session 4 | Bellows Ballroom DEF 11:00am - 11:45am Address of the President | Fred A. Luchette, MD, MSc Bellows Ballroom DEF 11:45am - 12:15pm CSA Foundation Awards & New Member Introductions Bellows Ballroom DEF
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CSA_2018_FinalProgram.indd 11 3/6/18 8:49 PM SCHEDULE AT A GLANCE (continued)
Friday, March 16 12:15pm - 1:15pm President’s Luncheon for New Members Private Dining Room 1:15pm - 3:15pm Scientific Session 5A Bellows Ballroom DEF 1:15pm - 3:15pm Scientific Session 5B | Robert King Room 3:15pm - 3:30pm Refreshment Break & Exhibits Bellows Ballroom ABC 3:30pm - 4:30pm Big Data and Healthcare Analytics Bellows Ballroom DEF 4:30pm - 5:30pm Annual Business Meeting (Members Only) | Bellows Ballroom DEF 6:00pm - 7:00pm Reception | Bellows North Foyer 7:00pm - 10:00pm Nonie Lowry Dinner Dance Bellows ABC
Saturday, March 17 7:30am - 11:30am Registration Open 7:30am - 9:00am Continental Breakfast for Physicians & Spouses | Bellows Foyer 8:00am - 9:40am Scientific Session 6 Bellows Ballroom DEF 9:40am - 10:10am Debate | Robotics vs Open Whipple Bellows Ballroom DEF 10:10am - 10:20am Refreshment Break | Bellows Foyer 10:20am - 11:40am Scientific Session 7 Bellow Ballrooms DEF Meeting Concludes 12 CENTRAL SURGICAL ASSOCIATION
CSA_2018_FinalProgram.indd 12 3/6/18 8:49 PM SCIENTIFIC PROGRAM
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CSA_2018_FinalProgram.indd 13 3/6/18 8:49 PM SCIENTIFIC PROGRAM Thursday, March 15
Thursday, March 15
7:30am - 8:00am Quick Shot Session 1 Moderator: Timothy Pritts MD, PhD | University of Cincinnati
7:30am - 7:40am QS 1. FEASIBILITY OF INTRA-OPERATIVE ANGIOEMBOLIZATION FOR TRAUMA PATIENTS USING C-ARM DIGITAL SUBTRACTION ANGIOGRAPHY A Alnumay MD, A Beckett MD, D Deckelbaum MD, P Fata MD, K Khwaja MD, T Razek MD, J Grushka MD Presenter: Abdulaziz Alnumay MD | McGill University Health Centre
7:40am - 7:50am QS 2. HYPERCALCEMIA IN THE CRITICALLY ILL SURGICAL PATIENT: PAMIDRONATE VS NO PAMIDRONATE HS Dolman MD, LR Howell PharmD, PJ Faris PharmD, L Hall Zimmerman PharmD, AE Baylor MD, TT Lavery MD, J Ciullo MD, JG Tyburski MD, RF Wilson MD Presenter: Heather Dolman MD | Wayne State University
7:50am - 8:00am QS 3. COMPLETION THYROIDECTOMY: A RISKY UNDERTAKING? CY Teng MD, KJ Nicholson MD, KL McCoy MD, SE Carty MD, L Yip MD Presenter: Cindy Teng MD | University of Pittsburgh
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CSA_2018_FinalProgram.indd 14 3/6/18 8:49 PM SCIENTIFIC PROGRAM Thursday, March 15
8:00am - 9:00am Local Program Moderator: Steven M. Steinberg, MD, MBA | The Ohio State University
Targeting Epigenetic Events in the Treatment of Sepsis Jon Wisler, MD | The Ohio State University
Development of a Protein Therapeutic to Treat Chronic Wounds Jianjie Ma, PhD | The Ohio State University
Tissue Nanotransfection Technology for Conversion of Adult Tissue Function Sashwati Roy, PhD | The Ohio State University
Laser Hair Removal to Decrease Pilonidal Disease Recurrence in Adolescents: From Observation to RCT Katherine Deans, MD, MHSc | Nationwide Children’s Hospital
9:00am - 9:30am Debate | POEM vs. Heller for Achalasia? Moderator: Nathaniel J. Soper, MD | Northwestern Medicine
Pro | POEM Michael B. Ujiki, MD | NorthShore University HealthSystem
Pro | Heller W. Scott Melvin, MD | Montefiore Medical Center and The Albert Einstein School of Medicine
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CSA_2018_FinalProgram.indd 15 3/6/18 8:49 PM SCIENTIFIC PROGRAM Thursday, March 15
10:00am - 11:40am Scientific Session 1 Moderator: Fred Luchette MD, MSc | Loyola University Medical Center
10:00am - 10:20am 1. TRANSPLANTATION OF HUMAN INTESTINAL ORGANOIDS INTO MOUSE MESENTERY: A MORE PHYSIOLOGIC AND ANATOMIC ENGRAFTMENT SITE AR Cortez MD, HM Poling BS, NE Brown BA, A Singh BA, MM Mahe PhD, MA Helmrath MD Presenter: Alexander Cortez MD | Cincinnati Children’s Hospital Medical Center Invited Discussant: Carlos Chan MD, PhD | University of Iowa
10:20am - 10:40am 2. EFFICIENCY OF CARE AND COST FOR EMERGENCY GENERAL SURGERY CONDITIONS: COMPARISON BY SURGEON TRAINING HA Ladhani MD, BM Zosa MD, E Verbus BS, CP Brandt MD, JA Claridge MD MS Presenter: Sarah E. Posillico, MD | MetroHealth Medical Center Invited Discussant: Juan A. Asensio MD | Creighton University Medical Center
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10:40am - 11:00am 3. EFFICACY OF SURGEON-PERFORMED, ULTRASOUND-GUIDED CERVICAL LYMPH NODE FINE NEEDLE ASPIRATION IN PATIENTS WITH THYROID PATHOLOGIES B Kahramangil MD, D El-Dabh BS, E Kose MD, V Krishnamurthy MD, J Jin MD, J Shin MD, A Siperstein MD, E Berber MD Presenter: Eren Berber MD | Cleveland Clinic Foundation Invited Discussant: Samuel Snyder MD | University of Texas Rio Grande Valley School of Medicine
11:00am - 11:20am 4. TEMPORAL EXPRESSION OF CIRCULATING MICRO-RNA FOLLOWING SEVERE INJURY SL Barnes MD, NJ Galbraith MD PhD, JV Carter MD PhD, SP Walker BS, SA Gardner BS, HC Polk MD Presenter: Norman Galbraith MD, PhD | University of Missouri & University of Louisville Invited Discussant: Timothy Pritts, MD, PhD | University of Cincinnati
11:20am - 11:40am 5. AN ENHANCED RECOVERY PROGRAM (ERP) IN COLORECTAL SURGERY: DOES IT IMPACT DISCHARGE AND POST DISCHARGE OPIOID PRESCRIBING? AW Gerrish MD, SL Fogel MD, ER Lockhart MS, MS Nussbaum MD, FC Adkins MD Presenter: Ashley Gerrish MD | Virginia Tech Carilion School of Medicine Invited Discussant: Melissa Times, MD | MetroHealth Medical Center
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CSA_2018_FinalProgram.indd 17 3/6/18 8:49 PM SCIENTIFIC PROGRAM Thursday, March 15
12:40pm - 2:20pm Scientific Session 2 Moderator: Timothy Pawlik MD, MPH, PhD | The Ohio State University
12:40pm - 1:00pm 6*. SURGEON ASSOCIATED VARIATION IN BREAST CANCER STAGING WITH SENTINEL NODE BIOPSY KE Larson MD, C Tu MS, J Dalton PhD, SA Valente DO, SR Grobmyer MD Presenter: Stephen Grobmyer MD | Cleveland Clinic Foundation Invited Discussant: Tina Yen MD, MS | Medical College of Wisconsin
1:00pm - 1:20pm 7*. IMPROVING THE MORTALITY INDEX BY CAPTURING PATIENT ACUITY THROUGH INTERPROFESSIONAL REAL TIME DOCUMENTATION IMPROVEMENT CR Horwood MD, SD Moffatt-Bruce MD PhD, T Latimer, CJ Powers MD PhD, GD Rushing MD, DS Eiferman MD Presenter: Chelsea R Horwood MD | The Ohio State University Invited Discussant: A. Peter Ekeh MD, MPH | Wright State University
1:20pm - 1:40pm 8*. DEFINING THE TIME COURSE OF MORTALITY FOLLOWING LIVER TRANSPLANTION EW Beal MD, D Tumin PhD, D Azoulay MD, S Black MD PhD, K Washburn MD, TM Pawlik MD MPH PhD Presenter: Eliza Beal MD | The Ohio State University Invited Discussant: Joseph Buell MD, MBA | Tulane University Medical Center * CSA Best New Member paper 18 CENTRAL SURGICAL ASSOCIATION
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1:40pm - 2:00pm 9. LONG TERM EXPERIENCE WITH DIAPHRAGM PACING FOR TRAUMATIC SPINAL CORD INJURY: EARLY IMPLANTATION POST INJURY IS MORE BENEFICIAL RP Onders MD, MJ Elmo ACNP, C Kaplan, R Schilz DO PhD Presenter: Raymond Onders MD | University Hospitals Cleveland Medical Center Invited Discussant: Jonathan Saxe MD | St Vincent Hospital
2:00pm - 2:20pm 10. DNA PROFILE COMPONENTS PREDICT MALIGNANT OUTCOMES IN SELECT CASES OF INTRADUCTAL PAPILLARY MUNCINOUS NEOPLASM WITH NEGATIVE CYTOLOGY RE Simpson MD, NJ Cockerill MS, MT Yip-Schneider PhD, EP Ceppa MD, MG House MD, NJ Zyromski MD, A Nakeeb MD, MA Al-Haddad MD, CM Schmidt MD PhD MBA Presenter: Rachel Simpson MD | Indiana University School of Medicine Invited Discussant: R. Matthew Walsh MD | Cleveland Clinic Foundation
2:20pm - 2:40pm 11. THE IMPACT OF ENHANCED RECOVERY PATHWAYS ON COST OF CARE AND PERI-OPERATIVE OUTCOMES IN SURGICAL ONCOLOGY PATIENTS N Bhutiani MD, SA Quinn BS, KM McMasters MD PhD, CR Scoggins MD MBA, P Philips MD, Robert CG Martin II MD PhD Presenter: Neal Bhutiani MD | University of Louisville Invited Discussant: Natalie Joseph MD | MetroHealth Medical Center
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CSA_2018_FinalProgram.indd 19 3/6/18 8:49 PM SCIENTIFIC PROGRAM Thursday, March 15
3:00pm - 4:00pm Scientific Session 3 Moderator: Linwah Yip MD | University of Pittsburgh
3:00pm - 3:20pm 12. TEN YEAR REASSESSMENT OF THE SHORTAGE OF GENERAL SURGEONS(GS): INCREASES IN GENERAL SURGEON RESIDENCY(GSR) GRADUATION NUMBERS ARE INSUFFICIENT TO MEET FUTURE GS DEMAND TM Pawlik MD, B Satiani MD, DP Way MEd, TE Williams MD Presenter: E Christopher Ellison MD | The Ohio State University Invited Discussant: Michael Nussbaum MD | Virginia Tech Carilion
3:20pm - 3:40pm 13. FAILURE OF GASTRIC PROPHYLAXIS AGAINST STRESS BLEEDING (SB) REFLECTS INADEQUATE PH CONTROL JW Mesquita MD, CM Kline MD, CE Lucas MD, P Vernier RN, AM Ledgerwood MD Presenter: Jose Wilson Mesquita MD | Wayne State University Invited Discussant: Donald Fry MD | MPA Healthcare Solutions
3:40pm - 4:00pm 14. A COMPARISON OF THE BOEY, PULP, AND AAST EGS GRADE FOR PERFORATED PEPTIC ULCER DISEASE MC Hernandez MD, MJ Thorn CNP, VY Kong MBChB PhD, JM Aho MD PhD, DH Jenkins MD, MD Zielinski MD, DL Clarke MBChB PhD Presenter: Matthew Hernandez MD | Mayo Clinic, Rochester Invited Discussant: Jon Gould MD | Medical College of Wisconsin
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CSA_2018_FinalProgram.indd 20 3/6/18 8:49 PM SCIENTIFIC PROGRAM Thursday, March 15
4:00pm - 4:30pm Quick Shot Session 2 Moderator: Stephen Barnes MD | University of Missouri
4:00pm - 4:10pm QS 4. DOES SPECIFIC IMMUNOSUPPRESSIVE AGENTS AFFECT POST RENAL TRANSPLANT INFECTIONS D Monlezun MD PhD, M John MD, C McDermott BA, G Parker PhD, M Darden PhD, JF Buell MD MBA Presenter: Joseph Buell MD, MBA | Tulane University
4:10pm - 4:20pm QS 5. ADHERENCE TO RECOMMENDED VTE PROPHLAXIS IN ABDOMINAL AND PELVIC ONCOLOGIC SURGERY IN A COMMUNITY HOSPITAL MK Zipple MD, ER Itenberg DO, HS Dolman MD Presenter: Monica Zipple MD | Saint Joseph Mercy Oakland
4:20pm - 4:30pm QS 6. TREATMENT OF INTRA-ABDOMINAL HYPERTENSION PREVENTS PROGRESSION TO ABDOMINAL COMPARTMENT SYNDROME IN COMPLEX VENTRAL HERNIA REPAIR R Chandra, RA Jacobson MD, KW Millikan MD, JL Poirier PhD, NF Siparsky MD Presenter: Raghav Chandra | Rush University Medical Center
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Friday, March 16
7:30am - 8:30am Leadership That Gets Results Moderators: John Schaffner, MBA, Certified Professional Coach | The Ohio State University Fisher School of Business; Daniel S. Eiferman, MD, MBA | The Ohio State University
8:30am - 9:00am Quick Shot Session 3 Moderator: C. Max Schmidt MD, PhD, MBA, Indiana University School of Medicine
8:30am - 8:40am QS 7. WORKFLOW EFFICIENCY PILOT STUDY OF SURGERY VIEWER© - A SECURE HANDS-FREE INTRAOPERATIVE MULTIMEDIA INTERFACE FOR GOOGLE GLASS™ S Ahmad, J Tann, A Clark, J Gaddy, A McKenzie, A Zentz, C Jackson, B Naumann, J Castaneda, S Toy, C Leighow, B Kiburz, T Green Presenter: John Tann MD | University of Missouri
8:40am - 8:50am QS 8. OUTCOMES OF BARIATRIC SURGERY ARE EQUIVALENT IN MEDICARE AND NON-MEDICARE PATIENTS AT TEN-YEAR FOLLOW-UP MO Meneveau MD, AD Michaels MD, RB Hawkins MD MSc, JH Mehaffey MD, B Schirmer MD, PT Hallowell MD Presenter: Max Meneveau MD | University of Virginia
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8:50am - 9:00am QS 9. DISSEMINATED INJECTION OF VINCRISTINE- LOADED SILK GEL IMPROVES THE SUPPRESSION OF NEUROBLASTOMA TUMOR GROWTH J Zeki BS, B Yavuz PhD, J Coburn PhD, N Ikegaki PhD, J Harris MD, D Kaplan MD, B Chiu MD Presenter: Jamie Harris MD | University of Illinois at Chicago
9:20am - 11:00am Scientific Session 4 Moderator: Margo Shoup MD | Northwestern Medicine
9:20am - 9:40am 15. A POSTOPERATIVE PARATHYROID HORMONE ALGORITHM TO REDUCE SYMPTOMATIC HYPOCALCEMIA FOLLOWING COMPLETION/TOTAL THYROIDECTOMY: A RETROSPECTIVE ANALYSIS OF 591 PATIENTS IG Mazotas MD, TWF Yen MD, J Park BS, AA Carr MD, DB Evans MD, TS Wang MD Presenter: Ioanna Mazotas MD | Medical College of Wisconsin Invited Discussant: Kelly McCoy MD | University of Pittsburgh
9:40am - 10:00am 16. EARLY GENETIC COUNSELING AND DETECTION OF CDH1 MUTATION IN ASYMPTOMATIC CARRIERS IMPROVES SURVIVAL IN HEREDITARY DIFFUSE GASTRIC CANCER MA Moslim MD, B Leach LGC, CA Burke MD, RM Walsh MD Presenter: Maitham A Moslim MD | Cleveland Clinic Foundation Invited Discussant: Jeffrey Hardacre MD | University Hospitals of Cleveland
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10:00am - 10:20am 17. REPEAL OF THE MICHIGAN HELMET LAW: IMPACT ON ORGAN DONATION RATES S Thorp MD, J Le MD, NS Adams MD, AT Davis PhD, CJ Gibson MD, GP Wright MD, CH Rodriguez MD, GA Iskander MD, AJ Chapman MD Presenter: Stephen Thorp MD | Spectrum Health Invited Discussant: Wendy Wahl MD | Saint Joseph Mercy Ann Arbor
10:20am - 10:40am 18. WISCONSIN’S ENTERRA THERAPY™ EXPERIENCE: A MULTI-INSTITUTIONAL REVIEW OF GASTRIC ELECTRICAL STIMULATION FOR MEDICALLY REFRACTORY GASTROPARESIS A Shada MD, A Nielsen, S Marowski, M Helm RN, L Funk MD, A Kastenmeier MD, A Lidor MD, JC Gould MD Presenter: Jon Gould MD | Medical College of Wisconsin Invited Discussant: L. Michael Brunt MB | Barnes-Jewish Hospital/ Washington University School of Medicine
10:40am - 11:00am 19. TIME TO RE-EVALUATE COLONOSCOPY AGE CUTOFF? ADENOMAS MORE COMMON IN ELDERLY THAN THOUGHT J Fischer MD, J Thiele MD, N Engelking RN, J Rakinic MD Presenter: James Thiele MD | Springfield Clinic-Southern Illinois University Invited Discussant: William Cirocco MD | The Ohio State University
11:00am – 11:45am Address of the President | So Many Commitments, So Little Time: Is This a Recipe for Burn Out? Fred Luchette MD, MSc | Loyola University Medical Center
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1:15pm - 3:15pm Scientific Session 5 - A Moderator: R. Matthew Walsh MD | Cleveland Clinic Foundation
1:15pm - 1:35pm 20. RISK FACTORS FOR 30-DAY READMISSION FOLLOWING ADRENALECTOMY AC Beck MD, P Goffredo MD, G Lal MD, JR Howe MD, RJ Weigel, MD PhD Presenter: Anna C. Beck MD | University of Iowa Invited Discussant: Tina Yen MD, MS | Medical College of Wisconsin
1:35pm - 1:55pm 21. LONG TERM WEIGHT CHANGE AND HEALTH OUTCOMES FOR SLEEVE GASTRECTOMY AND MATCHED ROUX-EN-Y GASTRIC BYPASS PARTICIPANTS IN THE LONGITUDINAL ASSESSMENT OF BARIATRIC SURGERY (LABS) STUDY BH Ahmed MD, WC King PhD, WF Gourash PhD, SH Belle PhD, AS Hinerman MPH, AP Courcoulas MD Presenter: Bestoun Ahmed MD | University of Pittsburgh Invited Discussant: Peter Hallowell MD | UVA Medical Center
1:55pm - 2:15pm 22. THE EDUCATING ENIGMA: DOES TRAINING LEVEL IMPACT POST-OPERATIVE OUTCOME? GL Bonner MD, SM Kalantar MD, M Abbas MD, R Mustafa MD, L Khaitan MD Presenter: Gwen Bonner MD | University Hospitals Cleveland Medical Center Invited Discussant: Gary Dunnington MD | Indiana University School of Medicine
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2:15pm - 2:35pm 23. FINE NEEDLE ASPIRATION BIOPSY OF THYROID NODULES: IS ULTRASOUND-GUIDANCE NECESSARY? KC Choong MD, CR McHenry MD Presenter: Kevin Choong MD | MetroHealth Medical Center Invited Discussant: Tracy Wang MD, MPH | Medical College of Wisconsin
2:35pm - 2:55pm 24. DOES LAPAROSCOPIC LIVER RESECTION REDUCE THE INCIDENCE OF POST-OPERATIVE BILE LEAKS: A MULTI-INSTITUTIONAL ANALYSIS AA Smith MD PhD, J Buell MD MBA, D Iannitti MD Presenter: Joseph Buell MD, MBA | Tulane University Invited Discussant: Shimul Shah MD, MHCM | University of Cincinnati
2:55pm - 3:15pm 25. SURGEON VOLUME CORRELATES WITH PERIOPERATIVE BLOOD TRANSFUSIONS AFTER PANCREATICODUODENECTOMY K Wima MS, Y Kim MD, SA Ahmad MD, SA Shah MD Presenter: Vikrom Dhar MD | University of Cincinnati Invited Discussant: Juan Sanabria MD MSc | Case Western Reserve & Marshall University
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1:15pm - 3:15pm Scientific Session 5 - B Moderator: Wendy L. Wahl MD | Saint Joseph Mercy Ann Arbor
1:15pm - 1:35pm 26. COMMUNICATION THROUGH SIMULATION: DEVELOPING A CURRICULUM TO TEACH INTERPERSONAL SKILLS VA Fleetwood MD, B Veenstra MD, A Wojtowicz BS, J Kerchberger MD, J Velasco MD Presenter: Vidya Fleetwood MD | Rush University Medical Center Invited Discussant: Gerald Fried MD | McGill University
1:35pm - 1:55pm 27. HCAHPS SCORES AS A SURROGATE FOR QUALITY DOES NOT CORRELATE WITH TQIP QUALITY MEASURES AT A LEVEL 1 TRAUMA CENTER C Thoma-Perry, BA, E. Blocher-Smith, BS, L Jacobson, MD Presenter: Jonathan Saxe MD | Marian College of Osteopathic Medicine / St. Vincent Hospital Invited Discussant: Salman Ahmad MD | University of Missouri
1:55pm - 2:15pm 28. INCREASING THE NUMBER OF LEVEL II TRAUMA CENTERS IN A GIVEN GEOGRAPHIC AREA: IS THERE A MEASURABLE EFFECT ON TRAFFIC FATALITIES? DN Reed MD, H Singh MBBS, JJ Oury BS, RM Mason BS, R Jones Pharm.D., AM Chard RN, B Henriksen PhD Presenter: Donald N. Reed, Jr. MD | Lutheran Hospital Invited Discussant: Amit Basu MD | Jamaica Hospital Medical Center
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2:15pm - 2:35pm 29. OUTCOMES OF SURGICAL MANAGEMENT OF DUODENAL INJURIES AT AN URBAN, COMMUNITY BASED, LEVEL 1 TRAUMA CENTER A Basu MD, RJ Robitsek PhD, J Chan MD, A Wong MD, K McKenzie DO, D Sammett MD PhD, A Khalil MD, S Schubl MD, A Magh MD, A Alpuerto BS, G Doughlin MD, K Fretwell MD Presenter: Amit Basu MD | Jamaica Hospital Medical Center Invited Discussant: Kenneth Davis MD | University of Cincinnati
2:35pm - 2:55pm 30. DIRECT ORAL ANTICOAGULANTS (DOAC) DO NOT WORSEN OUTCOMES IN TRAUMATIC BRAIN INJURY (TBI) FROM LOW LEVEL FALLS IN THE ELDERLY M Yassen PharmD, J Hecht PharmD, C Callahan PharmD, WL Wahl MD Presenter: Jason Hecht PharmD, BCCCP, BCPS | Saint Joseph Mercy Ann Arbor Invited Discussant: Fred Luchette MD, MSc | Loyola University Medical Center
2:55pm - 3:15pm 31. TIMING OF CAROTID ENDARTERECTOMY AFTER A RECENT MILD TO MODERATE STROKE SS Hans MD, I Catanescu Presenter: Sachinder Singh Hans MD | Henry Ford Macomb Hospital Invited Discussant: Mounir J. Haurani MD | The Ohio State University
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3:30pm – 4:30pm Big Data and Healthcare Analytics Moderator: Paul C. Kuo, MD | University of South Florida/ Tampa General Hospital
Overview – Potential for the Future, Why Big Data Now? Paul C. Kuo, MD | University of South Florida/ Tampa General Hospital
Traditional Statistics vs. KDD/Statistical Learning Erich Huang, MD, PhD | Duke University
Statistical Approaches vs. Machine Learning Adrienne N. Cobb, MD | Loyola University Medical Center; Andrew J. Benjamin, MD | University of Chicago
Panel Discussion
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8:00am - 9:40am Scientific Session 6 Moderator: Daniel S. Eiferman MD, MBA | The Ohio State University
8:00am - 8:20am 32. SURGICAL STAGING IS SUPERIOR TO PET SCAN FOR ASSESSMENT OF DISEASE RESPONSE FOLLOWING CHEMOTHERAPY FOR MEDIASTINAL LYMPHOMA LT Kane BS, H Savas MD, MM DeCamp MD, A Bharat MD Presenter: Liam Kane BS | Northwestern University Invited Discussant: Jeffrey Sussman MD | University of Cincinatti
8:20am - 8:40am 33. MEDICARE OUTCOMES IN ELECTIVE MAJOR VASCULAR SURGERY SM Nedza MD, M Pine MD, AM Reband BS, C-J Huang PhD, G Pine BA Presenter: Donald Fry MD | MPA Healthcare Solutions Invited Discussant: Sachinder Hans MD | Henry Ford Health System
8:40am - 9:00am 34. PREDICTING BURN PATIENT MORTALITY WITH ELECTRONIC MEDICAL RECORDS A Cobb MD, PC Kuo MD MBA Presenter: Matthew Cheung BS | Loyola University Medical Center Invited Discussant: Steven Steinberg MD | The Ohio State University
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9:00am - 9:20am 35. SUPERUSERS: DRIVERS OF HEALTHCARE COSTS IN THE NATIONAL TRAUMA POPULATION LA Gil BS BA, A Kothari MS MD, S Brownlee BA, H Ton-That MD, R Gonzalez MD, FA Luchette MSc MD, MJ Anstadt MD Presenter: Lindsay Gil BS, BA | Loyola University Medical Center Invited Discussant: Brian Harbrecht MD | University of Louisville
9:20am - 9:40am 36. IMPACT OF ANTICIPATED FINANCIAL BURDEN ON PATIENT DECISION TO UNDERGO CONTRALATERAL PROPHYLACTIC MASTECTOMY J Huang AB, AB Chagpar MD Presenter: Julian Huang AB | Yale University School of Medicine Invited Discussant: Jose M Velasco MD | Rush University
9:40am – 10:10am Debate | Robotics vs. Open Whipple Moderator: C. Max Schmidt, MD, PhD, MBA | Indiana University School of Medicine
Pro | Robotic Whipple Amer Zureikat, MD | UPMC Department of Surgery
Pro | Open Whipple Carl Schmidt, MD | The Ohio State University
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10:10am - 11:30am Scientific Session 7 Moderator: Peter Angelos MD, PhD | University of Chicago
10:10am - 10:30am 37. OPERATIVE TIME IN ESOPHAGECTOMY: DOES IT AFFECT OUTCOMES? NP Valsangkar MD, H Salfity MD, L Timsina PhD, M Kilbane BSN, E Ceppa MD, D Ceppa MD, T Birdas MD Presenter: Nakul Valsangkar MD | Indiana University School of Medicine Invited Discussant: Matthew Schuchert MD | University of Pittsburgh Medical Center
10:30am - 10:50am 38. ADDITIONAL AND REPEATED CT SCAN IN INTER-FACILITIES TRAUMA TRANSFERS: ROOM FOR IMPROVEMENT D Bracco MD, G Artho MD, D Deckelbaum MD, DS Mulder MD, T Razek MD Presenter: David Bracco MD, PhD, MBA | David S Mulder Trauma Center Invited Discussant: Daniel Eiferman MD, MBA | Ohio State University
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10:50am - 11:10am 39. POSTOPERATIVE OPIOID PRESCRIBING PRACTICES AND THE IMPACT OF THE HYDROCODONE SCHEDULE CHANGE WH Tan MD, JM McAllister MD, S Feaman MA CCRP, JA Blatnik MD, LM Brunt MD Presenter: Wen Hui Tan MD | Washington University in St. Louis School of Medicine Invited Discussant: Jonathan Saxe MD | St Vincent Hospital
11:10am - 11:30am 40. SAME DAY DISCHARGE AFTER THYROIDECTOMY IS SAFE AND EFFECTIVE HA Reinhart MD, SK Snyder MD, SV Stafford MD, VE Wagner BS , CW Graham MD, MD Bortz MD, X Wang PhD Presenter: Henry Reinhart MD | Baylor Scott and White Health, UT Rio Grande Valley School of Medicine Invited Discussant: Raymon Grogan MD, MS | Baylor Medical College
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CSA_2018_FinalProgram.indd 34 3/6/18 8:49 PM ORAL ABSTRACTS
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1. TRANSPLANTATION OF HUMAN INTESTINAL ORGANOIDS INTO MOUSE MESENTERY: A MORE PHYSIOLOGIC AND ANATOMIC ENGRAFTMENT SITE AR Cortez MD, HM Poling BS, NE Brown BA, A Singh BA, MM Mahe PhD, MA Helmrath MD Cincinnati Children’s Hospital Medical Center
Purpose: Significant progress towards growing patient specific human bowel occurred with our published methods to direct pluripotent stem cells into human intestinal organoids (HIO). HIOs form fully laminated and functional intestine when they are transplanted into the kidney capsule of mice. While sufficient for certain aspects of biological study, this retroperitoneal location presents limitations for disease modeling and translational studies needed for future human application. A limitation of our existing model is the inability to transpose the matured transplanted HIO (tHIO) intra-abdominally and place in continuity with the host’s intestine. Herein, we describe an alternative model involving HIO transplantation into the mesentery of mice. We hypothesize that this model will result in increased growth of tHIOs, similar to our kidney model. However, this more anatomically favorable engraftment site will provide vascular ingrowth into the splanchnic circulation, thereby enabling improved functional studies and placement into the host’s luminal content stream.
Methods: The H1 embryonic stem cell line was directed into definitive endoderm and subsequently into HIOs as previously described by our group. HIOs between 28 and 36 days were studied directly or transplanted into the mesentery of 5-8 week old male NOD-scid IL2Rgnull (NSG) mice. Gross and histologic analysis of the tissue was performed. Statistical analysis was performed using Student’s t-test. P-value <0.05 was considered statistically significant.
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Results: In vitro HIOs (n=15) were directly studied and compared to HIOs that were transplanted into the mesentery of mice (n=14) and allowed to grow for 10 weeks (Figure A, B). The survival rate was 93% and 86% of the tHIOs successfully engrafted. At the time of harvest, tHIOs were approximately 46 times larger than in vitro (1.75mm±0.44 vs 6.27mm±1.43, p<0.0001) (Figure C). Histologic analyses of tHIOs confirmed the presence of enterocytes, goblet cells, Paneth cells and enteroendocrine cells, as well as stem cell activity.
Conclusion: The mesentery of NSG mice is a suitable and viable location for the transplantation of HIOs, yielding grafts of reproducible size and quality. We believe that this improved engraftment site will serve to further aid in functional and translational studies of stem cell based intestinal organoid development.
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2. EFFICIENCY OF CARE AND COST FOR EMERGENCY GENERAL SURGERY CONDITIONS: COMPARISON BY SURGEON TRAINING HA Ladhani MD, BM Zosa MD, E Verbus BS, CP Brandt MD, JA Claridge MD MS MetroHealth Medical Center
Purpose: At our institution emergency general surgery (EGS) consults are seen by a designated service that is staffed by either trauma/surgical critical care boarded acute care surgeons (TACS) or boarded general surgeons (GS). Little is known regarding the effect that TACS have on outcomes when compared to GS across multiple EGS diagnoses. Therefore, the purpose of this study was to evaluate differences in outcomes for common EGS conditions when managed by TACS versus GS.
Methods: All adult patients admitted between February 2014 and May 2017 with a diagnosis of acute appendicitis, acute cholecystitis, bowel obstruction, incarcerated hernia without obstruction, or acute abdomen for which the EGS service was consulted were included. Data collected included patient demographics, consult attending type, time and day of consultation, operations (OR), and costs. Primary outcomes were time from consultation to OR, operative time, length of stay (LOS), and costs for ED, OR, and total hospitalization. Subgroup analysis of patients with acute appendicitis or acute cholecystitis was performed.
Results: A total of 1363 patients were included; 384 (28.2%) with acute appendicitis, 477 (35.0%) with acute cholecystitis, 406 (29.8%) with bowel obstruction, 22 (1.6%) with incarcerated hernia without obstruction, and 74 (5.4%) with an acute abdomen. TACS saw 836 (61.3%) patients and GS saw 527 (38.7%) patients. There were no differences in age, frequency of specific EGS diseases, operative management or operative time between the 2 groups. Patients seen by TACS had significantly
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shorter time from consultation to OR than patients seen by GS, however, there were no differences in total LOS (Table 1). Subgroup analysis of 861 patients diagnosed with either acute appendicitis or acute cholecystitis demonstrated that TACS had significantly shorter time to OR (8 vs 17 hrs, p<=0.001) and total LOS (2 vs 3 days, p=0.021) than GS (Table 1).
Conclusion: TACS surgeons provided more efficient management of EGS conditions when compared to GS, demonstrated by shorter time to OR for all EGS patients and shorter LOS for acute appendicitis and acute cholecystitis patients. These results add credibility to TACS primarily staffing EGS services.
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3. EFFICACY OF SURGEON-PERFORMED, ULTRASOUND- GUIDED CERVICAL LYMPH NODE FINE NEEDLE ASPIRATION IN PATIENTS WITH THYROID PATHOLOGIES B Kahramangil MD, D El-Dabh BS, E Kose MD, V Krishnamurthy MD, J Jin MD, J Shin MD, A Siperstein MD, E Berber MD Cleveland Clinic Foundation
Purpose: Although the utility of surgeon-performed, ultrasound- guided (SP-UG) fine needle aspiration (FNA) of thyroid nodules is well established, data on lymph node (LN) FNA are scant. We aim to study the efficacy of SP-UG cervical LN FNA and its impact on the management of patients with thyroid pathologies.
Methods: This is an IRB-approved study of patients who underwent SP-UG cervical LN FNA for thyroid pathologies between 2002 and 2017. All procedures were performed by endocrine surgeons at a tertiary center. Clinical parameters were obtained through chart review. Multivariable logistic regression was performed.
Results: 147 patients (58.4% female, n=104) underwent 178 FNAs (124 for postoperative follow-up, 54 for preoperative work-up; 87 had thyroglobulin washout). Mean age was 49.2±17.8 years and BMI 28.0±6.3 kg/m2. Underlying pathology was thyroid cancer (differentiated [71.4%, n=105/147] and medullary [12.9%, n=19/147]) and benign thyroid nodule (15.7%, n=23/147). Biopsied LNs were 52.8% (n=94/178) left-sided and 47.2% (n=84/178) right-sided. 75.3% (n=134/178) of LNs were in the lateral and 24.7% (n=44/178) in the central compartment. Mean size of biopsied LNs was 1.4±0.7 cm. Overall, sufficient FNA sampling rate was 93.3% (cytology malignant: 50.6% [90/178], benign: 39.9% [71/178], indeterminate: 2.8% [5/178]). On logistic regression, sampling success was independent of demographics, LN side, size, and compartment. Excluding indeterminate and insufficient aspirations, FNA prompted addition of lateral neck dissection in 44.4% (25/45) of
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preoperative patients. In postoperative follow-up, FNA prompted central and lateral neck dissection in 21.9% (19/87) and 40.2% (35/87) of patients, respectively. FNA result correlated with final pathology in 98.7% (75/76) of excised LNs. Excluding indeterminate and insufficient aspirations, FNA cytology showed 88.9% (72/81) concordance with thyroglobulin washout.
Conclusion: To our knowledge, this is the largest study looking at the utility of SP-UG FNA of cervical LNs in patients with thyroid pathology. Sampling success was high, comparable to that reported for thyroid nodules. We recommend adoption this practice to perform a highly accurate and convenient, single-visit comprehensive evaluation of patients with thyroid nodules and cancer.
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4. TEMPORAL EXPRESSION OF CIRCULATING MICRO-RNA FOLLOWING SEVERE INJURY SL Barnes MD, NJ Galbraith MD PhD, JV Carter MD PhD, SP Walker BS, SA Gardner BS, HC Polk MD University of Missouri & University of Louisville
Purpose: Major trauma can lead to immune dysfunction which can predispose patients to infection, multi-organ failure and death. The search for valid markers of subtle predisposition to infection in the newly admitted trauma patients have been studied over the past 20 years. MicroRNAs (miRNAs) are short non-coding RNAs that regulate and alter gene expression in innate signaling pathways after injury. The purpose of this study was to confirm previously reported differences in miRNAs identified on screening studies in patients with severe injury via sequential observations.
Methods: Fourteen severely injured patients with hemorrhagic shock were studied with sequential blood samples from admission to the intensive care unit (ICU) (time 0), then at 6, 12, 24 and 48 hours thereafter. RNA was extracted from PAXgene tubes and ten previously reported dysregulated miRNAs (let 7a, let 7f, let 7i, miR-19b, miR-106a, miR-142, miR-186, miR-199, miR- 221, miR-618) were verified using single assay qRT-PCR (Surgery, 2014). Fourteen healthy volunteers were used as controls.
Results: Mean Injury Severity Score (ISS) was 26 and mean patient age was 42 and. On average 11 units of packed red blood cells were transfused. Seven patients developed infection (median, day 8) and one patient died. miR-106a was significantly downregulated at 0 h, 24 h and 48 h as compared to controls (p=0.02, p<0.01, p=0.03, respectively. See Figure). miR-618 was upregulated at 0 h after injury (p<0.05). At 24 h after injury, miR- 618 and miR-199 were upregulated and let-7i was downregulated (p<0.05). All but miR-106a returned to the levels of normal by 48
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h. In patients who developed infection, miR-106a levels appeared more downregulated than those who did not (p>0.05).
Conclusion: miR-106a was significantly downregulated in trauma patients following major injury for up to 48 h. Target genes of miR-106a include TNF-α and IL-10, which are known to govern the immune response after trauma. Therapeutic manipulation miR-106a expression may, in the future allow for early correction of immune dysfunction.
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5. AN ENHANCED RECOVERY PROGRAM (ERP) IN COLORECTAL SURGERY: DOES IT IMPACT DISCHARGE AND POST DISCHARGE OPIOID PRESCRIBING? AW Gerrish MD, SL Fogel MD, ER Lockhart MS, MS Nussbaum MD, FC Adkins MD Virginia Tech Carilion School of Medicine
Purpose: The multi-modal approach to pain control in enhanced recovery programs (ERP) have been demonstrated to decrease opioid use in hospital, and decrease length of stay. The purpose of this study is to investigate if similar decreases are achieved in discharge and post discharge opioid prescribing.
Methods: A retrospective review was performed of patients undergoing colorectal surgery from November 2014-2016 at an academic tertiary referral center. Data regarding patient demographics, LOS, diagnoses, operative procedures and multimodality pain management were collected. Post discharge narcotic prescribing was quantified in morphine milligram equivalents(MME) at time of discharge, 30 days and 60 days post discharge by reviewing the prescription history in the electronic medical record. T-tests were used to analyze continuous variables, and chi-square tests were used to analyze categorical variables. Forward selection linear regression models were used to examine factors predictive of MME prescribed at discharge, 30 days, and 60 days usage.
Results: 775 patients were reviewed (324 treated on ERP protocol and 451 off ERP protocol). ERP patients had shorter LOS (6.74 vs. 9.0 days, p<0.0001). There were no differences in preoperative narcotic use (20.68% vs. 21.73%, p=0.72) or postoperative complications (10.49% vs 13.75, p=0.175). ERP patients were more likely to receive perioperative pain control including epidural or spinal anesthetics (59.6% vs 35.7%, p<0.0001). At discharge, ERP patients were prescribed higher amounts of opioids (MME 307.4 vs. 242.5, p=0.001), and were
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more likely to receive additional opioid prescriptions in the next 30 days (28.7% vs 18.85%, p=0.0013) and receive higher amounts of opioids in the first 30 days post discharge (213.2 vs. 98.3, p=0.0249). No statistical difference in prescribing was seen at 60 days post discharge. Forward selection linear regression models with a model R2=0.105 suggest that preoperative narcotic use (F=45.47, p<0.0001, partial R2=0.056), age (F=34.47, p<0.0001, partial R2=0.040), and treatment on ERP protocol (F=8.16, p=0.004, partial R2 =0.010), were predictive of opioid prescribing (MME) at time of discharge.
Conclusion: ERP patients surprisingly received more opioid prescribing (MME) at discharge and within the first 30 days post discharge. Alternative confounding variables such as individual provider prescribing habits require further investigation.
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6. SURGEON ASSOCIATED VARIATION IN BREAST CANCER STAGING WITH SENTINEL NODE BIOPSY KE Larson MD, C Tu MS, J Dalton PhD, SA Valente DO, SR Grobmyer MD Cleveland Clinic Foundation
Purpose: Axillary staging in breast cancer (BC) is essential for informing adjuvant treatment and prognosis. Sentinel lymph node (SLN) biopsy is the gold standard for axillary staging, so it is paramount that this operation be both precise and accurate as excessive SLN removal increases morbidity while under staging risks inadequate treatment. The goal of this study was to assess if there is individual surgeon associated variation in the number of SLN removed and the subsequent oncologic yield of SLN biopsy for BC.
Methods: All patients in the SEER-Medicare database who underwent surgical treatment of BC from 2007-2011 were eligible for inclusion. De-identified provider codes were used to track operations performed by individual surgeons. Only records in which a provider could be linked to a specific BC operation were analyzed. The total number of SLN removed and the number that were pathologically positive (oncologic yield) were recorded. Surgeon variation by T-stage was analyzed using linear mixed effect and logistic regression models.
Results: Database query identified 15,571 patients who met inclusion criteria, representing 2478 providers. The providers performed 1.3 SLN biopsy procedures per year on average (range 1-103 per provider per year). The lowest quartile of providers performed 1 or fewer SLN procedures per year. The highest quartile of providers performed at least 8 SLN procedures per year. The average number of SLN removed per operation increased significantly with increasing T stage for all providers (p<0.001), including when both N0 (p<0.001) and node positive (p=0.003) patients were evaluated separately. There was no
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statistically significant surgeon-associated variation in the number of SLN removed for each T stage. However, there was a statistically significant surgeon-associated variation in the oncologic yield (SLN positivity rate) by T stage. (Table)
Conclusion: Although the average number of SLN removed is consistent among surgeons, there is a statistically significant surgeon-associated variation in the SLN positivity rate (oncologic yield), and thus variation in the axillary staging of BC patients based on provider. These findings suggest concern for appropriate identification of the SLN and the need for practice standardization in SLN BC operations. New outcome oriented quality metrics related to SLN biopsy yield may help ensure optimal patient care.
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7. IMPROVING THE MORTALITY INDEX BY CAPTURING PATIENT ACUITY THROUGH INTERPROFESSIONAL REAL TIME DOCUMENTATION IMPROVEMENT CR Horwood MD, SD Moffatt-Bruce MD PhD, T Latimer, CJ Powers MD PhD, GD Rushing MD, DS Eiferman MD The Ohio State University
Purpose: The observed to expected mortality ratio (O:E) is an adjustment factor for reporting inpatient mortality and is used as a measure for hospital quality and outcome rankings. The ratio comprises a fixed observed value divided by an adjustable expected value which is determined by patient acuity and co-morbidities. The goal of this study is to describe a single institution’s mortality index reduction initiative through improved documentation of patient severity.
Methods: Data was prospectively collected and reviewed from October 2015-May 2016 on patients discharged from the Acute Care Surgery (ACS), Open Heart Surgery (OHS), Neurosurgery (NS), and Hospital Medicine (HM). Mortalities were reviewed by a committee comprised of quality nurses, coding staff, documentation specialists, and physicians prior to billing. Each mortality was reviewed to identify any missed diagnosis codes that correlated with the patient’s primary diagnosis related group (DRG). The coding staff explicitly complied with the official coding guidelines and had the final approval or denial for every code captured based on these guidelines. These captured codes would then be risk adjusted based on the VizientTM risk adjustment model for mortality and the O:E ratio was calculated.
Results: Every service reviewed showed improvement in the expected mortality rate. Additional coding opportunities were present in 55.6% of ACS cases, 35.29% of HM cases, 24.32% NS cases and 18.3% of OHS cases. The most frequent added diagnoses codes that lead to changes in the expected mortality were seen for coagulopathy (15.35% improvement, 15 codes added), fluid and electrolyte disorders (28.82% improvement,
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6 codes added), and ventilator present on admission (12.73% improvement, 5 codes added). A total of 70 codes were improved during the 8-month time period. The ACS service showed the most improvement with a 35% reduction in the O:E index ratio over the 8 months.
Conclusion: Institutional O:E mortality ratio can be improved upon by targeting high acuity services and capturing coding opportunities. Improvement in documentation allows hospitals to receive credit for the high acuity of patients cared for by these services. Lowering the O:E ratio improves institutional quality scores and national rankings.
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8. DEFINING THE TIME COURSE OF MORTALITY FOLLOWING LIVER TRANSPLANTION EW Beal MD, D Tumin PhD, D Azoulay MD, S Black MD PhD, K Washburn MD, TM Pawlik MD MPH PhD The Ohio State University
Purpose: In-hospital, 30- and and 90-day mortality are typically used to assess surgical quality among patients undergoing hepato-pancreato-biliary surgery. In contrast, following liver transplantation, the United Network for Organ Sharing (UNOS) uses 1-year mortality as the standard quality metric to assess program performance. We sought to define the cause, as well as timing of LT-related mortality to determine an optimal time- frame for the assessment of LT related surgical quality.
Methods: Data on adult, first-time liver transplant recipients transplanted between February 1, 2002 and December 31, 2015 were obtained from the UNOS database. The cause of death following LT was categorized as related to rejection, surgical, or other. Surgery related causes of death included graft failure due to vascular thrombosis or biliary tract complications, as well as post-operative death due to hemorrhage, cardiac or cerebrovascular complications. Cause of death was analyzed relative to time of mortality within the first year after LT.
Results: Among the 61,859 patients included in the analytic cohort, median age was 55 years and most were male (67.8%). Median time on the waiting list was 79 days (IQR 15-271). Overall, 2,518 (4%) patients died in-hospital following LT; 1,633 of these deaths (64.8%) were related to surgery. In contrast, 3,158 (5.1%) and 6,310 (10.2%) patients died 90-days and 1-year following LT. Among patients who died at 90-days, 1,924 (60.9%) were related to surgery, whereas 3,139 (49.2%) deaths at 1-year were surgery-related. Median time to death for surgical related causes was 46 days (IQR 7-148). Of note, surgery-related causes of death predominated until 1 year post-transplant with
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surgery-related causes of death especially predominating at 60-120 days after LT (Figure). Among all surgery-related deaths, the most common cause was multiple system organ failure (N=920, 24.0%) followed by cardiac arrest (N=709, 18.5%).
Conclusion: Causes of death deemed related to surgery are disproportionately responsible for mortality up to 120 days after LT. An intermediate time point to assess mortality would assist in benchmarking transplant program quality in addition to the standard 1-year outcomes.
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9. LONG TERM EXPERIENCE WITH DIAPHRAGM PACING FOR TRAUMATIC SPINAL CORD INJURY: EARLY IMPLANTATION POST INJURY IS MORE BENEFICIAL RP Onders MD, MJ Elmo ACNP, C Kaplan, R Schilz DO PhD University Hospitals Cleveland Medical Center
Purpose: Cervical spine injury (SCI) can result in catastrophic respiratory failure requiring invasive mechanical ventilation (MV) which is a leading cause of mortality and cost. Diaphragm Pacing (DP) was developed to replace/decrease mechanical ventilation. This is the largest long term analysis to be reported of a subgroup of traumatic SCI.
Methods: A retrospective review of prospective IRB approved protocols. All patients underwent laparoscopic diaphragm mapping and implantation of electrodes. DP electrodes were characterized and diaphragm strengthening with mechanical ventilator weaning was initiated immediately post operatively.
Results: From March 2000 through June 2017 there have been a total of 486 DP implants at this single site. Within this group, 155 had spinal cord damage and 92 of those patients had SCI secondary to trauma. The manner of injury: MVA 44, Sports 22, Falls 12, GSW 7, Crush 3, Forceps Delivery 2, Assault 1, and electrocution 1. The age at time of injury ranged from birth to 74 years old with the average of 27.3 years and median age of 23 years. Time on mechanical ventilation prior to DP was an average of 47.5 months(6 days to 25 years with median of 1.58 years). Patients’ highest level of injury: 27 C1, 36 C2, 14 C3, 7 C4, 5 C5 and 3 C6. Twelve patients had cardiac pacemakers. A total of 83% of patients achieved 4 consecutive hours of pacing with fifty-six patients(60.8%) being full time and an additional 13% using DP >12 hours. DP decreased the need and risk of cuffed tracheostomy with 60% of patients going to cuffless tracheostomy and 7 decannulations. One patient with early DP implant avoided tracheostomy. Five patients were not successful in weaning off MV. Five patients had full recovery of automatic
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breathing with subsequent DP removal. There have been 23 deaths with no primary respiratory origin. Subgroup analysis showed that earlier DP implantation leads to greater 24 hour use of DP and no need for any MV. This group also had the greater proportionate of recovery of natural breathing.
Conclusion: DP can successfully decrease need for mechanical ventilation for a significant number of SCI patients. Earlier implantation should be considered.
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10. DNA PROFILE COMPONENTS PREDICT MALIGNANT OUTCOMES IN SELECT CASES OF INTRADUCTAL PAPILLARY MUNCINOUS NEOPLASM WITH NEGATIVE CYTOLOGY RE Simpson MD, NJ Cockerill MS, MT Yip-Schneider PhD, EP Ceppa MD, MG House MD, NJ Zyromski MD, A Nakeeb MD, MA Al-Haddad MD, CM Schmidt MD PhD MBA Indiana University School of Medicine
Purpose: Predicting malignancy in intraductal papillary mucinous neoplasm (IPMN) remains challenging. Current approaches include combinations of clinical, radiographic, endoscopic, cytology, and pancreatic fluid DNA criteria. Interpace Diagnostics reports an integrated molecular profile (IMP) combining a pancreatic fluid DNA profile with clinical data into a malignant potential score. This integration makes interpreting the actual role of DNA components difficult. We sought to determine the utility of the DNA profiling components alone in predicting malignant outcomes.
Methods: We retrospectively reviewed records from over 1100 patients who underwent surgery or surveillance for cystic pancreatic lesions. We excluded non-IPMN cases, (e.g., solitary, undifferentiated, pancreatic cysts without a pancreatic duct connection) and cases where preoperative cytology was definitive for high-grade atypia or adenocarcinoma. A total of 285 DNA profiles from 227 patients were gathered: 100 were followed by surgical resection whereas 185 underwent surveillance for a minimum of 23 months. We analyzed DNA profile components alone and in combination by chi-squared analysis, and calculated sensitivity (Sn), specificity (Sp), and positive likelihood ratio (LR+.) Malignant outcomes were high- grade dysplasia, invasive IPMN, and adenocarcinoma on surgical pathology or evidence of mesenteric vascular invasion, metastases or cytologic evidence of high-grade atypia or adenocarcinoma during surveillance.
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Results: High quantity DNA (>10ng/μL) was the most significant predictor (p= 0.01) of malignant outcome with a Sn of 75%, but only 53% Sp, indicating non-malignant cases may exhibit high quantity DNA. High clonality mutations of tumor suppressor genes (HC LOH) were 98% Sp, indicating the presence of this mutation strongly predicts malignancy; however, the Sn was 20% demonstrating only select malignancies exhibit the HC LOH profile. The combination of high quantity DNA and HC LOH had 99% Sp, with the highest LR+ of 15, indicating a high post-test likelihood of malignancy when these two factors are present. The presence of a KRAS mutation alone was not a predictor of malignancy, but when combined with high quantity DNA (Sp 85%) and HC LOH (Sp 99%) strongly predicted malignancy.
Conclusion: DNA mutations alone generally lack sensitivity for predicting malignancy, thus should not be used as a screening tool in IPMN. However, where cytology fails, the presence of certain DNA profile components are highly specific for malignancy and may alert the physician to more aggressive disease requiring resection.
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11. THE IMPACT OF ENHANCED RECOVERY PATHWAYS ON COST OF CARE AND PERI-OPERATIVE OUTCOMES IN SURGICAL ONCOLOGY PATIENTS N Bhutiani MD, SA Quinn BS, KM McMasters MD PhD, CR Scoggins MD MBA, P Philips MD, Robert CG Martin II MD PhD University of Louisville
Purpose: Enhanced recovery after surgery (ERAS) protocols have increasingly been adopted by various surgical subspecialties in efforts to standardize peri-operative patient care, decrease length of stay, minimize narcotic usage, decrease complication rates, and decrease overall cost to hospitals and patients. This study sought to evaluate the impact on the above parameters of a prospectively-implemented ERAS protocol for patients undergoing operative intervention for hepatopacreatobiliary (HPB) or gastroesophageal (GE) malignancies at an academic institution.
Methods: Patients undergoing HPB or GE procedures for malignancy at an academic institution between January 2013 and May 2017 were classified according to whether or not they were placed on a peri-operative ERAS protocol. This involved pre-operative carbohydrate loading and intravenous fluid administration, the placement of an epidural catheter for analgesia, non-narcotic pain medication on call to the operating room, volume-restricted intraoperative resuscitation, early enteral feeding, and early ambulation. Groups were compared along variables including operative time, length of intensive care unit stay (ICU LOS) and total hospital stay (LOS), number of days requiring mechanical ventilation, readmission, incidence and severity of complications, and overall cost of care. Univariate analysis was performed using two-sided student’s t-test for continuous variables and Fisher’s exact test for categorical variables. Multivariable analysis was performed using logistic regression analysis.
Results: Of 377 total patients undergoing HPB or GE procedure,
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149 were placed on an ERAS protocol. HPB patients comprised the majority of both the non-ERAS (67.1%) and ERAS groups (75.2%). There was a significant association between ERAS protocol use and increased peri-operative antibiotic use (98.0% ERAS vs. 87.3 non-ERAS, p<0.001), decreased intra-operative crystalloid use (6265±7200 cc ERAS vs. 9279±11410 cc non- ERAS, p=0.004), and decreased requirement for ICU stay (20.1% ERAS vs. 36.4% non-ERAS, p<0.001) (Table 1). There were no differences in total operative time, requirement for mechanical ventilation, ICU LOS, rate of DVT chemoprophylaxis, complication rate, complication severity, LOS, or readmission rate. Total hospital costs were significantly lower among ERAS patients compared to their non-ERAS counterparts ($10,688.38 ± 10,518.22 vs. $15,439.22 ± 14,201.24, p<0.001). On multivariable analysis, ERAS protocol use was independently associated with decreased rate of ICU admission (odds ratio = 0.33, 95% confidence interval = 0.18-0.61, p<0.001). It was not associated with any difference in length of stay, readmission rate, or complication rate.
Conclusion: ERAS pathways can be safely implemented in patients undergoing operative intervention for HPB and GE malignancies. Additionally, their institution can help standardize peri-operative practices, decrease requirement for ICU admission, and decrease total hospital costs among these patients.
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12. TEN YEAR REASSESSMENT OF THE SHORTAGE OF GENERAL SURGEONS(GS): INCREASES IN GENERAL SURGEON RESIDENCY(GSR) GRADUATION NUMBERS ARE INSUFFICIENT TO MEET FUTURE GS DEMAND TM Pawlik MD, B Satiani MD, DP Way MEd, TE Williams MD The Ohio State University
Purpose: In 2008 our group projected an estimated increase in the general surgical workforce (GSW) shortage from 7% in 2020 to 19% in 2050. In order to determine if recent increases in GSR training numbers have corrected the projected GSW shortages, we reassessed our population based GSW projections.
Methods: We reviewed the latest population data from the Census Bureau relative to the number of certificates granted from the American Board of Surgery (ABS), as well as the number of residents entering and completing ACGME approved GSR from 2006 -2015. Using recent population estimates (Table 1), we assumed that 7.53 GS were needed per 100,000 people. In the period 2006 – 2015, the ABS granted 10,098 certificates, averaging 1,010/year. The number of trainees entering GSR ranged from 1,062-1302, averaging 1,174 /year. Trainees completing GSR ranged from 1,042 to 1,137 for an average of 1,080/year (ACGME 2006-2015). The model deducted 150 certificates or trainees/year to account for GS graduates going into vascular, cardiothoracic, or other specialty fields; the model also estimated 729 retirements / year based on 30 years of practice to determine the number of GS available.
Results: The population is currently estimated to increase to 439M by 2050, 19 M more than the 2004 census bureau estimate used in the 2008 report. The projected GSW shortage will be 7,257 (22%) using ABS certificates and 5,157(16%) using graduating GSR numbers compared with an estimation of 6,000 (19%) reported in 2008(Table 1)
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Conclusion: Although there has been an increase in the number of ABS certificates and graduating GSR trainees, it will not be sufficient to keep up with projected population growth. In order to meet the estimated GSW demand, we will need to increase current GS graduation numbers by about 100/ year to 1,180 certifiable GS residents annually. Parenthetically, this approximates the 1,174 first year GS residents entering training each year . By expanding categorical training , so that all of the PGY 1 GS residents could complete 5 years of training and thereby be eligible for ABS certification , we could add an additional 100 GS to the pool completing training per year and hence meet the future GS demand.
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13. FAILURE OF GASTRIC PROPHYLAXIS AGAINST STRESS BLEEDING (SB) REFLECTS INADEQUATE PH CONTROL JW Mesquita MD, CM Kline MD, CE Lucas MD, P Vernier RN, AM Ledgerwood MD Wayne State University
Purpose: Gastric prophylaxis (GP) against stress gastritis (SG) with histamine 2 blockers (H2B) or protein pump inhibitors (PPI) is a quality standard in septic SICU patients (pts) on prolonged ventilatory support in order to reduce gastric pH below 3.5, thus, preventing conversion of pepsinogen (Pg) to P. Since gastric pH is not monitored, this study assesses the efficacy of GP with pH monitoring.
Methods: 100 septic, ventilated SICU pts with nasogastric tubes (NGT) were studied for 481 days. All received H2B or PPI. Daily pH control was judged as poor (1-3), moderate (3-5), or good (>5). Pts with poor pH received an enhanced GP with double- dose or an infusion PPI. NGT bile or blood and transfusions for SG were recorded.
Results: GP was poor for 37 days, moderate for 83 days, and good for 279 days. NGT blood occurred on 19 days (51%) with poor, 19 days (23%) with moderate, and 17 days (4%) with good control (p<0.05 for poor vs. moderate and moderate vs. good). Transfusions for SG occurred on 5 days (14%) during poor, 3 days (4%) during moderate, and 1 day (0.3%) during good control (p<0.05). Bile was present with good control (96%). Enhanced GP improved pH control and reduced NGT blood. Transfusion for SG after enhanced therapy was required on one day (7%) with poor control and never for moderate or good control.
Conclusion: GP against SG in septic SICU pts is best monitored for efficacy by NGT pH to ensure that Pg is not converted to P, thereby, reducing bleeding.
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NOTES
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14. A COMPARISON OF THE BOEY, PULP, AND AAST EGS GRADE FOR PERFORATED PEPTIC ULCER DISEASE MC Hernandez MD, MJ Thorn CNP, VY Kong MBChB PhD, JM Aho MD PhD, DH Jenkins MD, MD Zielinski MD, DL Clarke MBChB PhD Mayo Clinic, Rochester
Purpose: Perforated peptic ulcer disease (PPUD) is a potentially severe disease and outcomes are often determined by patient comorbidities and acute physiology. Several scoring systems exist to to estimate disease severity and outcomes. We aim to validate the AAST PPUD grading system and compare with the Boey and PULP scoring systems.
Methods: Dual center retrospective review of patients ≥18 years old with perforated peptic ulcer disease during 2010 and 2016 was performed at both Rochester, Minnesota, USA and Pietermaritzberg Kwa-Zulu Natal Province South Africa. Demographics, preoperative physiologic and symptom data, comorbidity status (Charlson Comorbidity score), procedure details, postoperative complications were recorded. AAST grades were generated based on intraoperative findings. The Boey and PULP scores were also generated. Summary, univariate and logistic regression, and area under the receiver operating curves (with 95% confidence intervals) with pairwise comparison were performed to compare AAST grade, Boey, and PULP scores for several outcomes.
Results: There were 306 patients, 42% were female with a mean (±SD) age of 56 ±19.8 years. AAST grades (n, %) included: I (30, 9.8%), II (38, 12.4%), III (104, 34.1%), IV (76, 24.8%), V (58, 18.9%). Initial management included: midline laparotomy (50.5%, n=154), laparoscopy (18.6%, n=57), laparoscopy converted to laparotomy (0.9%, n=3), and endoscopy (30%, n=92). Complication rates were: I (20%), II (26.3%), III (76.9%), IV (90.7%) and V (93.1%) p=0.0001. Length of stay increased
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with AAST grade: I 1[1-2]), II 3[2-4], III 7[5-11], IV 9[5-17], V 11[5-17] p=0.0001. On regression the following predictors of any complication were (OR; 95% CI): AAST grade (I reference, II (1.48; 0.4-5), III (10.9; 4.1-33), IV (30.5; 9.8-48.4), V (45.4; 12.8- 65.1), heart rate > 110 (1.83; 1.45-2.11) and Charlson Comorbidity status >3 (3.8; 1.6-10.1). In Table, pairwise comparison revealed that the AAST grade for PPUD more accurately discerned several clinical outcomes compared to the Boey and PULP scores.
Conclusion: The AAST grading system correlates well with clinical outcomes, complications, complication severity and operative management suggesting initial validity. We demonstrate that the AAST EGS grade was able to more aptly describe and distinguish several peri-operative outcomes when compared to other severity scoring systems for PPUD. In conjunction with patient physiology and comorbidities, increasing anatomic severity as described by the AAST EGS grade appears to be valid for PPUD.
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15. A POSTOPERATIVE PARATHYROID HORMONE ALGORITHM TO REDUCE SYMPTOMATIC HYPOCALCEMIA FOLLOWING COMPLETION/TOTAL THYROIDECTOMY: A RETROSPECTIVE ANALYSIS OF 591 PATIENTS IG Mazotas MD, TWF Yen MD, J Park BS, AA Carr MD, DB Evans MD, TS Wang MD Medical College of Wisconsin
Purpose: Hypoparathyroidism is the most common complication following completion/total thyroidectomy. An institutional protocol for selective calcium/calcitriol supplementation was established based on 4-hour postoperative parathyroid hormone (PTH) levels. The aim of this study was to evaluate the outcomes of this protocol five years after implementation.
Methods: We retrospectively reviewed all patients who underwent completion/total thyroidectomy from 1/2012- 12/2016. Based on our previously published prospective randomized trial, selective oral calcium/calcitriol supplementation was initiated based on the 4-hour postoperative PTH level: no routine supplementation (PTH ≥10pg/mL), calcium±calcitriol (PTH 5-10), or calcium+calcitriol (PTH <5). Symptomatic hypocalcemia was defined as perioral or acral paresthesias that improved with supplementation. Long-term hypoparathyroidism was defined as PTH <10 and calcium/ calcitriol supplementation >6 months postoperatively.
Results: Of 591 patients, 448 (76%) had a 4-hour postoperative PTH ≥10; 30 (7%) reported transient symptoms that were managed with outpatient supplementation. The 143 (24%) patients with a PTH <10 were more likely to report symptoms, receive intravenous calcium, have a diagnosis of thyroid cancer, receive central compartment neck dissection, have inadvertent parathyroidectomy, and develop long-term hypoparathyroidism (Table). Compared to asymptomatic patients, symptomatic patients with PTH <10 were more likely to be younger (55 vs. 47
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years; p<0.001) and female (92% vs. 77%; p=0.02). No other factors were associated with symptomatic hypocalcemia. Among 72 patients with PTH 5-10, 55 (76%) were discharged on calcium alone; 10 (18%) subsequently received calcitriol. Comparing those discharged on calcium alone vs. calcium+calcitriol, the median PTH was higher (7.3 vs. 6.1; p=0.028) for those on calcium alone, but there was no difference in reported symptoms, receipt of central compartment neck dissection, or inadvertent parathyroidectomy. Long-term hypoparathyroidism occurred more frequently in those with a 4-hour postoperative PTH <5 compared to 5-10 or ≥10 (15% vs. 3% vs. 0%; p<0.001).
Conclusion: After completion/total thyroidectomy, patients with a 4-hour postoperative PTH ≥10 can be safely discharged without routine supplementation. Patients with PTH <10 are high-risk (50%) for symptomatic hypocalcemia, and the addition of calcitriol to calcium supplementation should be strongly considered, particularly in those that are younger and female. Long-term hypoparathyroidism was very uncommon (0.4%) if the 4-hour PTH was ≥5.
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16. EARLY GENETIC COUNSELING AND DETECTION OF CDH1 MUTATION IN ASYMPTOMATIC CARRIERS IMPROVES SURVIVAL IN HEREDITARY DIFFUSE GASTRIC CANCER MA Moslim MD, B Leach LGC, CA Burke MD, RM Walsh MD Cleveland Clinic Foundation
Purpose: Hereditary diffuse gastric cancer (HDGC) is associated with E-cadherin (CDH1) germline mutations. There is an increasing trend of detecting CDH1 mutations with multigene cancer panels. The implications of CDH1 mutations in those without a family history of gastric cancer are uncertain.
Methods: A registry of patients who underwent genetic counseling for CDH1 mutation was queried between February 2011 and August 2017.
Results: Twenty-one patients with CDH1 mutation were identified. Most indications for CDH1 genetic screening were family history of HDGC (48%) and young onset of personal or family history of breast cancer (33%). Unsuspected CDH1 mutations were detected in 52% undergoing multigene cancer panels. Eight patients underwent total gastrectomy, five had metastatic gastric cancer at presentation and referred to palliative care (table), five are waiting for or had surgery at an outside hospital and three refused surgery. Patients who underwent gastrectomy at our institute had a median age of 31 years and were predominately females (75%). Four patients (50%) were known to have gastric cancer based on preoperative screening endoscopy utilizing Cambridge surveillance protocol. Seven (87%) were asymptomatic at diagnosis and had diffuse type (signet-ring) gastric cancer with poor differentiation on final pathology (stage IA). Three out of four patients (75%) who underwent prophylactic gastrectomy had gastric cancer on final pathology. The most common location of cancer was in the fundus (62.5%). Median follow-up is 10.5 months with no recurrence, metastases or mortality. The metastatic disease
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group (n=5) consists of symptomatic males with a median age of 40 years. All died with a median of 11 months from diagnosis. Unsuspected CDH1 carriers were older (median 44 versus 24 years) and more likely to have both metastatic disease and mortality (50% versus 28.6%) compared to patients with family or personal history of HDGC.
Conclusion: CDH1 mutations associated HDGC are a biologically aggressive variant of gastric cancer. Curative total gastrectomy is achieved in asymptomatic patients, however symptomatic patients were found to have terminal disease with fatal outcome. Unsuspected CDH1 carriers are becoming increasingly diagnosed on multigene panels which at a minimum warrant genetic counseling and aggressive screening endoscopic examinations.
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17. REPEAL OF THE MICHIGAN HELMET LAW: IMPACT ON ORGAN DONATION RATES S Thorp MD, J Le MD, NS Adams MD, AT Davis PhD, CJ Gibson MD, GP Wright MD, CH Rodriguez MD, GA Iskander MD, AJ Chapman MD Spectrum Health
Purpose: The 35-year-old Michigan universal helmet law was repealed in April of 2012. The impact on organ donation and recovery rates is unknown. Prior studies have estimated organ donations from fatal motorcycle collisions increase by 10% following a helmet law repeal. Our primary objective was to determine the effect of the Michigan helmet law repeal on organ donation. Our secondary objective was to compare the difference in organ donation between helmeted and non-helmeted riders.
Methods: The Gift of Life Michigan organ donation database was queried from 4/2008 through 5/2015 in conjunction with the Michigan Trauma Quality Improvement Program database from the same time period. All motorcycle collision (MCC) fatalities were examined. On scene mortality, dirt bikes, and mopeds were excluded.
Results: The organ donation rate pre-repeal was 0.9% (18/1970) which was not significantly different from the post-repeal rate of 1.0% (26/2706; p=0.87). The proportion of donations in the non-helmeted group 22/1334 (1.7%) was significantly higher than the helmeted group 17/2148 (0.8%; p=0.02). The rate of unhelmeted donors in the post-repeal period was 67.4% (21/31), which was significantly greater than the rate for helmeted riders (33.3%, 10/30; p = 0.007).
Conclusion: There was no increase in the rate of organ donation following the repeal of the Michigan universal helmet law. However, we identified a greater than two-fold increase in the rate of donations among non-helmeted riders compared to helmeted riders. These findings suggest that the repeal of a
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universal helmet law results in increased availability of organs for donation from non-helmeted riders.
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18. WISCONSIN’S ENTERRA THERAPY™ EXPERIENCE: A MULTI-INSTITUTIONAL REVIEW OF GASTRIC ELECTRICAL STIMULATION FOR MEDICALLY REFRACTORY GASTROPARESIS A Shada MD, A Nielsen, S Marowski, M Helm RN, L Funk MD, A Kastenmeier MD, A Lidor MD, JC Gould MD Medical College of Wisconsin
Purpose: Gastric electrical stimulation (GES) is a treatment for diabetic or idiopathic gastroparesis symptoms refractory to medical management. We sought to evaluate the long-term outcomes of GES in Wisconsin over a more than 10-year period.
Methods: Data was prospectively collected from patients undergoing surgery to initiate GES therapy at two Wisconsin institutions from 2005-2017. The validated Gastroparesis Cardinal Symptom Index (GCSI) was administered preoperatively and at intervals postoperatively. Prokinetic and narcotic medication use was retrospectively gathered. Long-term symptom assessment was attained via telephone interview.
Results: There were 119 patients who received GES therapy (64 diabetic and 55 idiopathic). 75.6% of patients were female (64% diabetic and 89.1% idiopathic). Prior to surgery, feeding tubes were present in 21.6% of diabetics and 16.7% of idiopathic patients (p=0.37). All devices were placed laparoscopically and there were no perioperative complications. Mean length of hospital stay was 1.9±2.3 days. Mean follow-up was 34.1±27.2 months in diabetic and 44.7±26.2 months in idiopathic patients (p=0.08). Feeding tubes were eventually removed in 67% of all patients who had one in place prior to GES. Four patients who did not have a feeding tube at the time of GES eventually required one. Eight patients (6.7%) opted to have the GES device removed. Three patients underwent subtotal gastrectomy and two a subsequent pyloroplasty. There were 18 patients who died during the study interval (14.3%). No mortalities were
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device related. Diabetics had the highest rate of mortality (25% mean interval of 16.7±2.9 months post implantation). GCSI scores improved significantly (Table). Prokinetic medication use significantly decreased at 1 year or more (53.1% vs. 29.2%; p=<0.0001). Daily narcotic medication use also decreased significantly at 1 year or more (38.3% vs. 23.0%; p<0.0001). At a mean follow-up 49.4±42.4 months, mean satisfaction scores with symptomatic outcomes were 4.1 (scale 0-5, 4=very satisfied).
Conclusion: GES therapy leads to improved gastroparesis symptoms and quality of life in patients with medically refractory diabetic or idiopathic gastroparesis. Patients are able to decrease prokinetic and narcotic medication use and achieve long-term satisfaction. Diabetic patients who develop symptomatic gastroparesis have a high mortality rate over time, likely due to diabetic complications.
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19. TIME TO RE-EVALUATE COLONOSCOPY AGE CUTOFF? ADENOMAS MORE COMMON IN ELDERLY THAN THOUGHT J Fischer MD, J Thiele MD, N Engelking RN, J Rakinic MD Springfield Clinic-Southern Illinois University
Purpose: Colorectal cancer is most frequently diagnosed between ages 65 to 74. Current recommendations for colorectal cancer screening using colonoscopy describe beginning at age 50 and continuing until age 75, with screening for patients aged 76 to 85 based on individual patient health and prior history. Newly diagnosed colorectal cancers in patients 80 and older are not uncommon; however, data on adenoma prevalence in this age group is sparse. We sought to investigate if adenoma prevalence continues to increase with age, and whether extending criteria for colorectal cancer screening could allow older individuals access to potentially life extending procedures.
Methods: The EMR of a large multi-specialty clinic that serves one million people in central Illinois was queried from January 2015 through October 2016. Inclusion criteria were age over 50 and screening indication for colonoscopy. Exclusion criteria were age 50 or younger, and any history of adenomatous polyps or colorectal cancer. 5,762 patients were eligible (54.2% male). Average age was 60 (SD = 8). One or more adenomas were detected in 46.3%; sessile serrated adenoma (SSA) was detected in 6.5%. Cochran-Armitage Test for Trend was used to identify a trend in the adenoma detection rate with increasing age.
Results: Adenoma detection rate significantly increased with advancing age (50-59, 60-69, 70-79, and 80-90; p=0.0023). This trend was consistent for both males and females (p=0.0307 and p=0.0104, respectively). Females had a significantly greater number of adenomas (p<0.0001) which persisted throughout each age group except for age 80-90 (p<0.001). No significant trend was seen for SSA rates and increasing age for overall
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group or male and female separately (p=0.7455, p=0.5757 and p=0.992, respectively).
Conclusion: Our study found a statistically significant increasing adenoma detection rate in both genders through age 79, with a trend of continued increased adenomas after age 80. We also found that women in these age groups have a higher risk for adenoma than men. These findings suggest that the current recommendation of ending routine screening after age 75 deserves re-evaluation. Additionally, the finding of significantly higher adenoma rates in women as compared to men is counter to current literature and deserves further investigation.
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20. RISK FACTORS FOR 30-DAY READMISSION FOLLOWING ADRENALECTOMY AC Beck MD, P Goffredo MD, G Lal MD, JR Howe MD, RJ Weigel, MD PhD University of Iowa
Purpose: Readmissions represent a significant burden to the health care system and the ability to identify patients at risk can help direct resources. Risk factors for 30-day readmission after adrenalectomy are examined in this study.
Methods: Patients who underwent adrenalectomy were selected from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database from 2011 to 2015 by Current Procedural Terminology (CPT) codes. Student’s T-test, chi square test and multinomial logistic regression were used to examine patient demographics, surgical characteristics, and post-operative complications. Total relative value units (RVUs) were used to represent operative complexity.
Results: Among the 4290 patients who underwent adrenalectomy, 247 (5.7%) were readmitted on average 13.7±8.1 days post operatively and 9.5±7.6 days after initial discharge. Seventy-eight percent of patients had a laparoscopic adrenalectomy and their risk of readmission was significantly lower when compared to those who underwent open adrenalectomy (5.1 vs 7.9%, p=0.002). Increased operative time and higher total RVUs had significantly higher rates of readmission (p<0.001), but were higher in open cases than laparoscopic (194±101 minutes vs. 139±71 and 30.6±19 RVUs vs. 22.2±5.2, respectively). Diagnosis of malignancy and Cushing’s syndrome had higher rates of readmission (8.0%, p=0.021 and 7.4%, p<0.001) but did not retain significance on multivariate analysis as shown in Table 1. The major pre-operative predictive factors on multivariate analysis were non-elective surgery (OR 2.432, CI 1.579-3.746), American Society of Anesthesiologist
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(ASA) classification ≥3 (OR 1.590, CI 1.086-2.329), and pre- operative dialysis (OR 4.582, CI 1.394-15.056). Major post- operative risk factors on multivariate analysis included superficial surgical site infection (OR 4.378, CI 2.103-9.115), organ space infection (OR 3.281, CI 9.705-72.909), and return to the operating room (OR 8.743, CI 3.940-19.403).
Conclusion: The current study identified major predictors of readmission in patients undergoing adrenalectomy. Recognition of readmission risk may assist in pre-operative surgical planning and advocates for stricter follow-up with a lower threshold to readmit, scan, or look for post-operative complications.
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21. LONG TERM WEIGHT CHANGE AND HEALTH OUTCOMES FOR SLEEVE GASTRECTOMY AND MATCHED ROUX-EN-Y GASTRIC BYPASS PARTICIPANTS IN THE LONGITUDINAL ASSESSMENT OF BARIATRIC SURGERY (LABS) STUDY BH Ahmed MD, WC King PhD, WF Gourash PhD, SH Belle PhD, AS Hinerman MPH, AP Courcoulas MD University of Pittsburgh
Purpose: Data from a multicenter longitudinal study of bariatric surgery in the United States was used to compare weight change and health outcomes in patients who underwent SG or RYGB.
Methods: This study includes the 57 participants who underwent SG and 57 matched (sex, age, and baseline body mass index (BMI)) participants who underwent RYGB from the Longitudinal Assessment of Bariatric Surgery (LABS), an observational cohort study. Adults undergoing initial bariatric surgical procedures between 2006-2009 were followed and completed 6 month, 12-month and then annual research assessments for up to 7 years. Participants who underwent SG were intended to have a second stage procedure. Data were censored at the time of the second planned procedure for 10 SG participants and their matched RYGB participants. Mixed models were used to evaluate percent weight change from baseline through 7 years, and diabetes, dyslipidemia, and hypertension prevalence through 5 years.
Results: Of the 59 participants who underwent SG, 57 were matched to a participant who underwent RYGB. Participants were largely female (68%), white (81%), and had a median (IQR) age of 49 (37, 56 years). At baseline, the median (IQR) BMI was 57.7 kg/m2 (46.8, 63.1), range 35.5-75.2 kg/m2 for SG group, and the median (IQR) BMI in the RYGB group was 56.0 kg/m2 (47.2, 63.2), range 35.7-76.8 kg/m2. Figure 1 shows observed and modeled weight change by procedure, and the mean difference in weight change between procedures by time
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point. Seven years following SG, mean (95% CI) weight loss was 23.6% (20.7-26.4and after RYGB was 30.4% (27.5-33.3 ,a difference of 6.8%. 23.6% 32.3 kg (23.6, 48.2), or 22.0% (17.7, 35.1) of baseline weight and after RYGB was 40.2 kg (31.4, 55.9) and 29.7% (22.7, 42.2). For both groups prevalence of diabetes, low HDL and hypertension, were significantly lower five years after surgery vs baseline; high LDL was also significantly lower for RYGB.
Conclusion: Higher risk or super obese participants following SG lost less weight than matched RYGB counterparts at 7 years. Both groups exhibited improvements in comorbidities through 5 years.
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22. THE EDUCATING ENIGMA: DOES TRAINING LEVEL IMPACT POST-OPERATIVE OUTCOME? GL Bonner MD, SM Kalantar MD, M Abbas MD, R Mustafa MD, L Khaitan MD University Hospitals Cleveland Medical Center
Purpose: Bariatric procedures are amongst the most complex laparoscopic general surgery cases performed. The threshold for acceptance of complications in these cases is low given their elective nature. Using the MBASQIP database, post-operative outcomes in bariatric surgery were evaluated to determine the effect of trainee involvement throughout a range of accredited centers.
Methods: The MBSAQIP database was queried for patients undergoing bariatric surgery in 2015. Data was collected regarding post-operative complications including: surgical site infections, sepsis, UTI, length of stay, operative time, renal failure, pulmonary embolism, DVT, pneumonia, and re-operation. These were analyzed against the presence and level of trainees using ANOVA test; p<0.05 was considered significant.
Results: A total of 168,093 procedures met inclusion criteria. Of these, 125,078 were performed without trainee involvement; 14,883 were performed with a fellow and 28,132 were performed with a resident. Of the cases without trainees, 25% were RYNGB, 59% were SG, and 16% consisted of numerous other categories. Cases in which fellows were involved consisted of 35% RYNGB, 51% SG, and 13% other; cases with residents consisted of 27% RYNGB, 59% SG, and 15% other. The three groups were similar with regard to patient age, BMI, and comorbidities. The operation length differed significantly between the groups; fellow involvement averaged 117 minutes, residents 105 minutes and those without trainees 85 minutes (p<0.001). The operative time with fellows was consistently longer regardless of the type of procedure performed. Post-operative infectious events were
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more likely in cases in which fellows were involved (2% versus 1% with p<0.001). Rate of UTI was greater with either fellows or residents (1% versus 0% with p<0.001). Overall length of stay was also longer with fellows and residents (2.01 versus 2.05 versus 1.8 with p<0.001 respectively). No differences were noted in the other aforementioned post-operative complications.
Conclusion: The majority of bariatric surgery cases are performed outside training programs. Of the cases utilizing trainees, fellow involvement was associated with the longest operative times, highest infections, increased UTIs, and prolonged length of stay. These post-operative events are most likely attributed to prolonged OR time; thus, further training outside the operative suite should be considered.
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23. FINE NEEDLE ASPIRATION BIOPSY OF THYROID NODULES: IS ULTRASOUND-GUIDANCE NECESSARY? KC Choong MD, CR McHenry MD MetroHealth Medical Center
Purpose: Current guidelines recommend either ultrasound or palpation-guided fine needle aspiration (FNA) biopsy for evaluation of a thyroid nodule. However it has been suggested that US-guided FNA (US-FNA) should be used routinely in all patients with a thyroid nodule to reduce the rate of nondiagnostic results. The purpose of this study was to determine if there is any difference in non-diagnostic rates between the two methods of FNA at our institution.
Methods: A retrospective review of a prospectively maintained thyroid database was completed to determine the rates of nondiagnostic FNA in patients with nodular thyroid disease evaluated from 1990 to 2016. US-FNA was performed by radiologists with on-site evaluation of specimen adequacy by a cytopathology team. Palpation-guided FNA (P-FNA) was performed by endocrinologists and an endocrine surgeon without on site evaluation of adequacy. A Chi-square test was used to determine if there was a significant difference in the rate of nondiagnostic FNA between groups.
Results: From 1990-2016, 2223 patient underwent FNA biopsy as a part of their evaluation for nodular thyroid disease, 1067 (48%) had an US-FNA and 1167 (52%) had a P-FNA biopsy of a thyroid nodule. The average nodule size was 2.6 cm for US-FNA and 4.2 cm for P-FNA. 52% of the thyroid nodules evaluated with US-FNA biopsy were palpable (p~0). US-FNA biopsy was non- diagnostic in 4.6% of patients compared to P-FNA biopsy, which was nondiagnostic in 6.0% of patients (p=0.51).
Conclusion: The rate of nondiagnostic FNA is similar whether US guidance is used or not. In order to minimize resource utilization and expense at our institution, US-FNA is used selectively for nonpalpable nodules and when P-FNA is nondiagnostic. 75TH ANNUAL MEETING 2018 81
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NOTES
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24. DOES LAPAROSCOPIC LIVER RESECTION REDUCE THE INCIDENCE OF POST-OPERATIVE BILE LEAKS: A MULTI-INSTITUTIONAL ANALYSIS AA Smith MD PhD, J Buell MD MBA, D Iannitti MD Tulane University
Purpose: The reported rate of post-operative bile leak after liver resection is variable, ranging from 4 and 19%. More recent data suggests laparoscopic surgery has decreased this incidence. The objective of this study was to determine the rate of bile leak from two high volume laparoscopic liver surgeons and to determine associated risk factors.
Methods: A retrospective analysis of a database maintained by two high volume surgeons was conducted between 2000-2017. All consecutive open and laparoscopic liver cases were reviewed. Outcomes were compared using a Fisher’s exact test and an unpaired two-tailed t test. Multivariate analysis was conducted to determine risk factors associated with post-operative bile leak. A p value <0.05 considered to be significant.
Results: In a cohort of 924 liver resections, 513 laparoscopic cases reported complications, including cardiac (n=6, 1.2%), pulmonary (n=27, 5.3%), infection (n=8, 1.6%), wounds (n=16, 3.1%), readmission (n=20, 3.9%), and bile leak (n=15, 2.9%). Multivariate analysis determined that post-operative infections, wound complications, and readmissions were associated with open liver resection (p<0.0001). The incidence of post-operative bile leak was lowest in laparoscopic resections (n=15/513, 2.9% vs. n=24/411, 5.8%, p=0.0324). Risk factors identified included: increased estimated blood loss (885.4+54.2 vs 289.0+12.8 mL, p<0.0001) and longer operative time (306.7+4.7 vs 160.2+7.1 min, p<0.0001).
Conclusion: Our data would suggest that the incidence of post-operative bile leak is lower than previously reported. Laparoscopic liver resection appears to decrease this incidence.
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The association of bile leak with increased blood loss and operative times suggests bile leak is associated with more complex liver resections. Additional studies are needed to further delineate this relationship.
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25. SURGEON VOLUME CORRELATES WITH PERIOPERATIVE BLOOD TRANSFUSIONS AFTER PANCREATICODUODENECTOMY K Wima MS, Y Kim MD, SA Ahmad MD, SA Shah MD University of Cincinnati
Purpose: Although studies have demonstrated the association between center volume and operative mortality for patients undergoing pancreatic surgery, the specific impact of surgeon volume on granular quality outcomes including perioperative blood use remains ill-defined.
Methods: The University HealthSystems Consortium database was queried for all pancreaticoduodenectomies (PDs) performed between 2011-2013 (n=9,572). Patients were grouped according to surgeon volume into low (n=3033), medium (n=3198), and high (n=3341) volume groups. Blood transfusion requirements were monitored throughout the hospital stay and categorized into none (0 units, n=6133; 64%), low (1-2 units, n=1448; 15%), medium (3-5 units, n=1225; 13%), and high (≥6 units, n=776; 8%) transfusion groups. Logistic regression models were used to determine predictors of perioperative transfusion requirement, 30-day readmission, in-hospital mortality, and total direct cost.
Results: 36% of patients undergoing PDs performed at academic centers across the United States required perioperative blood transfusions, of which 22% received 6 or more units. Patients with high transfusion requirements were more often non-white, with government or no insurance, and of higher severity of illness (all p < 0.01). Having high transfusion requirements correlated with higher 30-day readmission rates (OR 1.23, 95% CI 1.02 – 1.47; p = 0.03), increased total direct cost (RR 1.84, 95% CI 1.73 – 1.96; p < 0.01), and worse in-hospital mortality (OR 16.47, 95% CI 9.28 – 29.24; p < 0.01). On multivariate analysis, high surgeon volume was associated with decreased perioperative transfusion requirements (high versus low volume, OR 0.61, 95% CI 0.48 – 0.77; p < 0.01), lower total direct cost (RR 0.93, 95% CI 0.89 –
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0.98; p < 0.01), and reduced 30-day readmission rates (OR 0.78, 95% CI 0.67 – 0.92, p < 0.01).
Conclusion: High blood transfusion requirements is a quality indicator after pancreaticoduodentomy. Surgeons performing high volume pancreatic surgery transfuse blood less often, which may be due to differences in patient selection, operative technique, or postoperative management. It is important to recognize the relative influences of surgeon characteristics on outcomes following high-risk surgery.
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26. COMMUNICATION THROUGH SIMULATION: DEVELOPING A CURRICULUM TO TEACH INTERPERSONAL SKILLS VA Fleetwood MD, B Veenstra MD, A Wojtowicz BS, J Kerchberger MD, J Velasco MD Rush University Medical Center
Purpose: Nontechnical issues are linked to up to 60% of adverse events in surgery, particularly interpersonal and communication skills. Both are one of the core competencies of medical education. Although simulation is a keystone in the acquisition of surgical technical skills, its applicability in other competencies remains elusive. Hypothesis: Simulation scenarios can test and improve the communication skills of interdisciplinary teams. Objectives included: To develop a simulated high-fidelity operating room environment and challenge communication skills with a crisis situation. To evaluate learners’ communication skills using NOTECHS II scale. To compare learner self-evaluations with independent proctor evaluations to determine insight and correctability.
Methods: Based on the six-step system of curriculum development we created a simulated intraoperative crisis. Anesthesia and surgical residents with a surgical nurse were asked to perform a laparoscopic cholecystectomy. A tension pneumothorax was created and the ensuing interaction and teamwork was evaluated via direct observation and videotape. Participants also self-evaluated before and after the debriefing using a NOTECHS II scale. Timing of events and time to communication was measured as a method of feedback to learners. Data was analyzed using Chi square analysis in SPSS.
Results: All participants found the simulation to be a realistic depiction. The average time from development of hypotension to communication of deterioration was 62.7 seconds; time to intervention was 104.0 seconds. The average NOTECHS II
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scores were significantly different between groups being highest for surgical senior residents (Table 1) and lowest for surgical juniors. Insight was measured by comparing self-evaluations to proctor evaluations; higher scores denoted greater differences and therefore lower insight. Surgical juniors demonstrated significantly lower insight. Correctability was calculated as the difference between pre- and post- self-evaluation and was not significantly different between groups but tended to be higher in surgical juniors.
Conclusion: Time to communication of significant patient deterioration was greater than one minute, indicating a need for enhanced communication in the operating room. Junior surgical residents scored lowest both on nontechnical skills and insight and should be taught nontechnical skills through simulation. Our curriculum is a suitable and reproducible model to educate residents in communication skills.
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27. HCAHPS SCORES AS A SURROGATE FOR QUALITY DOES NOT CORRELATE WITH TQIP QUALITY MEASURES AT A LEVEL 1 TRAUMA CENTER C Thoma-Perry, BA, E. Blocher-Smith, BS, L Jacobson, MD Marian College of Osteopathic Medicine / St. Vincent Hospital
Purpose: The Trauma Quality Improvement Program (TQIP) was designed by the American College of Surgeons (ACS) to measure quality benchmarks across ACS certified trauma centers. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey was developed to report patient satisfaction with inpatient care and has been used as a surrogate for quality of care by the Affordable Care Act (ACA). Previous work has compared HCAHPS data to non-standardized quality measures. The purpose of this study was to determine the correlation of hospital HCAHPS data to TQIP quality analysis a nationally recognized quality program.
Methods: : A retrospective review of available TQIP and HCAHPS results from an ACS Level 1 Trauma Center from 2016- 2017 was performed. TQIP and HCAHPS data was represented as either above, at or below the mean of national data and was analyzed using Fischer’s Exact Test.
Results: HCAHPS scores from wards participating in care of trauma patients were summarized by perceived level of quality. TQIP data for risk-adjusted mortality was included in analysis for all trauma admissions. Fischer’s Exact Test was used to analyze contingency tables of data and was found to support the null hypothesis (p = 0.1109).
Conclusion: Overall HCAHPS rating is most significant for hospitals as it is a global view of patient satisfaction and used to determine a portion of hospital reimbursement. It is thought that higher patient satisfaction is correlated with lower readmission rates and improved outcomes thus resulting in cost-savings.
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However, it appears that HCAHPS rating does not correlate with measured outcomes in terms of risk-adjusted mortality for trauma admissions. It is suggested from this data that trauma patients be considered independently from other hospitalizations and that HCAHPS may not be an appropriate tool to determine reimbursement for trauma admission
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28. INCREASING THE NUMBER OF LEVEL II TRAUMA CENTERS IN A GIVEN GEOGRAPHIC AREA: IS THERE A MEASURABLE EFFECT ON TRAFFIC FATALITIES? DN Reed MD, H Singh MBBS, JJ Oury BS, RM Mason BS, R Jones Pharm.D., AM Chard RN, B Henriksen PhD Lutheran Hospital
Purpose: Motor vehicle crashes (MVCs) account for more than 27% of trauma deaths in the United States. Many studies found that access to a designated trauma center (TC) increases the chance of survival from MVCs. This study was designed to determine if the addition of the second level II TC in Northeast Indiana & Northwest Ohio (NE IN) decreased the rate of fatalities in MVCs more than if the center had not been added.
Methods: MVC fatality data was collected from National Highway Traffic Safety Administration (NHTSA) Fatality Analysis Reporting System (FARS), and population from the U.S. Census Bureau from 2006-12. NE IN had one Level II TC in 2006 and after 2009 there were two Level II TCs. NE IN counties were divided into cohorts based on distance to the closest TC. For a local control, another area within the state with one level II TC throughout the study period was used.
Results: The national average for MVC fatalities decreased across the 6 years by 24.8% while the decline in the control area was 17.5%. After the addition of the 2nd level II TC, NE IN area counties showed an overall reduction in MVC-caused fatality rate of 32.0%, exceeding that of national and control areas. The fatality rate per 100,000 pop. national averages, control area, and study area dropped 3.56, 3.11, and 5.41 from 2006-12 (Fig. 1), respectively.
Conclusion: This study found that the addition of a second Level II trauma center in the study area decreased the rate of fatalities from MVCs greater than control area and national averages
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during the study period. This suggests the benefit of adding a second trauma center to fixed area and population and is an example framework of how other areas can assess their trauma center placement.
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29. OUTCOMES OF SURGICAL MANAGEMENT OF DUODENAL INJURIES AT AN URBAN, COMMUNITY BASED, LEVEL 1 TRAUMA CENTER A Basu MD, RJ Robitsek PhD, J Chan MD, A Wong MD, K McKenzie DO, D Sammett MD PhD, A Khalil MD, S Schubl MD, A Magh MD, A Alpuerto BS, G Doughlin MD, K Fretwell MD Jamaica Hospital Medical Center
Purpose: To describe the outcomes of operative procedures among duodenal trauma patients between 2000-2015.
Methods: Patients were identified from the records of weekly M&M meetings. Medical records were accessed from archived paper charts for the years 2000-2010 and from the EMR for 2011-2015. Analyses compared patients having one operation with those needing multiple operations. Analyses of continuous variables used robust, non-parametric statistics with bootstrapped confidence intervals (Modern Statistics for the Social and Behavioral Sciences. R.W.Wilcox, 2010; CRC press) while Fisher’s exact test was used for nominal variables.
Results: There were 27 patients operatively treated for duodenal trauma. Twenty-four were male, and the mean age was 31 ± 11.3 years. Mechanism was GSW in 19 cases, SW in 6, 1 IVC filter, and 1 blunt). The Duodenal Injury Scores were grade I (n = 1), grade II (n = 15), grade III (n = 9), grade IV and grade V (n = 1 each). The average ISS was 22.8 ± 15.5, and average time from injury to operative intervention was 1.9 ± 1.2 hours. Initial operative procedures for duodenal repair included suturing alone (n = 7), suture + pyloric exclusion (PE; n = 1), suture + PE + gastrojejunostomy (GJ; n = 13), excision alone (n = 2), excision + GJ (n = 1), or duodenojejunostomy (n = 2), and right hemicolectomy (n = 1, missed duodenal injury). Returns to the operating room were needed in 14 patients (51.8%). Concomitant injuries included liver (n = 17), large intestine (n = 10), stomach (n = 9), IVC (n = 7), small intestine (n = 7), kidney (n = 7), pancreas
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(n = 5), gall bladder (n = 4), mesentery/mesocolon (n = 4), diaphragm (n = 3), and portal vein, SMA, SMV, gonadal vein, bile duct, ureter (n = 1 each). The most common complications were respiratory failure (n = 11), intra-abdominal abscess (n = 5), sepsis (n = 5) and acute renal failure (n = 4). The average length of ICU stay was 18 ± 32 days, mean number of days on ventilator was 11.6 ± 27.5 days, and average length of hospital stay was 35 ± 42.1 days. Twenty four patients were discharged from the hospital and one was transferred after two operations to a tertiary care facility for biliary and duodenal reconstruction. There were 2 deaths (one in the OR and one on post op day 4). The table compares patients that had one operation with those needing multiple operations.
Conclusion: Multiple operations were associated with increased ventilation requirement, longer lengths of stay both in the ICU and overall, as well as an increased incidence of sepsis. We were able to obtain satisfactory outcomes in these difficult-to- treat injuries by using aggressive resuscitation, prompt surgical intervention and meticulous supportive care post-operatively.
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30. DIRECT ORAL ANTICOAGULANTS (DOAC) DO NOT WORSEN OUTCOMES IN TRAUMATIC BRAIN INJURY (TBI) FROM LOW LEVEL FALLS IN THE ELDERLY M Yassen PharmD, J Hecht PharmD, C Callahan PharmD, WL Wahl MD Saint Joseph Mercy Ann Arbor
Purpose: Falls are now the leading cause of trauma, particularly in the elderly. With increasing patient age, the use of anticoagulants for comorbidities is also increasing. There is little data on elderly patient outcomes after TBI) while anticoagulated with DOAC compared to warfarin. We hypothesize that patients treated with anticoagulation would have higher mortality and more complications than non-anticoagulated patients, and patients on DOAC would have more fatal outcomes due to lack of reversal agents.
Methods: Patients aged 65 years or older admitted to a level 1, 2, or 3 trauma center hospital within the healthcare network with 24-hour neurosurgical care were identified through the administrative database. Patients with ICD-9 codes consistent with a low level fall and who had ICD-9 codes consistent with traumatic brain injury were included from the database from 5/2013 through 10/2015. Preadmission use of either warfarin or any DOAC was extracted from the database. Standard statistical analysis was performed where p≤0.05 defined significance
Results: : 2944 patients age 65 years or older sustained low level falls. Of these, 700 sustained TBI with 177 patients on anticoagulants prior to admission (Table). Patients on anticoagulants were more likely to have cardiac disease (p≤0.001), pulmonary comorbidities (p≤0.001) or a clotting disorder (p=0.023) compared to non-anticoagulated (No AC) patients. Warfarin patients had the highest neurosurgical intervention rate (18%) compared to DOAC (2.8%, p≤0.02) or No AC (11%, p≤0.02). Overall mortality and mortality after
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neurosurgical intervention were not different between the No AC, warfarin or DOAC groups (Table). Warfarin patients were more likely to receive either plasma (p<0.001) or red cell transfusion (p=0.035) with higher ICU LOS (p≤0.001) compared to DOAC or No AC patients (Table). With logistic regression, only advancing age (p≤0.05) and lower Glasgow Coma Scale (GCS) (p≤0.001) were associated with higher mortality, where each additional year of age increased the odds of death by 3.7% and each point decrease in GCS corresponded to an increase of 33% in the odds of death.
Conclusion: Elderly patients treated with a DOAC who sustained a low level fall and documented TBI did not have increased morbidity or mortality compared to those treated with either warfarin on no anticoagulation. Concerns over the use of DOAC agents in this population may be overstated and deserve more scrutiny.
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31. TIMING OF CAROTID ENDARTERECTOMY AFTER A RECENT MILD TO MODERATE STROKE SS Hans MD, I Catanescu Henry Ford Macomb Hospital
Purpose: Multicenter trials have clearly shown benefit of early carotid endarterectomy (CEA) in patients with recent neurological symptoms with 70% or greater ICA stenosis. Patients with crescendo TIAs and stroke in evolution were also included in some studies. We report results of early and delayed CEA in patients with mild to moderate stroke.
Methods: Retrospective analysis of patients undergoing CEA after sustaining a stroke in the distribution of the branches of the middle cerebral artery (MCA) with greater than or equal to 70% ipsilateral internal carotid artery (ICA) stenosis (January 1998 to September 2017) performed in two mid-sized teaching hospitals with stroke certification. Data has been kept on a continuous basis in the vascular registries. All patients were evaluated by a stroke neurologist with documentation of the deficit by NIH Scale. Patients with transient ischemic attack (TIA) or severe stroke (NIH >15) were excluded. Indwelling shunt was used if patients developed neurological deficit with carotid cross clamping under cervical block anesthesia (CBA) or if ischemic EEG changes developed under general anesthesia (GA).
Results: Out of 91 consecutive patients undergoing CEA for mild to moderate stroke, 59 had CEA within 2 weeks of stroke (Group A) and 32 patients had CEA from 2-8 weeks of stroke (Group B). All patients underwent initial carotid duplex and a non-contrast CT scan of the head. There was preponderance of males in Group B. Risk factors in the form of coronary artery disease; hypertension, diabetes mellitus, hyperlipidemia, nicotine abuse and chronic obstructive pulmonary disease were similar in both groups (Table 1). MRI of the brain (56), CTA carotid neck (78), MRA Neck (14), Carotid and cerebral angiography (14) were
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obtained. NIH stroke scale was similar in both groups (Table 1). Two patients developed severe stroke while awaiting CEA and did not undergo the operation. Perioperative stroke developed in four patients with mortality in all (stroke/mortality rate 4.3%). Four patients (4.3%) developed postoperative seizures. There was no MI, permanent cranial nerve palsy or re-exploration for neck hematoma. Demographics, Clinical presentation and complications are shown in Table 1.
Conclusion: Early as well as delayed CEA in patients with recent mild to moderate stroke results in satisfactory outcome with no difference in the incidence of perioperative stroke or seizure. However, in order to prevent recurrent stroke during the waiting period, early CEA should be preferred.
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32. SURGICAL STAGING IS SUPERIOR TO PET SCAN FOR ASSESSMENT OF DISEASE RESPONSE FOLLOWING CHEMOTHERAPY FOR MEDIASTINAL LYMPHOMA LT Kane BS, H Savas MD, MM DeCamp MD, A Bharat MD Northwestern University
Purpose: Mediastinal lymphoma affects young individuals, typically in the second through fourth decades of life, and constitutes over 7% of all lymphomas. The primary treatment modality remains systemic chemotherapy with or without radiation. Response to therapy is determined using PET scan. Unfortunately, in over 25% of patients, PET remains positive and it is unclear whether persistent PET avidity in the mediastinum represents residual disease or inflammatory changes resulting from therapy. Percutaneous image guided biopsy has typically resulted in poor accuracy due to the heterogeneity of the residual mass as well as the difficult nature of needle access. We hypothesized that minimally invasive thoracoscopic techniques would enable better sampling of the PET avid mediastinal lesion, allowing accurate assessment of residual disease following first- line treatment of mediastinal lymphomas.
Methods: This is a retrospective analysis of a prospectively maintained database. Between January 2009 and December 2015, all patients (n=77) who underwent initial surgical incisional biopsy for diagnosis were included. The surgical biopsies were performed using minimally invasive techniques (video- thoracoscopy or robotic surgery) and required the surgeon to keep performing the biopsy until frozen section was positive or at least until the mass on the ipsilateral hemi-mediastinum was resected. Statistical analysis was performed by a biostatistician using SPSS software.
Results: Of the study cohort, 34 patients underwent surgical restaging for PET avid residual mass while 43 either had a complete response with no PET activity or were lost to follow
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up. The cohort of 34 patients included 76% Caucasians, 50% females, and had a median age of 28 years. The types of lymphoma were predominantly Hodgkins (32%) and Diffuse Large B cell Lymphoma (38%). In these 34 patients with residual PET activity, surgical biopsy revealed presence of lymphoma in 53% of patients. Patients detected to have persistent lymphoma revealed no significant difference in tumor volume reduction compared to those with no residual disease (51% versus 39%) and no significant difference in reduction in PET SUV (68% versus 60%). In all biopsies, significant adhesions between lung and mediastinum were noted, and the median length of the surgical procedure was 75 minutes. However, there were no surgical complications. The length of stay for all patients was less than 24 hours. All patients detected to have residual lymphoma underwent second-line therapy guided by the pathological analysis.
Conclusion: While the current standard for patients with mediastinal lymphoma presenting with residual PET activity after completion of first line therapy is surveillance alone, our data suggests that a large number of these patients have residual lymphoma which can be safely diagnosed using minimally invasive surgery. Detection of residual lymphoma has significant implications in further treatment of these patients.
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33. MEDICARE OUTCOMES IN ELECTIVE MAJOR VASCULAR SURGERY SM Nedza MD, M Pine MD, AM Reband BS, C-J Huang PhD, G Pine BA MPA Healthcare Solutions
Purpose: Major vascular operations are common in the high-risk Medicare population. The goal of this study was to examine the 90-day post-discharge outcomes for these elective procedures, and benchmark hospital performance to better inform providers of the opportunity for care improvement.
Methods: The Medicare Limited Dataset for 2012-2014 was used to examine the risk-adjusted outcomes of elective open aortic procedures, endovascular aortic procedures, and peripheral vascular reconstruction of the lower extremities. All emergency diagnoses and all emergency department admissions were excluded. Logistic prediction models were designed to predict the adverse outcomes (AOs) of inpatient deaths (IpDs), post-operative length-of-stay outliers (prLOSs), 90-day post- discharge deaths without readmission (PD-90s), and 90-day post-discharge readmissions (RA-90s) after non-associated exclusions. Observed and predicted AOs were defined for each hospital, and risk-adjusted outcomes were then computed for all hospitals with a minimum of 4.5 predicted AOs for the study period.
Results: For open aortic surgery, there were 11,040 cases in 326 eligible hospitals that had 251(2.3%) IpDs, 789(7.1%) prLOSs, 101 PD-90s(0.9%), and 2,253(20.4%) RA-90s for an overall AO (one or more AO) rate of 27.8%(3,073/11,040). The best performing decile of hospitals had a median AO rate of 11.3% (P<0.001), and the poorest performing decile had a median AO rate of 43.5%(P<0.001). For endovascular aortic procedures, there were 40,956 cases in 874 eligible hospitals that had 228(0.6%) IpDs, 3,381(8.3%) prLOSs, 335(0.8%) PD-90s, and 7,925(19.4%) RA-90s for an overall AO rate of
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26.0%(10,632/40,956). The best performing decile of hospitals had a median AO rate of 13.4%(P<0.001) and the poorest performing decile was 37.6%(P<0.001). For peripheral vascular reconstruction, there were 24,434 cases in 690 eligible hospitals that had 156(0.6%) IpDs, 1,374(5.6%) prLOSs, 247(1.0%) PD-90s, and 6,578(26.8%) RA-90s for an overall AO rate of 31.5%(7,705/24,434). The best performing decile of hospitals had a median AO rate of 16.7%(P<0.001), and the poorest performing decile was 45.8%(P<0.001).
Conclusion: In the era of abbreviated inpatient stays, AOs most commonly occur as readmissions following discharge. Risk- adjusted hospital performance varies widely in vascular surgery outcomes. Benchmarking risk-adjusted performance is necessary to direct hospital improvement initiates.
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34. PREDICTING BURN PATIENT MORTALITY WITH ELECTRONIC MEDICAL RECORDS A Cobb MD, PC Kuo MD MBA Loyola University Medical Center
Purpose: Burns are the fourth most common mechanism of trauma worldwide. While there exists a robust literature on mortality-associated factors in burn patients, such as socioeconomic status, etiology, and gender, it is unknown if electronic medical records (EMR) implementation impacts mortality. Using burn injury as an information and communication intensive surgical care model, we hypothesize that EMR functionality and interoperability are critical determinants of outcome.
Methods: We utilized the HCUP State Inpatient Database (SID) for Washington (n=779), California (n=1,642), and Florida (n=1,281) for 2009-2010, as well as New York (n=2,218) from 2009-2013. Hospital data were acquired from the American Hospital Association Information Technology (AHAIT) survey. We calculated the functionality and interoperability scores from the AHAIT survey. We grouped ICD-9 burn codes into 5 categories: 39% surface area (SA) 3rd degree, 69% SA 3rd degree, 90% SA 3rd degree, unspecified degree in any location, and unspecified degree on a mucosal surface. To understand the relative importance of diagnosis related group (DRG24), common comorbidities, total surface area and degree of burn, gender, ethnicity, age, and EMR functionality and interoperability, we utilized extreme gradient boosting (Python). This is a supervised machine learning model based on a greedy decision tree with subsequent boosting. The data was broken into training and test sets, with high accuracy and area under the curve (AUC) as objectives. We increased the number of estimators and decreased the learning rate (0.1) of the algorithm to avoid overfitting.
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Results: In each state our models had an accuracy and AUC of over 0.90. EMR functionality was among the top 12 variables in New York, California, and Florida. The most important variables were measured by relative importance in arbitrary units. In each state those variables were increasing age (relative impact=297), increasing length of stay (288), and increasing total charges (246), DRG24 “505”, or extensive burns without a skin graft for 96+ hours (118), 90% SA 3rd degree (86.8). Surprisingly, having lower EMR functionality (97) was a more important predictor than all comorbidities except for coagulopathies and electrolyte disorders by at least a factor of two. Interestingly, EMR interoperability across the states was not a significant predictor.
Conclusion: These data indicate that EMR functionality as defined by the quantity and quality of recorded data is significantly predictive of mortality. EMR interoperability was significant only for California. This suggests that data recording and presentation, but not information exchange, significantly impacts burn mortality.
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35. SUPERUSERS: DRIVERS OF HEALTHCARE COSTS IN THE NATIONAL TRAUMA POPULATION LA Gil BS BA, A Kothari MS MD, S Brownlee BA, H Ton-That MD, R Gonzalez MD, FA Luchette MSc MD, MJ Anstadt MD Loyola University Medical Center
Purpose: Today’s healthcare spending is driven by a very small percentage of Americans, many of whom are patients with prolonged lengths of stay. These patients accrue months’ or even years’ worth of hospital charges. The objective of this study was to characterize superusers in the trauma patient population.
Methods: The National Trauma Data Bank (NTDB) for 2008- 2012 was queried. Superusers were defined as those with a length of stay in the top 0.06% of the population, corresponding to the definition of a rare condition per the Rare Diseases Act of 2002. Superusers were compared to the remainder of the population to determine differences in demographics, comorbidities, prehospital factors, and outcomes (ICU length of stay, vent days, and complications). Multivariate analysis was utilized to determine independent predictors of being classified as a superuser.
Results: 3,615,508 patients met our inclusion criteria with 34,710 qualifying as superusers. Superusers were classified as having a length of stay greater than 37 days. While the average user had a mean length of stay of 4 days, superusers had a mean length of stay of 58 days (P<.001). Superusers arrived with a lower GCS score (10.6 vs 13.8, P<.001), greater ISS (23.8 vs 9.3, P<.001) and were more likely to be admitted to the ICU from the ED (60.9% vs 36.8%, P<.001). Superusers experienced longer stay in the ICU (29 vs 4.4 days) and required a longer duration of mechanical ventilation (24.1 vs 4.8 days). The hospital course of superusers was more likely to be complicated by pneumonia (16.3% vs. 1.2%), ARDS (5.6% vs 0.5%), decubitus ulcer (4.8% vs 0.2%), and AKI (3.1% vs 0.4%). Age (OR: 1.02, 95% C.I.: 1.01- 1.02), male gender (OR: 0.54, 95% C.I.: .52-.55), Black/African
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American race (OR: 1.28, C.I.: 1.23-1.32), and Medicaid insurance (OR: 4.4, 95% C.I.: 4.23-4.66) were independent predictors of classification as a superuser.
Conclusion: Age, gender, race and insurance were associated with prolonged utilization of inpatient care in the trauma patient population. This subset of the trauma population confers a disproportionate burden on the healthcare system and can serve as a potential target for early inpatient discharge planning to improve the efficiency of care.
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36. IMPACT OF ANTICIPATED FINANCIAL BURDEN ON PATIENT DECISION TO UNDERGO CONTRALATERAL PROPHYLACTIC MASTECTOMY J Huang AB, AB Chagpar MD Yale University School of Medicine
Purpose: We sought to determine whether anticipated financial burden is associated with the decision to undergo contralateral prophylactic mastectomy (CPM) over unilateral mastectomy (UM).
Methods: Female patients with unilateral breast cancer who underwent mastectomy at a large academic institution were surveyed regarding their decision to undergo CPM or not, and the impact of anticipated financial burden on this decision. Non- parametric statistics were performed using SPSS version 24.
Results: 109 patients were approached, of whom 101 (92.7%) completed the survey. Median age of respondents at the time of surgery was 49 (range 29-82). 55 patients (54.5%) had CPM. 15.8% of respondents reported that their surgical decision-making was affected, at least somewhat, by anticipated costs. The proportion of patients who felt that financial burden affected their decision, however, was similar between CPM vs. UM patients (12.7% vs. 19.6%, respectively, p=0.417). CPM patients more often anticipated a “very large” financial burden compared to UM patients (25.5% vs. 8.7%, respectively, p=0.037). While overall, there was a strong correlation between anticipated financial burden and anticipated out of pocket costs (OOP, p=0.005), there was no difference in the proportion of CPM vs. UM patients who anticipated their OOP costs to be >$10,000 (13.5% vs. 9.1%, respectively, p=0.541). More patients who had CPM opted for reconstruction (87.3% vs. 67.4%, p=0.002) and tended to be younger at the time of surgery than their UM counterparts (median age 46 vs. 58.5, p<0.001). Race (p=0.666), disease stage (p=0.965), education
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(p=0.659), insurance type (p=0.259), income (p=0.935), and marital status (p=0.484) did not differ between UM and CPM patients. Controlling for patient age and the decision to undergo reconstruction, the anticipation of a “very large” financial burden did not independently affect the decision to undergo CPM (p=0.152).
Conclusion: About 15% of patients state that financial considerations at least somewhat affect their surgical decision making. While CPM patients are more likely to anticipate a “very large” financial burden compared to UM patients, this does not seem to deter them from the contralateral procedure.
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37. OPERATIVE TIME IN ESOPHAGECTOMY: DOES IT AFFECT OUTCOMES? NP Valsangkar MD, H Salfity MD, L Timsina PhD, M Kilbane BSN, E Ceppa MD, D Ceppa MD, T Birdas MD Indiana University School of Medicine
Purpose: The effect of operative duration on postoperative outcomes after esophagectomy is not well understood. We explored the relationship between increasing operative duration and postoperative morbidity and mortality by the type of esophagectomy performed.
Methods: Esophagectomies with orthotopic gastric reconstruction performed between 2010 and 2015 were queried from the National Surgical Quality Improvement Program (NSQIP) Participant Use File. Linear and multivariate regression analyses and ANOVA were used to determine if operative duration correlated with outcomes independent of comorbid conditions. Subset analysis was performed by the type of esophagectomy.
Results: A total of 5098 patients were included in the analysis, with a median age and operative time of 64 years and 353 minutes, respectively. Operative time inflection points were identified and cut point analysis was used to define low, medium, and high operative duration groups for each esophagectomy type (see Table). In the transhiatal group, longer operative times correlated with pneumonia, unplanned reintubation, prolonged intubation, sepsis or septic shock, unplanned reoperation, 30- day mortality and length of stay. For Ivor-Lewis esophagectomy there was similar correlation with most postoperative complications, but not mortality. Among patients with McKeown esophagectomy, there was no correlation between longer operative times and postoperative morbidity or mortality.
Conclusion: Prolonged operative time can have an independent
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adverse impact on postoperative morbidity, which varies by surgical approach. We have identified unique cut-points in the operative time for transhiatal (over 333 minutes) and Ivor-Lewis esophagectomy (over 422 minutes), which can be used as a prognostic marker for worse postoperative outcomes. In selected patients undergoing esophagectomy, operative duration could be used as an indicator of surgical quality.
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38. ADDITIONAL AND REPEATED CT SCAN IN INTER- FACILITIES TRAUMA TRANSFERS: ROOM FOR IMPROVEMENT D Bracco MD, G Artho MD, D Deckelbaum MD, DS Mulder MD, T Razek MD David S Mulder Trauma Center
Purpose: Despite ATLS recommendations, trauma patients often receive advanced imaging modalities in local hospitals before being transferred to a tertiary facility. The problem of repeat CT scanning due to technical and CT scan protocol issues is ongoing. The objective of the present study is to assess the importance of repeat scanning (excluding technical / compatibility issues) and the need for additional CT in trauma transfert patients.
Methods: All secondary transfers to our tertiary facility having a CT scan done in the local hospital, with images available in the tertiary centre PACS system over 9 years were reviewed. Patient were considered having a repeat scan if the same body region was scanned upon arrival not for follow up reasons. Patient were considered to receive an additional scan if another body region was scanned as a part of the initial assessment.
Results: Over 9 years, 6292 patients were received from local hospitals. 704 (11%) received 1155 CT scan examinations in local hospitals. Patients being scanned in local hospitals were sicker (Median ISS 19 vs 11), required more ICU admission (34% vs 30%) and more mechanical ventilation (32% vs 25%). During initial evaluation, 43% of patients receiving a scan in a local hospital need the same body part scanned and 55% of them requires another body part to be imaged as their initial trauma evaluation. Patients having a CT in local hospital received 3.54 CT examination (1.64 in local hospital plus 1.90 in trauma center), significantly more than the patients without CT in local hospital (2.62 exams). When corrected for ISS, the patients having a CT in peripheral hospitals have an OR of hospital death
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of 1.51. Patients with a CT in local hospital spend 700 minutes versus 300 minutes in local hospitals.
Conclusion: Repeat and additional images are a waste of resources and expose the patient to additional risks. Ct scan workflow between local and trauma hospitals can be improved by standardizing the scanning protocols across a trauma system, having raw data available from one hospital to another and changing the approach of local hospital doctors when they send a patient to CT scan from “finding an injury which need level 1 trauma centre” to “not missing any injuries”.
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39. POSTOPERATIVE OPIOID PRESCRIBING PRACTICES AND THE IMPACT OF THE HYDROCODONE SCHEDULE CHANGE WH Tan MD, JM McAllister MD, S Feaman MA CCRP, JA Blatnik MD, LM Brunt MD Washington University in St. Louis School of Medicine
Purpose: With the epidemic of prescription opioid abuse in the United States, there is a need to better understand postoperative opioid prescribing patterns. Currently, there are no widely accepted guidelines for postoperative pain management. In 2014, hydrocodone was moved from Schedule III to II, meaning that it could no longer be “called in” to a pharmacy, prompting concerns of inconveniencing patients or promoting overprescription. We sought to describe current postoperative opioid prescribing patterns and determine the impact of the hydrocodone schedule change on the type and amount of opioid prescribed.
Methods: Opioid prescribing practices for common surgical procedures at a single, large academic medical center were analyzed retrospectively from January 2013-December 2016. Prescription data were obtained from the hospital pharmacy, converted into oral morphine equivalents, and separated by CPT code. Wilcoxon-Mann-Whitney test was used to compare OME prescribed before and after the hydrocodone schedule change and Fisher’s exact test used to compare frequencies of drugs.
Results: A total of 7,046 patients (7,361 prescriptions) for 29 different operations were included in this study. A median of 200-225 OME were prescribed for procedures such as lumpectomy, parathyroidectomy, laparoscopic cholecystectomy, and inguinal hernia repair. A median of 525-675 OME were prescribed for procedures such as hepatic lobectomy, laparoscopic and open partial colectomy, Whipple, and video- assisted thoracic lobectomy. Prescribing practices varied widely within procedures, from 50 OME for some patients to 5,000 OME for others. For the vast majority of procedures, there was
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no significant difference in the number of OME prescribed before and after the hydrocodone schedule change. However, before the rule change, hydrocodone compounds were 33.8% of post- discharge prescriptions compared to 27.0% after. At the same time, oxycodone and oxycodone compounds rose from 63.7% to 67.9%, while the rate of tramadol prescriptions rose from 0.08% to 2.8%.
Conclusion: Although hydrocodone, oxycodone, and related compounds were the most popular opioid prescriptions, the number of OME prescribed varied considerably across surgical procedures. Generally, more OME were prescribed for more invasive procedures. The hydrocodone schedule change did not affect median OME prescribed for most procedures, though it may have affected which opioid was prescribed after discharge.
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40. SAME DAY DISCHARGE AFTER THYROIDECTOMY IS SAFE AND EFFECTIVE HA Reinhart MD, SK Snyder MD, SV Stafford MD, VE Wagner BS , CW Graham MD, MD Bortz MD, X Wang PhD Baylor Scott and White Health, UT Rio Grande Valley School of Medicine
Purpose: Historically, thyroidectomies were performed as an inpatient procedure due to concerns for life-threatening postoperative bleeding. We aim to demonstrate that thyroidectomy can be performed safely in the outpatient setting and complications that arise can be dealt with safely.
Methods: A 7 year retrospective analysis (2009-2016) of thyroidectomies performed by a single surgeon was undertaken. No patients were excluded. Outcomes including hematoma, blood loss, recurrent laryngeal nerve (RLN) injury, symptomatic hypocalcemia, and postoperative ER visits were identified.
Results: A total of 1482 thyroidectomies were performed: 1341 (90%) as outpatient and 141 (10%) as inpatient. Outpatient procedures included 752 total thyroidectomies (TT) +/- central lymph node dissection (CLND) (56%), 495 total lobectomies (TL) +/- CLND or partial thyroidectomy (PT) (37%), and 94 PT (7%). Inpatient procedures included 103 TT +/- CLND (73%), 28 TL +/- CLND or PT (20%), and 10 PT (7%). Average time to discharge was 2:45. Five patients (3 TT, 1 TT + CLND, 1 PT) developed postoperative hematomas (0.34%). All 5 hematomas were outpatient and were identified at hour 3, 9, 10, 13, and 42 after discharge. All hematomas were successfully evacuated in the OR under local anesthesia without bedside decompression, adverse sequelae with an average hospital stay of 2 days. There was no significant difference between TT, TL, and PT procedures for postoperative hematoma (p=0.17). Outpatient compared to inpatient thyroidectomy was significantly more likely to have a lower American Society of Anesthesia score (2.3 vs 3.0, p<0.01), lower mean blood loss (84 vs 199 ml, p<0.01),
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and fewer RLN injuries (2.8% vs 6.9%, p=0.01). There was no significant difference between the outpatient and inpatient group for mean resected thyroid weight (33 vs 42 Gm, p=0.07), symptomatic hypocalcemia (6.5% vs 10.3%, p=0.12), 30 day postoperative emergency room visit (9.0% vs 10.3%, p=0.61), and postoperative hematoma (0% vs 0.43%, p=1.0). There was one inpatient death due to stroke.
Conclusion: While considered surgical emergencies, postoperative hematomas can be safely managed without life- threatening complications suggesting outpatient thyroidectomy can be safely performed by an experienced surgeon and the sequelae can be dealt with in a safe and effective manner.
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QS 1. FEASIBILITY OF INTRA-OPERATIVE ANGIOEMBOLIZATION FOR TRAUMA PATIENTS USING C-ARM DIGITAL SUBTRACTION ANGIOGRAPHY A Alnumay MD, A Beckett MD, D Deckelbaum MD, P Fata MD, K Khwaja MD, T Razek MD, J Grushka MD McGill University Health Centre
Purpose: Angioembolization (AE) is an essential and growing component in the management of trauma patients. The critical decision of transferring a patient to the operating room or the Interventional radiology suite can be bypassed by combining both options using intra-operative angioembolization (IOAE) using C-Arm digital subtraction angiography in the absence of other more costly alternatives (e.g RAPTOR suits). This case series aims to establish the feasibility of intra-operative angioembolization using low cost C-Arm digital subtraction angiography.
Methods: This retrospective case-series was conducted in our level 1 trauma center from January 2011 to August 2017 for all patients who underwent IOAE with a concomitant surgical intervention. We assessed their demographics, baseline hemodynamics, type and site of embolization, Inferior vena cava filter (IVC filter) and outcomes.
Results: A total of 27 patients (23 Males, 4 Females) received IOAE using the C-Arm digital subtraction angiography, with all being hemodynamically unstable in the emergency department. The mean age was 41 years (range: 18-76 years), with a mean baseline PH of 7.16 and lactate of 7.4. The access used was right Femoral (common or External), with the use of Gel foam slurry, pledgets, coils, or a combination of the former for embolization. All but 3 cases required AE of the internal iliac or branches of it. All cases achieved successful cessation of bleeding confirmed with post embolization angiography, with none of the cases requiring another operative/angiographic intervention for
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bleeding. Nineteen of the patient had successful placement of an IVC filter at the time of the procedure. Eighteen of the 27 patients survived.
Conclusion: Our results suggest Intra-operative angioembolization using C-Arm digital subtraction angiography is a feasible management option in severe trauma patients with an advantage of concurrent operative intervention and ongoing active resuscitation with good success in hemorrhage control.
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QS 2. HYPERCALCEMIA IN THE CRITICALLY ILL SURGICAL PATIENT: PAMIDRONATE VS NO PAMIDRONATE HS Dolman MD, LR Howell PharmD, PJ Faris PharmD, L Hall Zimmerman PharmD, AE Baylor MD, TT Lavery MD, J Ciullo MD, JG Tyburski MD, RF Wilson MD Wayne State University
Purpose: Hypercalcemia in critically ill patients can evolve into life threatening arrhythmias. Recently, hypercalcemia has been associated with increased mortality.This study evaluated pamidronate, a bisphosphonate, for the treatment of hypercalcemia in critically ill surgical patients to determine effectiveness and safety.
Methods: This retrospective study evaluated critically ill surgical patients admitted to the intensive care unit for three consecutive years with hypercalcemia. Patients were excluded with primary hyperparathyroidism or pregnancy. Patients were case-matched on a 1:1 basis for age and severity of illness (APACHE II score). Hypercalcemia was defined as an ionized calcium (ioCa) >1.25 mmol/L. Groups were compared pamidronate (PAM) versus no pamidronate (NoPAM). Effectiveness was defined as time to hypercalcemia resolution. Safety was defined based on adverse effects. Data were analyzed with SPSS v21.0, and a p-value <0.05 was considered significant.
Results: Of the 30 patients (15 PAM vs 15 NoPAM) evaluated, the mean age was 54 ± 13 years with an overall APACHE II of 22±9 and SOFA score of 8±5. For effectiveness, time of hypercalcemia to normalization was longer with PAM (11±10 PAM vs 4±5 NoPAM, days, p=0.01). Duration of hypercalcemia was longer with PAM, (18±9 PAM vs 6±7 NoPAM days, p<0.001). The number of hypercalcemia episodes was similar between groups, 2±1 PAM vs 2±1 NoPAM, episodes, p=0.20. Baseline ioCa were similar between groups. Time from admission until onset of hypercalcemia was shorter in the PAM group, 6±3 PAM vs 18±12 NoPAM, days, p=0.003. Regarding safety, renal
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failure requiring dialysis tended to be more likely with PAM, 53% PAM vs 20% NoPAM, p=0.12. Overall, 66% of the patients developed an arrhythmia with the most common being sinus tachycardia (55%) although the type of arrhythmias did not differ between groups. ICU length of stay tended to be longer with PAM, 41±30 PAM vs 25±22 NoPAM, days, p=0.12. In-hospital mortality was not different.
Conclusion: Hypercalcemia in critically ill surgical patients is a significant problem. Patients receiving pamidronate had longer time to hypercalcemia normalization and the incidence of renal failure tended to be higher. Pamidronate may not serve a role in hypercalcemia of critical illness in surgical patients and should be reevaluated.
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QS 3. COMPLETION THYROIDECTOMY: A RISKY UNDERTAKING? CY Teng MD, KJ Nicholson MD, KL McCoy MD, SE Carty MD, L Yip MD University of Pittsburgh
Purpose: Thyroid lobectomy is often needed for definitive diagnosis of indeterminate thyroid nodules. If malignancy is diagnosed, a second operation may be needed to facilitate radioactive iodine ablation and/or surveillance. Clinical factors and patient preferences can guide the appropriate extent of initial surgery, but it remains controversial if 2-stage thyroidectomy has added operative risk. The aim of this study was to compare complication rates for lobectomy (Lobe), total thyroidectomy (TT), and completion thyroidectomy (CT).
Methods: In a case cohort study design, we retrospectively reviewed thyroidectomies performed prior to 7/31/17 and selected the most recent 100 cases of each of the following: Lobe, TT, and CT. CT was defined as cases with prior lobectomy without violation of the contralateral operative field. No patient was included in more than 1 cohort. Procedure-specific complications included reoperation for hematoma/seroma, recurrent laryngeal nerve (RLN) injury as confirmed by direct laryngoscopy, and hypoparathyroidism defined as hypocalcemia requiring calcitriol supplementation. Duration was defined as transient (<6 months) or permanent (≥6 months). Patients undergoing concurrent parathyroid exploration were excluded.
Results: Demographics were similar between the three groups; age (mean 52.9 years, p=0.54), BMI (mean 31.0, p=0.14), and women (77%, p=0.75). Final pathology was malignant in 159 (53%) patients. Two reoperations were needed for hematoma/seroma in patients who had TT and none in the Lobe or CT cohorts (p=0.33). No patients had permanent hypoparathyroidism or RLN injury. Transient RLN injury occurred in three (3%) Lobe, two (2%) TT, and no (0%) CT patients
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(p=0.38) while the incidence of transient hypoparathyroidism was 3% following TT and 0% after CT (p=0.12). Transient hypoparathyroidism was not associated with either parathyroid autotransplantation (N=8, p=0.15) or incidental resection of parathyroid tissue (N=49, p=0.09). Post-surgical hypothyroidism (e.g. a new requirement of L-T4 postoperatively) was observed in 34% of Lobe patients.
Conclusion: The rate of procedure-specific complications was low in expert hands (3%) and complication rates were equivalent for patients undergoing initial Lobe, TT, or CT. At initial lobectomy, unnecessary exploration of the contralateral compartment should be avoided, and patients can be counseled that 2-stage thyroidectomy has no apparent added risk compared to initial TT.
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QS 4. DOES SPECIFIC IMMUNOSUPPRESSIVE AGENTS AFFECT POST RENAL TRANSPLANT INFECTIONS D Monlezun MD PhD, M John MD, C McDermott BA, G Parker PhD, M Darden PhD, JF Buell MD MBA Tulane University
Purpose: Chronic immunosuppression has long been held as a risk factor in post transplant infections. Little data exists on the contributions of specific agents in the risk of infection type. This study evaluates the risk of particular agents on the incidence of infections.
Methods: Retrospectively reviewed a cohort of renal transplant recipients undergoing transplant at a single institution between ’07-’17. Using this cohort, a Propensity Scored Adjusted Effects Regression Analysis was performed evaluating the risk of infections occurring in 852 renal transplants recipients.
Results: 388 renal transplant recipients (46%) suffered a collection of infections: UTI (n=185;47.7%), viral (n=152;39.1%), sepsis (n=96;24.7%), wound infections (n=84;21.6%), pneumonia (n=60;15.4%), and fungal infections (n=27;7.0%). The Propensity Scored Regression Analysis:
Conclusion: The risk for infection and sepsis are highest with CMV antigen and lowest under myfortic immunosuppression. Surprisingly the risk of post transplant viral infections was decreased under long-term myfortic as well as alemtuzumab induction. Conversely wound infections were not related to a particular immunosuppression but rather the recipients Body Mass Index (BMI).
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NOTES
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QS 5. ADHERENCE TO RECOMMENDED VTE PROPHLAXIS IN ABDOMINAL AND PELVIC ONCOLOGIC SURGERY IN A COMMUNITY HOSPITAL MK Zipple MD, ER Itenberg DO, HS Dolman MD Saint Joseph Mercy Oakland
Purpose: The 2012 American College of Chest Physicians (ACCP) guidelines for VTE prophylaxis in abdominal and pelvic oncologic surgery include in-hospital prophylaxis and extended duration (4-week) chemical prophylaxis with low molecular weight heparin (LMWH) These recommendations are supported by the National Comprehensive Cancer Network and several major national organizations. We reviewed adherence rates to these recommendations at our community hospital, and compared these to statewide rates Michigan Surgical Quality Collaborative (MSQC) data.
Methods: This is a retrospective review of high risk (Caprini score ≥5) adult patients undergoing abdominal or pelvic oncologic surgery during a 2-year time period from 1/1/2015 – 12/31/2016. Comparable data from MSQC was available from 10/8/15 – 12/31/16.
Results: Of the 427 subjects included, 62.3% (n=266) patients received in-hospital prophylaxis [general surgery 93.7% (n=106), urology 54.3% (n=126), gynecology 40.0% (n=32)]. Patients who received recommended in-hospital prophylaxis were older in age, more likely to receive pre-operative prophylaxis, and had a longer length of stay (>3 days) than patients who did not (p< 0.05). There was no association between gender, age, race, or comorbidities and in-hospital VTE prophylaxis. Only five subjects were prescribed extended- duration prophylaxis, all general surgery subjects, resulting in an adherence rate of 4.5% in this population. This sample size was too small to evaluate with any statistical significance. Outcomes are as listed: DVT 0.9% (n=4), PE 0.7% (n=3), bleeding requiring transmission 2.9% (n=13),
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readmission rates 8.8% (n=33). In contrast to our community hospital rates, statewide rates of prophylaxis prescription in the general surgery population showed in-hospital adherence rate of 89.6% (n=1871), and extended prophylaxis with LMWH of 12.5% (n=234). In the gynecology rates of in-hospital prophylaxis was 41.8% (n=190) and extended prophylaxis 20.3% (n=99).
Conclusion: This study shows that despite vast evidence from multiple national guidelines in a high-risk population, rates of extended-duration VTE prophylaxis prescription are lower than the state average in our community hospital. We have instituted formal hospital guidelines for VTE prophylaxis recommendations in this population, as well as educational interventions targeting resident and attending surgeon staff. Future research will include an analysis of changes in rates of appropriate prescription after these interventions.
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QS 6. TREATMENT OF INTRA-ABDOMINAL HYPERTENSION PREVENTS PROGRESSION TO ABDOMINAL COMPARTMENT SYNDROME IN COMPLEX VENTRAL HERNIA REPAIR R Chandra, RA Jacobson MD, KW Millikan MD, JL Poirier PhD, NF Siparsky MD Rush University Medical Center
Purpose: Abdominal compartment syndrome (ACS) is a devastating complication of abdominal surgery. Very little is known about intra-abdominal hypertension (IAH), the condition which precedes ACS. Patients who undergo separation of components (SOC) for complex ventral hernia repair (CVHR) are at risk for developing ACS. To determine the utility of IAH screening and treatment for the prevention of ACS, we conducted a retrospective cohort study of a single-surgeon CVHR experience.
Methods: We conducted an institutional review board-approved chart review of 175 consecutive patients over 7 years (2009- 2016) who underwent SOC for CVHR by a single surgeon at Rush University Medical Center. Demographic information, body mass index (BMI), prior hernia repair, concurrent panniculectomy, operative time, bladder pressure (BP), post-operative serum creatinine (Cr), sedation, paralytic therapy, and ventilator support from the first post-operative week were reviewed.
Results: BP was measured every 2 hours during the first 24 hours after surgery, and as needed thereafter. Fentanyl and propofol were administered for sedation (to a Richmond Agitation Sedation Scale -3 to -4) in 113 patients (65%) who were felt to have a tight abdominal closure. Paralytic therapy (cisatracurium, vecuronium, rocuronium) was employed in 29 patients (17%) with an elevated BP (BP > 20 mmHg) combined with an elevated Cr (Cr > 1mg/dL) or a subjectively tight closure. IAH (BP > 20 mmHg) was identified in 33 patients (19%). Of these patients, 11(6%) were noted to have elevated BP and Cr, consistent with ACS. The mean BMI for patients with an elevated
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BP was 42 kg/m2, whereas the mean BMI was 35.8 kg/m2 in patients without an elevated BP (p=0.005). Longer operative time was significantly associated with an elevated BP (p=0.01), as well as the administration of sedation (p<0.0001). Neither panniculectomy nor previous hernia repair were significantly associated with elevated BP. No patient required re-operation for IAH or ACS.
Conclusion: IAH occurs commonly in patients who undergo SOC for CVHR. Longer operative time and higher BMI were associated with the development of IAH. Rigorous screening for, and treatment of, IAH is effective in preventing ACS in the early post-operative period.
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QS 7. WORKFLOW EFFICIENCY PILOT STUDY OF SURGERY VIEWER© - A SECURE HANDS-FREE INTRAOPERATIVE MULTIMEDIA INTERFACE FOR GOOGLE GLASS™ S Ahmad, J Tann, A Clark, J Gaddy, A McKenzie, A Zentz, C Jackson, B Naumann, J Castaneda, S Toy, C Leighow, B Kiburz, T Green University of Missouri
Purpose: Capturing surgical images can be challenging. Issues include HIPAA compliance, the sterile field and interruptions in workflow. Recently the Google Glass™ heads-up-display system has been adopted by the medical field for applications such as image capture, live streaming and decision support. The ability to use voice commands to control this hands-free heads-up-display system is appealing to surgeons. Very few studies, however, have been reported in the literature using Google Glass™ for this purpose. Common concerns raised by those studies include protection of patient privacy and image quality.
Methods: We designed a custom application for Google Glass™ called Surgery Viewer© (SV) that allowed the surgeon to use voice commands to capture patient images with remote access to their electronic medical record (EMR). The images are transferred to their EMR immediately after capture, bypassing local storage and prohibiting cloud upload, where they can be edited or embedded. This pilot study tested SV both in the operating room and in an outpatient surgical wound clinic. The application was compared to a standard digital camera (DC) and an Apple iOS© device using another image capture (IC) application linked to a patient’s EMR. Comparative workflow metrics included timings of image capture and a usability survey.
Results: Sixteen patients were studied in the operating room and in the outpatient clinic setting. Average times to log onto applications or turn on devices were 18.39s, 9.91s and 2.11s for SV, IC and DC respectively. Times to select the correct patient were 9.61s, 11.02s and 4.55s. Significant differences were noted in image upload times. While images captured by SV and IC were
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instantaneously uploaded to the EMR’s multimedia manager, the DC images took on average 4.06 hours to be manually uploaded. Usability surveys indicated ease of use and interest in using SV in the future while endorsing some concerns about user interface and battery life.
Conclusion: SV performed equivalently with IC while DC took much longer to upload. Users found the application easy to learn and use the glasses. Concerns included the log-on procedure, ambient distraction of voice recognition, viewfinder perspective and battery life. Further research is warranted.
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QS 8. OUTCOMES OF BARIATRIC SURGERY ARE EQUIVALENT IN MEDICARE AND NON-MEDICARE PATIENTS AT TEN-YEAR FOLLOW-UP MO Meneveau MD, AD Michaels MD, RB Hawkins MD MSc, JH Mehaffey MD, B Schirmer MD, PT Hallowell MD University of Virginia
Purpose: Bariatric surgery is the most effective intervention for achieving durable weight loss and reduction of comorbid conditions in patients with morbid obesity. Limited data exists on the impact of insurance status for Medicare patients compared to non-Medicare and there is no comparison of long-term outcomes between these groups. We hypothesized that there is no difference in excess weight loss and comorbidity resolution in Medicare versus non-Medicare patients with 10-year follow-up.
Methods: All patients who underwent roux-en-y gastric bypass at a single academic medical center from 1985 through 2005 were identified using an institutional bariatric database. Patients were stratified by Medicare insurance status for univariate analysis. The primary outcome of interest was 10-year percent reduction in excess BMI (REBMI).
Results: A total of 617 patients undergoing roux-en-y gastric bypass with complete follow-up information were identified, with 117 (19%) insured under Medicare. Medicare patients were older (43.3 vs 41.0 years, p=0.01) and had a greater preoperative BMI (55.1 kg/m2 vs 52.4 kg/m2, p= 0.03) than non-Medicare patients. There were no differences in preoperative comorbidities or the composite comorbidity index (3.24 vs 3.23, p= 0.33). There were no differences in long-term excess BMI reduction with Medicare patients having 59.2% REBMI versus 51.8% in the non-Medicare group at 10 years (p=0.16). Similarly there was no difference in percent difference in comorbidity resolution (0.32 vs 0.28, p= 0.78) (Table).
Conclusion: Bariatric surgery is equally beneficial in Medicare
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and non-Medicare patients at 10 years. As bariatric surgery leads to substantial reductions in excess BMI and obesity-related comorbid conditions, these findings support the continued and expanded coverage of bariatric surgery operations by Medicare.
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QS 9. DISSEMINATED INJECTION OF VINCRISTINE- LOADED SILK GEL IMPROVES THE SUPPRESSION OF NEUROBLASTOMA TUMOR GROWTH J Zeki BS, B Yavuz PhD, J Coburn PhD, N Ikegaki PhD, J Harris MD, D Kaplan MD, B Chiu MD University of Illinois at Chicago
Purpose: Advance stage neuroblastoma patients require intensive multi-agent chemotherapy. We have shown that intra- tumoral implantation of sustained release vincristine-loaded silk gel can decrease orthotopic neuroblastoma tumor growth in mice. This system utilizes diffusion for the drug to reach the tumor cells. We hypothesize (1) injecting the vincristine-loaded silk gel at eight different locations within the tumor instead of only in the center decreases the diffusion distance, (2) decreasing the diffusion distance can improve the tumor growth suppression.
Methods: Human neuroblastoma cells, KELLY, were injected into the left mouse adrenal gland to create neuroblastoma tumor. After tumor reaches 100mm3 by ultrasound, silk gel loaded with Vincristine 50ug was injected into either center of tumor or eight different sections throughout the tumor. The release profile of the vincristine-loaded silk gel was measured in vitro. Experiment endpoint was tumor size >1000mm3. Histologic evaluation of tumors was performed. Data was analyzed by Mann-Whitney test, and p<0.05 was considered significant.
Results: Regardless of the way the intra-tumoral injections were given, vincristine-loaded silk gels were able to suppress tumor growth up to an “inflection” point of 458.7±234.4 mm3 for center-point injection and 514.3±165.8 mm3 for eight-point injection before tumor growth accelerated. At the inflection point, the tumor volume increased by >200 mm3. Tumors (5 animals) after center-point injection took 6.6±4.1 days to reach the “inflection” point and those (6 animals) after eight- point injection took 13.3±3.9 days (p<0.05). Silk gel released
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34.9±1.5mg of vincristine at day6 and 42.5±1.6mg at day13. Assume each injection represented the center of a sphere and using sphere volume equation V=4/3 pr3, splitting the spherical tumor into 8 small spheres decreased the diffusion radius by 2. Cross-section of the post-treatment tumor sample revealed silk gels deposited at separate locations and histology of tumor demonstrated tumor necrosis adjacent to the silk gel.
Conclusion: Injecting vincristine-loaded sustained release silk gel at 8 separate locations instead of one within the neuroblastoma tumor halved the diffusion distance and doubled the days to reach the tumor growth “inflexion” point. Future administration of sustained release local drug therapy should consider disseminated applications to improve tumor growth suppression.
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2002 - Patient Outcomes for Colon Resection According to Surgeon’s Training, Certification and Experience. Jay B. Prytowski, et al. Northwestern University Medical School and University of Illinois College of Medicine, Chicago, Illinois
2003 - The Relationship of Surgeon and Hospital Volume to Outcome Following Gastric Bypass Surgery in Pennsylvania: A Three-Year Summary Anita Courcoulas, et al. University of Pittsburgh, Pittsburgh, Pennsylvania
2004 - Diffusion and Implementation of New Technology in Vascular Surgery: The Case of Aorto-Iliac Occlusive Disease Gilbert Upchurch, et al. University of Michigan Medical Center, Ann Arbor, Michigan
2005 - Intraoperative Parathyroid Hormone Testing Improves Cure Rates in Patients Undergoing Minimally Invasive Parathyroidectomy Herbert Chen, et al. University of Wisconsin, Madison, Wisconsin
2006 - Acute Limb Ischemia Associated with Aortic Dissection, Clinical Relevance and Current Therapy Peter Henke, et al. University of Michigan, Ann Arbor, Michigan
2007 - Total Pancreatectomy (R0 Resection) Improves Survival Over Sub-Total Pancreatectomy in Isolated Neck Margin Positive Pancreatic Adenocarcinoma C. Max Schmidt, et al. Indiana University, Indianapolis, Indiana
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CSA_2018_FinalProgram.indd 137 3/6/18 8:49 PM “BEST PAPER BY A NEW MEMBER” AWARD (continued) 2008 - Reoperative Parathyoidectomy: Improved Imaging and Intraoperative Parathyroid Monitoring Results in a Successful Focused Approach Tina Yen, et al. Medical College of Wisconsin, Milwaukee, Wisconsin
2009 - Does DCIS Accompanying Invasive Carcinoma Affect Prognosis? Anees Chagpar, et al. University of Louisville, Louisville, Kentucky
2010 - Impact of Standardized Trauma Documentation to the Hospital’s Bottom Line Stephen Barnes, et al. University of Missouri, Columbia, Missouri
2011 - Laparoscopic Antireflux Surgery Prevents Aspiration of Pepsin After Lung Transplantation P. Marco Fisichella, et al. Loyola University, Chicago, Illinois
2012 - Dysphagia Post-Fundoplication; More Commonly Hiatal Outflow Resistance than Poor Esophageal Body Motility CL Wilshire, S Niebisch, CE Jones, VR Litle, CG Peyre, TJ Watson, JH Peters University of Rochester Medical Center Rochester, Minnesota
2013 - Socioeconomic Disparities in the Surgical Management of Peptic Ulcer Disease Jason Smith, et al. University of Louisville, Louisville, Kentucky
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CSA_2018_FinalProgram.indd 138 3/6/18 8:49 PM “BEST PAPER BY A NEW MEMBER” AWARD (continued) 2014 - Cost Discrepancies For Common General Surgery Diagnoses In Ohio: Implication Of Hospital Characteristics For Charge And Payment Differences Bryce Robinson University of Cincinnati, Cincinnati, Ohio
2015 - The Clinical Significance of Parathyroid Atypia: Is Long Term Surveillance Necessary? Kelly McCoy University of Pittsburgh, Pittsburgh, Pennsylvania
2016 - Patient Safety Indicator 11 Does Not Accurately Identify Patients Who Received Poor Quality of Care Michelle Nguyen, MD The Ohio State University
2017 - Benefit of Social Media on Patient Engagement and Satisfaction: Results of A 6-Month Pilot Study Using Facebook Vikrom Dhar MD* *CSA New Member Is Senior Author, Shimul Shah, MD, MHCM University of Cincinnati, Cincinnati, Ohio
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John Abad, MD | Warrenville, IL Zahraa AlHilli, MD | Cleveland, OH Jeffrey Blatnik, MD | St. Louis, MO Carlos Chan, MD, PhD | Iowa City, IA Callisia Clarke, MD | Milwaukee, WI Jeremy Grushka, MDCM, MSc | Montreal, Quebec Natalie Joseph, MD | Cleveland, OH Eric Kimchi, MD, MBA | Columbia, MO David Krpata, MD | Cleveland, OH Amy Lloyd, MD | La Crosse, WI Timothy Pawlik, MD, MPH, PhD | Columbus, OH Raphael Pollock, MD, PhD | Columbus, OH Ajita Prabhu, MD | Cleveland, OH Cristiano Quintini, MD | Cleveland, OH Diane Radford, MD | Cleveland, OH Timothy Ridolfi, MD | Milwaukee, WI Melissa Times, MD | Cleveland, OH Alfonso Torquati, MD, MSCI | Chicago, IL Brad Watkins, MD | West Chester, OH
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Please visit the Members Only tab at www.centralsurg.org for CSA member contact information
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CSA_2018_FinalProgram.indd 142 3/6/18 8:49 PM PAST PRESIDENTS
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PRESIDENT Roy D. McClure* 1940-1941 Grover C. Penberthy* 1941-1942 Roscoe R. Graham* 1942-1946 Casper F. Hegner* 1946-1947 George M. Curtis* 1947-1948 Henry K. Ransom* 1948-1949 J. Dewey Bisgard* 1949-1950 Walter G. Maddock* 1950-1951 B. Noland Carter* 1951-1952 R. Kennedy Gilchrist* 1952-1953 James T. Priestley* 1953-1954 Leon J. Leahy* 1954-1955 Rudolf J. Noer* 1955-1956 Robert M. Zollinger* 1956-1957 Hilger P. Jenkins* 1957-1958 William A. Altemeier* 1958-1959 Charles D. Branch* 1959-1960 Robert T. Tidrick* 1960-1961 Chester B. McVay* 1961-1962 Angus D. McLachlin* 1962-1963 Samuel P. Harbison* 1963-1964 Edward S. Judd* 1964-1965 Carl E. Lischer* 1965-1966 D. Emerick Szilagyi* 1966-1967 Fraser N. Gurd* 1967-1968 Edwin H. Ellison* 1968-1969 E. Lee Strohl* 1969-1970 Stanley O. Hoerr* 1969-1970 Vallee L. Willman* 1971-1972 John M. Beal* 1972-1973 Charles L. Eckert* 1973-1974 William J. Fry* 1974-1975 Robert A. Mustard* 1975-1976 Charles A. Hubay* 1976-1977 * Deceased 144 CENTRAL SURGICAL ASSOCIATION
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Alexander J. Walt* 1977-1978 Robert E. Condon* 1978-1979 John E. Jesseph* 1979-1980 Robert J. Freeark* 1980-1981 Seymour I. Schwartz 1981-1982 Lloyd D. MacLean* 1982-1983 Ward O. Griffen, Jr. 1983-1984 Lloyd M. Nyhus* 1984-1985 George E. Block* 1985-1986 Larry C. Carey 1986-1987 Daniel W. Elliott* 1987-1988 Robert J. Baker 1988-1989 Jay L. Grosfeld* 1989-1990 Jeremiah G. Turcotte 1990-1991 Donald Silver 1991-1992 Jack. R. Pickleman 1992-1993 Folkert Belzer* 1993-1994 Roger G. Keith 1994-1995 J. Roland Folse 1995-1996 Jerry M. Shuck 1996-1997 Henry Buchwald 1997-1998 David Nahrwold 1998-1999 Josef Fischer 1999-2000 David Mulder 2000-2001 William Baker 2001-2002 Jonathan B. Towne 2002-2003 Layton F. Rikkers 2003-2004 Mark A. Malangoni 2004-2005 Fabrizio Michelassi 2005-2006 Thomas Stellato 2006-2007 E. Christopher Ellison 2007-2008 Richard H. Bell 2008-2009 William Turnipseed 2009-2010 Michael Nussbaum 2010-2011 Gerald Fried 2011-2012
* Deceased 75TH ANNUAL MEETING 2018 145
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Gerald M. Larson 2012-2013 Nathaniel J. Soper 2013-2014 Christopher R. McHenry 2014-2015 Scott Gruber 2015-2016 W. Scott Melvin 2016-2017
* Deceased
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SECRETARY George M. Curtis 1940-1946 Walter G. Maddock 1946-1949 James T. Priestley 1949-1952 Robert M. Zollinger 1952-1955 Charles D. Branch 1955-1958 Angus D. McLachlin 1958-1961 Carl Lischer 1961-1964 Edwin H. Ellison 1964-1967 Vallee L. Willman 1967-1970 William J. Fry 1970-1973 Alexandar J. Walt 1973-1976 Robert J. Freeark 1976-1979 Ward O. Griffen, Jr 1979-1982 Larry C. Carey 1982-1985 Jay L. Grosfeld 1985-1988 Jack R. Pickleman 1988-1991 J. Roland Folse 1991-1994 David J. Nahrwold 1994-1997 William H. Baker 1997-2000 Fabrizio Michelassi 2000-2003 E. Christopher Ellison 2003-2006 Michael S. Nussbaum 2006-2009 Nathaniel J. Soper 2009-2012 Fred A. Luchette 2012-2015
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TREASURER Charles H. Hubay 1972-1975 John E. Jesseph 1975-1978 Robert P. Hummell 1978-1981 Robert J. Baker 1981-1984 Donald Silver 1984-1987 Jerry M. Shuck 1987-1990 Henry Buchwald 1990-1993 Josef E. Fischer 1993-1996 Layton F. Rikkers 1996-1999 Thomas A. Stellato 1999-2002 Carol EH Scott-Conner 2002-2005 William Turnipseed 2005-2008 Christopher McHenry 2008-2011 Scott Gruber 2011-2013 Margo Shoup 2013-2016
REPRESENTATIVE TO THE AMERICAN BOARD OF SURGERY Lloyd M. Nyhus 1973-1977 William J. Fry 1977-1982 John S. Najarian 1982-1988 Jeremiah G. Turcotte 1982-1988 Olga Jonasson 1988-1994 Richard A. Prinz 1994-2000 Michael S. Nussbaum 2000-2006 Fabrizio Michelassi 2006-2012
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RECORDER Robert E. Condon 1972-1977 John J. Bergan 1977-1982 Jeremiah G. Turcotte 1982-1987 Gordon L. Hyde 1987-1992 Jonathan Towne 1992-1997 Mark Malangoni 1997-2002 Richard H. Bell, Jr. 2002-2007 Gerald Larson 2007-2011 W. Scott Melvin 2011-2014 Tina W.F. Yen 2014-2017
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OFFICERS
President Nathaniel J. Soper, MD
1st Vice-President Christopher R. McHenry, MD
Secretary and Executor Scott A. Gruber, MD
Treasurer W. Scott Melvin, MD
Board Members at Large Herb Chen Stephen Barnes Kelly McCoy
Ex-Officio Members Fred A. Luchette, MD, President CSA L. Michael Brunt, MD, Secretary CSA
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CSA_2018_FinalProgram.indd 152 3/6/18 8:49 PM CSA CAPITAL CAMPAIGN
Donations listed were raised as part of the Capital Campaign through February 28, 2018
For a complete list of lifetime donations, please visit www.centralsurg.org/foundation/contributors
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The CSA Foundation started in the early 1990’s because of diminished funding of the NIH. Since then, CSAF has provided over $250,000 in research grants to 30 recipients. In a recent survey of past grant winners, 90% reported that the CSAF grant money helped facilitate preliminary data which led to greater funding. The Capital Campaign seeks to raise $350,000 to ensure future opportunities for emerging young surgeons for years to come.
Thank you to our CSA Capital Campaign Donors!
PLATINUM SILVER $2500/year x 5 years $500/year x 5 years L. Michael Brunt Donald Fry Fred A. Luchette Scott Gruber David Mulder Michael Nussbaum Michael Ujiki
GOLD $1000/year x 5 years BRONZE $250/year x 5 years E. Christopher Ellison Gerald Larson Daniel Eiferman Christopher McHenry Matthew Goldblatt W. Scott Melvin Bruce Harms Timothy Pritts Peter Rossi C. Max Schmidt Anthony Senagore Margo Shoup Wendy Wahl Ronald Weigel Tina Yen
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DONOR OTHER DONATIONS $100/year x 5 years $1000 Peter Angelos Clifford Cho David Bentrem James DeBord Scott Chapman Daniel Deziel Herb Chen Nathaniel Soper Steven De Jong Margaret Dunn Under $500 Jon Gould Daniel Abbott Peter Hallowell Amin Andalib Brian Harbrecht John Aucar Jeffrey Hardacre Bruce Averbook Charles Lucas William Baker Mark Malangoni Robert J. Baker Jeffrey Matthews Louis Bernhardt Jonathan Saxe Michael Dalsing Elizabeth Shaughnessy Gerald Fried Samuel Snyder Andrea Gruber Steven Steinberg Jeffrey Hardacre Thomas Stellato John Lew Mark Talamonti Fabrizio Michelassi Scott Wilhelm Richard Prinz Diane Radford Donald Reed, Jr. Jonathan Saxe Joseph Skemp Vic Velanovich Wendy Wahl
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1995 - Frank E. Johnson, MD St. Louis University International Traveling Scholarship in Health Outcomes Research
1996 - Scott A. Dulchavsky, MD Wayne State University Renal Apoptosis During Ischemia Reperfusion Injury
1997 - Peter Angelos, MD Northwestern University Sponsor: Raymond J. Joehl, MD The Teaching of Ethics in Surgical Training: The Development of a Curriculum
1997 - Scott A. Engum, MD Indiana University Sponsor: Jay L. Grosfield, MD Experimental Assessment of Small Intestinal Sub Mucosa as a Prosthetic Diaphragm Substitute in a Growing Animal Model
1998 - Randall S. Sung, MD University of Michigan Sponsor: Jonathan S. Bromberg, MD Cytokine Inhibition in Adenovirus-Mediated Gene Transfer
1999 - Jeffrey J. Susman University of Cincinnati Sponsor: Josef E. Fischer, MD Modulation of Type 1/Type 2 Tumor Immune Responses to Improve Adoptive Immunotherapy
2000 - Henry J. Schiller, MD SUNY Upstate Medical University Sponsor: Frederick B. Parker, MD Alveolar Mechanics and Ventilator Induced Lung Injury
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2001 - Tina R. Desai, MD University of Chicago Sponsor: Bruce L. Gewertz, MD The Role of IL-6 Hypoxic Endothelial Barrier Dysfunction
2002 - Christian M. Schmidt, MD Indiana University Sponsor: James Madura, MD Role of Cyclooxygenase-2 in Human and Pancreatic Experimental Tumorigenesis
2003 - Hank C. Hill, MD Roswell Park Cancer Institute Sponsor: Boris W. Kuvshinoff II, MD Neoadjuvant Tumor Immunotherapy in a Surgical Metastasis Model
2004 - Mark R. Hemmila, MD University of Michigan Sponsor: Darrell A. Campbell, Jr., MD Trauma Care Quality Improvement
2005 - Andy C. Chiou, MD University of Illinois Sponsor: James R. De Bord, MD Surgical Resident Rotation in the Office of Human Research Oversight’s Institutional Review Board
2006 - Katharine Yao, MD Loyola University Medical Center TraumaList and LoyolaList: A Pilot Project to Improve “Hand Off” Communications and Workflow Efficiency
2007 - Charles P. Heise, MD University of Wisconsin Salmonella Mediated Type III Secretion of Interleukin-10 for Prevention of Th2 Mediated Inflammatory Bowel Disease
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2008 - Clifford S. Cho, MD University of Wisconsin School of Medicine Experimental Manipulation of Melanoma-Induced Immune Suppression
2009 - David J. Bentrem, MD Northwestern University Study of 5-Lipoxygenase, an Arachidonic Acid Pathway Enzyme, in Colon Cancer
2010 - David P. Foley, MD University of Wisconsin Determining the Role of Nrf2 in a Murine Model of Hepatic Ischemia Reperfusion Injury
2011 - Anthony Visioni, MD University Hospitals Case Medical Center Modulating KLF4 to Target Tumor-Associated Macrophages in Melanoma
2012 - Jacqueline Jeruss, MD, PhD Northwestern University CDK Inhibition and Restoration of SMAD3 Signaling in Aggressive Breast Cancer Subtypes
2013 – Philip Wai, MD Loyola University Characterization of Immune-Editing Mechanisms in the Microenvironment of Hepatocellular Carcinoma
2014 – Joshua M. V. Mammen, MD, PhD, MBA University of Kansas Medical Center Targeting Notch in Melanoma Stem Cells
2015 – Evie Carchman, MD University of Wisconsin The Role of Autophagy in Anal Cancer Prevention
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2016 - Daniel I-Hsin Chu, MD The University of Alabama at Birmingham Detailing The Role of the Human Gastrointestinal Microbiome in Anastomotic Healing, Leaks and Outcomes after Colorectal
2017 - Salman Ahmad, MD University of Missouri Health Care Traumatic Platelet Inhibition via Dense Granules and Flow Cytometry – A Mixing Study with Normal and Emergency General Surgery Patients
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2012 - Ankush Gosain, MD, PhD University of Wisconsin Identification and Characterization of Gastrointestinal Mucosal Immune Defects in Hirschsprung’s Disease
2013 - David F. Schneider, MD, MS University of Wisconsin The Effect of Immune Modulating Medications on Solid Tumor Incidence and Stage at Presentation in Non-Transplant Patients
2014 – Fumito Ito, MD, PhD University of Michigan Health System Induced Pluripotent Stem Cells to Generate Patient and Tumor Specific T Cells
2015 – Steven J. Schwulst, MD Northwestern University The Role of Innate Immunity in the Traumatic Brain Injury-induced Immune Suppression Syndrome
2016 - Samantha Tarras, MD Wayne State University The Utility of the Measurement of Clostridium Difficile Toxin Levels and Toxin Gene Sequences in Blood Samples to Index Disease Severity: An Earlier Marker than Clinical Parameters?
2017 - Courtney Balentine, MD University of Alabama at Birmingham Pilot Evaluation of the Virtual Acute Care for Elders Program for Older Patients Having Complex Gastrointestinal Surgery
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Please make the following change to my listing:
Name
Spouse’s Name
Institution
Street Address
City, State, Zip
Phone
Submit to: Central Surgical Association 2625 West 51st Terrace Westwood, KS 66205
t: 913.402.7102 [email protected] www.centralsurg.org
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Name
Date
Submit to: Central Surgical Association 2625 West 51st Terrace Westwood, KS 66205
t: 913.402.7102 [email protected] www.centralsurg.org
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1941 – Ann Arbor 1981 - Dearborn 1942 - Chicago 1982 - Chicago 1943-44-45 – No meetings 1983 - Milwaukee 1946 - Chicago 1984 - Pittsburgh 1947 - Chicago 1985 - Montreal 1948 - Chicago 1986 - Chicago 1949 - Cleveland 1987 - Louisville 1950 - Chicago 1988 - Columbus 1951 - Chicago 1989 - Alberta 1952 - Toronto 1990 - Chicago 1953 - Chicago 1991 - Indianapolis 1954 - Detroit 1992 - Madison 1955 - Chicago 1993 - Cincinnati 1956 - Rochester 1994 - Chicago 1957 - Chicago 1995 - Cleveland 1958 - Columbus 1996 - Minneapolis 1959 - Montreal 1997 - Chicago 1960 - Chicago 1998 - Ann Arbor 1961 - St. Louis 1999 - St. Louis 1962 - Cincinnati 2000 - Chicago 1963 - Chicago 2001 - Tucson 1964 - Rochester, MN 2002 - Pittsburgh 1965 - Milwaukee 2003 - Toronto 1966 - Chicago 2004 - Chicago 1967 - Pittsburgh 2005 - Tucson 1968 - Cleveland 2006 - Louisville 1969 - Chicago 2007 - Chicago 1970 - Detroit 2008 - Cincinnati 1971 - Minneapolis 2009 - Sarasota 1972 - Chicago 2010 - Chicago 1973 - Toronto 2011 – Detroit 1974 - Cincinnati 2012 – Madison 1975 - Chicago 2013 – Amelia Island 1976 - Rochester, NY 2014 – Indianapolis 1977 - Buffalo 2015 – Chicago 1978 - Chicago 2016 – Montreal, Quebec 1979 - Omaha 2017 – Chicago (CSA/MSA) 1980 - St. Louis
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CSA_2018_FinalProgram.indd 168 3/6/18 8:49 PM Central Surgical Association 2625 West 51st Terrace Westwood, KS 66205
t: 913.402.7102 [email protected] www.centralsurg.org
CSA_2018_FinalProgram.indd 169 3/6/18 8:50 PM SAVE THE DATE CSA 2019 Annual Meeting
March 7-9, 2019 Innisbrook Palm Harbor, Florida
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