Major open abdominal wall reconstructions

GENERAL SURGERY examine CHF’s impact on surgical outcomes for patients undergoing a diverse array of non-cardiac operations.

Accuracy of near infrared fluorescent cholangiogram in laparoscopic cholecystectomy for symptomatic cholelithiasis vs acute and chronic cholecystitis Raul J Rosenthal, MD, FACS, Fernando Dip, MD, David Nguyen, MD, Morris Sasson, MD, Marı´a Eugenia Szretter Noste, Emanuele Lo Menzo, MD, PhD, FACS, Conrad H Simpfendorfer, MD, FACS, Samuel Szomstein, MD, FACS Cleveland Clinic-Florida, Weston, FL

METHODS: Data of 1,268,999 patients in 2009-2013 ACS NSQIP Participant Use Files documented new onset CHF within 30 days before operation and the postoperative risk of serious morbidity, reoperation, readmission, and mortality. Multivariable logistic regression was used to obtain odds ratios (OR) for these outcomes in 24 ACS NSQIP procedure groups. ORs were calculated in models that controlled for age, sex, race, emergency surgery status, ASA Score, BMI, and other preoperative factors.

INTRODUCTION: Fluorescent cholangiography is an incisionless method that has demonstrated to be feasible and cost-effective in the identification of extrahepatic bile ducts. The aim of this study is to evaluate the effectiveness to of this novel technique in patients undergoing laparoscopic cholecystectomies, and to compare the visualization of biliary structures in acute cholecystitis and cholelithiasis.

RESULTS: Of all patients, 0.7% had CHF. Unadjusted ORs indicate large adverse effects of CHF on surgical outcomes for most procedures considered. Adjusted ORs were 1.52 (1.44-1.61; p <0.001) for serious morbidity; 1.29 (1.17-1.42; p<0.001) reoperation; 1.39 (1.29-1.50; p<0.001) readmission; 1.96 (1.80 - 2.13; p<0.001) for 30-day mortality. CHF had the most substantial effect on serious morbidity and mortality for those undergoing carotid endarterectomy (all outcomes) and open and endovascular repair of aortic aneurysm (serious morbidity, unplanned intubation). Superficial and deep surgical site infections or surgical wound healing were not affected by CHF.

METHODS: Patients undergoing laparoscopic cholecystectomy were included. A single dose of 0.05 mg/kg indocyanine green was administered intravenously one hour prior to surgery. During the procedure, alternating exposure from xenon to infrared lights was used to identify extrahepatic biliary structures. A questionnaire to assess the surgeon’s visibility of extrahepatic bile ducts was administered.

CONCLUSIONS: CHF is a strong predictor of serious morbidity, unplanned reoperation, any readmission, and surgical mortality for a wide array of operations. Surgeons must pay particular attention to recognizing CHF and correct it when possible or optimize management of the condition before elective operations.

RESULTS: Visualization of cystic duct was observed in 94% of cases in acute cholecystitis, 83% of cases in chronic cholecystitis, and 100% of cases in cholelithiasis with fluorescent cholangiography. Differences in visualizing the cystic duct were found between acute cholecystitis, chronic cholecystitis, and cholelithiasis, p¼0.03. Greater visibility of the cystic duct was observed in the cholelithiasis group (p¼0.04) when comparing the cholelithiasis and chronic cholecystitis group. The cystic duct was visible in fluorescence without any dissection in 69% of cases, and in 96% with dissection.

Major open abdominal wall reconstructions Mojtaba Fayezizadeh, MD, Arnab Majumder, MD, Clayton C Petro, MD, Ajita S Prabhu, MD, Heidi L Elliott, MD, Yuri W Novitsky, MD, FACS University Hospitals Case Medical Center, Cleveland, OH INTRODUCTION: Utilization of enhanced recovery pathway protocol (ERP) has been shown to improve outcomes in several surgical specialties. However, its use in hernia surgery has not been investigated to date. We hypothesized that our ERP accelerated intestinal recovery and shortened hospitalization in patients undergoing major open AWR.

CONCLUSIONS: Fluorescent cholangiography provides accurate identification of the extrahepatic biliary anatomy during laparoscopic cholecystectomy. Cystic duct visualization was the highest compared to other biliary structures in acute and non-acute processes. Due to the evolving state of this technique in its applicability, fluorescent cholangiography should not replace intraoperative cholangiography but serves as a compliment in preliminary visualization of abdominal content.

METHODS: Consecutive patients undergoing major open AWR with our ERP were compared to a matched historical cohort. Our multimodal ERP included pre-op immune enhancing nutrition, peri-operative use of opioid receptor antagonists, non-opioid analgesics and early feeding. Main outcome measures included patient demographics, opioids use, return of bowel function, time to GI-3 (regular diet/flatus/bowel movements), length of stay (LOS), and readmissions.

Congestive heart failure increases risks of serious morbidity, reoperation, readmission and mortality for a wide array of non-cardiac operations R Scott Jones, MD, FACS, Florence E Turrentine, PhD, RN, Min-Woong Sohn, PhD University Of Virginia Health System, Charlottesville, VA

RESULTS: Between January and December 2014, 84 consecutive patients undergoing AWR with our ERP were compared to a matched historic cohort. The ERP group had significantly shorter times to both clears and regular diet: 1.1 v 2.7 days and 3.0 v 4.8 days, respectively. There was no significant difference in post-

INTRODUCTION: Congestive heart failure (CHF) predicts morbidity and mortality in surgery. The extent of CHF’s influence on surgical outcomes is not fully understood. Our aim is to

ª 2015 by the American College of Surgeons Published by Elsevier Inc.

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Scientific Forum: 2015 Clinical Congress

operative emesis (4.7 v 5.0%). The ERP group had significantly faster times to flatus, bowel movement and GI-3 (3.1 v 3.9, 3.6 v 5.2, and 3.4 v 4.8 days, respectively). The average LOS decreased from 6.1 to 4.3 days, p< 0.001. The ERP group had a significantly lower 90-day readmission rate (3.6% v 14.4%). CONCLUSIONS: Implementation of a comprehensive ERP in major AWR was not associated with any adverse effects. Multimodal perioperative pain management, oral opioid receptor blockade and early feeding strategies resulted in accelerated intestinal recovery, shorter hospitalizations and fewer readmissions. The use of our ERP appears to result in improved outcomes in patients undergoing complex open AWRs. Partitioning length of stay to understand readmission risk: survival analysis in the American College of Surgeons (ACS) NSQIP database Cheryl K Zogg, MSPH, MHS, Timothy M Pawlik, MD, FACS, Thomas C Tsai, MD, MPH, John A Rose, MD, MPH, John W Scott, MD, MPH, Adil H Haider, MD, MPH, FACS Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard School of Medicine, Harvard School of Public Health, Boston, MA; The Johns Hopkins University School of Medicine, Baltimore, MD INTRODUCTION: There is concern of a tradeoff between length of stay (LOS) and unplanned readmission, but whether prolonged LOS represent variations in clinical care, unmeasured disease severity, or postoperative complications remains unclear. The objective of this study was to decompose inpatient LOS into prolonged preoperative and postoperative phases in order to assess the relationship between prolonged LOS and readmission risk. METHODS: 2012-2013 ACS-NSQIP procedure-targeted data and participant-use files were used to identify all patients who underwent colectomy with 2weeks post-discharge follow-up. Survival analysis (time-to-event) techniques examined differences in time from discharge to first unplanned readmission. Multiple imputation, where appropriate for missing data, and propensity-scores were used to account for known baseline differences in demographic/clinical factors, extended operative time, and pre-discharge complications. RESULTS: Among 33,517 colectomy patients, overall unplanned index-hospital readmission rate was 10.1%. For elective admissions, the risk-adjusted relative-risk (HR: hazard ratio) for unplanned readmission increased with increasing overall (17-50%) and postoperative (12-49%) LOS, but was unrelated to preoperative LOS. Longer postoperative and overall LOS also associated with 17-25% shorter risk-adjusted time-to-readmission (TR: time ratio). Among emergency admissions, relative-risk of readmission but not time to readmission was associated with increased overall and postoperative LOS (106-214% and 172-240%, respectively). Reasons for readmission varied with variations in LOS. CONCLUSIONS: Prolonged postoperative LOS results in increased risk for earlier unplanned readmission, suggesting that

J Am Coll Surg

the relationship between LOS and readmission may be driven by the development of postoperative complications. Improving the quality of surgical care by decreasing complications has potential to decrease both LOS and readmission risk. Patient factors influence surgeons’ workload Ahmad Nourallah, MD, Denny Yu, PhD, Juliane Bingener, MD, FACS, Susan Hallbeck, PhD, Cornelius A Thiels, DO, MBA, Amro M Abdelrahman, MBBS Mayo Clinic, Rochester, MN INTRODUCTION: We hypothesized that patient factors such as BMI, age and gender influence surgeon workload. METHODS: During a RCT comparing single port or four-port laparoscopic cholecystectomy workload was measured using the validated SURG-TLX questionnaire. At the end of each procedure mental, physical and temporal demands, task complexity, situational stress, distractions, and degree of difficulty experienced by a single surgeon were self-reported on the 20-point SURG-TLX scale. Patient demographics, case difficulty rated by an independent observer and operative duration were recorded. Analyses of covariance were conducted using MiniTab (v.16.2.4). RESULTS: 48 procedures with a mean duration of 7426 min were captured, of which 12 were performed in men (mean BMI 298) and 36 in women (mean BMI 316). Men were significantly older (mean age 5817) than the women (mean age 4417; p¼0.001), more often presented difficult dissection (33% vs 11%, p¼0.007) and longer operative duration (887 min vs 694 min, p¼0.03). Increasing operative time was significantly related to increasing physical, mental, and temporal workload, task complexity, situational stress, and degree of difficulty. After adjusting for operative time, operating on men remained significantly correlated to increased physical workload (p¼0.001). Patient age did not correlate with workload. When operating on patients with a BMI over 25, significantly lower situational stress (p¼0.028) and distractions (p¼0.009) were reported. CONCLUSIONS: In this study, male gender was associated with increased physical workload. BMI did not influence physical workload in this study with low mean BMI. These data may be considered during scheduling of surgical procedures to balance workload. Patient reported outcomes after splenectomy in patients with symptomatic splenomegaly Ahmad Nourallah, MD, Juliane Bingener, MD, FACS, Pamela E Skaran, Brittny Major, Thomas Witzig, Jeff A Sloan, PhD Mayo Clinic, Rochester, MN INTRODUCTION: Patients with splenomegaly may undergo splenectomy to improve quality of life (QOL). It is unknown whether splenectomy indeed improves QOL. METHODS: Patients who underwent an elective splenectomy between 2008 and 2015 at our institution for a diagnosis of splenomegaly were identified. The electronic medical record was reviewed