Perioperative Optimization Of Senior Health (POSH): A Multidisciplinary Approach To Improve Post-Surgical Outcomes In An Older, High-Risk Population

ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS gallbladder disease and treated with same day cholecystectomy (SDC). Methods: We retrospectively reviewed all patients over age 18 admitted to a single academic hospital July 2011 to February 2012 with a primary diagnosis of cholecystitis. Diagnosis of cholecystitis was made by the senior surgical resident or attending surgeon based on history, clinical exam, and ultrasonography findings suggestive of cholecystitis. Timing of surgery was left to the discretion of the attending surgeon. SDC was defined as a cholecystectomy performed on the same day as the surgical consult. Surgical pathology results were used to further categorize cholecystitis as acute or chronic. Data was analyzed using Chi-square for categorical variables and Student’s t-test for continuous variables. Results: There was no significant difference in age or ASA class between SDC and non SDC groups (Table 1). SDC was performed in 29% of patients (61/209) admitted to the hospital for cholecystitis. Of these patients 37.7% (23/61) were taken directly to the OR from the ED. Hospital length of stay (LOS) for SDC was 1.7 and 1.8 days for acute and chronic cholecystitis compared to 3.0 and 3.6 days for acute and chronic non SDC patients. Total hospital charges for acute and chronic SDC patients were $44,485 and $45,556 compared to $53,226 and $50,753 for non SDC patients. Two patients (2/61, 3.2%) in the SDC group required conversion from laparoscopic to an open cholecystectomy, compared to six patients (6/148, 4.0%) in the non SDC group. Fast track SDC (FT-SDC) patients taken directly to the OR from the ED had and average LOS of 1.3 days, and average hospital charges of $44,276. One patient in the FT-SDC group required ERCP for a retained common bile duct stone. All FT-SDC patients had a laparoscopic cholecystectomy. Conclusions: Same day surgery for patients presenting to the emergency department with cholecystitis results in significant reduction in length of stay (p<.01) and hospital costs (p<.01). Further reductions in hospital length of stay and costs were seen in those patients taken directly to the operating room from the ED, without an increase in surgical complications. Further studies are needed to improve clinical care pathways for biliary disease, and to better define patient selection criteria for fast track surgery. 38.3. Perioperative Optimization Of Senior Health (POSH): A Multidisciplinary Approach To Improve Post-Surgical Outcomes In An Older, High-Risk Population. M. E. Lidsky,1 P. J. Speicher,1 S. McDonald,2 C. M. Poer,2 M. Yanamadala,2 L. Landerman,2 H. E. Whiteson,2 M. T. Heflin,2 H. K. White,2 J. Thacker,1 S. K. Pruitt,1 C. R. Mantyh,1 S. A. Lagoo1; 1Duke University Medical Center - Surgery, Durham, NC, USA; 2Duke University Medical Center - Geriatrics, Durham, NC, USA Introduction: The elderly represent an ever-increasing population, and the perioperative care of this vulnerable group will challenge providers for the foreseeable future. In an attempt to improve outcomes for patients known to have higher rates of postoperative morbidity, we created a multidisciplinary team to optimize the care provided to these high-risk older adults. Methods: All patients over 85 years and high-risk surgical candidates (e.g. dementia, recent weight loss, multimorbidity, and polypharmacy) over 65 undergoing abdominal surgery were referred for multidisciplinary evaluation. Demographics, preoperative interventions, and postoperative outcomes were analyzed. Results: 58 patients (mean age ¼ 76.1 6 6.8 years) undergoing elective surgery have participated. Common geriatric-specific perioperative interventions included delirium management (56.9%), promotion of safe mobility (31.0%), comorbidity management (37.9%), pain management (36.2%), and minimizing polypharmacy (12.1%). The most common operations were colectomy (34.78%), herniorrhaphy (13.1%) and cholecystectomy (6.52%). Depending on criteria, 13.8%-29.3% of POSH patients experienced delirium, consistent with published rates among older surgical patients. Average length of stay (LOS) for POSH patients was 5.5 6 3.1 days (range 1 to 17), which is shorter than the average LOS of 8.4 6 8.1 days (range 1 to 68) in a comparable sample of 102 patients who

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underwent surgery prior to POSH. Conclusions: A multidisciplinary approach to perioperative care for older high-risk patients undergoing abdominal surgery results in shorter hospitalizations. We hypothesize these interventions will lead to decreased costs and improved outcomes. Prospective studies are needed to determine if the POSH model is associated with improved patient outcomes for older adults undergoing elective surgery. 38.4. Liver Stiffness Measurement Predicts Posthepatectomy Liver Failure. K. Taura,1 Y. Koyama,1 K. Tanabe,1 G. Yamamoto,1 T. Nishio,1 E. Hatano,1 S. Uemoto1; 1Kyoto University - Surgery, Kyoto, KYOTO, Japan Introduction: Posthepatectomy liver failure (PHLF) is a fatal complication after partial hepatectomy. Studies have demonstrated usefulness of indocyanine green (ICG) clearance test for the prediction of PHLF. The criteria for maximum permissible resection volume based on ICG clearance test is accepted worldwide. However, more accurate prediction of PHLF is demanded. Liver fibrosis is the common consequence of chronic liver injury and is directly associated with liver dysfunction. Recently noninvasive assessment for liver fibrosis by liver stiffness measurement (LSM) is gaining wide acceptance. The purpose of this study is to evaluate the usefulness of LSM for predicting PHLF. Methods: One hundred and forty-nine patients (97 primary liver tumors and 52 metastatic liver tumors) undergoing partial hepatectomy between August 2011 and May 2013 were prospectively enrolled. Preoperative LSM was performed with ACUSON model S2000 ultrasound system (Siemens Medical Solutions) equipped with Acoustic Radiation Force Impulse (ARFI) system. The liver stiffness was expressed as shear wave velocity (SWV) (m/s). Remnant of the liver (REM) (%) was calculated by CT volumetry and the weight of resected specimens. ICG elimination rate (ICG K) was also measured preoperatively as well as general blood test. PHLF was defined according to the criteria proposed by International Study Group of Liver Surgery (Surgery. 2011 May;149(5):713-24.) and gradad as A , B, or C. Liver fibrosis was graded as F0 to F4 by METAVIR score. The ability of SWV, ICG K, and general hematological/biochemical factors for the prediction of PHLF was compared by receiver operating characteristic (ROC) analysis. Results: The mean SWV was 1.29, 1.39, 1.72, 1.85, and 2.66 for F0 to F4, respectively. Grade A PHLF occurred in 14 patients (9%) whereas grade B in 11 patients (7%) and grade C in 3 patients (2%). The area under the curve (AUC) of the ROC curve (AUROC) for the prediction of PHLF was (in descending order) 0.76 for platelet count (PLT), 0.73 for PT-INR, 0.71 for SWV, 0.69 for hyaluronic acid (HA), 0.65 for T-Bil, 0.56 for ICG K, and 0.53 for ALB. AUROC for grade B or C PHLF was 0.81 for PLT, 0.77 for SWV, 0.71 for HA, 0.66 for PT-INR, 0.63 for ICG K, 0.62 for T-Bil, and 0.61 for ALB. Taking the impact of REM for PHLF into consideration, we defined the SWV-REM index as ‘‘150/SWV + REM’’. The AUROC of the SWVREM index for the prediction of PHLF and grade B or C PHLF was 0.75 and 0.81, respectively whereas that of REM ICG K (defined by ICG K x REM/100) was 0.64 and 0.68, respectively. Combination of PLT and SWV further increased the predictive capacity to 0.81 (for PHLF) and 0.89 (for grade B or C PHLF). Conclusions: Preoperative LSM is useful for the prediction of PHLF as well as PLT. 38.5. Preoperative Internal Biliary Drainage Increases the Risk of Bile Juice Infection and Pancreatic Fistula after Pancreatoduodenectomy: A Prospective Observational Study. T. Fujii,1 M. Kanda,1 M. Suenaga,1 H. Takami,1 Y. Inokawa,1 S. Yamada,1 H. Sugimoto,1 S. Nomoto,1 Y. Kodera1; 1Nagoya University - Department Of Gastroenterological Surgery (Surgery II), Nagoya, Aichi, Japan Introduction: Endoscopic biliary drainage comprises two procedures. Endoscopic retrograde biliary drainage (ERBD) is an internal drainage method that involves placement of a plastic intrabiliary stent. Major advantages of the ERBD are the absence of discomfort due to the