Anastomotic Outcomes in Military Exploratory Laparotomies in the Modern Combat Era

Background Intestinal anastomoses in military settings are performed in severely injured patients who often undergo damage control laparotomy in austere environments. We describe anastomotic outcomes of patients from recent wars. Methods Military personnel with combat-related intra-abdominal injuries (June 2009-December 2014) requiring laparotomy with resection and anastomosis were analyzed. Patients were evacuated from Iraq or Afghanistan to Landstuhl Regional Medical Center (Germany) before being transferred to participating U.S. military hospitals. Results Among 341 patients who underwent 1053 laparotomies, 87 (25.5%) required ≥1 anastomosis. Stapled anastomosis only was performed in 57.5% of patients, while hand-sewn only was performed in 14.9%, and 9.2% had both stapled and hand-sewn techniques (type unknown for 18.4%). Anastomotic failure occurred in 15% of patients. Those with anastomotic failure required more anastomoses (median 2 anastomoses, interquartile range [IQR] 1-3 vs. 1 anastomosis, IQR 1-2, P = .03) and more total laparotomies (median 5 laparotomies, IQR 3-12 vs. 3, IQR 2-4, P = .01). There were no leaks in patients that had only hand-sewn anastomoses, though a significant difference was not seen with those who had stapled anastomoses. While there was an increasing trend regarding surgical site infections (SSIs) with anastomotic failure after excluding superficial SSIs, it was not significant. There was no difference in mortality. Discussion Military trauma patients have a similar anastomotic failure rate to civilian trauma patients. Patients with anastomotic failure were more likely to have had more anastomoses and more total laparotomies. No definitive conclusions can be drawn about anastomotic outcome differences between hand-sewn and stapled techniques.

Comparing Emergent and Elective Colectomy Outcomes in Elderly Patients: A NSQIP Study

Introduction. With the increasing prevalence of colorectal cancer (CRC) worldwide, especially in the elderly, and the variability between physiological and chronological age and its impact on functional status, acute symptoms leading to emergent surgery due to colorectal malignancy may lead to increased morbidity and mortality. The aim of this study is to identify the outcome differences of elective vs. emergent open colectomy in patients above 80 years. Methods. The National Surgical Quality Improvement Program (NSQIP) database was reviewed from 2010 to 2014 for open colectomy based on CPT codes. Comparison between groups was done based on the clinical context at presentation as elective or emergent surgery. Data were analyzed using SAS. Results. Elective colectomies were performed in 8289 (70.8%) vs. emergent colectomies in 3409 (29.1%). Emergent colectomy patients had higher American Society of Anesthesiologists (ASA) preoperative classification III-IV, 1429 (42.0%) and 224 (6.6%), vs. 1238 (14.9%) and 21 (0.2%) in elective colectomy patients p < 0.0001 . Emergent colectomy patients had more comorbidities such as chronic obstructive pulmonary disorder (493 (14.5%) vs. 796 (9.6%)), congestive heart failure (206 (6.0%) vs. 310 (3.8%)), dialysis (106 (3.1%) vs. 56 (0.7%)), and acute renal failure (166 (4.9%) vs. 46 (0.6%)) p < 0.0001 , respectively. Postoperative morbidity and mortality were significantly higher in emergent colectomy (1651 (48.4%) and 872 (25.6%)) vs. elective colectomy (1859 (22.4%) and 567 (6.8%)) p < 0.0001 , respectively. Conclusion. Emergent open colectomy in elderly patients carries a higher risk of morbidity and mortality when compared to elective open colectomy with risk factors being higher ASA classification and more comorbidities.

COVID-19 Modulates Inflammatory and Renal Markers That May Predict Hospital Outcomes among African American Males

Background and Objectives: African Americans and males have elevated risks of infection, hospitalization, and death from SARS-CoV-2 in comparison with other populations. We report immune responses and renal injury markers in African American male patients hospitalized for COVID-19. Methods: This was a single-center, retrospective study of 56 COVID-19 infected hospitalized African American males 50+ years of age selected from among non-intensive care unit (ICU) and ICU status patients. Demographics, hospitalization-related variables, and medical history were collected from electronic medical records. Plasma samples collected close to admission (≤2 days) were evaluated for cytokines and renal markers; results were compared to a control group (n = 31) and related to COVID-19 in-hospital mortality. Results: Among COVID-19 patients, eight (14.2%) suffered in-hospital mortality; seven (23.3%) in the ICU and one (3.8%) among non-ICU patients. Interleukin (IL)-18 and IL-33 were elevated at admission in COVID-19 patients in comparison with controls. IL-6, IL-18, MCP-1/CCL2, MIP-1α/CCL3, IL-33, GST, and osteopontin were upregulated at admission in ICU patients in comparison with controls. In addition to clinical factors, MCP-1 and GST may provide incremental value for risk prediction of COVID-19 in-hospital mortality. Conclusions: Qualitatively similar inflammatory responses were observed in comparison to other populations reported in the literature, suggesting non-immunologic factors may account for outcome differences. Further, we provide initial evidence for cytokine and renal toxicity markers as prognostic factors for COVID-19 in-hospital mortality among African American males.

O-B02 Robotic versus Laparoscopic Roux-en-Y Gastric Bypass: A comparison of short-term outcomes and weight loss

Background The benefits of robotic over laparoscopic surgery for Roux-en-Y gastric bypass (RYGB) are debatable, with current evidence suggesting no significant differences in short-term outcomes. This study compares short-term outcomes and excess weight loss (EWL) % difference between these two techniques. Methods A retrospective study of patients undergoing RYGB between January 2016 and November 2020 at a single centre. Demographic, peri-operative and EWL% data were analysed. Results 424 RYGB procedures were performed by three surgeons including 77 robotic (RRYGB) and 347 laparoscopic (LRYGB) operations. The first 8 RRYGB were excluded being early in the learning curve and the operative technique was modified afterwards. There were no statistically significant demographic differences. The median operative time was 179 (151 – 195) and 149 (123 -171) minutes in the RRYGB and LRYGB groups respectively (P &lt; 0.001). There were no statistically significant differences between both groups in complications, length of stay, 30-day readmission and EWL% at 6 and 12 months. The EWL% at 2 years was 88.5 (+/-19.1) and 66.6 (+/-29.8) in the RRYGB and LRYGB groups respectively (P = 0.003). Conclusions RRYGB increases the operative time with no significant short-term outcome differences. The EWL% was higher at 2 years, probably due to a narrower hand-sewn gastro-jejunal anastomosis.

Women’s outcomes following mixed-sex, women-only, and home-based cardiac rehabilitation participation and comparison by sex

Background Despite women’s greater need for cardiac rehabilitation (CR), they are less likely to utilize it. Innovative CR models have been developed to better meet women’s needs, yet there is little controlled, comparative data assessing the effects of these models for women. This study compared outcomes in women electing to participate in mixed-sex, women-only, or home-based CR, and a matched sample of men. Methods In this retrospective study, electronic records of CR participants in Toronto who were offered the choice of program model between January 2017 and July 2019 were analyzed; clinical outcomes comprised cardiorespiratory fitness, risk factors and psychosocial well-being. These were assessed at intake and post-6-month program and analyzed using general linear mixed models. Results There were 1181 patients (727 women [74.7% mixed, 22.0% women-only, 3.3% home-based]; 454 age and diagnosis-matched men) who initiated CR; Cardiorespiratory fitness among women was higher at initiation of mixed-sex than women-only (METs 5.1 ± 1.5 vs 4.6 ± 1.3; P = .007), but no other outcome differences were observed. 428 (58.9%) women completed the programs, with few women retained in the home-based model limiting comparisons. There were significant improvements in high-density lipoprotein cholesterol (P = .001) and quality of life (P = .001), and lower depressive symptoms (P = .030) as well as waist circumference (P = .001) with mixed-sex only. VO2peak was significantly higher at discharge in mixed-sex than women-only (estimate = 1.67, standard error = 0.63, 95% confidence interval = 0.43–2.91). Conclusion Participation in non-gender-tailored women-only CR was not advantageous as expected. More research is needed, particularly including women participating in home-based programs.

Modelling welfare estimates in discrete choice experiments for seaweed-based renewable energy

We explore what researchers can gain or lose by using three widely used models for the analysis of discrete choice experiment data—the random parameter logit (RPL) with correlated parameters, the RPL with uncorrelated parameters and the hybrid choice model. Specifically, we analyze three data sets focused on measuring preferences to support a renewable energy programme to grow seaweed for biogas production. In spite of the fact that all three models can converge to very similar median WTP values, they cannot be used indistinguishably. Each model is based on different assumptions, which should be tested before their use. The fact that standard sample sizes usually applied in environmental valuation are generally unable to capture the outcome differences between the models cannot be used as a justification for their indistinct application.

Unicompartmental knee arthroplasty: A PearlDiver study evaluating complications rates, opioid use and utilization in the Medicare population

Purpose Despite increased utilization of unicompartmental knee arthroplasty (UKA) for unicompartmental knee osteoarthritis, outcomes in Medicare patients are not well-reported. The purpose of this study is to analyze practice patterns and outcome differences between UKA and TKA in the Medicare population. It is hypothesized that UKA utilization will have increased over the course of the study period and that UKA will be associated with reduced opioid use and lower complication rates compared to TKA. Methods Using PearlDiver, the Humana Claims dataset and the Medicare Standard Analytic File (SAF) were analyzed. Patients who underwent UKA and TKA were identified by CPT codes. Postoperative complications were identified by ICD-9/ICD-10 codes. Opioid use was analyzed by the number of days patients were prescribed opioids postoperatively. Survivorship was defined as conversion to TKA. Results In the Humana dataset, 7,808 UKA and 150,680 TKA patients were identified. 8-year survivorship was 87.7% (95% CI [0.861,0.894]). Postoperative opioid use was significantly higher after TKA (186.1 days) compared to UKA (144.7 days) (p < 0.01, Δ = 41.1, 95% CI = [30.41, 52.39]). In the SAF dataset, 20,592 UKA patients and 110,562 TKA patients were identified. Survivorship was highest in patients > 80 years old and lowest in patients < 70 years old. In both datasets, postoperative complication rates were higher in TKA patients compared to UKA patients in nearly all categories. Conclusions UKA represents an increasingly utilized treatment for osteoarthritis in the Medicare population and may be comparatively advantageous to TKA due to reduced opioid use and complication rates after surgery. Level of evidence Level III

676. Impact of Stratified Testing Algorithm Utilizing Rapid Testing and Polymerase Chain Reaction (PCR) Tests for Viral Infections

Background In 2017, the multiplex respiratory viral panel (RVP) test was the only test available for patients (pts) with respiratory symptoms in our emergency department (ED). In 2018, the more rapid influenza/respiratory syncytial virus (Flu/RSV) test was incorporated in a stratified testing algorithm (STA) – depending on clinical features and physician discretion, pts underwent either Flu/RSV or RVP. We analyzed the STA impact by comparing data between winters of 2017 and 2018. Methods In a retrospective, single-center cohort study in suburban NY, admitted pts ≥18 years diagnosed with viral infections (by either test) were included. We excluded pts diagnosed at another hospital, admitted to intensive care or observation (&lt; 24 hours) units and pts with missing data. Data was collected through electronic medical chart review. Primary outcomes were clinical evaluation time [time between triage and test order]; laboratory-turnaround (lta) time (between order and result); ED length of stay [EDLOS] (between admit order and bed assignment). Secondary outcomes included isolation time (between result to start of isolation precautions), treatment time (between result to influenza treatment). Outcome differences were assessed using Chi-Square and Mann-Whitney rank sum tests for categorical and continuous variables, respectively. Results 734 pts were included in the study [368 in 2017; 366 in 2018]. Median age was 75 years and 55.9% were female. After implementing the STA, EDLOS was significantly lower [Table 1], with no significant differences in other parameters. Lta times were slightly higher after implementation [25 minutes (2017) v/s 29 minutes (2018)]. Table 1. Differences in clinical and laboratory turnaround times among patients admitted with viral infections in winters of 2017 and 2018 Conclusion A stratified diagnostic algorithm may have reduced EDLOS, but without significant differences in other outcomes. A higher lta time might have been due to testing constraints, heterogeneous pt populations or other confounders. Prospective studies will help assess the real-world impact of such algorithms. Disclosures Prashant Malhotra, MBBS, MD,FACP, FIDSA, Gilead Sciences (Scientific Research Study Investigator, Other Financial or Material Support, Site PI for a industry funded multi center research study)