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Reflux Control Is an Important Component of the Management of Barrett'sEsophagus - Results From a Retrospective Cohort of 1834 PatientsCraig S. Brown, Brittany Lapin, Chi Wang, Jay Goldstein, John G. Linn, Woody Denham,Stephen P. Haggerty, JoAnn Carbray, Mark Talamonti, Michael B. Ujiki

Introduction: Barrett's esophagus (BE) is the most predictive risk factor for development ofesophageal adenocarcinoma, a malignancy with the fastest increasing incidence rate in theUS. Based on the assumption that all patients progress through low-grade dysplasia (LGD)to high-grade dysplasia (HGD) and finally to esophageal adenocarcinoma (EAC), we wereinterested in studying factors that may affect the rate of progression to LGD or greater. Wewere particularly interested in investigating the question of whether control of reflux, eithersurgically or medically, protects patients from progression to dysplastic disease or adenocarci-noma. Methods: We retrospectively collected and analyzed data from a cohort of BE patientsparticipating in this single-center study comprised of all patients diagnosed with BE at asingle health system's hospitals and clinics over a 10 year period. Patients were followed inorder to identify those progressing from BE to LGD, HGD, and EAC. Mean follow up periodwas 5.4 years (9903 patient-years). We collected information from the patient's electronicmedical records regarding demographic data, endoscopic findings, histological findings,smoking and alcohol history, medication use including PPI's, and history of bariatric andantireflux surgery. Risk adjusted model was performed using multivariable logistic regressionin SAS 9.3 (Cary, NC). Results: This study included 1834 total BE patients, 105 of whichhad their BE progress to LGD, HGD, or EAC (confirmed by biopsy) with an annual incidencerate of 1.1%. Compared to the group that did not progress, the group that progressed wasolder (63.8±13.5 vs. 68.8±13.1. p<.001) and likely to be male (61% vs. 69%, p=0.098). Inthe multivariable analysis, patients who had a history of antireflux surgery (n=44) or PPIuse without surgery (n=1708) were found to progress at lower rates than patients who didnot have antireflux surgery or were not taking PPI's (OR=0.23, 95% CI 0.12-0.42). Conclu-sions: In patients with BE without dysplasia, reflux control was associated with decreasedrisk of progression to LGD, HGD, or EAC. The results support the use of reflux controlstrategies such as PPI therapy or surgery in patients with non-dysplastic BE.

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Prevalence, Impact and Predictors of Hospital Acquired Conditions AfterMajor Surgical Resection for Cancer: A NSQIP AnalysisDaniela Molena, Benedetto Mungo, Miloslawa Stem, Anne O. Lidor

Background: The Centers for Medicare and Medicaid Services (CMS) initiated a nonpaymentpolicy for certain hospital acquired conditions (HAC) in 2008. As of 2013, 11 HAC havebeen identified; however, since their occurrence is linked - at least in part - to preoperativecomorbidities, the preventability of HAC in these patients is questionable. This study aimedto determine the rate of the 3 most common HAC in patients undergoing major surgicalresections for cancer: surgical site infection (SSI), urinary tract infection (UTI), and deepvein thrombosis (DVT). Additionally, the association of HAC with patients' characteristicsand their effect on post-operative outcomes were investigated. Methods: Patients 18 yearsof age and older with a diagnosis of esophageal, gastric, hepatic, gallbladder, biliary, pan-creatic, colic, anal and lung cancers, who underwent surgical resection were identified usingthe American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database (2005-2012). Patients were grouped into two categories for comparison:HAC versus non-HAC patients. Outcomes, including 30-day mortality, mean length of stay(LOS), return to operating room, readmission and discharge destination were compared.Multiple pre-operative patient variables were considered and multivariate regression analysiswas performed to identify risk factors for developing HAC. Results: 74,381 patients wereidentified, of whom 9,478 (12.74%) developed at least one of the three HAC. SSI was themost common (7.52%), followed by UTI (2.93%) and VTE (2.30%). The rate of HACdecreased from 15% to 11% over the study period. Pancreatic surgery was associated withthe highest rates of SSI (10.88%) and UTI (3.83%), while the highest rates of VTE wereobserved in esophagectomy (5.92%). HAC patients had significantly higher rates of 30-daymortality (3.65% vs. 2.18%, p<0.001), return to operating room (12.34% vs. 4.61%,p<0.001), 30-day readmission (25.88% vs. 9.36%, p<0.001), and had longer LOS (10 vs.6 days, p<0.001). Moreover, HAC patients were significantly less likely to be dischargedhome and more likely to be directed towards rehabilitation, acute care and skilled care.Multivariate analysis revealed that several peri-operative patients' factors, including dyspnea,steroid use and emergent surgery, were significantly associated with HAC (Table). Conclu-sion: Our data demonstrate that the development of HAC is strongly associated with pre-operative patient characteristics. These data suggest that the nonpayment policy might beexcessively penalizing healthcare providers, since inherent patient factors are not modifiableand seem to play an important role in the development of HAC in this population. Thesefindings are important to help inform health care policy decisions regarding access to carefor patients undergoing cancer surgery.TABLE. Multivariable logistic regression analysis of variables associated with hospitalacquired condition (HAC)

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Bariatric Surgery Improves Histological Features of Nonalcoholic Fatty LiverDisease and Liver FibrosisAndrew A. Taitano, Michael Markow, Jon E. Finan, Donald E. Wheeler, John PaulGonzalvo, Michel M. Murr

Introduction Nonalcoholic fatty liver disease (NAFLD) is prevalent in bariatric patients. Wesought to determine the effects of surgically-induced weight loss on the histological featuresof NAFLD in patients undergoing bariatric surgery. Methods A blinded pathologist reviewedall liver biopsies done during the index bariatric procedure and any liver biopsies doneduring subsequent abdominal operations from 1998-2013. Biopsies were examined usingH&E, trichrome and iron stains and graded using the Brunt classification. Data for analysiswas collected prospectively and included demographics and weight loss. Results Pairedbiopsies for 152 patients (82% women) were included. Mean interval between biopsies was29±22 months. Mean age was 46±11 years. Mean pre-op BMI was 52±10 kg/m2; meanexcess body weight loss was 62±22% at the time of the subsequent biopsy. The findingson the initial biopsy were steatosis (78%) lobular inflammation (42%), chronic portalinflammation (68%). Steatohepatitis was present in 33%. Fibrosis (Grade 2-3) was presentin 41%, and cirrhosis was present in 2%. On post-op biopsy, steatosis resolved in 70% (82/118); lobular inflammation resolved in 74% (46/62); chronic portal inflammation resolvedin 32% (32/99) and steatohepatitis resolved in 88% (44/50). Fibrosis of any grade resolvedin 21% and improved in another 23% of patients. Specifically, Grade 2 fibrosis was presentin 52 patients pre-op; 16 (31%) resolved, 16 (31%) improved, and 15 (29%) did not worsenpost-op. Of the 10 patients with bridging fibrosis (Grade 3), one resolved and seven improved.Cirrhosis improved in one of three patients who had it preoperatively. Conclusion Bariatricsurgery improves liver histology in severely obese patients and is associated with resolutionof steatosis or steatohepatitis in the majority of patients. More importantly, Grade 2 or 3(bridging) fibrosis is resolved or improved in 65% of patients. Bariatric surgery should beconsidered as the treatment of choice of NAFLD in severely obese patients.

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Morbidity Mortality and Weight Loss Outcomes After Reoperative BariatricSurgery in the USARanjan Sudan, Ninh T. Nguyen, Matthew M. Hutter, Stacy A. Brethauer, Jaime Ponce,John M. Morton

Background: Obesity is a chronic disease that is successfully treated by different primarybariatric operations but, some patients will need reoperations. Although complications arecovered by insurance carriers, requests for reoperations for inadequate weight loss or resolu-tion of comorbidities are frequently denied. The perception of high complication ratesand uncertain benefits after reoperations, combined with paucity of good data are likelycontributory. Therefore, our aim was to evaluate the safety and weight loss outcomes afterreoperative bariatric surgery from a large bariatric surgery-specific database. Methods: Themulti-institutional prospective database for the American Society for Metabolic and BariatricSurgery was queried for all patients undergoing bariatric operations between 6/2007 and03/2012. Operations for correction of complications as well as inadequate outcomes fromthe primary operations were included. Morbidity was defined as serious adverse events(bleeding, leaks, pulmonary embolism etc.). Excess weight loss (EWL) was calculated fromthe time of reoperation. Results: 404,222 patients had no reoperations while 20,406 (4.8%)underwent reoperations. In the reoperative group, women were over represented (86 versus78.5%), as were Caucasians (73 versus 69%) and Black race (15 versus 12%). Reoperativepatients had a mean age of 46 ± 11.33 vs. 45 ± 11.86 years. Reoperations were within oneyear of the index bariatric operation in 25% of patients, one to five years in 40%, six toten years in 21% and more than 10 years in 14% after primary operation. The rate of

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