01.01 Mimetic sHDL Nanoparticles: a Novel Drug-Delivery Strategy to Target Triple-Negative Breast Cancer

Posted on January 18, 2016

P. T. White1, C. Subramanian1, R. Kuai2, J. Moon2,5, B. M. Timmermann3, A. Schwendeman2, M. S. Cohen1,4 5University Of Michigan,Department Of Biomedical Engineering,Ann Arbor, MI, USA 1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,College Of Pharmacy,Ann Arbor, MI, USA 3University Of Kansas,Department Of Medicinal Chemistry,Lawrence, KS, USA 4University Of Michigan,Department Of Pharmacology,Ann Arbor, MI, USA

Introduction: Triple negative breast cancer (TNBC) remains a therapeutic challenge today, highlighting the critical need for discovery and development of safer novel therapies. Withanolides are a unique class of naturally-derived Hsp90 inhibitors that are highly efficacious in preclinical TNBC models, but fairly hydrophobic in vivo. Synthetic high-density lipoprotein (sHDL) nanoparticles have been safely used in clinical cardiology trials and recently shown by our group to conjugate to withanolides to improve drug delivery, solubility, and efficacy in aggressive adrenal cancers in vivo. sHDL provides targeted drug delivery as a ligand to the SR-B1 surface receptor leading to cholesterol uptake and efflux. TNBCs highly overexpress SR-B1 and we hypothesize that combining withanolides with sHDL will enhance their delivery to TNBCs through improved targeting via SR-B1.

Methods: Validated human TNBC cell lines (MD-MBA468LN,MDA-MB231,SUM159) were evaluated for SR-B1 mRNA expression levels by qPCR, and protein levels confirmed by Western blot. Fluorescent labeled sHDL was used to evaluate SR-B1 mediated drug uptake in vitro under fluorescence microscopy, and used for tumor targeting in vivo with whole body IVIS spectrum imaging of mouse xenograft tumors (MD-MBA468LN). Withanolide (WGA-TA) IC50 values were obtained using 72 h CellTiter-Glo (CTG) assays.

Results: All TNBC cell lines had significantly (p<0.01) higher SRB1 expression by qPCR and Western blot compared to fibroblast or Jurkat cells (SUM159 4-5 fold, MDA-MB468LN 8-10 fold, MDA-MB231 2-4 fold). Fluorescent labeled sHDL uptake in vitro demonstrated cytosolic uptake of nanoparticles at significantly (p<0.05) higher levels within the high SR-B1 expressing cell line (MDA-MB468LN) compared to the lower SR-B1 expressing cell line (MDA-MB231). Fluorescent sHDL uptake was almost completely inhibited by receptor saturation through pre-treatment with 10-fold excess sHDL (p<0.05). In vivo tumor uptake of fluorescent labeled sHDL using IVIS spectrum imaging in the MDA-MB469LN mouse xenograft model demonstrated highest radiant efficiency in the tumor, with uptake in the liver where it is metabolized and significantly (p<0.05) lower radiant efficiency in other organs. Using CTG assays, treatment with sHDL up to 20 μM showed no changes to cell viability. In TNBC, IC50 values of WGA-TA vs. sHDL-WGA-TA were not statistically different with IC50 concentrations ranging from 18-125 nM. Both formulations had significantly lower IC50 values when compared to MCR5 control cells (6-41 fold lower; p<0.05).

Conclusion: Conjugation of WGA-TA with sHDL nanoparticles confers improved SR-B1 receptor-mediated targeting both in vitro and in vivo in TNBC without inhibiting the potency of withanolides in these tumor cells. This nanocarrier delivery system warrants further translational evaluation in vivo in patient-derived xenograft of TNBC to determine if improved targeting will confer enhanced treatment benefit and survival.

78.12 Perioperative Complications Of Surgical Treatment For Isolated Open Tibia Fractures In The Elderly

Posted on January 18, 2016

N. N. Branch1, R. Wilson1 1Howard University College Of Medicine,Washington, DC, USA

Introduction: Elderly patients are an increasing proportion of the population. Perioperative outcomes of elderly patients who sustain open tibia fractures may be affected by a variety of factors including nutritional status, bone quality, comorbid conditions and gender. Therefore, we aim to determine the 30 day perioperative complications associated with open reduction and internal fixation (ORIF) of open tibia fractures in the elderly.

Methods: A retrospective analysis of the National Trauma Data Bank (NTDB) from 2007-2010 utilizing ICD-9 codes (823.10, 823.30, and 823.90) was conducted. Cases >18 years old, who underwent open reduction and internal fixation of the tibia at a level I or level II trauma center were included. Patients were then stratified by age into four groups, with those 18-24 years serving as the reference group and the elderly being those 65 years and older.

Results: 9,331 open tibia fractures during the study period underwent ORIF, of which 7,201 cases met inclusion criteria. The majority were white (67%), males (74%), between 25-44 years old (42%). Patients with private insurance (23%) and injury via motor vehicle collisions (25%) were most common. Elderly patients comprised 9.3% of the total population of which 86% were White and 52% were male. Elderly patients were 78% more likely to have fixation after hospital day 2 (OR: 1.78 CI: 1.52-32.08 p<0.001), 2.5 times more likely to have a bleeding complication (OR: 2.5 CI: 1.13-5.54 p=0.024), and almost 5 times more likely to have cardiac arrest within 30 days (OR: 4.93 CI: 1.04-23.46 p=0.045). Developing superficial (OR: 3.91 CI: 1.14-13.5 p=0.031), organ/space (OR: 1.75 CI: 1.19-2.59 p=0.005), or any surgical site infection (OR: 1.95 CI: 1.35-2.84 p<0.001) were more likely in the elderly compared to those ages 18-24 years. A greater proportion of the elderly developed systemic sepsis (χ2= 34.7 N = 9.95 p=0.019). Elderly patients were 72% more likely to have at least one perioperative complication (OR: 1.72 CI: 1.27-2.35 p=0.001), and 26% more likely to have a longer length of stay (OR: 1.26 CI: 1.18-1.36 p<0.001). Elderly patients were six times more likely to die (OR: 6.05 CI: 2.07-17.69 p<0.001).

Conclusion: Elderly patients represent a small proportion of isolated traumatic open tibia fracture cases with a slight majority being among elderly men. There is a clear disparity in their preoperative surgical outcomes, having greater odds of developing perioperative infections or any complication. Elderly patients who sustain open tibia fractures were subject to having the most profound perioperative complication of all; death. This may be secondary to their markedly increased odds of perioperative cardiac arrest, which prolonged length of hospitalization. Additional research is warranted to determine this patient population’s long-term postoperative functional status and complications of interest such as nonunion and malunion.

78.13 A Surge in Rope Swing Injuries in Setting of Extreme Drought

Posted on January 18, 2016

K. S. Romanowski2, E. S. Salcedo1, J. M. Galante1, C. S. Cocanour1 1University Of California – Davis,Division Of Trauma And Acute Care Surgery,Sacramento, CA, USA 2University Of Iowa,Division Of Acute Care Surgery,Iowa City, IA, USA

Introduction: California and the Western United States are in the midst of a severe drought that has been intensifying for the last four years. With lower water levels in the lakes and rivers, a new mechanism of injury has emerged. Patients are sustaining serious injuries and are doing so with a much higher incidence than previously seen. Patients are presenting with injuries sustained while using rope swings in areas previously with safe water levels.

Methods: Following IRB approval, a retrospective chart review of all admitted trauma patients seen following rope swing accidents during the summers (July to September) of 2013 and 2014 was performed. Data collected included: demographics (age, gender), injury characteristics (ISS, types of injuries), outcomes (length of stay, surgical procedures), and discharge disposition. Values are expressed as mean ± SD.

Results: During summer of 2013, only 2 patients presented with injuries following falls from rope swings. In summer of 2014, 13 patients presented with injuries sustained while using rope swings. This represented a 650% increase from the previous year. The mean age of patients was 28.9±14.2 (range 10-56) years. Eight patients were women (61.5%). Patients fell from a mean height of 14.3±6.3 (6-25) feet. Only 2 patients (15.4%) had a loss of consciousness and all patients presented with a Glasgow Coma Scale (GCS) of 15. The mean ISS was 9.17±6.5 (1-25). These 13 patients sustained 22 injuries. The most frequent injuries were: pelvic fractures (3 patients), lumbar spine fractures (3 patients) and concussions (2 patients). They required a mean of 1±0.96 (0-3) procedures. The mean length of stay was 5.46±4.0 (1-15) days and 11 patients (84.6%) were discharged home from the hospital. One patient went to a skilled nursing facility and one patient left against medical advice. Eight patients (61.5%) required durable medical equipment at the time of discharge. One patient was readmitted for cellulitis.

Conclusion: As the drought intensifies and water levels get lower, there has been a surge in patients presenting with injuries that were sustained using rope swings. The patients are presenting with serious, potentially life-threatening injuries that often require surgical procedures and inpatient hospital stays. Additionally the majority of these patients require durable medical equipment at discharge. All of this produces significant societal cost. The public must be made aware of the dangers of rope swings and those that are located in areas with severely low water levels or dangerous conditions should be removed.

78.14 Preventing Unplanned Hospital Readmissions: Defining the Population is the First Step

Posted on January 18, 2016

M. G. Rosenthal1, J. H. Ra1, D. Ebler1, D. J. Skarupa1, J. J. Tepas1, T. S. Hester1, S. Saquib1, A. J. Kerwin1 1University Of Florida COM-Jacksonville,Acute Care Surgery,Jacksonville, FL, USA

Introduction: In an era of decreasing reimbursements the incentive to decrease readmissions has never been greater. It has been suggested that trauma readmission is an indicator of poor hospital care or fragmented discharge. Even though readmissions are relatively low readmissions add significant cost, are resource intensive, tie up already limited resources and lead to worse outcomes, including mortality. Between 15 to 38% of trauma readmissions require an operation during readmission and are associated with a 4.6% mortality rate.

The Affordable Care Act will penalize hospitals for unplanned readmissions. While this does not pertain to trauma patients currently, there is concern that in the future it will. The 30 day rate of unplanned readmission in US Medicare patients is estimated to be 20% for both medical and surgical patients. The literature suggests that trauma patients have a lower readmission rate compared to medical and surgical patients. Further studies are needed to determine reasons for readmissions and risk factors that predispose patients to unplanned readmissions. Once these have been elucidated efforts can be made to highlight patients who are at increased risk and enact strategies to reduce preventable readmissions.

Methods: This is a retrospective review of trauma patients over the age of 16 with an unplanned readmission within 30 days of discharge. Cases registered from July, 2012 to June, 2015 were included from our Level 1 trauma center registry. Reasons for readmission were categorized and patient outcomes following readmission were evaluated as well as hospital resource usage.

Results: Of 5,650 patients, 159 (2.81%) required unplanned readmission. The most common reasons were disease/ symptom progression (30.2%), wound complications (28.9%), pain control (11.8%) and VTE disease (9.4%). Missed injuries accounted for 3.1% of readmissions. 76 (48%) required a surgical or invasive procedure. 63% were readmitted within 1 week of initial discharge and 60.3% required less than 1 week LOS after readmission . The mean LOS after readmission was 7 days. The mortality rate for those requiring readmission was 3.1%.

Conclusion: Our trauma readmission incidence and readmission mortality rate is consistent with previously published studies. Given that the preponderance of these occur within 1 week after discharge, are for disease/symptom progression or pain control and require a hospital stay less than 7 days trauma programs should use their quality management programs to identify system improvements to reduce these types of readmissions. This will benefit both patients and hospitals.

78.15 Characterization of Injury Rates by Population Density in Florida

Posted on January 18, 2016

A. Lai1, D. Kim1, C. Kapsalis1, D. Ciesla1 1University Of South Florida College Of Medicine,Tampa, FL, USA

Introduction:
Traumatic injuries are the third leading cause of mortality amongst Americans. Injury mechanisms can be separated into individual events (e.g. falls) or interaction events (e.g. motor-vehicle accidents). Interaction events occur between individuals and are expected to be higher amongst regions with higher population density. We aimed to see whether collisions mechanisms in Florida counties increased with population density.

Methods:
Data for this retrospective cohort study were obtained from the 2013 Florida Agency for Healthcare Administration (AHCA) discharge database. All patients with trauma alert charges or admission type defined as trauma were included. Additionally, any admissions classified as urgent or emergent with any ICD-9 codes between 800 and 957 were included. Patients were excluded if they were pronounced dead on arrival. County populations were taken from the 2013 Census Data estimates, and county-level characteristics were taken from 2010 Census Data estimates.

Results:

Age-adjusted population density was not a significant predictor of low-energy mechanisms (p=0.1063); however, median county age was a significant predictor in the model (p=0.0340). The model was a significant (p=0.0173). Age-adjusted population density was not a significant predictor of high-energy mechanisms (p=0.8271). Median age was not a significant predictor (p=0.8218), and the model was not significant (0.9433).

Conclusion:
Both low-energy and high-energy mechanisms do not appear to be linearly correlated with population density after adjustment for median county age. The data suggest that both trauma mechanisms appear to occur independent of population density in Florida.

78.16 Factors Associated with Mortality After Fixation Of Isolated Open Tibia Fractures

Posted on January 18, 2016

N. N. Branch1, R. Wilson1 1Howard University College Of Medicine,Washington, DC, USA

Introduction: All who sustain open fractures may present with isolated musculoskeletal injuries or multisystem trauma putting them at risk for complications. Research is limited regarding the association between open tibia fractures and mortality; what exists suggests the two are not intrinsically linked. We sought to assess the factors which impact perioperative mortality after open reduction and internal fixation (ORIF) of isolated open tibia fractures (IOTF) using the National Trauma Data Bank (NTDB).

Methods: A retrospective analysis of the NTDB from 2007-2010 utilizing ICD-9 codes was conducted. Patients ≥ 18 years, who underwent ORIF of IOTF at a level I or II trauma centers were included. Those excluded were cases who died in the emergency department and those who were dead on arrival. Multivariate logistic regression analyzed covariates including, Glasgow Coma Scale (GCS), injury severity score (ISS), congestive heart failure, and age.

Results: 7,201 cases met the inclusion criteria. The majority were White (67%), males (74%), ages 25-44 years (42%), injured due to a motor vehicle collisions (25%), with private insurance (23%). 1.01% (n=73) of patients in our cohort died within 30 days of surgery. Among the mortalities 54 were White, 24 were female and 21 were 65 years or older. Having fixation on hospital day (HD) 1 increased odds of death (OR: 2.46 Cl: 1.05-5.78 p=0.038), compared to having fixation by HD 2. Insurance, race, gender, and GCS were not associated with perioperative death (Table 1), however the elderly were six times more likely to die (OR: 6.05 CI: 2.07-17.69 p<0.001). Patients with an ISS between 16-24 & 25-75 were five times (OR: 5.14 CI: 2.14-12.39 p<0.001) and more than nine times (OR: 9.67 CI: 4.08-22.94 p<0.001) more likely to die. Among comorbidities analyzed only those with congestive heart failure (CHF) had increased odds of death (OR: 9.32 CI: 3.00-28.94 p<0.001). Patients with any perioperative complication were almost three times more likely to die after surgery (OR: 2.9 CI: 1.57-5.36 p=0.001).

Conclusion: While the number of deaths among patients with isolated open tibia fractures was relatively small across the study period, many would argue that even one percent constitutes too many lives lost. GCS was not predictive of perioperative mortality, however, increasing ISS was predictive likely due to multisystem trauma. The elderly had a disproportionately higher odds of death compare to all other age groups. Analyzing more recent data might offer additional insight into the potential persistence of the results found here and identification of any modifiable factors to decrease perioperative death after ORIF of open tibia fractures.

78.17 The Impact of Change in GCS Score on Outcomes After Traumatic Brain Injury

Posted on January 18, 2016

H. Aziz1, P. Rhee1, A. A. Haider1, N. Kulvatunyou1, A. Tang1, T. O’Keeffe1, D. J. Green1, R. Latifi1, R. S. Friese1, B. Joseph1 1University Of Arizona,Tucson, AZ, USA

Introduction:
Glasgow coma scale (GCS) score is used widely to assess the neurological status of patients with traumatic brain injury (TBI). However, the role of change in GCS score as a prognostic indicator in these patients has never been studied before. We hypothesized that change in GCS score at 6-hours after arrival reliably predicts mortality and need for delayed neurosurgical intervention in patients with TBI.

Methods:
We performed a 2-year (2013-2014) retrospective analysis of all patients with a diagnosis of intracranial hemorrhage on initial CT scan. We divided our patient population into 2 groups, patients with unchanged or improved 6-hour GCS score and patients with a decline in GCS scores. Our primary outcome measures were; mortality, delayed craniotomy (> 6-hour), and progression of intracranial bleed. Secondary outcome measures were; hospital and ICU length of stay. Multivariable logistic regression analysis was performed

Results:
A total of 232 patients were included. Mean age was 45.8±25.2 years and median head-AIS was 3 [3-4]. 138 (58.5%) patients had an improved 6-hour GCS score as compared to their admission GCS score. The rates of mortality (2.4% vs. 18.1; p<0.001), delayed craniotomy (0.8% vs. 11.4%; p=0.001), and progression of head bleed (6.3% vs. 16.2%; p=0.02) were significantly lower in the patients with improved 6 hour-GCS scores. Improved 6-hour GCS score was independently associated with lower odds of mortality (OR [CI]; 0.1 [0.02-0.53]; p=0.007). Even in the subgroup of severe TBI patients, an improved 6-hour GCS score was independently associated with lower odds of mortality (OR [CI]; 0.09 [0.01-0.81], p=0.03)

Conclusion:
An improvement in 6-hour GCS following traumatic brain injury is associated with lower odds of mortality. This may help direct critical decisions in patients in whom the prognosis following traumatic brain injury is unclear.

78.18 The Prevalence of Psychiatric Diagnoses in Hospitalized U.S. Trauma Patients

Posted on January 18, 2016

L. Townsend1, M. Esquivel1, P. T. Leitz1, T. G. Weiser1, P. M. Maggio1, D. Spain1, L. Tennakoon1, K. Staudenmayer1 1Stanford University,Surgery,Palo Alto, CA, USA

Introduction: It has been estimated that 20-40% of Americans have a mental illness. We hypothesized that psychiatric diagnoses would be common in patients hospitalized for trauma in the United States and that this diagnosis would be associated with poor outcomes.

Methods: The Nationwide Inpatient Sample (NIS, 2012) was used to determine national estimates for the number of patients admitted with an injury. Psychiatric diagnoses were identified using diagnosis codes according to the Diagnostic & Statistical Manual of Mental Disorders, Fifth Edition. Unadjusted and adjusted analyses were performed. Survey weights were used to derive national estimates.

Results: A total of 1.96 million patients were admitted to hospitals in the United States in 2012 due to trauma. Of these, 861,160 (44%) had a psychiatric diagnosis. This rate was higher when compared to non-trauma inpatients (11.3 million/34.5 million, 33%, p <0.001). Psychiatric diagnoses varied by age group. For those <18 years, neurodevelopmental disorders were the most common (41%). For ages 18-64, drug and alcohol abuse predominated (41%), while dementia and related disorders (48%) were the most common in adults ≥65. Drug and alcohol abuse were common in both those <18 years (14%) and adults ≥65 years (12%). Patients hospitalized for trauma who had a psychiatric diagnosis differed in all measures compared to those without a psychiatric diagnosis. On average those with a psychiatric diagnosis were older (62 vs. 58 years, p<0.001), more often female (53% vs. 49%, p<0.001), more often white (74% vs. 68%, p<0.001), and less severely injured (mean ISS 8.8 vs. 9.6, p<0.001). Mortality was low for all trauma patients, but was lower for trauma patients that had a psychiatric diagnosis in both unadjusted and adjusted analysis (2.0% vs. 3.1%, OR 0.55, p<0.001). However, patients with a psychiatric diagnosis were more often discharged to skilled nursing care (42% vs. 32%, p<0.001) and less often to home (42% vs. 50%, p<0.001).

Conclusion: Psychiatric conditions are present in almost ½ of all hospitalized trauma patients in the United States, which is more common than what is observed in hospitalized non-trauma patients. The most common diagnosis was drug and alcohol abuse. Psychiatric diagnoses were associated with a greater number of discharges to skilled nursing facilities rather than home, suggesting an increased burden by those with a psychiatric diagnosis. The frequency of psychiatric conditions in the trauma population suggests efforts should be made to address this component of patient health to improve outcomes.

78.19 Understanding 30-day Death or Stroke Following Surgical Clipping for Intracranial Aneurysm

Posted on January 18, 2016

H. Hong1, R. R. Kelz2, M. J. Smith1 1University Of Pennsylvania,Neurosurgery,Philadelphia, PA, USA 2University Of Pennsylvania,Surgery,Philadelphia, PA, USA

Introduction: The role of open surgical clipping as the optimal treatment for patients with intracranial aneurysm (ICA) remains unclear. Existing studies to address this issue lack the ability to reliably adjust for disease-specific and procedure-specific variables that may significantly influence treatment outcomes. The aim of this study was to identify factors associated with postoperative death/stroke following surgical clipping for brain aneurysm.

Methods: A retrospective cohort study of patients undergoing surgical clipping for ICA repair was conducted using the multi-institutional American College of Surgeons National Quality Improvement Project (ACS NSQIP) participant use file (2006-2013). The primary outcome measure was a composite variable, 30-day death or stroke (30dDS). Patient, disease, and procedure characteristics were compared using the Chi-square test. A multivariate logistic regression model was developed to determine the factors associated with 30dDS.

Results: A total of 974 adult patients were identified for inclusion during the 8-year study period. The overall 30dDS was 12.7% with 63 deaths and 80 strokes. In the multivariate model, patients with hypertension requiring antihypertensive medication, or in a coma state prior to the operation were noted to have a significantly higher risk of 30dDS (OR=2.4, 95% CI 1.2-5.1 and OR=6.8, 95% CI 2.2-22.8 respectively).

Conclusion: Preoperative hypertension requiring antihypertensive medication and coma status are independently associated with 30dDS in patients undergoing open surgery for ICA. Hypertension and state of unconsciousness should be considered as priority risk factors in management of ICA, regardless of other medical comorbidities. These factors should be a part of the preoperative discussion when getting informed consent.

78.20 Diabetes Impacts Brain Structure in Patients Undergoing Carotid Artery Interventions

Posted on January 18, 2016

E. Hitchner1, S. Rao1, S. Soman3, W. Zhou1,2 1VA Palo Alto Healthcare System,Vascular Surgery,Palo Alto, CA, USA 2Stanford University,Vascular Surgery,Palo Alto, CA, USA 3Harvard School Of Medicine,Radiology,Boston, MA, USA

Introduction: Cognitive change has been demonstrated in patients undergoing carotid interventions; however, the impact of these procedures on brain structure is unclear. Here we investigate how patient demographics and co-morbidities stratify differences in brain volume prior to and following carotid intervention.

Methods: Patients scheduled to undergo a carotid intervention were prospectively recruited under an IRB-approved protocol at a single academic center. Both patients undergoing carotid artery stenting (CAS) and carotid endarterectomy (CEA) were included. All subjects underwent pre- and post-operative MRI that included a T1 structural sequence. The T1 images were processed using FreeSurfer 5.3, with resulting segmentations reviewed and edited as needed under neuroradiologist supervision. Demographics were collected and analyzed to look for correlations with derived brain volumetrics.

Results:48 patients were recruited to the study; 42 completed all procedures and were included in the analysis. 99% of the patients were male with an average age of 70 years. As expected, older patients had smaller brain volume and larger ventricles. No significant relationships were found between change in brain segment volumes and procedure type (CAS vs. CEA), current smoking, or prior neurologic symptoms. History of alcohol abuse correlated with a decrease in caudal middle frontal volume (p=.04). Diabetics were found to experience a significant decrease in contralateral segment volumes, including the thalamus (p=.06), anterior cingulate (p=.01), and caudal middle frontal (p=.04) regions. Similarly, a relationship was found between patients with coronary artery disease (CAD) and a decrease in contralateral isthmus cingulate (p=.01) and rostral middle frontal volumes (p=.05). These changes were not replicated on the ipsilateral side, suggesting that revascularization may mitigate the effect of diabetes and CAD on brain structure.

Conclusion:Volumetric MRI data may provide insight on the impact of carotid interventions on the brain. Further work investigating this relationship is warranted.

78.21 External Radiation Therapy for Hepatocellular Carcinoma; A Systematic Review of Current Evidence

Posted on January 18, 2016

M. Tanious1, J. Robbins1, N. Berger1, A. Hammad1, R. Rajeev1, K. K. Turaga1, F. M. Johnston1, S. Tsai1, K. K. Christians1, T. Gamblin1 1Medical College Of Wisconsin,Milwaukee, WI, USA

Introduction: External radiation therapy (XRT) for hepatocellular carcinoma (HCC) has been limited due to potential radiation induced liver disease (RILD). Interest in XRT has recently grown due to the ability to deliver focused high doses of XRT. We aimed to evaluate and synthesize the recent published data regarding HCC and stereotactic body radiotherapy (SBRT).

Methods: A systematic literature search using a predefined protocol was utilized to identify publications of XRT and HCC in PubMed, Ovid Medline, Scopus, Web of Science (WOS), and Cochrane Library (2000-2015). Primary outcomes of interest were overall survival (OS) and toxicity associated with SBRT.

Results: From a pool of 5,064 articles, 10 involving SBRT were retained for data extraction consisting of 5 retrospective cohort studies, 4 prospective observational studies and 1 prospective phase 2 trial. A total of 565 patients were identified of which 404 were male (72%). Median OS range was 11-41 months, while 1-, 2- and 3- year OS rates ranged from 50-95%, 43-83%, and 23-70%, respectively. Objective tumor response rates of 63-86% and progression of disease at follow-up was documented in 0-8% of cases. Grade 3/4 toxicities due to SBRT were observed in 0-26%, and RILD was observed in 11 patients (2%) with 3 deaths from liver failure.

Conclusion: SBRT for HCC lesions may offer an effective therapy in selective cases. With encouraging OS outcomes and infrequent reported hepatic toxicity, XRT represents a potential treatment for inoperable patients.

08.01 Prolonged Hospital Stays for Patients Discharged to Post-Acute Care after Colorectal Cancer Surgery

Posted on January 18, 2016

E. A. Bailey1, G. C. Karakousis1, R. Hoffman1, M. Neuwirth1, R. R. Kelz1 1Hospital Of The University Of Pennsylvania,Department Of Surgery,Philadelphia, PA, USA

Introduction: As payment models move toward bundled reimbursement for an entire episode of care, including services provided after discharge, it is important to reduce excess utilization of costly inpatient care. The aim of this study was to compare inpatient length of stay (LOS) and cost differences for colorectal cancer surgery patients who did not experience complications and were discharged to home versus a post-acute care facility. We also sought to identify risk factors associated with discharge to a facility.

Methods: All patients who underwent surgical resection for colorectal cancer in New York and California in 2009-2010 and were discharged to home or to post-acute care (skilled nursing facility or inpatient rehab) were identified.. Patients were excluded if they had a surgical complication or a LOS greater than the 75th percentile for a given procedure. Median LOS and median cost per hospitalization were calculated. A multivariate logistic regression analysis was performed to assess preoperative risk factors associated with discharge to post-acute care.

Results: Of the 35,807 patients initially identified, 11,946 (33.3%) were excluded for procedure-specific prolonged LOS or surgical complication. 23,861 patients were included in the study. Most patients were discharged to home (n=22,567, 94.6%) while 1,285 (5.4%) patients were discharged to a post-acute care facility. Patients discharged to home had a shorter median LOS (5 days [IQR 4,7]) than those discharged to a facility (7 days [IQR 6,9], p<0.001). Cost per hospitalization differed significantly between the two groups with a median of $16,882 (IQR $11,876, $24,146) per patient visit in the group discharged to home versus $20,705 (IQR $14,372, $28,208) in the group discharged to post-acute care (p<0.001). Factors associated with discharge to post-acute care by multivariate analysis included advanced age, female sex, race, 3 or more co-morbid conditions, presence of metastasis, emergent admission, at least 1 admission in the previous year, and being a Medicare patient (Table 1).

Conclusion: Even in the absence of a surgical complication, LOS following colorectal surgery was 2 days longer and $3,823 more costly for patients discharged to a post-acute care facility. Pre-operative factors such as age, sex, number of medical co-morbidities, and emergent nature of admission were significantly associated with a lower rate of being discharged to home. Early consultation with patient advocates and social services for discharge planning should be initiated for at risk patients to ensure a timely discharge and commencement of the true recovery process.

78.10 Robotic Esophagectomy: Is it time yet?

Posted on January 18, 2016

R. Sharma1, C. Ripat1, F. Pendola1, O. Picado1, D. Sleeman1,2, N. Merchant1,2, A. Livingstone1,2, D. Yakoub1,2 1University Of Miami- Miller School Of Medicine,Division Of Surgical Oncology At Department Of Surgery,Miami, FL, USA 2Sylvester Comprehensive Cancer Center,Division Of Surgical Oncology At Department Of Surgery,Miami, FL, USA

Introduction: Robotics offer improved instrumentation, precision and accuracy; it has recently been introduced to esophageal surgery. However, there is hardly any data from prospective studies to objectively evaluate its role. The aim of this systematic review was to assess the outcomes of robotic assisted esophagectomy (RAE).

Methods: A systematic literature search was performed using Medline (PubMed), Embase, Cochrane and Scopus. Studies reporting on short and long-term clinical outcomes of RAE were reviewed. Patient demographics, tumor characteristics, surgical outcomes such as operative time, blood loss, and post-operative complications and mortality were systematically collated. For comparative studies included, meta-analysis using random and fixed effect models was done by calculation of pooled relative risk with the corresponding 95% confidence interval (CI). Study quality was assessed using STROBE criteria.

Results: Our search yielded a total of 17 studies, only two of those compared RAE with thoracoscopic technique. The studies included a total of 666 patients with esophageal cancer who underwent RAE from May 2006 to April 2015. Tumor histology was adenocarcinoma in 386 (58%), squamous cell carcinoma in 162 (24%) and other in 118 (18%). Review of all included data on RAE showed a median blood loss of 148 (R: 10-5300) ml, operative time of 410 (R: 120-807) minutes, length of hospital stay of 10.4 (R: 4-182) days, and ICU stay of 2 (R: 0-136). Median number of lymph nodes harvested was 20, (R: 3-68). 30 day mortality was (n=12, 1.8%). Complications included cardiac (0-42.9%), pulmonary (0-71.4%), vocal cord paralysis (0-37.5%), anastomotic leak (0-37.5%), wound infection (0-14.3%), and DVT/PE (0-9.5%). Meta-analysis of data from the two comparative studies showed significantly lower length of hospital stay (Mean Difference -12.7 days, 95% CI -21.1 to -4.3, p=0.003) and less operative time (Mean Difference -38.3, 95% CI -67.2 to -9.4, p=0.0095) in the RAE group. There was no difference in lymph node harvest between the two groups. Post-operative complications were less in RAE group, yet they did not reach statistical significance.

Conclusion: RAE can be performed with comparable safety and oncologic outcomes to open and thoracoscopic techniques in patients with esophageal cancer. Prospective comparative studies are needed as surgeons advance on their learning curve for using this newly introduced technology, in order to accurately evaluate the long term therapeutic and economic value of this technique.

78.11 Experimental Evaluation of a Quantified Depth Shave Biopsy Device

Posted on January 18, 2016

L. G. Gutwein1, B. Davignon3, T. M. Katona2, C. L. Wade2, R. Sood1, S. S. Tholpady1 1Indiana University School Of Medicine,Plastic & Reconstructive Surgery,Indianapolis, IN, USA 2Indiana University School Of Medicine,Pathology & Laboratory Medicine,Indianapolis, IN, USA 3Rose Hulman Ventures,Terre Haute, IN, USA

Introduction: More diagnoses of skin cancer occur than all other cancers combined. The most common method to biopsy a skin lesion is the shave biopsy (SB). Shave biopsies are efficient and require no stitch therefore the preferred method to sample a lesion. However, SB application requires proficient technique primarily utilized by dermatologists. Additionally, the SB depth is subjective and uncertain at time of harvest. Malignant melanoma depth of invasion (Breslow depth) is the primary determinate of prognosis and guides clinical management of this disease. The decision point is 1mm depth of invasion measured from the stratum granulosum to determine the need for SLN biopsy and 1 vs. 2cm margin of excision. The present study examines an innovative SB design that is user friendly and quantifies the depth of specimen harvest at the time tissue acquisition.

Methods: A depth quantified SB prototype was constructed on a 3-D printer from DurusWhite, a polypropylene material, and fitted with custom fabricated scalpel blade. The depth of biopsy from the stratum corneum (surface of skin) was engineered to be at least 1.1mm. Fresh cadeveric abdominal tissue SB samples were harvested and placed immediately in formalin after the depth margin was inked. Hematoxylin and eosin staining was performed with microscopic analysis to determine depth harvest consistency.

Results: Five tissue samples were harvested and analyzed with light microscopy with the following depths from the stratum granulosom (greatest Breslow depths): 1.32, 1.48, 1.05, 1.42, and 1.10mm. The average depth of specimen harvest was 1.27 mm (standard deviation 0.19mm). The average specimen width where the depth was of at least 1.1 mm was 1.5mm (standard deviation 0.56mm). No specimen harvest violated the entire thickness of dermis indicating a safe device that leaves a wound to heal via secondary intention (as is standard in conventional shave biopsy).

Conclusion: Our innovative SB prototype proved consistent specimen harvest beyond 1mm from the stratum granulosum as required for accurate biopsy interrogation of malignant melanoma. Future studies will prove increased ease of use with direct controlled comparison to the conventional shave biopsy design. Implementation by primary care doctors and midlevel providers is the ultimate goal in order to decrease waiting time to lesion biopsy and reduce overall healthcare cost, as many lesions biopsied are ultimately benign.

77.18 Impact of insurance Status on Cytoreduction Surgery and Hyperthermic Intraperitoneal Chemotherapy

Posted on January 18, 2016

J. B. Oliver2, J. Rosado2, J. S. Patel2, K. M. Spiegler2, K. Houck3, R. J. Chokshi1 1New Jersey Medical School,Surgical Oncology,Newark, NJ, USA 2New Jersey Medical School,Surgery,Newark, NJ, USA 3New Jersey Medical School,Obstetrics And Gynecology,Newark, NJ, USA

Introduction: Cytoreduction surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) offer the best opportunity for long term survival for peritoneal metastasis for colorectal, appendicular, and ovarian cancers. Multiple studies have shown that individuals with cancer that are under insured have worse outcomes. However, to the best of our knowledge outcomes in the uninsured and underinsured undergoing CRS-HIPEC have not been investigated. Therefore, we looked at the outcomes in our series of CRS-HIPEC patients stratified by insurance status to see whether these individuals suffer worse outcomes.

Methods: Demographics, comorbidities, intraoperative variables, and post-operative outcomes for all patients undergoing CRS/HIPEC at a single institution from 2012 to 2015 were analyzed. Variables were examined with chi squared or Wilcoxon Ranked Sum Test where appropriate. Survival was analyzed with Kaplan Meier curves and Cox Proportional Hazard Regressions.

Results:During this time frame, 27 individuals underwent CRS-HIPEC. Sixteen of these individuals were underinsured (either Charity Care or Medicaid) while 11 were insured (Medicare or private insurance). The median age of the underinsured group was significant lower than that of the insured group (54.1 years vs 62.3 years, p=0.02). The groups had similar distributions of the Charlson Comorbidity Index (0 vs 0, p=0.86) and peritoneal carcinoma index (25.5 vs 18, p=0.42). The under insured group had a higher preoperative albumin levels (4.0 vs 3.3, p=0.04). Both groups had similar distribution and total number of organs resected (3.5 vs 4 total organs, p=1.00). Operative time trended to being longer in the under insured group (573.5 minutes vs 510 minutes, p=0.06). Both groups had similar rate of major complications (Clavien Dindo complication of 3A or greater, 64.3% vs 63.6%, p=0.97) and length of stay (12 vs 11 days, p=0.98). Median follow up time for the under insured group was 8.5 months while the median follow up for the insured group was 1.7 months. During the follow up, 4 individuals in each group died; at 44, 71, 73, and 733 days within the under insured group the deaths occurred and at 16, 40, 41, and 72 days within the insured group. Survival was significantly better within the under insured group (p=0.02). After controlling for age and preoperative albumin, the survival difference remained significant improved within the under insured group (HR 0.02, 95% CI 0.00-0.76, p=0.04).

Conclusion:In this small, single center study with very short follow up, there was an improvement in survival for those underinsured undergoing CRS-HIPEC and no difference in length of stay or complications. Larger studies with longer follow up are needed to confirm these findings.

77.19 The Use of Biomarkers or Advanced Body Imaging in Surveillance for Breast Cancer: A Systematic Review

Posted on January 18, 2016

E. R. Berger1,2, J. R. Schumacher3, D. Vanness3, L. O’Dwyer5, D. P. Winchester4, C. C. Greenberg3 1American College Of Surgeons,Division Of Continuous Quality Improvement,Chicago, IL, USA 2Loyola University Chicago Stritch School Of Medicine,Department Of Surgery,Maywood, IL, USA 3University Of Wisconsin School Of Medicine And Public Health,Wisconsin Surgical Outcomes Research Program,Madison, WI, USA 4American College Of Surgeons,Cancer Programs,Chicago, IL, USA 5Northwestern University Feinberg School Of Medicine,Galter Health Sciences Library,Chicago, IL, USA

Introduction: Almost 3 million breast cancer survivors in the United States are receiving post-treatment surveillance. Current ASCO and NCCN guidelines recommend against the routine use of biomarkers or advanced imaging for asymptomatic patients. These guidelines do not account for heterogeneity in individual patient risk or the significant advances in imaging and treatments that have been made since the studies on which these guidelines are based were conducted. As a result, utilization remains high. We performed a systematic review to assess recent evidence supporting surveillance with biomarkers or advanced body imaging for detection of distant recurrence after treatment for breast cancer.

Methods: A systematic search was conducted in March 2015 using MEDLINE(PubMed), Embase, and Cochrane CENTRAL Register of Controlled Trials for articles on breast cancer, diagnostic imaging, recurrence, and surveillance, and their word variants. After the removal of duplicates, a total of 2887 results were screened. Studies were excluded if conducted for screening/staging primary breast cancer, if patients had not been treated with curative intent, if patients were symptomatic, or if the study was conducted prior to the year 2000.

Results:Twenty nine studies met the inclusion criteria. Twenty three studies documented utilization of routine biomarkers and imaging for asymptomatic surveillance. Only two studies compared surveillance with guideline concordant care (clinical visits and mammography) with a more intensive protocol involving advanced imaging. The majority of studies used cross-sectional imaging and biomarkers as the comparison group despite recommendations against them. Nineteen studies evaluated the use of PET/CT in detecting recurrence compared to other cross sectional imaging in the setting of rising tumor markers (CA 15-3, CEA). There was no overall or disease-free survival benefits in any study. PET/CT demonstrated a consistently higher sensitivity and specificity in detecting distant recurrence compared to biomarkers and/or conventional imaging alone.

Conclusion:Our review found that current research mostly focused on investigating newer surveillance modalities, such as PET/CT, rather than generating evidence for or against current recommended guidelines. These studies suggest that although PET/CT is more accurate in detecting distant recurrence than other modalities, surveillance using advanced imaging or biomarkers did not yield significant improvements in survival for the post-treatment population. Because these studies did not consider patient risk factors or molecular subtypes, the question of whether surveillance using biomarkers or cross-sectional imaging might be valuable for subpopulations remains unanswered. Until evidence accounting for patient heterogeneity is generated, use of biomarkers and advanced imaging for asymptomatic surveillance among breast cancer survivors is likely to continue despite guidelines discouraging their use.

77.20 Outcomes of surgery for invasive breast carcinoma in Black women at an urban tertiary hospital

Posted on January 18, 2016

D. R. Springs1, G. Ortega2, S. Ajmerji1, A. Nehemiah1, R. T. Green1, L. Wilson3 1Howard University College Of Medicine,Washington, DC, USA 2Howard University College Of Medicine,Department Of Surgery,Washington, DC, USA 3Howard University College Of Medicine,Division Of Surgical Oncology,Washington, DC, USA

Introduction: Breast cancer is the most common non-skin neoplasia in women and has the second-highest mortality rate of cancers that affect women. Although the incidence of breast cancer is lower among Black women than among White women, mortality remains higher among Black women. Biological tumor characteristics such as grade at diagnosis and hormone receptor status have been implicated in this disparity. This study intends to evaluate the outcomes of surgical interventions for invasive breast carcinoma.

Methods: Conducted a retrospective review of a single institution’s breast cancer registry from 1990 to 2013. Data collected included demographics, histological grade, stage, hormone receptor status, therapeutic interventions, recurrence, and survival. Patients with diagnosis of infiltrating carcinoma, who were reported as Black, who were female, and for whom date of diagnosis was before 8/19/2009. The primary outcomes evaluated were five year survival (5YS) and five year disease-free survival (DFS). Group comparisons were conducted between patients who received breast conserving therapy (BCT: lumpectomy, partial mastectomy) and those who received a form of mastectomy (total/simple, radical, or modified radical). T tests were used to evaluate continuous variables, and Pearson’s chi-square test to evaluate categorical variables.

Results: 1164 patients met inclusion criteria. Of those, the mean age at diagnosis was 57.7. 94.4% (1099) had the primary diagnosis of infiltrating ductal carcinoma. 73.7% had surgical treatment, 59.4% had BCT, and 40.6% had mastectomy. 6.5% had tumor evaluated as grade I; 24.7% grade II; 50.9% grade III; 0.6% grade IV. 26.3% were stage 1 at biopsy; 38.0% stage 2; 14.8% stage 3; 2.1% stage 4. Hormone receptor status was evaluated for 531 patients; 64.2% (341) were estrogen receptor (ER) positive; 47.6% were progesterone receptor (PR) positive; 44.8% were both ER and PR positive. 380 patients had unequivocal determination of HER2NEU status: 19.7% (75) were HER2NEU positive. Of the entire cohort, 2.0% were triple positive; 8.4% were ER and PR positive, HER2NEU negative; 8.9% were triple negative. Of the patients who were ER positive, 52.3% (181) had 5YS (P<0.05); 55.5% (137) PR positive patients had 5YS (P<0.001); 60.2% (59) patients who were ER and PR positive, HER2NEU negative had 5YS (P<0.05). 63.9% (324) of patients who underwent BCT had 5YS; 48.9% (216) of patients who underwent some form of mastectomy had 5YS. On analysis adjusted for stage, grade, and hormone receptor status, patients who underwent mastectomy had a decreased likelihood of both 5YS (OR = 0.5, 95% CI: 0.3 – 0.9, P = 0.08) and DFS (OR = 0.5, 95% CI: 0.3 – 1.1, P = 0.5), though the difference is not significant.

Conclusion: No significant difference in 5YS or DFS was observed between the two intervention groups. Future analysis should evaluate the effect of adjuvant chemotherapy and radiation therapy after surgery on survival and recurrence.

78.01 Time to Death: A Story of Old?

Posted on January 18, 2016

J. C. Albarracin1, C. E. Wade1, B. Oyeniyi1, J. B. Holcomb1, S. D. Adams1 1University Of Texas Health Science Center At Houston,Department Of Surgery,Houston, TX, USA

Introduction:
Trauma mortality in the elderly population poses an alarming public health risk. The elderly are a rapidly increasing proportion of the population and account for a disproportionate number of trauma deaths. Elderly patients with injuries stay in the hospital twice as long as younger patients with similar injuries and are twice as likely to die. Previous studies have analyzed the temporal distribution of all trauma-related deaths, but none have focused specifically on the elderly, a growing segment of the population. The objective of our study was to evaluate and compare time to death in elderly and younger trauma patient populations. We hypothesized that the elderly would survive the initial injury but display an increase in delayed deaths in comparison to the young.

Methods:
We performed a retrospective review of adult trauma deaths over 5 years at at our Level I trauma center (1/2010-12/2014). We reviewed trauma registry data, Morbidity & Mortality reports and electronic medical records, and categorized patients as elderly (≥ 55 years) and young (16-54 years). The rate of mortality in each group was calculated and Injury Severity Scores (ISS) scores compared. The log-rank test was used to compare variables between the two populations, with significance set at p<0.05.

Results:
There were 27,977 admissions and 1,373 trauma deaths over the five-year period. The median age was 53± 23 years, which increased from 50± 24 years (n=264) in 2010 to 55± 23 years (n=265) in 2014. The median age of the elderly was 75± 12 years (n=666) and the young was 32± 12 years (n=707). The elderly displayed a lower rate of mortality (53.5%) within the first 48h than did the young (73.8%). After day 2, the elderly exhibited a higher rate of mortality that persisted for 13 days (38.1%) compared to the young (20.7%). The elderly died with a lower average ISS score compared to the young. The lower ISS of the elderly was more pronounced in the delayed deaths. When an age adjusted factor was added to the calculated ISS of the elderly, the averages mirrored that seen in the young. During days 0-2, the adjustment factor was +6, whereas in 3-13 and 14-40 day time periods the age adjustment factor was +10 and +7 respectively.

Conclusion:
We have demonstrated a significant difference in the temporal distribution of trauma mortality in the elderly through 13 days post-injury. These findings provide guidance for the care of the elderly trauma patient and a framework for adjusting expectations of survival between elderly and younger trauma patients.

78.03 Bariatric Surgery in Veterans with Pre-existing Lower Back and Extremity Degenerative Joint Disease

Posted on January 18, 2016

K. Hwa1, E. Kubat1, E. Hardin1, D. Eisenberg1 1Stanford School Of Medicine And Palo Alto VA HCS,Surgery,Palo Alto, CA, USA

Introduction: Musculoskeletal disease is common in the obese and veteran populations. We examined the impact of a dedicated physical therapist in a multidisciplinary bariatric clinic.

Methods: A prospective bariatric database was retrospectively reviewed. Bariatric patients were followed before and after surgery in a multidisciplinary clinic that included a physical therapist (PT). Patients had a PT-supervised six-minute walk test (6mwt) at each visit. The distance covered during the test was noted. Differences in means were compared using student's t-test.

Results: A PT followed 74 patients who underwent bariatric surgery. Their average preoperative body mass index (BMI) was 45.8 kg/m2, age 53 years, and 78% were male. Of these, 83.8% had preoperative complaints of musculoskeletal pain, 52.7% had a pre-existing diagnosis of degenerative disc disease or osteoarthritis of lower extremity joints. These patients underwent intensive follow-up by the PT before and after surgery, with interventions including instruction in joint-protective exercises, elastic band strengthening exercises, use of TENS units, chair exercises, and pool therapy. Patients underwent preoperative and postoperative 6-minute walk test (6mwt) to assess progress. At 12 months after bariatric surgery, the cohort of patients with a diagnosis of lower back or lower extremity joint disease receiving intensive physical therapy instruction had a significantly greater %EBMIL (62.8% vs. 49.7%, p=0.048) compared to the other patients who did not have a musculoskeletal diagnosis. There was also a greater increase in 6-mwt distance traveled, although this was not statistically significant (57.4% vs. 20.1%, p=0.212).

Conclusion:Lower back and lower extremity pain is common in veterans presenting for bariatric surgery. A majority of these patients have a prior diagnosis of degenerative joint or disc disease. Intensive preoperative and postoperative treatment by a PT results in superior weight loss and improved exercise tolerance.

78.04 Incidence and Predictors of Metachronous Inguinal Hernias in Veteran Patients

Posted on January 18, 2016

P. M. Patel1, A. Mokdad1, S. Kukreja1,2, S. Huerta1,2 1University Of Texas Southwestern Medical Center,Dallas, TX, USA 2VA North Texas Health Care System,Dallas, TX, USA

Introduction: Following open inguinal hernia repair, it is possible that a patient will present with an inguinal hernia on the opposite side that requires a subsequent surgery. We hypothesize that there are factors that can determine which patients will need a subsequent inguinal herniorrhaphy, allowing for an improved treatment plan that could involve fewer surgeries.

Methods: This a retrospective, single institution, single surgeon experience at the VA North Texas Health Care system between July 2005 to July 2015. Thus, all patients underwent the same standardized mesh repair. Using need for contralateral repair as the dependent variable, univariate analysis (UA) was performed using Fisher’s Exact Test for categorical and Student’s T-Test for continuous variables. All clinically relevant variables or those with a p ≤0.2 were entered in a multivariable logistic regression model with contralateral herniorrhaphy as the dependent variable. Data are expressed as means ± SD and significance was established at a p ≤0.05 (two-sided).

Results: During the study period, 623 patients underwent open inguinal hernia repair (99.7 ± 0.2% male, 59.92 ± 12.4 years in age, 26.9 ± 4.1 BMI, 72.3% Caucasian, American Society of Anesthesiologists average class of 2.5, morbidity rate of 6.6 ± 1.0%) by the same surgeon. Twenty-eight patients with metachronous hernias were identified (4.5%). Median follow up was 4.7 ± 2.7 years. The median time for a contralateral repair was 25.4 months. Complications with patients presenting for a contralateral repair were similar to the entire cohort (7.1 ± 4.9% vs 6.6 ±1 .0%; p=0.9). Univariate analysis demonstrated that patients with metachronous hernia repair were more likely to have a history of alcohol abuse (67.9±8.8% vs 40.7±2.0%, p=0.005). Multivariate analyses only demonstrated history of alcohol abuse to be an independent predictor of a contralateral repair (OR and 95% CI: 3.0, 1.3-7.0).

Conclusion: This study demonstrates that the incidence of metachronous hernias in veteran patients is low and the rate of recurrence and morbidity is similar to initial repair.

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