70.09 Prognostic Factors In Anaplastic Thyroid Neoplasms In The Adolescent And Young Adult Population

Posted on January 18, 2016

I. I. Maizlin1, G. McGwin2, M. Goldfarb3, K. W. Gow5, S. A. Vasudevan6, J. J. Doski4, A. B. Goldin5, M. Langer7, J. G. Nuchtern6, E. A. Beierle1 1Children’s Hospital Of Alabama, University Of Alabama,Division Of Pediatric Surgery,Birmingham, Alabama, USA 2University Of Alabama,School Of Public Health,Birmingham, Alabama, USA 3John Wayne Cancer Institute/Providence St. John’s Medical Center,Department Of Surgery,Santa Monica, CA, USA 4University Of Texas Health Science Center At San Antonio, San Rosa Children’s Hospital,Department Of Surgery/Pediatric Surgery Division,San Antonio, TX, USA 5Seattle Children’s Hospital,Division Of General And Thoracic Surgery,Seattle, WA, USA 6Baylor College Of Medicine,Division Of Pediatric Surgery,Houston, TX, USA 7Maine Medical Center,Division Of Pediatric Surgery,Portland, ME, USA

Introduction: The aggressive nature and rarity of anaplastic thyroid cancer (ATC) makes it difficult to determine patient outcomes, especially in single-institution studies with small cohorts and short follow-up. Furthermore, considering that ATC increases in frequency with age, no investigations of large data sets exist that have examined the adolescent and young adult (AYA) population. Therefore, we utilized the National Cancer Data Base to determine the importance of age as a prognostic factor in anaplastic thyroid cancer.

Methods: All AYA patients (≤39 yo) with diagnosis of ATC were reviewed from the National Cancer Data Base from 1998 to 2012. They were then compared to older patient groups [40-65 yo (middle age) and ≥ 66 yo (elderly)] with same diagnosis. Log-rank test was used to compare survival functions between age groups and chi-squared tests were used to compare tumor size, method of diagnosis, time from diagnosis to definitive treatment, presence of comorbidities (based on Charlson/Deyo Score), and type of surgery performed. Cox proportional hazards models were used to estimate hazard ratios (HR) and their associated p-values. A secondary analysis was performed to evaluate whether surgical intervention was associated with survival in AYA patients.

Results:Out of total of 3,154 patients with ATC, 39 patients fit the criteria of AYA. Median survival in the AYA group was 118.5 months compared to 61.1 months (p=0.06) in middle and 66.2 months (p=0.06) in elderly groups. Compared to the AYA group, the HR for middle age and elderly groups were 1.96 (p=0.02) and 1.73 (p=0.06), respectively. The age groups demonstrated similar tumor size (>4cm in 84.6% vs. 85.7% vs. 83.8%) at time of diagnosis. AYA group had a significantly lower prevalence of comorbid conditions (12.5%) when compared to other age groups (21.2% and 27.6% respectively). AYA group had greater mean period between diagnosis and definitive treatment (19.4 ±3.6 days vs. 16.3 ±0.8 vs. 15.1 ±0.5 days) and a higher rate of FNA prior to intervention (97.3% vs. 92.0% vs. 87.8%). Consequently, following adjustment for confounders (tumor size, comorbidities, method of diagnosis and surgery) mortality in the middle- and older-aged groups was approximately 50% higher compared to the AYA group [HR=1.52 (p=0.16) and HR=1.56 (p=0.14), respectively], though these differences were not statistically significant. Within the AYA group there was no significant difference in survival between surgery employed as initial treatment (followed by radiation and chemotherapy) and non-surgical (radiation and chemotherapy) intervention only.

Conclusion:While anaplastic thyroid cancer is an aggressive tumor with overall poor prognosis, adolescents and young adults appeared to have increased survival compared to older populations. Survival rates in the AYA population were not affected by surgical intervention as initial therapeutic modality, compared to radiation and chemotherapy alone.

70.10 Pancreatic Cancer Disparities in an Underserved Population: A Need for Accessible Healthcare

Posted on January 18, 2016

C. Mosquera1, J. Lee1, S. D. Kachare1, T. L. Fitzgerald1, E. E. Zervos1 1East Carolina University Brody School Of Medicine,Division Of Surgical Oncology,Greenville, NC, USA

Introduction: The 29 county subregion comprising eastern North Carolina (ENC) is characterized by rurality, poverty and cancer outcome disparities when compared to the rest of the state. This study was undertaken to identify factors in this unique region contributing to disproportionately poor outcomes for pancreatic adenocarcinoma (PCA).

Methods: All patients diagnosed with PCA from 1996-2015 in ENC were identified through a central tumor registry. Logistic regression was undertaken to determine demographic, tumor, treatment and socioeconomic factors that contribute to observed outcome disparities.

Results:916 patients with PCA were identified, 93% of which arose from counties whose median household income is below the federal poverty limit. Compared to the rest of the state, PCA incidence in ENC (per 100k) is significantly higher (12.5 ±1.4 vs. 11.6 ± 1.7, p<0.03) as is the death rate (11.8±1.7 vs. 10.5±1.5, p<0.001). Multivariate analysis identified 7 factors independently predictive of poor survival (Table1). African Americans comprised 40% of these patients and were over-represented in each category that predicted poor outcomes.

Conclusion: Improved access to healthcare in ENC would positively impact 4 of 7 factors that are associated with poor survival in PCA; 3 are immutable. In this underserved population, Medicaid expansion or full implementation of the Affordable Care Act carries the greatest potential to erase these disparities.

70.06 A Clinically Applicable Muscular Index Predicts Morbidity and Survival in Resectable Pancreatic Cancer.

Posted on January 18, 2016

D. Delitto1, S. M. Judge1, R. L. Nosacka1, T. J. George1, S. M. Wallet1, G. A. Sarosi1, R. M. Thomas1, K. E. Behrns1, S. J. Hughes1, A. R. Judge1, J. G. Trevino1 1University Of Florida,Gainesville, FL, USA

Background: The relationship between myopenia, nutritional status, and long-term oncologic outcomes remains incompletely defined in patients with resectable pancreatic cancer (PC). Additionally, more advanced technologies to quantify myopenia, including complex volumetric analysis and densitometric algorithms, are not always available in the clinical setting. We sought to reliably quantify prognostic indicators of preoperative cachexia as a predictor of clinical outcomes with routine imaging applicable to any office or hospital site.

Methods: Preoperative CT scans were electronically available and suitable for analysis in 73 of 82 consecutive patients with PC undergoing pancreaticoduodenectomy (PD) between November, 2010 and February, 2014. The psoas index was computed from cross-sectional areas of psoas muscles normalized to vertebral body area at L3. Correlation and proportional hazards analyses were performed to identify relationships between muscularity, preoperative nutritional markers, clincopathologic parameters and long-term survival.

Results: Psoas index correlated strongly with preoperative hemoglobin and albumin levels (P = .001 and .014, respectively), identifying a pattern of preoperative frailty. High psoas index, albumin and hemoglobin levels significantly correlated with improved long-term survival (HR 0.014, P < .001; HR 0.43, P < .001 and HR = 0.80, P = .014). However, on multivariate analysis, psoas index proved to be the only independent predictor of survival (HR 0.021; P = .003). Notably, rapid declines in psoas index during neoadjuvant chemotherapy were associated with poor postoperative outcomes, as were declines in psoas index during the postoperative period.

Conclusions: The data indicate that the psoas index, a measurement available in any clinical setting, is a statistically powerful predictor of survival in PC, when compared to tumor grade and stage as well as previously validated nutritional parameters.

70.07 Positive Margins Contribute to the Survival Paradox between Stage 2B/C and Stage 3A Colon Cancer

Posted on January 18, 2016

Q. D. Chu1, M. Zhou2, K. Medeiros2, R. H. Kim1, X. Wu2 1Louisiana State University Health Sciences Center-Shreveport,Surgical Oncology,Shreveport, LA, USA 2Louisiana State University Health Sciences Center,Louisiana Tumor Registry & Epidemiology And School Of Public Health,New Orleans, LA, USA

Introduction: We found a persistence of a survival paradox between Stage 3A and Stage 2B/C colon cancer who had optimal treatment. The underlying reasons are elusive. We hypothesized that positive surgical margins contribute significantly to this paradox.

Methods: We evaluated a cohort of 16,471 patients with stage 3A or stage 2B/C with ≥ 12 lymph nodes (LNs) retrieved (N=5,670) from 709,583 patients diagnosed with colon cancer in 2003-2012 from the National Cancer Data Base. All received chemotherapy. Patients with Stage 3A were further subdivided into those with < 12 LNs retrieved (N=3,195) and those with ≥ 12 LNs retrieved (N=7,606). Univariate and multivariate survival analysis were employed.

Results: The 5-year overall survival (OS) rate was 70.8% for stage 2B/C ≥ 12 LNs, 81.6% for stage 3A with < 12 LNs, and 85.6% for Stage 3A with ≥ 12 LNs (P<0.0001). Patients with stage 2B/C had significantly higher rate of positive surgical margins compared to stage 3A (19% vs 1%; P<0.0001). Significant predictors (P<0.01) of poor OS include stage 2B/C, community cancer program, advanced age, African-American ethnicity, Medicaid, low education level, high comorbidity index, and positive surgical margins.

Conclusion: Positive surgical margins contribute to the survival paradox between optimally treated Stage 2B/C and Stage 3A colon cancer patients.

70.04 Impact of Time from Initial Biopsy to Definitive Excision When Residual Melanoma is Present

Posted on January 18, 2016

A. Nadler1, K. J. Ruth2, J. M. Farma1, S. S. Reddy1 1Fox Chase Cancer Center,Surgical Oncology,Philadelphia, PA, USA 2Fox Chase Cancer Center,Biostatistics,Philadelphia, PA, USA

Introduction: The time from initial biopsy (bx) to definitive excision, or surgical interval (SI), does not appear to affect outcomes for melanoma. However, the impact of a prolonged SI where residual melanoma (RM) may be present in the final specimen is less clear. This study was undertaken to assess whether SI as it relates to the presence of RM in the final specimen affects prognosis.

Methods: A retrospective review of our institutional melanoma database from 2009 and 2011 was performed. Fisher exact tests and Kruskal Wallis tests were used to compare characteristics by RM status. Survival was estimated with Kaplan Meier methods and compared with the log-rank test. Cox proportional hazards regression was used to adjust for covariates.

Results: Of 240 patients in the database, 179 treated for non-metastatic cutaneous melanoma were included. The median age was 61 years and 51% were male (n=92). At initial bx, 60% (n=108) had a shave bx, 14% (n=25) had a punch bx, and 26% (n=46) had an excisional bx. All patients underwent a radical excision of the primary lesion and 74% (n=132) underwent a sentinel lymph node bx. The median SI was 41 days (range 8-1280) and it did not differ by biopsy type (p=0.36). On final pathology, 45% (n=81) had RM present. RM was more likely to be found in punch bx (n=19 of 25) compared to shave bx (46 of 108) and excisional bx (16 of 46) (76% vs. 43% vs. 35%, p=0.003). The presence of RM did not differ by Breslow depth (p=0.32). Median follow-up was 12.4 months (range 0.2-35.7), during which 13 patients had disease recurrence or died. Recurrence free survival (RFS) was significantly lower in patients with a longer SI (split at median ≤ 41 days for shorter SI vs. > 41 days for longer SI) (p=0.035). RFS at 12 months was 97.3% (CI 89.6-99.3) for a shorter SI and 89.7% (CI 78.1-98.3) for a longer SI; at 24 months, the RFS was 94.4% (CI 82.3-98.3) and 83.5% (CI 68.6-91.8), respectively. Differences in overall survival (OS) were borderline significant (p=0.069) with OS at 12 months was 98.7% (CI 91.2-99.8) for shorter SI and 94.7% (CI 84.3-98.3) for longer SI; at 24 months, the OS was 95.6% (CI 81.8-99.0) and 82.2% (CI 64.1-91.7), respectively. RFS and OS did not differ by RM status (p=0.20 and p=0.19, respectively). However, for SI and RM status in combination, patients who had RM and a longer SI had the lowest RFS with a 12 month RFS of 81.0% (CI.55.9-92.7) compared to 92.9% (CI 84.3-96.9) for the other groups combined (p=0.022). In multivariable analysis, with adjustment for stage, age, and Breslow depth, patients who had RM and a longer SI had borderline significance for RFS (p=0.074, hazard ratio = 2.99, 95% CI=0.90-9.98).

Conclusion: Longer SI, especially in combination with the presence of RM following initial bx, is associated with worse RFS. Patients anticipated to have RM should be triaged appropriately to avoid delays to definitive excision.

70.05 Colon Cancer Surgery at High and Low Mortality Hospitals

Posted on January 18, 2016

M. A. Healy1, H. Yin1, J. D. Birkmeyer2, S. L. Wong1 1University Of Michigan,Surgery, Center For Healthcare Outcomes & Policy,Ann Arbor, MI, USA 2Dartmouth Medical School,Surgery,Lebanon, NH, USA

Introduction: There is wide variation in mortality across hospitals for cancer surgery. While higher rates of mortality are commonly ascribed to high-risk resections, the impact of more common operations is unclear. We sought to evaluate causes of mortality following colon cancer operations across hospitals.

Methods: : 49 American College of Surgeons Commission on Cancer (ACS-CoC) hospitals were selected for participation in a CoC special study. We ranked hospitals using a composite measure of mortality and performed onsite chart reviews. We examined patient characteristics and mortality following colon resections at very high mortality (HMH) and very low mortality (LMH) hospitals (2006-2007).

Results: We identified 3,025 patients who underwent surgery at 25 LMHs (n = 1,391) and 24 HMHs (n = 1,634). There were wide differences in mortality between HMHs and LMHs (9.2% vs. 2.7%). Compared to LMHs, HMHs had more patients who were black (11.2% vs. 6.5%), had >2 comorbidities (22.7% vs. 18.9%), ASA class 4-5 (11.9% vs. 5.3%), and were functionally dependent (13.9% vs. 8.9%; p<.001 for all). For emergency resections, mortality was higher in HMHs versus LMHs (28.3% vs. 11.4%; OR 3.1, 95% CI 1.4-6.7) with ICU admission and prolonged mechanical ventilation more likely in HMHs.

Conclusion: There is significant variation in mortality across hospitals for colon cancer surgery. In emergent cases, perioperative mortality is nearly as high as 1 in 3 patients in HMHs, and many who die undergo ICU admission with mechanical ventilation. This finding reflects a need for improved surgical decision-making to enhance outcomes and quality of care at these hospitals.

70.01 Effectiveness of Postoperative Surveillance Endoscopy for Patients with Ulcerative Colitis

Posted on January 18, 2016

H. Ishii1, K. Hata1, J. Kishikawa1, H. Anzai1, K. Otani1, K. Yasuda1, T. Nishikawa1, T. Tanaka1, J. Tanaka1, T. Kiyomatsu1, K. Kawai1, H. Nozawa1, H. Yamaguchi1, S. Ishihara1, J. Kitayama1, T. Watanabe1 1Faculty Of Medicine, The University Of Tokyo,Department Of Surgical Oncology,Tokyo, , Japan

Introduction: The incidence of neoplasia after surgery of ulcerative colitis (UC) has not been sufficiently clarified, particularly in the Japanese population, and it is not evident whether surveillance endoscopy is effective for detecting dysplasia/cancer in the remnant rectum or pouch. The aims of the present study were to estimate and compare postoperative development of dysplasia/cancer in patients with UC who underwent ileorectal anastomosis (IRA) or ileal pouch-anal anastomosis (IPAA), and to evaluate the effectiveness of postoperative surveillance endoscopy.

Methods: We retrospectively reviewed 120 patients who received postoperative surveillance endscopy after IRA or IPAA in our institute for development of dysplasia/cancer in the remnant rectal mucosa or pouch.

Results: Three hundred seventy-nine endoscopy sessions were performed for 30 patients after IRA, while 548 pouch endoscopy sessions were performed for 90 patients after IPAA. In the IRA group, 5 patients developed dysplasia/cancer during postoperative surveillance and in all cases neoplasia was detected at an early stage. None of them developed neoplasia within 10 yr of diagnosis; the cumulative incidence of neoplasia after disease onset was 7.2, 12.0, and 23.9% at 15, 20, and 25 yr, respectively. In one case after stapled IPAA, dysplasia was found at the ileal pouch; a subsequent 9 endoscopy sessions in 8 years did not detect any dysplasia. Neoplasia was found more frequently during post-operative surveillance in the IRA group than in the IPAA group (p = .0028). The cumulative incidence of neoplasia after IRA was 3.8, 8.7, and 21.7% at 10, 15, and 20 yr, respectively, and that after IPAA was 1.6% at 20 yr.

Conclusion: The cumulative incidence of neoplasia after IPAA was minimal. Those who underwent IRA had a greater risk of developing neoplasia than those who underwent IPAA, although postoperative surveillance endoscopy was effective to detect dysplasia/cancer at an early stage. IRA can be an option of surgical procedure in selected cases in which it would be profitable to the patient, with more careful surveillance.

70.02 Gene expression of Angiopoietin, Tie and VEGF are associated with poor survival in breast cancer

Posted on January 18, 2016

R. Ramanathan1, A. L. Olex2, L. J. Fernandez1, A. R. Wolen2, D. Fenstermacher2, M. Dozmorov3, K. Takabe1 1Virginia Commonwealth University Medical Center,Surgery,Richmond, VA, USA 2Virginia Commonwealth University,Center For Clinical And Translational Research,Richmond, VA, USA 3Virginia Commonwealth University,Biostatistics,Richmond, VA, USA

Introduction:
Breast cancer is the second most common cancer affecting women in the United States, constituting an estimated 232,670 new cases in 2014. Angiogenesis is one of the known hallmarks of cancer that is essential for cancer progression and aggressiveness. The angiopoietin-2 (Ang2) ligand and its Tie receptors constitute one of the upstream cascades that control the angiogenic switch. However, its impact on cancer progression and prognosis has been a topic of debate, since its effect has been ‘context dependent’, i.e. results change depending on the experimental setting used. Using The Cancer Genome Altas (TCGA), we investigate associations between breast cancer patient survival and genomic expressions of genes involved in the Ang2-Tie pathway.

Methods:
The gene expressions of Ang2, Tie1 and Tie2 in the Ang2-Tie pathway and of VEGFA and VEGF receptors in the VEGF pathway were analyzed using the RNA-seq data for 886 individual patient tumor transcriptomes from TCGA. The mean age of the cohort was 58.5 ± 13.2 years. We identified gene-specific expression thresholds to dichotomize patients into high and low expression for a survival analysis using in-house R scripts and R’s ‘survival’ package. Associations with overall and disease free survival were investigated for each gene individually and for the combined effect of multiple genes.

Results:
Individual analysis of the genes revealed decreased disease free survival among tumors with high pro-angiogenesis factor Ang2 expression (p=0.04) and decreased overall survival with high Ang2 expression (p=0.03). High co-expression of Ang2 and endothelial cell surface receptors Tie1 and Tie2 were associated with poor overall survival. In the multi-gene analysis, disease free survival was significantly decreased among patients with high co-expression of Ang2 and VEGFA, and Tie1 and VEGF receptors 1-3.

Conclusion:
Ang2 binds to Tie2 to stimulate endothelial cell sprouting and angiogenesis, and high Ang2 expression is correlated with increased tumor vascularity in animal models. Ang2 also stimulates the well-studied downstream vascular endothelial growth factor (VEGF) pathways. Our results, from a large prospectively collected national breast cancer genome database, provide clinical evidence of the deleterious effect of Ang2 and Tie receptor overexpression in breast cancer patient survival through the Ang2-Tie and VEGF pathways. Novel therapies targeting this pathway are therefore expected to improve survival.

70.03 Single-Center Assessment of Gene Expression Classifier in Indeterminate Thyroid Nodule Management

Posted on January 18, 2016

R. Rokosh1, A. Kundel1, T. C. Hill1, J. Ogilvie1, K. Patel1 1New York University School Of Medicine,Department Of Surgery,New York, NY, USA

Introduction: The Afirma® Gene Expression Classifier (AGEC) has been shown to identify benign thyroid nodules among those classified as cytologically indeterminate with a negative predictive value of 94-95%. This test therefore has the potential to help avoid unnecessary surgery on Bethesda III and IV nodules that are ultimately found to be benign. Our study aimed to assess the clinical utility of the AGEC molecular assay for thyroid nodules with indeterminate cytopathology at a tertiary referral center.

Methods: Retrospective analysis of all indeterminate thyroid nodules evaluated with GEC from September 2012 to December 2014 at a large tertiary referral center was performed. Cytologic and AGEC diagnosis were compared with final surgical pathology in corresponding samples. A prevalence of malignancy of 40%, as established at our institution, was used to estimate performance characteristics with Bayes Theorem.

Results: Over the course of 27 months, 154 patients with indeterminate nodules by FNA who underwent AGEC testing were identified. Of these, AGEC classified 104 (67.5%) as suspicious, 43 (27.9%) as benign, and 7 (4.6%) as non-diagnostic. Of the 104 suspicious AGEC patients, 71 underwent thyroidectomy (2 patients were operated on elsewhere), and ———43/69 (62.3%) had malignant final pathology. Of the 43 benign AGEC patients, 8 underwent thyroidectomy and 1/8 (12.5%) had malignant final pathology. Based on these data, our AGEC sensitivity is 97.7% and specificity is 21.1%. Given the 40% prevalence of malignancy at our institution, the estimated negative predictive value of AGEC in our practice is 93.3%. Our mean follow-up time for this study was 7.8 months.

Conclusion: This study confirms that patients with suspicious AGEC have a high likelihood of having a malignancy and should undergo surgery. Our study suggests that practice-specific cancer incidence within the indeterminate cytopathology (Bethesda III-IV) group should be calculated at each institution to evaluate its unique NPV of Afirma analysis. Thus, the clinical utility of a benign AGEC result in surgical decision-making varies with disease prevalence, which is unique to each practice.

07.20 Does Music in the OR Impact Self-Perceived Performance? A Large Multi-Specialty Study

Posted on January 18, 2016

E. Taylor1, S. Lawrence1,2,3, E. Hechenbleikner1,2,3, Y. Hong1,2,3, C. Zheng1,2,3, L. Boyle1,2,3, W. Al-Refaie1,2,3 1Georgetown University Medical Center,Washington, DC, USA 2Georgetown University Medical Center,MH-SORC,Washington, DC, USA 3Georgetown University Medical Center,MGUH,Washington, DC, USA

Introduction: Music in the operating room (OR) has been shown to have diverse effects on physician and staff intraoperative performance. However, its influence on individual performance remains to be explored. This study aimed to identify the self-reported impact of music in the OR on performance in a major metropolitan academic teaching hospital.

Methods: The 10-item questionnaire was developed by a multidisciplinary team on the OR safety committee and sent to 375 OR physicians and staff via an online survey tool. Data were collected anonymously over five weeks. Chi-square analysis and logistic regression were used to analyze factors associated with frequency and self-evaluated impact of music in the OR.

Results: The overall response rate was 53%. Almost half of all respondents (47.5%) aged 30-50; women and men were equally presented in the sample. The majority of respondents (72%) often or always listened to music in the OR; 69% listened to music in the OR chosen by the attending surgeon. Respectively, 73%, 55% and 47% of respondents found music in the OR improved their mood, efficiency and concentration. However, 40% reported that music restricts their communication in the OR. Younger, male and surgeon respondents listen to music in the OR more often than their older, female and non-surgeon colleagues (all P<0.05). Similarly, the adjusted odds ratios showed similar trends predictive of favorable self-reported impact of music in the OR (Table).

Conclusion: This large, multi-specialty survey found that music in the OR improves mood for most participants but has a mixed impact on self-reported efficiency, concentration and communication. To corroborate our results, these trends need to be tested in other OR settings. Our findings encourage future investigation on the impact of music on OR dynamic and safety measures.

07.21 Assessing Patient Navigation Efficacy for Cancer Therapy

Posted on January 18, 2016

C. Jojola1, H. Cheng1, L. Wong1, K. Turaga1, T. C. Gamblin1, F. Johnston1 1Medical College Of Wisconsin,Surgical Oncology/ Surgery,Milwaukee, WI, USA

Introduction: Patient navigation (PN) is a process whereby patients with financial, social, and health-related barriers to care receive a personal escort to assist in overcoming obstacles to achieve timely treatment. The models of PN are diverse, and are often designed to prevent the marginalization of patients of low socioeconomic status and racial/ethnic minority groups. Herein we examine the literature assessing the efficacy of PN for patients with malignancies undergoing treatment.

Methods: The review was conducted according to the recommendations of the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) group with pre-specified inclusion and exclusion criteria. Data abstraction examined efficacy measurements, patient demographics, barriers to access, quality measures and models of patient navigation.

Results:A systematic review was performed by searching PubMed, CINAHL, The Cochrane Library and EMBASE. A total of 4029 citations were collected in Refworks, yielding 27 relevant articles, 19 published papers and 8 abstracts. Navigation was performed for patients with breast, gynecologic, lung, pancreatic, colorectal, and prostate cancer treatment. Four articles do not specify type of cancer treatment. When examining ethnicity, 27.9% Hispanics (SD +/- 15), 30.9% Blacks (SD +/-16), 46.4% Whites (SD +/- 23), 4.6% Asian (SD +/- 3), 9.5% Other (SD +/- 14) participated. Three articles had 100% Native American participation. On average, 60.3% of patients spoke English (SD+/- 22), 44.5% spoke Spanish (SD +/- 13) and 16% fell under the category of Other (SD +/- 13). The average mean age of patients was 58.4 years (SD +/- 6). Analysis of quality measures showed that PN alleviated financial barriers (10 articles), coordination of care (7 articles) and transportation barriers (7 articles). When averaged, the mean days from diagnosis to treatment was 38.54 +/- 16 with PN compared to 45.31 +/- 18 days for the control groups. The median days from diagnosis to treatment was 36 +/- 11 with PN compared to 44.75 +/- 11 days for the non-navigated group (Table 1). Palliative care was not examined in any studies.

Conclusion:: A majority of patients benefitting from PN were a member of a minority racial/ethnic group, and a large portion was non-English speaking. Most patients in PN programs held a breast cancer diagnosis, but colorectal, prostate, and lung cancers were common as well. Overall, patients receiving navigation initiated treatment sooner than did their non-navigated counterparts. The efficacy of PN warrants further study of its various models and exploration of how PN can be expanded to include both curative and palliative treatment for patients.

07.17 Institutional Experience with Concurrent Endocrine and Other Surgical Procedures

Posted on January 18, 2016

R. S. Morris1, T. W. Yen1, A. A. Carr1, S. D. Wilson1, D. B. Evans1, T. S. Wang1 1Medical College Of Wisconsin,Surgical Oncology,Milwaukee, WI, USA

Introduction: The number of endocrine procedures, specifically parathyroidectomy, thyroidectomy, and adrenalectomy, being performed in the United States is increasing.There is a paucity of literature on the feasibility of combining these procedures in patients who may have indications for other surgical procedures.Therefore, the aim of this study was to determine the effect of performing concurrent surgical procedures on postoperative outcomes.

Methods: This is a retrospective review of multiple prospective databases of 2,930 patients who underwent thyroidectomy, parathyroidectomy, and/or adrenalectomy in combination with another procedure, at a single institution. The other procedures included skin, soft tissue, breast or hernia (SSB), abdominal major, abdominal minor, cervical, and ‘Other’. Patient demographics, operative details, and 30-day outcomes were reviewed. ‘Endocrine-specific’ complications included recurrent laryngeal nerve [RLN] injury, hypoparathyroidism, cervical wound infection, hematoma and other. ‘General’ complications included pulmonary or cardiac events and/or complications related specifically to the concurrent procedure.

Results:The cohort is comprised of 104 patients (Table 1). Patients were managed by two surgical specialties (general surgery and an additional specialty such as orthopedics, neurosurgery or otolaryngology) in 25 (24%) patients and more than one surgeon in 57 (55%) patients. Overall, 19 (18%) patients had 21 complications, including endocrine-specific complications in eleven (11%) patients. These eleven complications included RLN injury (n=3; 3%), hematoma (n=2; 2%), wound infection (n=1; 1%), transient hypoparathyroidism (n=2; 2%) and other (n=3; 3%). One patient with hypoparathyroidism was treated with oral calcium supplementation; the other patient had a concurrent pancreatectomy and was managed with IV calcium until tolerating an oral diet. The remaining nine ‘general’ complications included pneumonia in a patient who also had RLN injury, postoperative arrhythmia in a patient who also had an additional complication, and six (6%) patients with complications specifically related to the concurrent procedure. The last patient underwent an open adrenalectomy and hysterectomy and developed a midline wound dehiscence, which could not be specifically attributed to either procedure.

Conclusion:This is a review of 104 patients undergoing a surgical endocrine procedure who underwent a concurrent surgical procedure, ranging from skin and soft tissue to major abdominal procedures. Short-term endocrine-specific complications were managed safely, suggesting that concurrent procedures can be considered, when needed, with minimal effect on patient outcomes.

07.18 Exploring the Impact of Marijuana and Trauma

Posted on January 18, 2016

J. Hannallah1, P. Rhee1, K. M. Ibraheem1, N. Kulvatunyou1, T. O’Keeffe1, A. Tang1, R. Latifi1, L. Gries1, D. J. Green1, R. Friese1, B. Joseph1 1University Of Arizona,Trauma Surgery,Tucson, AZ, USA

Introduction: The prevalence of marijuana abuse and dependence has been increasing among adults and adolescents trauma patients in the United States. Several studies have demonstrated effects of marijuana on the outcomes of diseases. The aim of this study was to assess the relationship between the presence of a positive toxicology screen for marijuana and mortality in trauma patients.

Methods: We performed a 5-year (2008-2012) retrospective analysis of adult trauma patients (>18 y/o) using the Arizona State Trauma database. We included patients admitted to the ICU with a positive toxicology screen for marijuana. We excluded patients with positive alcohol or other substance screening. Patient demographics, injury and vital parameters, and toxicology data were collected. Our outcome measures were mortality, ventilator days, and ICU and hospital length of stay. We matched the patients who were positive for marijuana (marijuana positive) to the ones who were negative (marijuana negative) using propensity score matching in a 1:1 ratio controlling for age, injury severity score, and GCS. We compared the outcomes in matched groups.

Results:A total of 24,535 patients were included in our analysis of which 1,938 (969: marijuana positive, 969: marijuana negative) were matched. Rate of positive screening for marijuana was 5.3% in trauma population. Mean age was 31 ± 14, 80% were male, and median ISS [IQR] was 19 [9 – 25]. There was no difference in hospital (6.6 ± 8.6 vs. 7.3 ± 9.0, p=0.09) or ICU (2.9 ± 5.6 vs. 3.4 ± 5.3, p=0.08) length of stay or total ventilation days (2.8 ± 6.5 vs. 2.9 ± 5.3, p=0.88) between the two groups. 37% of the marijuana positive patients were under ventilator compared to 27% of marijuana negative patients (p < 0.001). Patients with positive screening for marijuana had a lower mortality rate (4.7% vs. 7.2%, p=0.04) compared to patients who were negative on toxicology screening.

Conclusion:A positive marijuana screen is associated with decreased mortality in adult trauma patients on ventilator. This association warrants further investigation of the possible physiological effects of marijuana in trauma patients.

07.19 Natural History Of Retained Surgical Items: Building On Cumulative Experience

Posted on January 18, 2016

B. Styskel1, B. Wernick1, R. N. Mubang1, D. M. Sabol1, M. A. Granson1, J. C. Rosenfeld1, S. D. Moffatt-Bruce2, S. P. Stawicki1 1St. Luke’s University Health Network,Department Of Surgery,Bethlehem, PA, USA 2Ohio State University,Department Of Surgery,Columbus, OH, USA

Introduction: Despite tremendous technological and organizational progress over that last three decades, patient safety experts continue the struggle to eliminate ‘never events’. Among the most dreaded surgical misadventures are retained surgical items (RSI). Difficult to intercept, a number of different surgical tools and accessories continue to be ‘left behind’, yet little is known about the natural history of patients who ultimately suffer the consequences of these surgical errors.

Methods: An exhaustive literature search identified a total of 281 case reports and series describing 299 incidents of RSI between 1953 and 2015. All available details regarding each reported case were tabulated and standardized into the following categories: (a) demographics; (b) anatomic location of the retained object; (c) type of retained item; (d) time to identification/removal; (e) associated complications; and (f) pathology findings. Results are presented as descriptive statistics and frequencies.

Results: A total of 299 RSI instances were tabulated. There were 107 males and 192 females, with average age of 47 years. The most common anatomic location was abdominal (113), paraspinal/spinal (33), thoracic (30), pelvic (28), cranial/facial (19), and extremity (12). Surgical sponge was the most common RSI type (180), followed by other types of gauze (64), plastic/tubing (14), surgical instrument (9), and needle (8). Median time to retrieval was 365 days (range, 0 to 16,790 days, 25%-75% IQR 60-1,825 days, Figure 1). Twenty-four cases (8%) involved 2 or more procedures. Almost all (281/299, 94%) objects were removed, and in 52 instances (17%) bowel or other organ resection was required. Median RSI-attributable hospital length of stay was 7 days. Significant complications were reported in 93/299 (31%) cases.

Conclusion: This collected series of RSIs provides an important glimpse into the natural history and patterns of occurrence of these ‘never events’. One in four patients had significant RSI-related complications, and the median length of stay attributable to RSI was 6 days. Majority of RSIs in this series were recognized and removed within 2 years of index operation, with the remainder either remaining asymptomatic and being discovered incidentally at a later time, or becoming symptomatic after a long period of dormancy. These findings corroborate and highlight the need for a national RSI registry.

07.15 On-Call Paging in the Pre- and Post-Electronic Health Record Era

Posted on January 18, 2016

A. M. Jensen1, P. Pieper2, M. S. Nussbaum1, C. L. Leaphart1 1University Of Florida,Department Of Surgery,Jacksonville, FL, USA 2University Of Florida,College Of Nursing,Jacksonville, FL, USA

Introduction: The electronic health record and limits on resident work hours have altered patterns of communication between physicians and nurses. Effective handoffs between interdisciplinary teams and for teams transitioning from day to overnight call are important safety initiatives promoting quality patient care. Anecdotal evidence suggests that communication is adversely affected by using electronic health records thereby potentially decreasing quality of patient care. To assess the effects of the EHR and limited duty hours on communication patterns and handoffs, we measured paging volume and nature of calls for on-call interns in pre- and post-implementation periods of the EHR.

Methods: After IRB approval, a data dictionary was created to standardize categories of on-call pages to interns. A College of Nursing faculty member, blinded to the purposes of the study, categorized the data dictionary into emergent or non-emergent needs. For on-call interns in General Surgery, a check sheet was created from the data dictionary and reviewed prior to implementation during overnight calls from 5 PM – 6 AM. Volume of pages to on call interns was collated by hour and call type for an 8-week period (May –June 2015). The data dictionary was used to compare call volume and type in a pre- and post-implementation period of the EHR.

Results: Prior to implementation of the EHR, the most common reasons for intern pages were for order clarification (32%, n=82) and pain management (19%, n=50). Highest call volume occurred between 8 PM -2 AM with only 19% of pages (50/260) determined to be for emergent needs. Strikingly, after EHR implementation, Pareto analysis determined the highest reasons for call to be consult-related pages (29%,n=178), pain management (12%, n=74), and abnormal labs/test results/vital signs (12%, n=73), indicating that standardized order sets potentially decrease the need for order clarification. Highest call volume post-EHR implementation occurred between 8 PM – 2 AM with 71% of pages determined as emergent. Consistency of times for high volume paging in the pre- and post-EHR periods was determined to be related to hospital throughput and patient flow from the emergency department and operating room to the surgical floors.

Conclusion: Although limited duty hours and EHR implementation may alter communication patterns between nurses and physicians, standardization of orders may improve clarity of patient needs and quality of care being provided. Future efforts in improving delivery of care may focus on improved order sets with attention to specific patient needs.

07.16 Evaluating Variability in Implementation of Perioperative Time-Outs: Is There Room For Improvement?

Posted on January 18, 2016

S. P. Lawrence1,2, E. M. Hechenbleikner1,2, S. Cane3, L. Boyle1,3, W. B. Al-Refaie1,2,3 1Georgetown University Medical Center,Washington, DC, USA 2MedStar Georgetown Surgical Outcomes Research Center,Washington, DC, USA 3MedStar Georgetown University Hospital,Washington, DC, USA

Introduction: Surgical time-outs have been implemented in operating rooms (OR) to increase adherence to operative safety measures. Hospitals striving to become High Reliability Organizations must maximize safety protocol adherence and better understand sources of variability in heterogeneous OR settings. This study utilized a comprehensive auditing tool to analyze compliance and variation across the perioperative time-out process in a major metropolitan academic medical center.

Methods: Data were collected prospectively by 5 anonymous observers over 10 weeks. The auditing tool was developed by a multidisciplinary OR safety team with key stakeholders from anesthesiology, nursing, and surgery. The tool was a detailed checklist evaluating 3 phases of our time-out process: anesthesia, surgical (incision to closure), and debriefing (end of case before leaving the OR). The anesthesia time-out consisted of 7 criteria, the surgical consisted of 24 criteria, and the debriefing consisted of 10 criteria.

Results: In total, 111 time-outs were observed (anesthesia n=29, surgical n=50, and debriefing n=32). The time-outs were initiated during 50 OR cases across 24 surgeons within 7 surgical service lines. Across all service lines, the percentage of time-out content captured in anesthesia, surgical, and debriefing time-outs was 97%, 82%, and 71%, respectively. Between service lines, there were wide variations in the completion rate of surgical and debriefing time-outs (Table 1). Anesthesia time-outs were performed by an attending physician 86% of the time and occurred prior to induction in 97% of cases. Surgical time-outs were performed by an attending physician 98% of the time and occurred prior to draping in 96% of cases. Debriefing time-outs were always performed by an attending physician. Capture rates of surgical content varied from 16% (asking team members to call attention to any problems seen during the case) to 50% (asking team members to introduce themselves by name and role) to 62% (asking team members to address any special considerations during the case) and 100% (naming the procedure and patient information). Finally, within the debriefing time-out, the name of the procedure and reconciling the surgical tool counts were addressed in 84% of cases, while all other content was completed at or below the rate of the debriefing taking place (69%).

Conclusion: This perioperative auditing tool discovered wide variation in protocol adherence between surgical service lines. This practical checklist will be the basis for future designed interventions to target specialty-specific areas of need to ensure patient safety and surgical team cohesiveness in the operating room.

07.13 Reduction in Arterial Blood Gas Utilization Through Implementation of End-Tidal CO2 Monitoring.

Posted on January 18, 2016

M. A. Wasserman3, J. M. Sternbach3, M. W. Wandling3, M. L. Crandall1,3, N. M. Issa1,3, S. J. Schwulst1,3, K. Y. Bilimoria2,3, M. B. Shapiro1,3, M. Swaroop1,3 1Northwestern University,Department Of Trauma & Critical Care,Chicago, IL, USA 2Northwestern University,Surgical Outcomes And Quality Improvement Center,Chicago, IL, USA 3Northwestern University,Department Of Surgery,Chicago, IL, USA

Introduction:
Despite a lack of scientific evidence, obtaining multiple daily arterial blood gas (ABG) values on non-septic mechanically ventilated patients is commonplace in our Surgical Intensive Care Unit (SICU). Invasive arterial sampling has inherent risks to patients, and frequently may be replaced with less invasive monitoring tools. We aim to decrease ABG utilization for ventilatory monitoring by increasing the use of non-invasive end-tidal CO2 (ETCO2) monitoring.

Methods:
Through multidisciplinary meetings, educational materials were developed and distributed to all SICU healthcare providers, including nursing staff, respiratory therapists, and surgical residents. This education focused on appropriate ABG utilization, the capabilities of ETCO2 monitoring in managing mechanically ventilated patients, and the practical functionality of the ETCO2 devices. On September 1, 2014 a protocol mandating ETCO2 monitoring for all ventilated patients was implemented in the SICU. Using our institution’s Enterprise Data Warehouse, ABG and ETCO2 monitor utilization data was collected for three months preceding and three months following our intervention.

Results:
Prior to our educational intervention, 5.63 ETCO2 monitor recordings were documented per ventilator-day. Post-intervention, 16.0 ETCO2 recordings per ventilator-day were recorded. This difference was statistically significant (p<0.01) and represented a nearly three-fold increase in ETCO2 monitoring. There was a trend towards decreased ABG utilization following our intervention, though this did not meet statistical significance (4.62 pre-intervention vs. 4.13 post-intervention, p=NS).

Conclusion:
The increase in ETCO2 utilization following our intervention represents the first step in a culture shift away from considerable reliance on ABG values for routine ventilatory monitoring and toward a less invasive monitoring practice. Though there was a trend towards decreased ABG utilization following intervention, failure to reach statistical significance likely reflects a lack of comfort among providers in rapidly abandoning an ingrained practice.

07.14 The World Health Organization Surgical Safety Checklist Improves Post-Operative Outcomes

Posted on January 18, 2016

C. S. Lau1,3, R. S. Chamberlain1,2,3 1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2New Jersey Medical School,Surgery,Newark, NJ, USA 3Saint George’s University,Grenada, Grenada, Grenada

Introduction: The incidence of in-hospital adverse events is about 10%, with a majority of these related to surgery, and nearly half of these considered preventable events. To improve patient safety, the World Health Organization (WHO) developed a checklist to be used at critical perioperative moments (induction, incision, and prior to the patient leaving the operating room (OR)). This meta-analysis examines the impact of the WHO surgical safety checklist on the incidences of overall complications, surgical site infections (SSI), unplanned return to the OR within 30 days, and overall mortality.

Methods: A comprehensive literature search of all published studies assessing the use of the WHO surgical safety checklist in patients undergoing surgery was conducted using PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966-2015). Keywords searched included ‘World Health Organization’, ‘surgical checklist’, and ‘safety checklist’. Inclusion criteria were the use of the WHO surgical safety checklist in any surgical setting, with pre-implementation and post-implementation surgical outcome data. The incidence of various patient outcomes (total complications, SSIs, unplanned return to the OR within 30 days, and overall mortality) and adherence to safety measures (airway evaluation, use of pulse oximeter, presence of catheter lines, prophylactic antibiotics, confirmation of patient and surgical site, and sponge count) were analyzed.

Results: 10 studies involving 51,125 patients (27,490 prior to implementation and 23,635 patients after the implementation of the WHO surgical safety checklist) were analyzed. The implementation of the WHO surgical safety checklist significantly reduced the risk of total complications by 37.9% (RR = 0.621; 95%CI 0.519 – 0.742; p<0.001), SSIs by 45.5% (RR = 0.545; 95%CI 0.416 – 0.714; p<0.001), unplanned return to OR by 32.1% (RR = 0.679; 95%CI 0.484 – 0.954; p=0.025), and mortality by 15.3% (RR = 0.847; 95%CI, 0.752 – 0.954; p=0.006). There was also a significant increase in adherence to safety measures including airway evaluation, use of pulse oximetry, prophylactic antibiotics when necessary, confirmation of patient name and surgical site, and sponge count.

Conclusions: The use of the WHO surgical safety checklist is associated with a significant reduction in post-operative complications and mortality. The WHO surgical safety checklist is a valuable tool that should be universally implemented in all surgical centers and utilized in all surgical patients. Additional studies are required to determine optimal strategies for implementation of the WHO surgical safety checklist in different healthcare settings and countries.

07.11 Pardon the Interruption: An Observational Study of OR Interruptions

Posted on January 18, 2016

K. M. Caldwell1, L. R. Putnam1,2, S. Covey1, M. Diffley1, A. Hildebrandt1, A. Minzenmayer1, K. T. Anderson1,2, A. L. Kawaguchi1,2, K. P. Lally1,2, K. Tsao1,2 2Children’s Memorial Hermann Hospital,Pediatric Surgery,Houston, TX, USA 1University Of Texas Health Science Center At Houston,Pediatric Surgery,Houston, TX, USA

Introduction: Teamwork and effective communication are principles of safe patient care, especially in surgery. Distractions in the operating room can impair and/or interrupt these hallmarks as well as increase surgeon stress and fatigue, potentially compromising patient safety. However, little is known about the type and frequency of distractions in operating rooms. We aimed to characterize interruptions in pediatric operating rooms in order to identify areas for intervention.

Methods: Over an eight week period, a prospective, direct observational study was performed by five trained observers in an academic children’s hospital. Convenience sampling was performed across all pediatric surgical specialties. The number of phone calls, people entering, pages/text messages, equipment failures, and other events that interrupted workflow were recorded. Interruptions were further defined as essential or non-essential based on their contribution to patient care. Interruptions were analyzed in relation to surgical subspecialty and case duration.

Results: 208 operations were observed with a median (interquartile range) operating time of 40 (19-86) minutes. A total of 1,037 interruptions were recorded with a median of 2 (1-5) interruptions per case. People entering the operating room accounted for the highest proportion of interruptions (61%), where approximately one-third were non-essential (30.5%). Overall, 64% of all the interruptions were non-essential to patient care (Figure). In total, 63% of the operations had at least one non-essential interruption. Interruptions were more frequent as case length increased (median per case; <30 min = 1, 31-60 min = 2, 61-120 min = 4, >121 min = 14).

Conclusion: Non-essential interruptions are common in pediatric operating rooms. The impact of these distractions on patient safety remains unknown. Although no single interruption was observed to cause direct patient harm, patient safety in the operating room may be optimized through awareness, education, and limiting non-essential interruptions. Future interventions should target eliminating non-essential interruptions and minimizing essential ones through prevention and process improvement.

07.12 Clinical Acuity Shorthand System (CLASS) for Surgery: A Standardized Patient Classification Tool

Posted on January 18, 2016

B. F. Gilmore1, A. K. Brys2, N. S. Nath2, K. L. Rialon1, M. E. Barfield1, G. Pomann3, L. Ding3, J. Migaly1, P. J. Mosca1 1Duke University Medical Center,Department Of Surgery,Durham, NC, USA 2Duke University School Of Medicine,Durham, NC, USA 3Duke University,Department Of Bioinformatics And Biostatistics,Durham, NC, USA

Introduction:
The handoff of medical information from one provider to another can be inefficient and error-prone, potentially undermining patient safety. Though several tools for structuring handoffs exist, none provide a concise, standardized framework for ensuring that patient acuity is efficiently and reliably communicated. This prompted the development of a novel tool, the Clinical Acuity Shorthand System (CLASS) for Surgery. This is a patient classification system that incorporates the acuity and severity of illness, phase of care, and key comorbidities into a score that can be used during transitions of care to summarize the overall wellness of the patient and convey the need for additional interventions.

Methods:
Surgical trainees at a single center were asked to complete a voluntary, anonymous exam in which a novel patient classification system would be applied to 10 theoretical patient scenarios. Responses were scored on the accuracy of classification compared to target answers. Performance was evaluated overall and between groups of trainees; time required to complete the examination was also measured. Following completion of this exercise, respondents were surveyed regarding perceived utility of the system with regard to preventing medical errors and improving efficiency.

Results:
The study task was completed by 17 participants. Mean time from first exposure to the system to completion of the application task was 10.3 ± 8.4 minutes. Interns and junior residents were able to apply the system with comparable accuracy, and in fact exceeded the accuracy of senior residents. Most respondents indicated that such a system would be feasible to institute and could prevent medical errors arising from communication breakdowns.

Conclusion:
CLASS is a novel classification system that can be learned quickly and implemented readily by trainees, and can be used to convey key patient information concisely and with acceptable fidelity regardless of level of training. Further studies are necessary to determine whether CLASS has the potential to decrease the rate of communication-related medical errors during handoff.

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