74.09 Investigation of Visceral Skin Graft Revascularization and Separation from Peritoneal Contents

Posted on January 18, 2016

K. E. Caldwell1, R. M. Clark1, B. B. Coffman1, T. R. Howdieshell1 1University Of New Mexico HSC,Department Of Surgery,Albuquerque, NM, USA

Introduction:
Inability to close the abdominal wall after laparotomy for trauma may occur as a result of visceral edema, retroperitoneal hematoma, use of packing, and loss of tissue. When direct fascial closure is not feasible at initial admission, skin grafting of visceral granulation tissue provides temporary cutaneous coverage. Definitive abdominal wall reconstruction is planned when palpation yields graft separation from underlying viscera suggesting resolution of peritoneal inflammation.

Methods:
Following laparotomy for trauma, patients with persistent visceral distension or abdominal wall tissue loss precluding fascial closure underwent index admission visceral split thickness skin grafting and readmission graft excision and reconstruction. Real-time visceral skin graft perfusion and functional revascularization was determined by serial laser speckle contrast imaging (LSCI). Image analysis of CD-31 and α-SM actin immunostained histologic sections of harvested skin (nongrafted control) and excised visceral skin grafts was utilized to determine microvascular density and morphology. Quantitative RT-PCR arrays were performed on nongrafted control skin and excised visceral grafts to analyze the expression of a focused panel of genes involved in tissue injury and repair.

Results:
Five patients (3 male, 2 female) ranging in age from 26 to 45 years (mean 36 years) underwent visceral skin grafting for cutaneous coverage of an open abdomen. Time to graft excision ranged from 5 months to 1.5 years (mean 6.5 months). LSCI documented mean perfusion of pre-graft visceral granulation tissue of 1100 PU (range 900-1200 PU), and immediate skin graft application perfusion of 150 PU (range 120-190 PU), primarily a result of background perfusion through meshed interstices. By POD 5, skin graft perfusion doubled to a mean value of 300 PU, peaked at a mean of 350 PU by POD 14 concomitant with closure of meshed interstices, and remained unchanged until excision. Histologic examination revealed a 5-fold increase in excised graft thickness (mean control 400 µm vs. mean excised 2100 µm). Immunostaining documented a 2-fold increase in vessel number, a 3-fold increase in vascular surface area, and a dramatic increase in percentage of vessels covered by smooth muscle in excised grafts compared to control skin. RT-PCR demonstrated statistically significant up-regulation of genes involved in matrix structure and remodeling, cytoskeleton regulation, and WNT signaling; and down-regulation of key inflammatory cytokine and chemokine genes.

Conclusion:
Our preliminary data documents early visceral skin graft revascularization with a plateau in perfusion over the study interval. Histology reveals a marked increase in the mass of graft subdermal matrix composed of a complex supporting vascular network. The excised graft transcriptome is rich in extracellular matrix remodeling enzyme gene activity which may be important in graft separation from peritoneal contents.

74.10 The CD248+ Subpopulation of Adipose Derived Stromal Cells Posesses Enhanced Angiogenic Potential

Posted on January 18, 2016

E. R. Zielins1, M. Januszyk1, C. Blackshear1, E. A. Brett1, M. Chin1, S. Vistnes1, S. Menon1, S. Shailendra1, G. C. Gurtner1, M. T. Longaker1, D. C. Wan1 1Stanford University,Plastic And Reconstructive Surgery,Palo Alto, CA, USA

Introduction: Adipose-derived stromal cells (ASCs), the stem cell containing population derived from the stromal vascular fraction (SVF) of adipose tissue, has shown much promise as a technique to improve fat graft retention. As ASCs are a significantly heterogenous cell population, identification of cell subpopulations with enhanced secretion of pro-angiogenic growth factors would facilitate their use in strategies to further improve fat graft take.

Methods: Human lipoaspirate was enzymatically digested in order to obtain SVF cells. Individual ASCs were isolated via flow cytometry based on an established surface marker profile. As we have previously described, single cell transcriptional profiling of select angiogenic and adipogenic genes, as well as multiple cell surface markers, was employed. Applying a Fuzzy C-Means algorithm to this data allowed for partitioning of ASCs into multiple, functionally distinct clusters. Linear discriminant analysis was then performed to correlate surface marker expression with cluster definition. We then utilized flow cytometry, a cell proliferation assay, qRT-PCR, and an in vitro endothelial tube formation assay, to evaluate CD248, the most promising of these markers, for the potential to isolate cells with enhanced angiogenic potential.

Results: Using this strategy, we identified multiple markers with the potential capacity to delineate functional subgroups of ASCs based on angiogenic gene expression. Analysis of freshly harvested SVF cells by flow cytometry using CD248, the strongest correlating surface marker, showed 16% of cells were CD248+ and 84% were CD248–. Proliferation, gene analysis, and endothelial tube formation assays were performed, showing differences between CD248+, CD248-, and unsorted cell populations. qRT-PCR showed CD248+ cells to have significantly higher VEGFa secretion (**p<0.01) compared to both unsorted and CD248- cells. CD248+ cells additionally were found to promote increased endothelial tube formation in vitro in comparison to unsorted and CD248- cells.

Conclusion: Our methodology has identified multiple cell surface markers associated with ASC angiogenic capacity. The most highly correlated marker, CD248, characterizes a cell population with significantly enhanced angiogenic potential, suggesting that it may be used in in vivo applications for improvement of fat graft retention.

74.05 Comparing Operative Hand Experience by Surgical Specialty

Posted on January 18, 2016

J. Silvestre1, I. C. Lin1, L. S. Levin1, B. Chang1 1Perelman School Of Medicine,Division Of Plastic Surgery,Philadelphia, PA, USA

Introduction: Pre-requisite for hand surgery fellowship training in the United States encompass plastic, orthopedic, and general surgery residency training. Recent attention has sought to optimize hand surgery training in the US, and the purpose of this study was to determine the baseline operative experience in hand surgery for these three specialties.

Methods: Operative case log data for chief residents were obtained from the American Council of Graduate Medical Education (2011-2014). Data were grouped by specialty and compared by the number of total hand surgery procedures, fracture repair, soft tissue reconstruction, and digital amputations. Statistics for interspecialty comparisons utilized a one way analysis of variance (ANOVA) with a cutoff of p < 0.05 for significance.

Results: Data were available for 4,355 general surgery, 2,687 orthopedic, and 640 plastic surgery residents. Total number of hand operations by plastic surgery residents increased 13.6% over the study period, and those of orthopedic residents decreased 21.7%. Plastic surgeons reported the most hand cases (372.3 +/- 192) followed by orthopedic (260.3 +/- 120) and general surgery (0.6 +/- 0.1) (p < 0.05). Plastic surgeons performed more soft tissue reconstructions (60.7 vs 45.6) and digital amputations (14.9 vs 6.5) than their orthopedic colleagues (p < 0.05). Orthopedic residents reported more fracture repairs (78.2 vs 44.1, p < 0.05).

Conclusion: Relative to their orthopedic and plastic surgery trained colleagues, general surgery residents lack substantial hand surgery experience. Considerable inter-specialty variability exists regarding the types of hand operations performed during residency. These differences identify areas of strength and weakness prior to hand surgery fellowship training.

74.06 The Importance of Geographical Location in the Plastic Surgery Match

Posted on January 18, 2016

J. Silvestre1, I. C. Lin1, J. M. Serletti1, B. Chang1 1Perelman School Of Medicine,Division Of Plastic Surgery,Philadelphia, PA, USA

Introduction: The plastic surgery match is among the most competitive residency matches in recent years. While previous studies have correlated applicant characteristics with successful match outcomes, none have comprehensively investigated the role of geography in the Match. This study investigates regional effects in the Match.

Methods: Plastic surgery residents who matched during 2011-2015 were eligible for study inclusion. Names of residents were obtained from official residency program websites and cross-referenced with data obtained from the Student Doctor Network. For each resident, region of residency program and medical school were compared.

Results: 622 residents were identified from 67 programs. Most graduated from US medical schools (97.9%). 94 residents matched at a home institution (15.1%). Half of all residents matched in the same region as their medical school (48.9%). Programs in the South matched the greatest number of residents from the same region (60.8%) while West programs matched the least (30.8%, p < 0.001). No regional differences existed with regard to residents matching at their home institution (p = 0.268). More women matched at West programs (43.1%) versus East programs (30.6%, p < 0.05).

Conclusion: A significant number of residents matched at their home institution. Roughly half matched at a program in the same region as their medical school. Whether this regional phenomenon stems from applicant or program factors remains unknown. Yet, given the limited number of interviews and the high costs of interviewing, applicants and programs can use these data to optimize the application process.

74.07 Defining the Plastic Surgery Breast Curriculum

Posted on January 18, 2016

J. Silvestre1, B. Chang1, J. M. Serletti1 1Perelman School Of Medicine,Division Of Plastic Surgery,Philadelphia, PA, USA

Introduction: The Accreditation Council for Graduate Medical Education defines medical knowledge as one of six clinical care domains in which residents should receive instruction and display competency. The Plastic Surgery In-Service Training Exam (PSITE) is a commonly used tool to assess this domain during plastic surgery residency. The purpose of this study was to analyze the breast curriculum of the PSITE for content and referenced material.

Methods: Digital syllabi of six consecutive PSITEs (2008 – 2013) were reviewed for breast content. Questions were characterized and breast topics were summarized via overlap with the content outline for the American Board of Plastic Surgeons written board exam. Answer references were categorized by source and relative year of publication.

Results: 136 breast questions were analyzed (136/1174, 12%). Questions tended to appear in the Breast and Cosmetic (75%) section over the Comprehensive (25%) section (p < 0.001). Vignettes were most often clinic-focused (64%) over the operating room (19%, p < 0.001). Question taxonomy was evenly distributed between recall (34%), interpretation (28%), and decision-making (37%, p > 0.05). Only 6% of questions required photographic evaluation. Breast topics focused on aesthetic problems (35%), traumatic deformities (22%), and tumors (21%). Answer references comprised 293 citations to 63 unique journals published a median of 6 years prior to PSITE administration. Plastic and Reconstructive Surgery (57%) was the most cited journal (p < 0.001).

Conclusions: The PSITE affords a breast curriculum that may inform health providers and the general public regarding plastic surgery training in cosmetic and reconstructive breast surgery. Additionally, these data may help establish a benchmark for improving didactic, clinical, and operative experiences during plastic surgery residency training.

74.03 Maximizing the extent and utility of the pedicled ALT flap : Technical Pearls and Pitfalls

Posted on January 18, 2016

A. Vijayasekaran1, W. Gibreel1, K. Bakri1, B. Carlsen1, M. Saint-Cyr2, B. Sharaf1 1Mayo Clinic,Plastic Surgery/Department Of Surgery,Rochester, MN, USA 2Scott & White Healthcare,Plastic Surgery,Temple, Texas, USA

Introduction:
The (Anterolateral thigh) ALT flap was initially described as a free flap but over the last decade the use of the ALT flap as a pedicled flap (PALT) for locoregional reconstruction has increased. We sought to review our institutional experience with PALT flaps and analyze the technical nuances associated with increasing flap reach.

Methods:
This is a 10 years retrospective review of PALT flaps for locoregional reconstruction at the Mayo Clinic, Rochester, Minnesota from 2005 to 2015. Patient primary diagnosis, location and size of the surgical wound, radiation treatment, medical comorbidities, and peri-operative complications are presented. Descriptive statistics are reported in the form of mean ± standard deviation (SD), median (interquartile range, IQR), or counts (percentages) when applicable. Technical considerations to improve the reach of the PALT are described.

Results:
21 patients (76% males) underwent PALT flap for locoregional reconstruction. Mean duration of follow up was 20 months (range 0.4-64). Reconstruction after oncologic resection was the most common indication of PALT flap usage (n=13), followed by coverage of infected joints/prosthesis (n=8) and pressure ulcers (n=3). PALT was used for hip (n=5), groin (n=4), proximal thigh (n=3), trochanteric (n=3), lower abdomen (n=2), posterior thigh (n=2), ischial (n=1), and vaginal (n=1) reconstructions. In 28% of patients, the recipient site received pre-operative radiotherapy. A pattern of septocutaneous and musculocutaneous perforators existence in the same patients was observed in 3 patients only, the remaining 18 patients had an exclusive septocutaneous (n=9) or musculocutaneous (n=9) perforators vascular pattern. Musculo-fascio-cutaneous flaps were designed in 16 patients (4 of these were chimeric flaps), fascio-cutaneous flaps in 4 patients, and a cutaneous flap in one patient. Technical considerations to improve the reach of the PALT to cover groin, lower abdominal, perineal defects are described, including passing the flap under the rectus femoris muscle, division of the Sartorius muscle, subcutaneous tunneling of the flap, and trans-femur tunneling. The rectus femoris branch of the descending circumflex femoral artery was divided in 7 patients after confirming rectus muscle viability via clamping the vessel for 20 minutes with no evidence of any muscle necrosis. We present an algorithm to improve the reach of the PALT for various anatomic locations (Table 1).

Conclusion:

The PALT is a safe and reliable flap for locoregional reconstruction. Designing a flap with a distal skin paddle, Subcutaneous, submuscular and intermuscular tunneling and ligating the rectus branch are all technical details that help extend the reach of the PALT.

74.04 Recurrence and Cosmesis in Nipple-Sparing Mastectomy Versus Breast Conservation and Total Mastectomy

Posted on January 18, 2016

A. M. White1, C. R. Thomas1, G. M. Ahrendt1, M. Bonaventura1, C. De La Cruz2, E. J. Diego1, M. Gimbel2, R. Johnson1, V. Nguyen2, K. Shestak2, A. Soran1, P. F. McAuliffe1, K. P. McGuire1,3 1University Of Pittsburgh,Surgical Oncology/Surgery,Pittsburgh, PA, USA 2University Of Pittsburgh,Plastic Surgery,Pittsburgh, PA, USA 3University Of North Carolina At Chapel Hill,Surgical Oncology/Surgery,Chapel Hill, NC, USA

Introduction: The oncologic outcomes of breast conservation surgery (BCS) versus mastectomy (TM) have been well studied, with no significant difference identified in long term overall survival. Additionally, there is a growing body of evidence showing equivalent oncologic outcomes between nipple-sparing mastectomy (NSM) and TM, with up to 10 years of follow-up. In contrast, oncologic and cosmetic outcomes of NSM and BCS have never been directly compared. Our study addresses this critical need by comparing NSM to BCS and TM. We hypothesize that there is no significant difference in recurrence, survival or cosmesis between these groups.

Methods: This is a retrospective review of a prospectively maintained, IRB approved (PRO12110356) database of all NSM performed at a single institution from 2009 to 2015. 116 patients undergoing NSM were compared to 115 undergoing BCS and 124 undergoing TM. 56% (n=67) of patients undergoing TM had reconstruction. Subjects were matched by age, tumor size and histology. Patients were excluded if they had metastatic cancer, severe or uncontrolled systemic disease, or if they were not eligible for BCS. The primary endpoint, locoregional recurrence rate, was defined as ipsilateral breast, chest wall or axillary recurrence within the follow-up period. Secondary endpoints included total (locoregional and distant) recurrence rate, overall survival rate and cosmetic outcome. Cosmetic outcome was determined using a 4 point Likert scale (excellent, good, fair, poor) by physician extenders as part of our yearly Wellness Clinic appointment or at post-operative visits. Outcomes were compared using Pearson Chi square test.

Results: Average (± standard deviation) age was 48±9 years. Tumor size was <2cm for 82%, 2-5 cm for 15%, and >5 cm for 3% of patients. Histology was invasive ductal cancer for 51%, invasive lobular cancer for 9% and ductal carcinoma in situ for 40% of patients. Follow-up was 15±10, 27±15 and 34±21 months in the NSM, BCS and TM groups respectively. No significant difference was seen in locoregional recurrence rate between NSM (0.9%), BSC (0.8%), and TM (1.6%) or in total recurrence rate, NSM (7.8%), BCS (7.8%), and TM (5.6%) (p=0.7). Additionally, overall survival rates, (98.3%, 96.5% and 98.4%, p=0.6), were similar between NSM, BCS and TM, respectively. Cosmetic outcomes after NSM (excellent/good 99%, fair 1%) was equivalent to BCS (excellent/good 98.6%, fair 1.3%) and TM with reconstruction (excellent/good 98.3%, fair 1.6%), p=1.

Conclusion: A growing number of patients with breast cancer who are candidates for BCS elect to undergo NSM. However, there is no literature directly comparing NSM to BCS in oncologic and cosmetic outcome. Our study demonstrated no significant difference in recurrence rate, overall survival rate or cosmesis between NSM, BCS, and TM. These results may offer a framework for dialogue to assist surgical candidates with informed decisions.

74.01 Racial Disparities for Timely Alveolar Bone Grafting Surgery

Posted on January 18, 2016

J. Silvestre1, O. Jackson1 1The Children’s Hospital Of Philadelphia,Division Of Plastic Surgery,Philadelphia, PA, USA

Introduction: Cleft lip and palate are repaired in infancy, but full oral rehabilitation cannot progress without alveolar bone grafting (ABG) surgery. ABG is necessary to achieve stability of maxillary segments and provide the necessary bony support for tooth eruption. Delays in ABG can adversely affect orthodontic treatment and overall outcomes.

Methods: We conducted a retrospective study of patients receiving ABG surgery at a large, urban cleft referral center. Patient charts were reviewed for demographic and clinical data. The primary outcome of interest was age at ABG. Race was defined as Caucasian, Asian, Hispanic, or African American, with minority status given to Hispanic and African American. Insurance status was defined as public or private. Only non-syndromic patients with clefts involving the alveolus who received all cleft care at our institution were included in this study. A multivariate regression model was used to determine the impact of clinical and demographic variables on ABG timing. For purposes of comparison, Kruskal-Wallis and Mann-Whitney U tests were used with P values <0.05 considered significant.

Results: 233 patients underwent ABG surgery at 8.1 ± 2.3 years of age. African American and Hispanic patients received delayed ABG surgery compared to Caucasian patients by approximately one year (P < 0.05). There was no difference in ABG surgery timing by insurance status (P > 0.05).

Conclusions: The timing of ABG surgery varies by race, but not by insurance status. Greater resources may be needed to insure timely delivery of cleft care to African American and Hispanic children.

74.02 Tissue Expander Influence of Post-operative Radiation Therapy Effectiveness in Immediate R

Posted on January 18, 2016

T. Galbreath1, A. Eppler1, B. Irojah1, N. Young1, R. Grim1, D. M. Kenna1, A. Shah1, V. Ahuja1 1York Hospital,Surgery,York, PA, USA

Introduction:

Breast expanders used in immediate reconstruction following mastectomy either have an external metallic backstop port (EMP) that is connected to the expander by tubing, or an internal metallic backstop port (IMP) that is within the expander. It has been shown in the past that the metallic component can cause radiation scatter, but it unclear if the effect of scatter is clinically observable in recurrence rates.

Methods:

Data was collected for patients with breast cancer treated with mastectomy and post-operative radiation over the time period of 2000-2008 from a community hospital and surgery center. CPT codes searched include 19303, 19304, 19307; which correlate respectively with simple, subcutaneous, and modified radical mastectomy (MRM). Chart review was undertaken to categorize data into four groups: (1) no expander used, (2) muscle flap reconstruction, (3) expander with IMP or integrated port, and (4) expander with EMP or remote port. All patients included had similar radiation dosing. Each patient’s record was reviewed for findings of recurrence with follow-up minimum of 60 months. Chi-square test was used for comparisons. Inclusion criteria: modified radical mastectomy for local invasive ductal or lobular carcinoma, mastectomy with post-operative radiation, immediate breast reconstruction. Exclusionary criteria: re-operation for breast cancer, incompletion of radiation prescription or non-adherence to radiation prescription, those receiving radiation dosage of less than 50cGy, use of pre-operative radiation, mastectomy without radiation, tissue expander removal, exchange, or failure prior to completion of radiation therapy; other sources of en vivo attenuation; metastatic disease; inflammatory breast cancer; multifocal or bilateral breast cancer; less than 60 months of follow-up.

Results:

There were 102 cases that met inclusion criteria. The mean age of within the data set was 56.8 years of age. There were 70.6% who had no expander, 4.9% with muscle flap reconstruction, 18.6% with IMP, and 5.9% with EMP. A chi-square revealed there was no relationship between these 4 groups and recurrence (p = .066). A chi-square of IMP vs. EMP for recurrence also showed no significance (p= .759).

Conclusion:

There is no indication that the type of tissue expander used in immediate reconstruction following mastectomy for breast cancer impacts recurrence rates or effectiveness of postoperative radiation.

73.18 The Identification and Treatment of Intestinal Malrotation in Older Children

Posted on January 18, 2016

K. L. Weaver1, A. S. Poola1, K. W. Gonzalez1, S. W. Sharp1, S. D. St. Peter1 1Children’s Mercy Hospital- University Of Missouri Kansas City,Pediatric General Surgery,Kansas City, MO, USA

Introduction:
Intestinal malrotation is often diagnosed in infancy. The true incidence of malrotation outside of this age is difficult to estimate because the majority either have an atypical presentation or are asymptomatic, being recognized only intraoperatively during other procedures. We sought to first determine the incidence, patterns of presenting symptoms, and what led to a final diagnosis of malrotation in patients over the age of one. We also analyzed anatomic intraoperative findings and its correlation with resolution of symptoms.

Methods:
A retrospective review was conducted in patients older than one year of age who were treated for malrotation at a single pediatric tertiary care center between January 2000 and January 2015 by the pediatric general surgery service. Data analyzed included age at presentation, presenting symptoms, radiographic imaging performed, surgical intervention, intraoperative findings and postoperative follow-up. Patients predisposed to malrotation (situs inversus, gastroschisis, omphalocele and congenital diaphragmatic hernia) were excluded.

Results:
A total of 246 patients were diagnosed with malrotation, of which 77 patients (31%) were found to be older than one year of age. Out of this population, 25% were found incidentally during investigations for other disease processes. The most common presenting symptoms were vomiting (68%), abdominal pain (57%), gastroesophageal reflux (18%), bilious vomiting (17%), constipation (17%) and failure to thrive (14%). 56% of patients had similar episodes of these symptoms in the past and 19% had chronic abdominal pain. The method leading to diagnosis included UGI (61%), CT (26%), intra-operative finding (6.5%) and other (6.5%) which included barium enema, esophagram, ultrasound, and CT angiogram. Sixty patients had an UGI during their workup, of which 83% were diagnostic for malrotation, 13% were ‘suspicious for’ malrotation and the remainder was non diagnostic. Out of these UGI’s obtained, 27 commented on the position of the ligament of treitz, 11 were reported as a low lying ligament or low duodenojujunal junction. Out of these 11 patients 10 were confirmed to have malrotation, with the 11th not receiving surgical exploration. Out of those patients radiologically diagnosed, 75 had surgical intervention with 97% confirmed to have malrotation. Sixty percent were found to have a malrotated intestinal orientation, 33% with nonrotated, and 1% with reverse rotated orientation. Twenty two percent were found to be obstructed with 12% having a volvulus. Of the 68 patients with postoperative follow up, 59% reported alleviation of symptoms, 15% remained asymptomatic, and 26% had persistence of preoperative symptoms.

Conclusion:
Malrotation should be on the differential list despite age given the highly variable clinical presentation. An UGI should be conducted first for a prompt diagnosis and surgical correction should be undertaken despite atypical presenting symptoms.

73.19 Understanding Readmission in Children Undergoing Surgery: a Pediatric NSQIP Analysis

Posted on January 18, 2016

A. N. Kulaylat1, A. L. Stokes1, C. S. Hollenbeak1, B. W. Engbrecht1, D. V. Rocourt1, M. C. Santos1, R. E. Cilley1, P. W. Dillon1 1Penn State Hershey Medical Center,Department Of Surgery,Hershey, PA, USA

Introduction: Readmission is increasingly being utilized as an important outcome and measure of hospital quality, with financial incentives and penalties tied to performance. However, less is known about the reasons for readmission in children.

Methods: This was a retrospective review of pediatric patients (n=113,102) undergoing surgery (January 1, 2012 – December 31, 2013) at US hospitals enrolled in the Pediatric National Surgical Quality Improvement Program (NSQIP-P). Patient characteristics and clinical data were abstracted from the NSQIP-P participant use data file and compared, stratified by the occurrence of an unplanned readmission related to the index procedure. Multivariate logistic regression was used to model factors associated with 30-day readmission. Reasons for readmission were reviewed to determine the most common causes of readmission across the represented surgical specialties.

Results: While the prevalence of unplanned readmissions was 4.2% (n=4,727), only 58.8% (n=2,781) of these readmissions, or 2.5% of children overall, were identified as readmitted within 30-days for a reason related to the index procedure. Readmission was significantly associated with patient level factors such as comorbidities, as well as the urgency of the operation, and the occurrence of postoperative complications. Overall, the most common causes for readmission were surgical site infections (SSI) (36.2%), ileus/obstruction or gastrointestinal etiologies (14.2%), and graft/implant/prosthesis-related complications (12.1%). The median time from discharge to readmission was 7 days (IQR: 3-13 days). The most common causes for readmission and time until readmission varied between surgical specialties.

Conclusion: The reasons for readmission in children undergoing surgery are varied and influenced by multiple factors, such as patient characteristics, surgical specialty, and the occurrence of postoperative complications, particularly SSI. These data provide the opportunity for risk-stratification for readmission in pediatric surgical populations and help to identify potential areas for targeted interventions to improve quality in the care of children.

73.20 Single-port laparoscopic appendectomy is as safe as traditional 3-port appendectomy

Posted on January 18, 2016

N. A. Hamilton1, M. Wieck1, S. Krishnaswami1 1Oregon Health And Science University,Pediatric Surgery,Portland, OR, USA

Introduction: Laparoscopic appendectomy has become the preferred management for acute appendicitis. The use of a single laparoscopic umbilical incision (SPA), where the appendix is suture ligated in an extracorporeal manner similar to open appendectomy, has been proposed as a more cost effective alternative to 3-port appendectomy (3PA) which typically uses more ports and expensive surgical staplers. However, there have been concerns surrounding postoperative outcomes between the two techniques. We sought to review our experience with SPA and 3PA to identify any difference in clinical outcomes between the two techniques.

Methods: The charts of all children (ages 0-17) with a suspected diagnosis of acute appendicitis who underwent appendectomy at a tertiary pediatric referral center from January 2011-January 2014 were retrospectively reviewed. The surgical technique (SPA vs 3PA) was identified, as were any infectious complications. Data was analyzed using Chi square analysis to compare the outcomes in the two groups.

Results: Three-hundred thirty seven patients underwent appendectomy (141 SPA and 197 3PA), 35.6% of whom (40 SPA, 80 3PA) had perforated appendicitis. Of patients with perforated appendicitis, 20.8% developed intra-abdominal abscesses (5 SPA, 20 3PA, p=0.15). Eleven patients developed wound infections (4 SPA, 7 3PA, p=0.77).

Conclusion:SPA does not result in increased infection rates for acute or perforated appendicitis and should be considered an equivalent technical alternative to 3PA in the surgical management of appendicitis.

73.15 Nutritional Adequacy and Outcome in Neonatal and Pediatric Extracorporeal Life Support

Posted on January 18, 2016

K. A. Ohman1, T. CreveCouer1, A. M. Vogel2 1Washington University,Department Of Surgery,St. Louis, MO, USA 2Washington University,Division Of Pediatric Surgery,St. Louis, MO, USA

Introduction: Nutritional adequacy (NA) in intensive care unit patients is low and inversely correlated with morbidity and mortality. Neonatal and pediatric patients requiring extracorporeal life support (ECLS) represent a subset of critically ill patients whose nutritional delivery by enteral (EN) and parenteral (PN) routes has not been well characterized. Barriers to providing nutrition, particularly EN, exist although multiple studies document the feasibility and safety and current guidelines recommend EN for neonates on ECLS. This study describes nutritional delivery in neonatal and pediatric patients who received ECLS with a focus on NA and outcome.

Methods: A single-center, retrospective review of all neonatal and pediatric patients who underwent ECLS from January 1, 2013 through December 31, 2014 was performed. Demographic, clinical, and outcome data was abstracted. Daily energy and protein prescriptions and amount administered were recorded. NA for energy and protein was defined as the mean percentage of what was prescribed and defined as low (<50%), moderate (50-80%), and high (>80%). Patients whose duration of ECLS was < 48 hours were excluded. Congenital diaphragmatic hernia patients were excluded from EN analysis. Descriptive statistical analyses were performed.

Results: We identified 70 patients; 57.1% were male and median age was 4 months (IQR 72 months). 54 (77.1%) were initiated on venoarterial and 16 (22.9%) on venovenous ECLS. Overall survival was 62.9%. Mean ECLS duration was 220.1 hours; mean duration of mechanical ventilation was 20 days. Categories included: 12 (17.1%) neonatal respiratory, 14 (20.0%) pediatric respiratory, 16 (22.9%) neonatal cardiac, and 28 (40.0%) pediatric cardiac. 23 (32.9%) received nutrition prior to ECLS, but only 8 (11.4%) achieved goal EN prior to ECLS. Mean time to initiation of nutrition was 1.1 ± 1.3 days; mean time to initiation of EN was 4.2 ± 3.4 days. Mean time without any nutritional prescription was 1.4 ± 1.4 days; when nutrition was prescribed, mean energy NA was 92% of the daily goal for energy and 100% for protein. Energy NA, when prescribed, for neonatal respiratory, pediatric respiratory, neonatal cardiac, and pediatric cardiac was 89%, 88%, 95%, and 92%, respectively. However, EN only accounted for 24% of the NA goal. However, when all ECLS days are accounted for, including days without nutrition, only 27.1% achieve high NA. There was no direct correlation with survival. Gastrointestinal complications occurred in 13.6% of survivors and 26.7% of non-survivors.

Conclusion: NA in this neonatal and pediatric ECLS population is poor and utilization of enteral nutrition is low. When nutrition is prescribed, NA is met, but overall NA remains poor due to delayed onset and days without nutrition. Survival was not directly associated with NA as there are confounding variables, but improving NA may represent an opportunity to improve outcome in these critically ill patients.

73.16 Gastroschisis: Impact of delivery planning on patient outcomes

Posted on January 18, 2016

S. Burjonrappa1,2, A. Ivanovic2, S. Burjonrappa1,2 1Albert Einstein College Of Medicine,Bronx, NY, USA 2Saint Barnabas Medical Center,Livingston, NJ, USA

Introduction: Success rates of gastroschisis interventions have been increasingly examined but little data is available regarding the impact of the timing of these interventions as well as fetal delivery itself on outcomes. This study aimed to examine the relationships between overall outcomes of patients diagnosed with gastroschisis and timing of delivery (planned versus non planned) and mode of delivery (cesarean section versus vaginal delivery). The primary outcome evaluated was the length hospitalization, and secondary outcomes evaluated included: time to extubation, age at return of bowel function, and time to tolerance of oral feeds.

Methods: This work was performed as a ten-year retrospective chart analysis including patients from 2005 to 2013. Inclusion in the study required a pre-operative diagnosis and a surgical intervention for gastroschisis. We identified 29 patients of interest who were filtered based on availability of the specific timing of each intervention. Chi-square test was used to determine statistical differences amongst categorical variables and the student t-test was used to determine differences amongst continuous variables.

Results: The major factors influencing the Length of hospitalization were age at return of bowel function (p = 0.0213) and age at tolerance of oral feeds (p = 0.0116). Further early extubation was also correlated to a shorter hospital (p = 0.0003). Analysis of mode of delivery, comparing vaginal delivery to Cesarean section, showed that patients delivered by Cesarean section had a reduced length of hospitalization as compared to those delivered vaginally (p = 0.0080). Mode of delivery did not significantly impact the other patient outcomes but we did find that time to oral feeds was increased in those patients undergoing unplanned deliveries (p = 0.0176). No other outcomes were impacted by undergoing a planned versus unplanned gastroschisis delivery. Further, our results show a significant and positive correlation between birth weight and gestational age (p = 0.0164).

Conclusion: Our data suggests that patients delivered without prior planning will have an extended time to tolerance of oral feeds. In addition, we find that patients delivered by Cesarean section will have shorter lengths of hospitalizations. Factors influencing length of stay after gastroschisis, such as return of bowel function and time to tolerance of oral feeds may be related to mode and timing of delivery. Many present studies focus solely on the impact of silo and primary closure in determining gastroschisis outcomes. We recommend that future analysis of larger databases should focus also on peri-partum factors that may influence outcomes in gastroschisis.

73.17 Management of Gallbladder Abnormalities in Pediatric Patients with Metachromatic Leukodystrophy

Posted on January 18, 2016

J. Kim1, Z. Sun1, V. K. Prasad2, J. Kurtzberg2, H. Rice1, E. T. Tracy1 1Duke University Medical Center,Surgery,Durham, NC, USA 2Duke University Medical Center,Pediatrics,Durham, NC, USA

Introduction:
Metachromatic leukodystrophy (MLD) is a lysosomal storage disease (LSD) that leads to progressive neurological deterioration without hematopoietic stem cell transplantation (HSCT). Visceral involvement, including sulphatide deposition in the gallbladder wall, is known to occur in MLD. Our objective was to examine the incidence and outcomes of gallbladder abnormalities in children with MLD compared with children with similar LSDs, such as adrenoleukodystrophy (ALD) and Krabbe Disease.

Methods:
We conducted a retrospective review of 24 consecutive children with MLD and 64 consecutive children with either ALD or Krabbe disease who underwent HSCT at our institution between 1994-2009. Baseline characteristics and unadjusted outcomes were compared using the Kruskal-Wallis test for continuous variables and Pearson χ2 test for categorical variables, with significance defined as p < 0.05.

Results:
In total, gallbladder abnormalities were present in 17 (71%) MLD patients compared with 17 (27%) ALD/Krabbe patients (p < 0.001). In the MLD group, these abnormalities included sludge (54%), wall thickening (38%), contracted gallbladder (42%), cholelithiasis (12%), and polyposis (8%). Prior to HSCT, gallbladder abnormalities were found in 5 (21%) MLD patients and 2 (3%) ALD/Krabbe patients (p = 0.006). After HSCT, an additional 12 (50%) MLD patients and 12 (19%) ALD/Krabbe patients developed gallbladder abnormalities (p = 0.008). Follow-up imaging was available for 14 of the 17 MLD patients who had gallbladder abnormalities. In 13 (93%) MLD patients with follow-up imaging, the gallbladder disease persisted or progressed. Definitive management—laparoscopic cholecystectomy or percutaneous cholecystostomy—was ultimately recommended for 3 (13%) MLD patients and 1 (2%) ALD/Krabbe patients.

Conclusion:

Children with MLD have a significantly greater incidence of gallbladder abnormalities than children with other LSDs, both prior to and after HSCT. Given these findings, children with MLD undergoing HSCT should receive gallbladder imaging pre-transplant and at regular intervals post-transplant. Laparoscopic cholecystectomy should be considered for persistent, symptomatic gallbladder abnormalities.

73.13 The Effect of Growth on Serial Haller Indices

Posted on January 18, 2016

A. S. Poola1, B. G. Dalton1, K. W. Gonzalez1, D. C. Rivard2, J. F. Tobler2, C. W. Iqbal1 1Children’s Mercy Hospital – University Of Missouri Kansas City,Pediatric Surgery,Kansas City, MO, USA 2Children’s Mercy Hospital – University Of Missouri Kansas City,Radiology,Kansas City, MO, USA

Introduction:
The Haller Index (HI) has been used as a marker for severity of pectus excavatum. However, how the HI may be affected by growth of the chest wall over time is unknown. Understanding this effect would be valuable in determining if the HI is a useful and objective measure of correction in pectus excavatum; specifically, patients undergoing investigational techniques for repair such as magnetic correction which results in a more gradual change of the chest wall

Methods:

A single institution, retrospective chart review from 2004-2014 was conducted. Patients aged 0-18 years without known chest wall deformities that underwent at least 5 computed tomography (CT) scans were included to assess for changes in the anterior-posterior (AP) dimension, transverse dimension, and the HI.

Results:
Forty-four patients were identified. All patients had an oncologic diagnosis for which serial chest CT scans were obtained. 59 percent of the patients were male. The mean age at initial CT evaluation was 12 years (range: 4-16 years). The mean time between initial and 5th CT scan was 41 months (range: 7-80 months). Over that period, the mean change in height was 10 cm (range: 0-32 cm). Thirty two patients grew more than 5 cm during this time. The mean AP diameter changed at a different rate than the mean transverse diameter (0.9 versus 1.6 cm, p=0.005). This affected the HI over that time which differed by a mean of 0.2 (range: 0.0-0.8).

Conclusion:
Based on serial CT imaging, the rate of growth of the AP diameter and the transverse diameter of the chest varies over time which can affect the HI by as much as 0.8. Therefore, other objective measures should be sought that may more effectively measure pectus excavatum severity for use in investigational trials.

73.14 Initial Spontaneous Pneumothorax in Children and Adolescents: Operate or Wait?

Posted on January 18, 2016

L. M. Soler1, D. W. Kays1, S. D. Larson1, J. A. Taylor1, S. Islam1 1University Of Florida,Pediatric Surgery,Gainesville, FL, USA

Introduction: The management of primary spontaneous pneumothorax (PSP) in children is controversial, with some studies suggesting a recurrence rate of 50% over a 4 year period and advocating no surgery for the first occurrence. The purpose of this study was to understand the optimal management of a first episode of spontaneous pneumothorax.

Methods: A retrospective cohort at a single center over 12 years (2002-2014) was studied. Cases of PSP in the 5-19 year age group were selected and other pneumothoraces excluded. Data regarding pre, hospital, and post hospital course was collected and analyzed, with recurrent PSP the primary outcome variable.

Results: 362 cases of pneumothorax in children were found, and 81 met the inclusion criteria for PSP. An overall recurrence rate of 44.4% was noted, with 89% within 12 months of the initial PSP. Recurrent PSP cases were older and taller, but were similar to the non recurrent ones in use of chest tubes, and in the proportion of initial CXR being moderate or larger pneumothorax. CT scan use was not significantly different between recurrent and non recurrent groups, and 5/6 CT scans read as ‘normal’ had recurrence. Thoracoscopic surgery resulted in a significantly lower rate of recurrent PSP (Table). Patients who did not undergo surgery had a 50% recurrence rate with 90% within 12 months of the initial PSP.

Conclusion: Recurrence after PSP in children and adolescents was high and a majority occurred within a year requiring readmission. A negative CT scan for subpleural blebs still had a high recurrence, while thoracoscopic blebectomy and pleurodeisis had significantly lower recurrence. These data may suggest a more aggressive surgical approach to initial PSP in children.

73.11 Small Bowel Volvulus in Pediatric Patients: a Nationwide Population-Based Analysis

Posted on January 18, 2016

D. M. Schwartz1, Z. V. Fong1, D. C. Chang1 1Massachusetts General Hospital,General Surgery,Boston, MA, USA

Introduction:
Small bowel volvulus in children is a devastating condition that most commonly occurs in patients with congenital malrotation. Failure of normal rotation and fixation of the intestine leads to a narrowed mesenteric root, which predisposes these patients to midgut torsion. The resultant bowel ischemia and obstruction require expedited surgical management to avoid the serious consequences of short gut syndrome, sepsis and death. Small bowel volvulus predominately affects the pediatric population with up to 80% of patients affected within the first month of life and 90% within the first year. Current clinical knowledge of this disease is based mainly on analyses of single institution experiences or case studies. Using a national database inquiry, we aim to characterize the epidemiology and outcomes of this disease at the population-level and to define predictors of mortality.

Methods:
The Nationwide Inpatient Sample database, was retrospectively reviewed for patients 18 years old or less with small bowel volvulus (International Classification of Diseases, 9th Edition [ICD-9] code 560.2 excluding gastric/colonic procedures) from 1998 to 2010. Bivariate analysis was performed to define the demography of patients with small bowel volvulus. Baseline characteristics of patients who required small bowel resection were compared using bivariate statistical tests (Fisher Exact and Student’s T-tests). Predictors of mortality were modeled using logistic regression.

Results:
There were 2422 hospitalizations for small bowel volvulus, and of these, 1751 (72.3%) required surgical intervention. Small bowel volvulus occurred more frequently in male (61.3%) than female (38.7%, ratio 1.6 to 1) patients. Most cases presented emergently (86.1%), and the majority of patients were treated at urban (91.3%) and teaching hospitals (72.3%). The overall mortality rate was 3.1%. Mean age was 7.2 years (SD 6.4 years), and this average was unchanged when the cohort was restricted to only those patients with volvulus as their primary diagnosis. Patients who required small bowel resection were more likely to present with shock (50% vs. 19.5%, p<.0001) or peritonitis (46.9% vs. 19.6%, p< .0001), and more likely to be premature (20.3% vs. 33.3%, p<.014). On multivariate regression, predictors of mortality identified included vascular insufficiency (incidence 18.5%, OR 30.5, 95% C.I. 10.3 – 90.1, p<0.001) and shock (incidence 3.7%, OR 8.8, 95% C.I. 2.6 -29.3, p<0.001).

Conclusion:

This epidemiological study demonstrates an analysis of the trends of small bowel volvulus in a pediatric populace that accurately represents the national population. Male predominance of this disease is confirmed and a real world mortality rate of 3.1% is defined. Mean age for this cohort is higher than has been described previously. Vascular insufficiency and shock were strong predictors of mortality, and should be incorporated in future clinical nomograms and risk-calculators.

73.12 Protocoling post-operative care in pyloromyotomy patients: Minimizing variance improves outcomes

Posted on January 18, 2016

K. Zirschky1, N. A. Hamilton1, K. Lofberg1, T. L. Sims1, K. Azarow1 1Oregon Health And Science University,Pediatric Surgery,Portland, OR, USA

Introduction: Clinical practice guidelines, which direct care of medical conditions and performance of clinical procedures, are increasingly common in medicine. However, benefits of clinical guideline implementation for surgical procedures and post-operative care in the pediatric population have not yet been well documented. One area of patient care with significant variability in physician practice is the postoperative management of infants with hypertrophic pyloric stenosis.

Methods: We established clinical practice guidelines for the postoperative care of patients with pyloric stenosis as agreed upon by faculty consensus. A retrospective chart review was designed to evaluate the effects of the implementation of the guidelines. All infants diagnosed with hypertrophic pyloric stenosis at our two major referral children’s hospitals from October 2012 to March 2013 were included in the control group. We allowed for a 6 month period for implementation of the protocol. Those diagnosed with hypertrophic pyloric stenosis from September 2014 to February 2015 were included in the protocol study group. Exclusion criteria for both groups included significant co-morbidities. Charts were reviewed for compliance to the protocol, post-operative complications (as defined by NSQIP), re-admission rates, and length of post-operative hospital stay. The two study groups were then compared using standard statistical analysis, including student t-test to compare the mean length of hospital stay between the control and protocol groups.

Results: There were 41 patients eligible for the study. The control group (n = 24) and protocol group (n = 17) had similar characteristics in terms of age and gender distribution. The mean postoperative hospital stay of the control group and protocol group was 33.81 and 27.43 hours, respectively (p<0.05). No NSQIP complications were noted in either group and there was no significant difference in readmission rate (0 vs 0.05, p=N.S., respectively).

Conclusion:
The implemented guidelines for post-pyloromyotomy care significantly decreased length of hospital stay after surgery without significant impact on complication or re-admission rates.

73.08 Neuroimaging in CDH Patients Requiring ECMO: Does it Predict Neurodevelopmental Outcome?

Posted on January 18, 2016

A. K. Rzepecki1, M. Coughlin1, N. L. Werner1, H. Parmar2, M. Ladino Torres2, S. Patel2, G. B. Mychaliska1 1University Of Michigan,Pediatric Surgery,Ann Arbor, MI, USA 2University Of Michigan,Pediatric Radiology,Ann Arbor, MI, USA

Introduction: Patients with congenital diaphragmatic hernia (CDH) that require extracorporeal membrane oxygenation (ECMO) are at risk for poor neurodevelopmental outcomes. The aim of this study was to compare the head ultrasound (US) and MRI of these patients and correlate neuroimaging findings to neurodevelopmental outcome.

Methods: We conducted an IRB-approved retrospective review of all patients treated at C.S. Mott Children’s Hospital between 2006-2015 with a diagnosis of CDH who required ECMO. Patients were included if they had a head US and MRI in the neonatal period. Baseline patient characteristics, hospital course, and survival data were collected. Neurodevelopmental impairments were classified as 0=normal, 1=mild, 2=moderate, or 3=severe based on Peabody scores and clinical records from a multidisciplinary CDH clinic. MRIs were graded based on severity of abnormality as 0=no abnormality, 1=mild (ventricular dilation or small extra-axial hemorrhages), 2=moderate (large parenchymal hemorrhage or combination of mild hemmorrhagic and non-hemorrhagic abnormalities), or 3=severe lesions (multiple large parenchymal hemorrhage, diffuse atrophy, diffuse leukomalacia). Spearman’s rho was used to calculate a correlation coefficient between neurodevelopmental impairments and MRI grades.

Results: There were 64 patients with a diagnosis of CDH that required ECMO. 22 of these patients had both head US and MRI evaluation. The overall survival of this cohort was 77%. The defect was left-sided in 77%. The mean length of stay was 99±60 days, and the mean ventilator-free days in 60 days of life was 16±17. The mean duration on ECMO was 15±7 days. Median follow up among survivors (17/22) was 1,038 days (IQR 196-1,665). US did not demonstrate acute bleeding in any patients, but did identify dilated ventricles and prominence of extra-axial spaces in 14%. MRI of these patients also did not show significant bleeding, but found 2/22 (9%) with no abnormality, 7/22 (32%) with mild lesions, 3/22 (14%) with moderate lesions, and 10/22 (45%) with severe lesions. Neurodevelopmental impairment was mild in 6/17 children (35%), moderate in 3/17 (18%), severe in 5/17 (29%), and absent in 3/17 (18%). Spearman’s rho correlation coefficient between neurodevelopment impairments and MRI grades was 0.55 (Figure).

Conclusion: This study suggests that brain MRI and US correlate in the detection of major findings such as bleeding, however MRI is more accurate than US in detecting subtle changes such as volume loss in CDH patients that required ECMO. Correlation between MRI and neurodevelopmental outcomes was weak. These data suggest the importance of close surveillance for neurodevelopmental outcome regardless of early MRI findings.

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