84.04 Trends in Reconstructive Breast Surgery at a UK Tertiary Centre Pre & Post Acellular Dermal Matrices

Posted on January 26, 2017

H. K. Kankam1, G. J. Hourston1, L. J. Fopp2, A. A. Agrawal3, S. L. Benyon2, M. S. Irwin2, P. Forouhi3, J. R. Benson3,4, C. M. Malata2,3,4  1University Of Cambridge,School Of Clinical Medicine,Cambridge, CAMBRIDGESHIRE, United Kingdom 2Cambridge University Hospitals NHS Trust,Department Of Plastic Surgery,Cambridge, CAMBRIDGESHIRE, United Kingdom 3Cambridge University Hospitals NHS Trust,Cambridge Breast Unit,Cambridge, CAMBRIDGESHIRE, United Kingdom 4Anglia Ruskin University , Cambridge And Chelmsford,Postgraduate Medical Institute, Faculty Of Health Sciences,Cambridge, CAMBRIDGESHIRE, United Kingdom

Introduction:

Reconstructive breast surgery has evolved in the UK over the last decade with a doubling of the immediate reconstruction rate and the introduction of acellular dermal matrices (ADM). The reported advantages of ADMs (in optimising aesthetic outcome, providing inferolateral implant coverage and decreasing radiation-induced capsular contracture) have resulted in their adoption by plastic surgeons and their increased use in implant-based procedures. This study assesses the temporal and practice-changing impact of ADM on the types of post-mastectomy reconstructions performed in our Unit and the outcomes of implant-only techniques.

Methods:

We conducted a retrospective chart review of all patients undergoing post-mastectomy breast reconstruction at a University Teaching Hospital 18 months before and after adoption of ADM (21/10/2013). Patients were identified from the Unit’s reconstruction diary and plastic surgery theater registers. Demographic, procedural as well as complication data were collected for these two patient cohorts and compared.

Results:

Over the three year period a total of 266 reconstruction patients (340 breasts) with a mean age of 47.5 years were identified; 137 (166 breasts) before and 129 (174 breasts) following introduction of ADM. Reconstructions included autologous tissue-only (44%), implant-only (35%) and combined  (21%) techniques. Implant-only procedures increased from 16% to 53% following the advent of ADM (p<0.01, Chi-square test). The indications for all reconstructions were cancer (69%), risk-reduction (26%), salvage of prior surgeries (4%), and others including burns (1%). For the immediate reconstructions (cancer and risk-reduction groups), there were proportionally more implant-only procedures after the advent of ADMs. The proportion of latissmus dorsi (LD) flap reconstructions decreased after the introduction of ADMs (from 31% to 11%, p<0.01, Chi-square test) as did that of deep inferior epigastric perforator (DIEP) flaps (from 49% to 33%, p<0.01, Chi-square test).

The complications we reviewed (infection, wound breakdown, haematoma, seroma and capsular contracture) for the implant-only procedures were not significantly different whether or not an ADM was used (27% versus 19% without ADM, p=0.38 Chi-square test). The number of implant-only reconstructions that received adjuvant radiotherapy after the introduction of ADM did not differ significantly from that before (20% versus 17% respectively, p=0.83 Chi-square test).

Conclusion:

The present study showed that since ADM introduction to our centre, more breast reconstructions have been of the implant-only type with consequent reductions in the more expensive autolougous techniques. ADM use in post-mastectomy reconstruction has not resulted in increased complications contrary to widespread anecdotal reports. The possibility of post-operative radiotherapy was not seen as a total contraindication for implant-based reconstruction.

84.02 Patient Satisfaction with Bilateral Breast Reconstruction in Risk-Reducing and Therapeutic Mastectomy

Posted on January 26, 2017

F. Kazzazi1, R. Haggie1, P. Forouhi2, N. Kazzazi3, L. Wyld3,6, C. Malata2,4  1University Of Cambridge,Clinical School,Cambridge, CAMBRIDGESHIRE, United Kingdom 2Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust,Cambridge Breast Unit,Cambridge, CAMBRIDGESHIRE, United Kingdom 3Doncaster Royal Infirmary,Jasmine Breast Centre,Doncaster, SOUTH YORKSHIRE, United Kingdom 4Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust,Department Of Plastic And Reconstructive Surgery,Cambridge, CAMBRIDGESHIRE, United Kingdom 5Anglia Ruskin University,Postgraduate Medical Institute, Faculty Of Medical Sciences,Cambridge, CAMBRIDGESHIRE, United Kingdom 6University Of Sheffield,Sheffield, SOUTH YORKSHIRE, United Kingdom

Introduction:

Patients undergoing mastectomy and immediate breast reconstruction (IBR) for cancer may be expected to have different perceptions of long term outcomes compared with those who elect to have this operation as a risk-reducing measure. There are no reports directly comparing patient satisfaction between therapeutic and risk-reducing bilateral mastectomy and IBR. Our null hypothesis is that patients will report the same outcomes after bilateral surgery for cancer compared with risk reducing.

Methods:

Patients undergoing bilateral mastectomy and reconstruction from 2008-2014 at the Cambridge Breast Unit, were identified from a prospective register. The validated Breast-Q™ questionnaire was mailed to all following the “total Dillman method” of administering postal questionnaires. Q-SCORE software was utilised to analyse patient satisfaction and compare the two groups. 

Results:

112 patients had bilateral surgery. Of the bilateral reconstructions 14.3% were therapeutic (median age = 50) and 47.3% were risk-reducing (median age = 43). 38.3% of patients fell in a combined aetiology group of risk-reducing in one breast with therapeutic contralateral mastectomy (median age = 46). The overall response rate was 58.4%. The therapeutic group had higher patient satisfaction than risk reducing group across most domains (therapeutic/ risk-reducing); breast: 68.8/68.3, outcome: 81.3/75.6, psychosocial: 77.9/75.7, sexual: 62.1/53.8, physical: 72.6/74.0 admin: 85.6/84.1. The combination group scored lowest in most domains.

Conclusion:

RRM and immediate reconstruction has been a major advance in the management of patients who may later suffer cancer. The decision to have bilateral RRM is in many patients’ minds is influenced by the availability of IBR. Our study suggests it is important to counsel these patients well because of their lower satisfaction rates however, more investigation is required to understand the lower satisfaction of the combination group.

 

84.01 Umbilical Necrosis Rates After Abdominal Based Microsurgical Breast Reconstruction

Posted on January 26, 2017

J. A. Ricci1, P. Kamali1, B. Becherer1, D. Curiel1, W. Wu1, B. T. Lee1  1Beth Israel Deaconess Medical Center,Plastic And Reconstructive Surgery,Boston, MA, USA

Introduction:  Umbilical stalk necrosis represents a rare, yet important complication after abdominal based microsurgical breast reconstruction, which is both under-recognized and under-studied in the literature.  Once identified, umbilical reconstruction can be an extremely challenging problem. Previously unreported in the literature, this study aims to categorize this problem and identify associated risk factors, in an effort to prevent its occurrence.  

Methods:  All consecutive microsurgical free flaps for breast reconstruction at a single institution from February 2004 to February 2016 were reviewed. Non-abdominal based flaps were excluded. Patients were then divided in to cohorts depending on the development of umbilical necrosis postoperatively. Demographics, surgical characteristics and other complications were compared between the groups. 

Results: A total of 1335 flaps met the inclusion criteria, with 1286 flaps performed in patients who did not develop umbilical necrosis (96.3%) and 49 instances of umbilical necrosis identified (3.5%). Patients who developed necrosis tended to be older (49.4 yrs vs. 52.9 yrs; p <0.01), have higher BMI (31.3 vs. 27.8; p <0.01), have higher rates of hypertension (40.8% vs. 14.1%; p <0.01) and were more likely to be smokers (26.5% vs. 11.4%; p <0.01). Umbilical necrosis was associated with increased flap weight (829.8 g vs. 656.2 g; p <0.01), decreased time allotted to perforator dissection (150 min vs. 169 min; p =0.02) and increased number of perforators dissected per flap (2.5 vs. 2.2; p =0.03). There was no association with flap type (DIEP, SIEA or free TRAM), history of diabetes, previous abdominal surgery, use of preoperative imaging to identify perforators.  Umbilical necrosis was not associated with most complications, but was associated with a concomitant donor site seroma (14.2% vs. 5.1%, p =0.01). A total of six patients underwent eventual reconstruction of the umbilicus.

Conclusion: Umbilical stalk necrosis represents a rare, though serious complication for patients following abdominal based microsurgical breast reconstruction and to date, no series in the literature has focused on this complication. Overall, umbilical necrosis was found to occur at a rate of 3.5% and was found to be associated with several preoperative comorbidities. Additionally, it was associated with several intraoperative characteristics, including larger flap harvest, decreased time spent on perforator dissection and increased number of perforators harvested per flap. This information should help influence surgeon’s intraoperative decision making to prevent the development of this undesirable complication.

 

83.20 Impact of fresh frozen plasma transfusion on long-term outcomes in colorectal liver metastases

Posted on January 26, 2017

Y. Nakaseko1, K. Haruki1, H. Shiba1, Y. Takano1, S. Onda1, F. Suzuki1, M. Matsumoto1, T. Sakamoto1, T. Gocho1, Y. Ishida1, K. Yanaga1  1The Jikei University School Of Medicine,Department Of Surgery,Nishi-Shinbashi, MINATO-KU, TOKYO, Japan

Background: Blood transfusion has been reported to be associated with immunomodulation and poor oncologic outcomes in several malignancies.  The aim of the study was to investigate the influence of the use of fresh frozen plasma (FFP) on long-term outcomes in patients with colorectal liver metastases (CRLM) after hepatic resection.

Patients and

Methods: The study comprised 127 patients who had undergone elective hepatic resection for CRLM between April 2000 and December 2013.  We retrospectively investigated the influence of the use of FFP on recurrence-free survival as well as and overall survival and assessed impact on postoperative markers of inflammation.

Results: In multivariate analysis, more than 4 lymph node metastases of the primary cancer (p=0.001), bilobar distribution (p=0.002), and perioperative FFP transfusion (p=0.005) were independent risk factors for cancer recurrence, while more than 4 lymph node metastases of the primary cancer (p<0.001), presence of neo-adjuvant chemotherapy (p=0.002) and perioperative FFP transfusion (p=0.004) were independent risk factors for poor overall survival. In patients with FFP transfusion, tumor size (p = 0.004), anatomical resection (p<0.001), duration of operation (p = 0.039) and intraoperative blood loss (p < 0.001) were significantly greater.  Moreover, FFP transfusion was associated with higher white blood cell level on postoperative day 3 (p<0.001) and 5 (p=0.010), and lower serum C-reactive protein level on postoperative day 3 (p<0.001) and 5 (p=0.017).

Conclusion: Perioperative FFP transfusion is independently associated with poor long-term outcomes in patients with CRLM after hepatic resection.  FFP may have influence on postoperative inflammation by its immunosuppressive effect.
 

83.19 Using Adenoma Weight and Volume to Predict Multigland Disease in Primary Hyperparathyroidism

Posted on January 26, 2017

J. Lee1, M. B. Albuja-Cruz1, C. Burton1, C. D. Raeburn1, R. McIntyre1  1University Of Colorado School Of Medicne,GI, Tumor And Endocrine Surgery,Denver, CO, USA

Introduction:
Intraoperative parathyroid hormone (ioPTH) monitoring is the current gold-standard for intraoperative determination of multi-gland disease (MGD) in patient with primary hyperparathyroidism (PHPT).   A prior study found that the risk of persistent disease after minimally invasive parathyroidectomy (MIP) is higher if the weight of the resected gland is ≤ 200mg.  The purpose of this study is to determine if the volume and weight of first resected adenoma is a reliable predictor of MGD. This would provide surgeons immediate and inexpensive information to assist with the decision of conversion from a MIP to bilateral neck exploration (BNE). 

Methods:
Retrospective review of prospectively collected data of 469 consecutive patients who underwent initial parathyroidectomy for PHPT at a single tertiary medical center from 2010 to June 2015 was performed.  Intraoperative parathyroid hormone was used in all cases and intraoperative cure was defined by a >50% drop of the preoperative PTH at 10 minutes and within normal limits.  One hundred eighty-five patients met criteria for inclusion in this study.  Data was analyzed for patient demographics, operative procedure, first resected adenoma weight and volume, presence of MGD, complications, cure and persistence disease.

Results:
Of the 185 patients, 74% had a single adenoma and 26% had MGD. The mean weight for the single adenoma group was 846 mg compared to 461mg for the MGD group (P< 0.05).  A weight of ≥200mg was used as a cutoff to distinguish a single adenoma from MGD (sensitivity 87%, specificity 28%, PPV 76%, NPV 45% and accuracy 71%; P= 0.73). 
The mean volume for the single adenoma group was 1.13 compared to 0.5cm3 for the MGD group (P< 0.05). A volume of ≥0.2cm3 was used as cutoff to differentiate a single adenoma from MGD (sensitivity 83%, specificity 35%, PPV 78%, NPV 44% and accuracy 71%; P= 0.82).
Final cure rate for PHPT was achieved in 97% of the patients included in the study.  Then median follow up was 25 months.

Conclusions:
The weight and volume of the first resected adenoma are not accurate measures to determine the presence of multigland disease in patients with PHPT, despite significant difference in mean weight and volume between the single adenoma vs. MGD groups.  Surgeon judgment and ioPTH remains paramount in the in the operative management of this patient population.
 

 

83.18 DNR Orders and High Risk Pediatric Surgery: Professional Nuisance or Medical Necessity?

Posted on January 26, 2017

L. M. Baumann1,2, K. Williams1,2, F. Abdullah1,2, R. J. Hendrickson3, T. A. Oyetunji1,2  3Children’s Mercy Hospital- University Of Missouri Kansas City,Pediatric Surgery,Kansas City, MO, USA 1Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA 2Ann & Robert H Lurie Children’s Hospital Of Chicago,Pediatric Surgery,Chicago, IL, USA

Introduction:  There is a paucity of data in the literature regarding end-of-life care and do-not-resuscitate (DNR) status of the pediatric surgical patient, despite the fact that invasive procedures are frequently performed in very high risk and critically ill children.  There have been significant efforts in adult medicine to enhance discussions around end-of-life care, however, little is known about similar endeavors in the pediatric population.

Methods:  A retrospective review of the National Surgical Quality Improvement Program Pediatric (NSQIP Pediatric) was performed.   Patients <18 years old with ASA class 3 or greater who underwent elective operation in 2012-2013 were identified and included for analysis.  Demographic factors, principal diagnosis, associated conditions, DNR status and mortality were extracted.  Descriptive analysis was performed using Stata 11.

Results: A total of 114,395 records were initially identified, with 20,164 patients meeting the inclusion criteria.  91.6% of patients were ASA III, 8.3% ASA IV, and 0.1% ASA V. Less than 1% (0.18%) of all patients had a signed DNR order prior to operation.  Of severely ill patients defined by ASA IV, only 1 out of a hundred were DNR status.  There were no differences in gender, race, ethnicity or surgical department of patients with and without a DNR order. Of those children who died within 30 days of operation, 11.1% were DNR status.  Notably, 17.1% of children who died within this period had multiple operations performed prior to expiring.

Conclusion:  The rate of documented DNR status is extremely low in the high-risk pediatric surgical population undergoing elective surgery, even amongst severely ill children where systemic disease is a “constant threat to life”. It is unclear if this is due to physician hesitancy or parents’ unwillingness to make this difficult decision.  Regardless, well-informed end-of-life care and DNR status discussions in a patient focused approach are essential in the surgical care of children with complex medical conditions and critical illness. Better documentation of any DNR discussion will also allow better tracking and benchmarking.

83.17 Racial and Ethnic Disparities in Survival of Pediatric Sarcoma

Posted on January 26, 2017

A. J. Jacobs1, E. Lindholm2, C. Fein Levy3, J. D. Fish3, R. D. Glick2  1Hofstra Northwell School Of Medicine,Hempstead, NY, USA 2Cohen Children’s Medical Center,Pediatric Surgery,New Hyde Park, NY, USA 3Cohen Children’s Medical Center,Pediatric Hematology/Oncology,New Hyde Park, NY, USA

Introduction:
Childhood sarcomas are rare diseases, and the interdisciplinary care these patients require is specialized and expensive.  Vast improvements have been made in the diagnosis and treatment of these malignancies over the last decades.  The goal of this study was to determine treatment trends over time and to determine if racial or ethnic disparities exist for pediatric sarcoma patients in the United States.

Methods:
The United States’ National Cancer Institute’s Surveillance, Epidemiology, and End Results database (SEER) was used to identify patients aged 0-21 diagnosed with primary sarcomas from 1973-2012.  Patients were considered by race and ethnicity.  Survival curves were computed using the Kaplan-Meier method and the log-rank test.  Cox proportional hazard regression was used for multivariate analysis.

Results:
A total of 11,502 patients with histologically confirmed sarcoma were included in this study.  A greater proportion of patients were male (57%), and the majority of patients were between ages of 11 and 17 at time of diagnosis. Of the total population, 6877 (60%) patients had soft tissue tumors, and 4625 (40%) patients had bony tumors. The most common soft tissue tumors were non-rhabdomyosarcoma (66%), and the most common bony tumor was osteosarcoma (58%). The majority of patients presented with localized disease (36.9%), followed closely by regional disease 30.8%, and lastly distant disease (18.9%).  When stratified by race, there were significant differences between stage and tumor size at the time of diagnosis between white and non-white patients (Table 1). Among those patients with soft tissue sarcomas, 46% of non-Hispanic White patients received radiation therapy, compared to 40% of non-Hispanic Black patients (p=0.01). There was, however, no significant difference between the proportion of white and non-white patients who underwent surgery (p=0.21).  Overall 10–year survival improved during the study period from 52.5% in 1973-1979 to 65.3% in 2000-2012. The 10-year OS was 64.5% for non-Hispanic White patients, 62.3% for Hispanic patients, and 61.8% for non-Hispanic Black patients (p=0.01).

Conclusion:
While an improvement in pediatric sarcoma survival was seen over the past 4 decades, this survival improvement still lags far behind that of hematologic malignancies.  Racial and ethnic disparities are seen in the treatment patterns and survival of these rare tumors in the United States.  Non-white patients are presenting at a later stage and have overall worse survival than white counterparts.
 

83.16 Use of Prophylactic Radiation Therapy to Prevent Keloid Formation after Thyroid Surgeries

Posted on January 26, 2017

M. A. Anwar2, R. Kholmatov1, F. Murad1, D. Bu Ali1, E. Kandil1  1Tulane University School Of Medicine,New Orleans, LA, USA 2Wayne State University,Detroit, MI, USA

Introduction:

Keloid or hypertrophic scar following thyroid surgery can cause substantial patient distress with diminished quality of life, and poses a significant challenge to treat. Herein we examined the efficacy of prophylactic external-beam radiation therapy (EBR) for prevention of keloid formation in high-risk patients undergoing thyroid surgeries. 

Methods:
We reviewed our medical records between January 2013 and December 2015 to identify the patients with previous history of developing keloids who underwent thyroid surgeries at our institution. All the pertinent data on patients’ demographics, primary diagnoses, surgical procedures, radiation dosage, and outpatient follow-ups was collected. 

Results:
Nine patients with history of keloid formation received external beam radiation therapy for keloid prophylaxis following thyroid surgeries during the study period.  Radiation was initiated within 6 hours after surgeries. Average radiation dose was 1798 ±405 cGY. Patients were followed for an average of 14 ± 5.91 months. Only one patient, who underwent concomitant lateral and central neck dissection in addition to thyroid surgery, developed a keloid in less than 10% 0f her scar. In the remaining eight cases, no post-surgical keloid formation was observed and patients were satisfied with postsurgical scar. 

Conclusion:
To our knowledge, this is the first study to investigate the role of prophylactic EBR in high-risk patients undergoing thyroid surgery. Prophylactic EBR for prevention of keloid formation following thyroid surgeries is feasible and effective in high-risk patients. Further randomized prospective studies are warranted. 

83.14 Efficacy of Oral Antibiotics in Children with Post-Operative Abscess from Perforated Appendicitis

Posted on January 26, 2017

K. L. Weaver1, A. S. Poola1, K. W. Gonzalez1, S. D. St. Peter1  1Children’s Mercy Hospital,Department Of Pediatric General Surgery,Kansas City, MISSOURI, USA

Introduction:
Post-operative intra-abdominal abscess (PIAA) is the most common complication after appendectomy for perforated appendicitis (PA). This results in a protracted  medical course. Intravenous antibiotics by a peripherally inserted venous catheter are commonly employed to treat the abscess. We sought to evaluate the role of oral antibiotics in this population. 

Methods:
A retrospective review was conducted of children between January, 2005 to September, 2015 with a PIAA. Demographics, laboratory values, type and duration of antibiotics, interventions, imaging, length of stay, complications and hospital costs were all analyzed using descriptive statistics. Comparative analysis was performed on those who were treated with oral versus IV antibiotics after diagnosis of PIAA upon discharge utilizing a Pearson chi-square and Fisher’s exact test.  

Results:

103 children, of whom 66% where male with an average age at time of surgery of 11 + 3.6 years were included. Days of symptoms prior to admission was 3.2 + 2.3 days with a WBC of 17.9 + 6.4.  The median time to diagnosis of PIAA from appendectomy was 7 days (range 7-10) with 46% being treated with antibiotics only, 39% requiring drain placement and 15% aspiration. Mean total length of stay was 10 + 3.4 days. Comparing those who were discharged with oral antibiotics (42%) versus IV antibiotic therapy (58%), there was no significant difference in number of days of IV antibiotics prior to PIAA diagnosis, length of drain days if required, or total number of hospitalizations. However, there was a significant difference found in total length of hospital stay (9.1 vs. 10.7, p=0.02) and number of medical encounters required for treatment (3.4 vs. 4.4, p= <0.01). 

Conclusion:
PIAA treatment after appendectomy for PA can be treated with oral antibiotics with equivocal outcomes as IV antibiotic treatment, but with shorter length of hospitalizations and less medical encounters required. 
 

83.15 Use of Ultrasound for Distinguishing Non-Perforated from Perforated Appendicitis in Children

Posted on January 26, 2017

B. C. Weber3, K. G. Gill2, E. L. Riedesel2, R. S. Cartmill4, C. M. Leys1, J. E. Kohler1  1University Of Wisconsin,Pediatric Surgery,Madison, WI, USA 2University Of Wisconsin,Pediatric Radiology,Madison, WI, USA 3University Of Wisconsin,School Of Medicine And Public Health,Madison, WI, USA 4University Of Wisconsin,Wisconsin Surgical Outcomes Research Program,Madison, WI, USA

Introduction:  Acute appendicitis is one of the leading causes of surgery in children. Recent clinical trials suggest that simple acute appendicitis in pediatric patients can often be successfully treated non-operatively with antibiotics. Conversely, perforated appendicitis requires urgent appendectomy or percutaneous drainage and a prolonged course of antibiotics. As treatment strategies for perforated and simple acute appendicitis diverge, effective imaging to identify the presence or absence of perforation preoperatively is increasingly important. Ultrasound has a demonstrated effectiveness in diagnosing acute appendicitis, but its ability to detect perforation has not been well elucidated.

Methods:  We retrospectively analyzed health records of all pediatric patients who presented to a single pediatric Emergency Department with suspected appendicitis from 11/1/2014 to 12/31/2015. We abstracted data from radiology reports, operative notes, and pathology reports to determine the effectiveness of ultrasound at predicting perforated appendicitis based on concordance of ultrasound and surgical findings. We used the only evidence-based definition for perforation that is associated with an increased risk of abscess formation, a hole in the appendix or fecalith in the abdomen at the time of operation.

Results: A total of 480 ultrasounds for suspected appendicitis were performed during the study period. 85.6% of patients with appendicitis were successfully diagnosed using ultrasound. Of these 95 patients, 28 (29.5%) were perforated at operation and 67 (70.5%) were not perforated. The interpreting pediatric radiologist’s impression of perforation was correct 81.1% of the time with a specificity of 86.6% and sensitivity of 67.9%.

Conclusion: These data suggest that ultrasound is a reliable measure for identifying appendicitis and perforation in children with a sensitivity and specificity comparable to reports for computed tomography (CT) scans. The negative predictive value of ultrasound for perforation should allow safe attempts at non-operative management of appendicitis if perforation is not seen.

 

83.13 Readmission and Imaging Outcomes in Pediatric Complicated Appendicitis: a Matched Case-Control Study

Posted on January 26, 2017

K. L. Murphy1, R. P. Foglia1, S. E. Wolf1, A. C. Alder1  1University Of Texas Southwestern Medical Center,Dallas, TX, USA

Introduction:  Currently, the treatment guidelines for perforated appendicitis generally include primary appendectomy or non-operative management followed by an interval appendectomy 6 to 12 weeks post discharge (first-line antibiotics). First-line antibiotics along with abscess drainage and deferred appendectomy is selected with the intent to minimize complications of surgical management. However, investigation of specific, clinically-relevant outcomes identified that primary appendectomy reduced time away from normal activities and was associated with higher family satisfaction, fewer CT scans, and fewer visits to the emergency department. The benefits of each continue to be debated. The aim of this study was to compare clinically-relevant outcomes such as length of stay, imaging rate and readmission between patients selected for first-line antibiotics and first-line appendectomy using a matched case-control approach.

Methods:  The electronic medical record system at Children’s Medical Center was queried for all patients diagnosed with perforated appendicitis who underwent an appendectomy. A total of 3,491 were identified over 4 years.  Among 905 patients with perforated appendicitis, 105 underwent first-line antibiotic therapy. The patients were grouped by intervention, first-line antibiotics vs. first-line appendectomy.  No standardized protocol currently exists for management of delayed appendectomy at our institution.  The 291 patients were matched with a ratio of 1:2 and based on age, gender, and presence of a fecalith on imaging. Data points including length of stay (LOS), total number of imaging scans, and number of visits to the ED and readmission to the hospital were collected. The values are reported as mean and standard deviation.

Results: The first-line antibiotic group had significantly longer primary hospitalization (LOS) in addition to a longer total LOS (158.40 ± 129.10 vs. 108.19 ± 97.91, p < 0.0001; 199.72 ± 142.65 vs. 118.80 ± 93.217, p < 0.0001).  These were readmitted more often (0.21 ± 0.48 vs. 0.08 ± 0.311, p = 0.0026) though ED visits were statistically similar to primary appendectomy (0.17 ± 0.40 vs. 0.10 ± 0.35, p = 0.1024).  Re-hospitalization LOS was not longer (p = 0.2000).  The first-line antibiotic group also underwent more imaging scans during their initial hospital visit as well as after the primary diagnostic scan (1.02 ± 0.46 vs. 0.54 ± 0.57, p < 0.0001; 0.26 ± 0.52 vs. 0.06 ± 0.28, p < 0.0001).

Conclusion: In this study, we found that delayed appendectomy is associated with longer hospital stays, increased hospital admissions, and more imaging scans.  Readmissions are also higher.  These outcomes may be related to selection bias as well as lack of a standardized approach outlining when to scan patients and in access to outpatient surgical care.

                                                                                                                                           

83.12 Are Foley Catheters Needed in the Postoperative Care of Children with Perforated Appendicitis?

Posted on January 26, 2017

S. Mohammed1, Y. R. Yu1,2, R. Sola3, J. T. Lackey1, S. John4, E. Rosenfeld1,2, W. Zhang2, S. D. St. Peter3, S. R. Shah1,2  1Baylor College Of Medicine,Division Of General Surgery,Houston, TX, USA 2Texas Children’s Hospital,Division Of Pediatric Surgery,Houston, TX, USA 3Children’s Mercy Hospital- University Of Missouri Kansas City,Division Of Pediatric Surgery,Kansas City, MO, USA 4University Of Texas Health Science Center At Houston,Houston, TX, USA

Introduction: Patient-controlled analgesia (PCA) is often used for postoperative pain control in children with perforated appendicitis.  Additionally, some providers routinely use postoperative Foley catheters in this population to prevent urinary retention; however, this practice varies by surgeon and institution.  The objective of this study was to determine the rate of urinary retention in this patient population to guide future practice.

Methods: A retrospective review was performed of all pediatric patients (≤ 18 years old) who received PCA postoperatively for perforated appendicitis between July 2015 and June 2016 at two academic children’s hospitals.  Data collected included patient characteristics, intraoperative findings, postoperative narcotic use, and incidence of urinary retention and urinary tract infections.  Urinary retention was defined as the inability to spontaneously void during the postoperative period requiring straight catheterization or placement of a Foley catheter.  Statistical analysis was performed using the Wilcoxon rank test and Fisher’s exact test, as appropriate.  Additional univariate logistic regression analysis was performed to identify risk factors for urinary retention.

Results: A total of 313 patients (mean age 9.5 ± 3.9 years) underwent appendectomy for perforated appendicitis during the study period (175 at Hospital 1 and 138 at Hospital 2). An intraoperative Foley catheter was placed in 22 (13%) patients at Hospital 1, and 107 (78%) patients at Hospital 2 (p<0.0001).  For the combined study population there were 196 (63%) males and the overall postoperative length of stay was 5.6 ± 2.9 days.  The mean PCA morphine usage was 0.4 ± 0.3 mg/kg/day per patient.  Age, gender, and body mass index (BMI) was similar between those that had an intraoperative Foley catheter placed (n=129) and those that did not (n=184).  There were no urinary tract infections in either group.  The urinary retention rate was 4.3% (n=8) for patients without an intraoperative Foley catheter, and 0.8% (n=1) for those with an intraoperative Foley catheter after removal on the inpatient unit (p=0.06).  Univariate analysis of patient characteristics, intraoperative findings, PCA specifics (narcotic type, duration, average daily usage, and basal rate), postoperative length of stay, and postoperative abscess formation did not identify any significant risk factors for urinary retention.

Conclusion: Practice variations exist regarding placement of intraoperative Foley catheters in children with perforated appendicitis.  However, the risk of urinary retention in this population is low despite the use of patient-controlled analgesia.  Based on these results we conclude that children with perforated appendicitis do not require routine postoperative Foley catheter placement to prevent urinary retention.

 

83.11 Optimal Timing of Surgical Intervention for Patients with Gastroschisis and Atresia

Posted on January 26, 2017

H. E. Arnold1, H. Short1, K. Baxter1, C. D. Travers2, A. M. Bhatia1, M. M. Durham1, M. V. Raval1  1Emory University School Of Medicine,Division Of Pediatric Surgery, Department Of Surgery,Atlanta, GA, USA 2Emory University School Of Medicine,Department Of Pediatrics,Atlanta, GA, USA 3Emory University School Of Medicine,Department Of Surgery,Atlanta, GA, USA 4Emory University School Of Medicine,Department Of Pediatrics,Atlanta, GA, USA

Introduction:  Gastroschisis complicated by atresia represents a clinical challenge. In addition to the initial abdominal wall defect repair, these children require subsequent interventions to establish bowel continuity. After definitive abdominal closure, the second surgery is often delayed to enhance bowel recovery. The optimal timing of the second intervention has not been fully investigated. The purpose of this study was to determine if early intervention for patients with gastroschisis and atresia results in improved outcomes compared to late intervention. 

Methods:  Retrospective chart review of patients who underwent surgical repair of gastroschisis between January 1, 2009 and December 31, 2012 was performed at a quaternary children’s hospital. We identified a subset of patients who had gastroschisis complicated by atresia and compared those who had early intervention (<4 weeks) versus late intervention (>4 weeks) to manage the atresia.

Results: Of 143 gastroschisis patients identified, 13 (9.1%) had atresia including 5 (38.5%) primary abdominal wall closures and 8 (61.5%) that were delayed closures using a silo. From definitive closure to subsequent intervention for the atresia, 7 were considered early (<4 weeks, median 9 days), and 6 were considered delayed (>4 weeks, median 49 days). All patients in the early intervention group received ostomies, while patients in the late intervention group underwent primary anastomosis. Overall, 5 patients had major complications including 1 with volvulus, 1 with intestinal necrosis, and 3 with perforations. Of these, only one major complication occurred in the delayed group, which was the case of the volvulus. Excluding those patients with emergent complications (1 patient with necrosis, 1 patient with perforation) that forced earlier than planned intervention, overall length of stay trended toward shorter stays for early intervention patients (66 vs. 98 median days, p=0.30). Early intervention was associated with shorter time to enteral feeds (28 vs. 60 median days of life, p=0.02). 

Conclusion: In this single-center, retrospective review, patients undergoing early intervention for atresia after definitive gastroschisis closure trended toward shorter length of stay and earlier initiation of feeds despite uniformly receiving ostomies. The optimal timing of surgical intervention in this complex patient population warrants further investigation. 

 

83.10 Retained Foreign Bodies and Associated Surgical Procedures in Pediatric Patients

Posted on January 26, 2017

A. L. Schwartz1, M. M. Nourian1, B. T. Bucher1  1University Of Utah,Division Of Pediatric Surgery,Salt Lake City, UT, USA

Introduction:

Retained foreign bodies (RFB) discovered after surgery are documented as an Agency for Health Care Quality and Research Patient Safety Indicator (AHRQ PSI) for hospital quality. The AHRQ PSI measures absolute numbers and is not controlled for hospital or procedure volume. Several studies have documented the contributing factors to retained foreign bodies during surgery in adults; however, there is little data in children undergoing surgical procedures. The goal of this study is to identify a cohort of children with retained foreign bodies at U.S. children’s hospitals.

Methods:

We performed a retrospective case series study of pediatric patients that underwent surgery with RFB at 49 U.S. children’s hospitals using the Pediatric Health Information System Database (PHIS) from 2004 to 2015. Patients were defined as having RFB based on the AHRQ PSI definition. Patients with RFB present on admission were excluded from the study. Patient demographics, clinical, procedural, and hospital characteristics were collected. 

Results:

There were a total of 447 post-surgical patients who were identified with RFB from 2004-2015.  The majority of patients were between 2-12 years of age (36%), male (56%), Caucasian (64%), and non-Hispanic (43%). There was an equal share between Medicaid (40%) and Commercial Insurance (46%). Admissions were equally distributed between elective (37%) and emergent (40%). As expected, the patients were high acuity with 52% requiring NICU or PICU admission and 37% requiring mechanical ventilation. At least one complex chronic condition was present in 72% of the children in the cohort. Of the 1,257 procedures performed, the majority of procedures were operations on the digestive system (22%), cardiovascular system (20%), and respiratory system (19%). The median (IQR) number of procedures per patient was 1 (IQR 1-2). The hospital length of stay for a patient with RFB was 6±20 days. The majority of patients were discharged home (86%) and the mortality rate was 2.7%. The number of RFB per hospital per year decreased from 1.8 to 0.5 during the study period.

Conclusion:

We have identified a large cohort of children with a retained foreign body after surgery based on the AHRQ PSI. The majority of children had complex chronic medical conditions and high acuity hospital admissions. The majority of procedures with a retained foreign body in pediatric patients involve operations on the digestive system, cardiovascular system, and respiratory system. This study helps define a cohort of children who are at risk for retained foreign bodies. Future studies are needed to identify patient and procedure specific factors related to RFB in children. 

 

 

83.09 With Age Comes Wisdom: Is Mother's Age Predictive of Non-Accidental Trauma in Children?

Posted on January 26, 2017

J. Green1, R. N. Damle1, G. Keefe3, J. Brady3, M. Hazeltine3, P. P. Nazarey2, M. P. Hirsh2, J. T. Aidlen2  1University Of Massachusetts Medical School,General Surgery,Worcester, MA, USA 2University Of Massachusetts Medical School,Pediatric Surgery,Worcester, MA, USA 3University Of Massachusetts Medical School,Medical School,Worcester, MA, USA

Introduction:

Non-Accidental Trauma (NAT) rates are higher when parents have unplanned pregnancy, poor prenatal care or feel a lack of community support. Young parents are likely to have limited resources, exposing them to significant stressors. We explored whether the incidence of positive skeletal survey and suspected NAT in pediatric patients correlates with maternal age.

 

Methods:  

We performed a retrospective analysis of trauma patients (<18 years old) evaluated with skeletal surveys at our institution from 2005-2015. Patients were divided into 2 groups: Mother ≤ 25 and Mother >25 years old.  Incidence of suspected NAT (defined by a child being removed from custody) was compared between groups. Statistical comparisons were performed using Chi-squared analysis or Student’s t-test where appropriate.

 

Results:

A total of 96 patients were identified for inclusion, 48 in each group.  On average, children were younger in the younger mother’s group (21 months vs. 32 months, p < 0.001). There were no differences in race, gender, injury-severity-score or level of trauma activation between groups.  A positive skeletal survey was found in 22% of all patients: 25% of those with younger mothers and 21% of those with mothers >25 (p=0.63).   Most common injury locations were head (66%), upper extremities (28%) and lower extremities (19%), with no difference between groups. NAT was suspected in 58% of patients overall, with no difference between groups (65% vs 52%, p = 0.21) 

 

Conclusion:

Following evaluation for traumatic injuries, incidence of positive skeletal survey and suspicion of NAT rates are comparable in pediatric trauma patients regardless of the mother’s age.

 

 

83.08 Outcomes following Gastroschisis Repair: Associations with Gestational Age.

Posted on January 26, 2017

J. E. Sola1, E. A. Perez1, J. Parreco1, J. Tashiro1  1University Of Miami,Surgery,Miami, FL, USA

Introduction:  We hypothesized that clinical outcomes following gastroschisis repair are related to gestational age (GA).

Methods:  We queried the Kids’ Inpatient Database (2003-2012) for infants undergoing surgical treatment of gastroschisis (ICD-9-CM procedure code 54.71). Bivariate analysis compared outcomes associated with birth at ≥37 wk, ≥35 to <37 wk, and <35 wk GA.

Results: Overall, 4,437 cases of gastroschisis repair were identified in the dataset. Infants were born at GA ≥37 wk (12%), ≥35 to <37 wk (55%), and <35 wk (33%) GA. Birth weight was most commonly 2000-2499g (39%), followed by ≥2500g (23%), and 1750-1999g (13%). Infants were most commonly Caucasian (53%) and male (51%).

 

For infants born at ≥37 wk, procedure-specific complications were 2.3 (1.3, 3.9) times more likely vs. vs. ≥35 to <37 wk GA, p=0.002. No difference in rates of wound disruption, wound infection, blood transfusion, reoperation, sepsis, pneumonia, or post-procedural hemorrhage were detected. Length of stay (LOS) did not differ significantly.

 

For infants born at <35 wk, wound disruptions were 1.6 (1.1, 2.2) times more likely vs. ≥35 to <37 wk GA, p=0.006. Blood transfusions were 1.7 (1.4, 1.9) times more likely, p<0.001. Reoperations were 1.8 (1.1, 3.1) times more likely, p=0.023. Sepsis was 1.4 (1.1, 1.8) times more likely, p=0.007. Pneumonia was 2.0 (1.0, 3.9) times more likely, p=0.037. LOS for <35 wk (57±45 days) was longer vs. ≥35 to <37 wk GA (42±32 days), p<0.001. No difference in rates of wound infection, post-procedural hemorrhage, or procedure-specific complications were detected.

Conclusion: On a comparison of gastroschisis repairs performed for infants born at full- or pre-term, complications rates are higher for infants born at <35 wk vs. ≥35 to <37 wk GA. Procedure-specific complications however, were higher for infants born at ≥37 wk vs. ≥35 to <37 wk GA. Risk-adjusted analyses will provide further detail regarding the relationship between GA and outcomes after gastroschisis repair. 
 

83.07 Pressure Ulcer Formation in Pediatric Patients on Extracorporeal Membranous Oxygenation

Posted on January 26, 2017

S. Tam1, A. Mobargha2, J. Tobias3, C. Schad4, S. Okochi1, A. Shakoor1, W. Middlesworth1, V. Duron1  1New York Presbyterian Hospital,New York, NY, USA 2Copenhagen University Hospital,Copenhagen, -, Denmark 3Columbia University College Of Physicians And Surgeons,New York, NY, USA 4Morgan Stanley Children’s Hospital of New York,New York, NY, USA

Introduction:
Critically ill pediatric patients have been shown to be at risk for pressure ulcers similar to adult patients. Associated with this are increased morbidity and length of stay, decreased quality of life, and increased hospital costs. While the incidence of pressure ulcers in patients in pediatric intensive care unit patients has been studied, there are virtually no studies addressing pressure ulcers in pediatric patients on extracorporeal membraneous oxygenation (ECMO).

Methods:
The charts of patients 21 years and younger who underwent ECMO from November 2009 to November 2015 at our Tertiary Care Children’s Hospital were analyzed. All patients developed a pressure ulcer either during their ECMO run or within 7 days of decannulation according to nursing documentation. All data was collected and de-identified from the institution’s electronic medical record. Variables of interest included type of ECMO – venovenous (VV) or venoarterial (VA), amount volume of crystalloid and blood products received during the first 7 days or during the length of the ECMO run, albumin and lactate levels on the day of ulcer formation, and whether patients were on vasopressor supportreceived steroids.

Results:
From November 2009 to November 2015, 204 patients were placed on ECMO and 10% (20) developed a pressure ulcer during their ECMO run or within 7 days of decannulation. The average age of patients was 110 ± 86 months and 60% were male. The average body surface area was 1.1 ± 0.8 m2. Most patients were placed on venoarterial (VA) ECMO (85%) and the average length of the ECMO run was 460 ± 360 hours. A majority of the decubitus ulcers were stage I (40%) and stage II (35%). Patients received a mean of 4337 ± 2609 mL of crystalloid and 4337 ± 4727 mL of blood products during the first 7 days of their ECMO run. Mean albumin on the day of ulcer formation was 3.3 ± 0.5 g/dL and lactate was 1.1 ± 0.5 mmol/L. A majority of patients were on vasopressor support during their ECMO run (70%). 

Conclusion:
This is the only observational study to date evaluating pressure ulcer formation in pediatric patients receiving ECMO. These patients are at risk of pressure ulcer formation due to their prolonged immobility and critical illness. This baseline analysis emphasizes the need for further studies identifying which risk factors are associated with ulcer development in pediatric patients on ECMO. 
 

83.06 Appropriateness and Attitudes Regarding Frozen Section Utilization in a Tertiary Children’s Hospital

Posted on January 26, 2017

F. Hebal1, M. Browne2, P. Chou1,3, N. Wadhwani1,3, M. Reynolds1,3  1Ann & Robert H Lurie Children’s Hospital Of Chicago,Pediatric Surgery,Chicago, IL, USA 2Lehigh Valley Children’s Hospital,Pediatric Surgery,Allentown, PA, USA 3Northwestern University,Feinberg School Of Medicine,Chicago, IL, USA

Introduction: Frozen Section (FS) is an essential tool that can guide intraoperative decisions directly affecting the methods and endpoint of an operation. FS analysis, however, is a multistep process prone to technical error and errors in communication. Given the technical quality of FS compared to permanent section, discordance rates between FS and final diagnosis reported in previous studies ranges from 1.4-12.9%. The potential consequences to surgical care warrants review of intraoperative FS an important component of an institution’s quality assurance process. The purposes of this study were to assess FS utilization and attitudes regarding FS of pediatric surgeons and pathologists at a stand-alone pediatric tertiary care center.

Methods: We queried hospital EMR to identify FS ordered between June 2013 and June 2014 for patients of any age. Patient medical records were reviewed to identify operative surgeons and pathologists surveyed to assess attitudes regarding FS utilization, discordance between FS and permanent section results, and communication between pathologist and surgeon. Cohen's κ  was run to determine agreement between pathologist and surgeon responses.

Results: A total of 217 FS (205 patients) were identified. Of these, 20 mislabeled FS in query, and 12 incomplete surveys were excluded, leaving 185 FS (174 patients) for analysis. Of these, the majority were in Neurosurgery 77(42%) and Pediatric Surgery 76(41%), with remaining specialties accounting for 32(17%). Pathologists felt FS a) did not impact surgical procedure in 63(34%), b) differed from final pathology in 3(2%), and c) was unnecessary in 46(25%) of cases. Surgeons felt FS a) did not impact surgical procedure in 67(36%), b) differed from final pathology in 55(30%), and c) was unnecessary in 61(33%). Analysis showed minimal-to-no agreement between pathologist and surgeon responses. Additionally, surgeons felt FS did not affect outcome in 95(51%), and verbal FS results differed from written FS results in 25(14%) of cases. Survey and analysis summarized in Table 1.

Conclusion: Effective communication and consensus between pathologist and surgeon is crucial to successful FS use in the course of surgical care. Our study demonstrates marked difference between pathologist and surgeon attitudes regarding utilization, reported results, and necessity of FS. Intraoperative FS results given verbally in OR may have contributed to discrepancy between final pathology (as perceived by surgeons) and FS (as reported by pathologists). Notably, a 21% decrease in FS orders in the year following this study may suggest a practice change in surgeon participants. Further investigation is necessary to address these findings and impact on patient outcomes.

83.05 A Review of the Treatment of Splenic Cysts at Children's Medical Center

Posted on January 26, 2017

J. Hassoun1,2, O. Gezzer3, F. Qureshi1,2  3Howard University College Of Medicine,Washington, DC, USA 1Children’s Medical Center,Dallas, Tx, USA 2University Of Texas Southwestern Medical Center,Dallas, TX, USA

Introduction The management of non-parasitic splenic cysts in children is unclear. Options include partial or total splenectomy and rarely percutaneous aspiration and sclerotherapy. The aim of this study is to assess the outcomes of these interventions.

 

Methods Retrospective review of patients <18 years with splenic cysts (2009-2016) at a major children’s hospital was performed after IRB approval. Demographics, mode of intervention and outcome data were collected. Due to the small numbers, statistical analysis was limited.

 

Results 42 patients were identified and initial management was as follows: 32 observation alone, 10 underwent intervention (4 aspiration and sclerotherapy, 6 resection). Age (yrs) was higher for intervention than observation (p=0.004, table 1). Incidental finding was the most common presentation for patients that were observed (n=30; 100%, p<0.001) and abdominal pain for intervention groups: aspiration and sclerotherapy (n=3; 75%, p=0.16), resection (n=5; 83%, p=0.05). Cyst size (cm) was larger for intervention than observation (p<0.001, table 1).

Follow up was available for 20 of the 32 observed children, 18 requiring no intervention. 2 patients failed observation and required aspiration and sclerotherapy, one at 5 months and one at 3.5yrs due to persistence of symptoms and size increase, respectively. Of the 6 children who underwent aspiration and sclerotherapy; 2 patients underwent 1 round of sclerotherapy, 2 had multiple planned rounds and 2 required multiple additional unplanned rounds of sclerotherapy. 2 patients failed sclerotherapy and underwent resection. For the 8 children who underwent resection, procedures included open splenectomy (n=2), laparoscopic partial (n=2), or complete splenectomy (n=1) and laparoscopic cystectomy (n=3). Cysts were histologically identified as epithelial (n=4), mesothelial (n=2), pseudocyst (n=1), and unknown (n=1). One small recurrence was noted in 5 of 8 patients who followed up. Based on the number of cases, statistical significance could not be computed for recurrence rate. However, aspiration and sclerotherapy required more interventions and failed more often than resection patients.

 

Conclusions Observation of splenic cysts is an appropriate management strategy for small asymptomatic splenic cysts.  Percutaneous aspiration and sclerotherapy is associated with a higher rate of recurrence while surgical resection is associated with lowest recurrence rates and should be considered for patients with large or symptomatic cysts.

83.04 An Analysis of the Online Reputations of New England Pediatric Surgeons

Posted on January 26, 2017

K. Ashok1, P. Chang2,3  1New York University,New York, NY, USA 2University Of Cincinnati,Surgery,Cincinnati, OH, USA 3Shriners Hospitals For Children-Cincinnati,Cincinnati, OH, USA

Introduction:

Physician rating websites are quickly gaining popularity. Patients are increasingly using online information to read reviews and ratings in order to choose which physician to seek care from.  Previous studies have examined the online reputation of primary care specialists.  The goal of this investigation is to find how pediatric surgeons in New England are rated and describe the online comments found on the most popular rating websites.

Methods:

HealthGrades.com, RateMDs.com, Vitals.com, UCompareHealthCare.com, and doctors.WebMD.com were chosen from those used in similar studies. The APSA website directory was consulted to find names, locations of operation, and institutions of the 77 pediatric surgeons in New England. The average rating, range, number of ratings, and comments were also logged. The overall number of ratings and weighted averages were calculated. If the doctor did not have any entries on any website, this doctor was excluded from the group averages.

Results:
Vitals.com was the most robust site, with 61 profiles. HealthGrades and UCompareHealthCare were also robust, with 57 and 35 profiles respectively. WebMDs was sparse, with only six ratings. No doctor had any average aggregate ratings below 4 out of 5. However, about one third of the surgeons had at least one rating below 4.  26.0% of the doctors had ratings from 1 to 5, 3.90% had ratings from 2-5, one doctor had a rating of 1, one had ratings from 3-5, and one had ratings from 2.5-5.  

Positive comments included "Very professional" and "THE best pediatric surgeon."  Negative comments included "arrogant butcher", "wouldn't send a dog to be treated by him."

Conclusions:
Average ratings for the pediatric surgeons were for the most part very high (> 4) on average.  However, the average number of ratings was low for the vast majority of surgeons for most of the sites examined.  The comments left on the sites tended toward hyperbole but could emotionally affect potential patients seeking information about their prospective surgeon.  Pediatric surgeons need to be aware of their online reputation.
 

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