73.09 Resident Involvement and Outcomes after Surgery: A Double Edge Sword

Posted on January 18, 2018

M. Zeeshan1, M. Hamidi1, A. Tang1, E. Zakaria1, N. Kulvatunyou1, A. Jain1, L. Gries1, T. O’Keeffe1, B. Joseph1  1University Of Arizona,Tucson, AZ, USA

Introduction:
Diverticular disease is one of the leading causes for outpatient visits and hospitalizations. Resident participation in surgical procedures is essential for training. However, there is paucity of data regarding the outcomes after resident involvement in surgical procedures for diverticulitis. The aim of our study was to determine if the resident participation in surgery correlates with outcomes for patients undergoing surgical procedures in diverticulitis.

Methods:
We analyzed the National Surgical Quality Improvement Program database (2005-2012). We included all patients who had diagnosis of diverticular disease and underwent surgical management. Patients were stratified into two groups based on presence of resident during surgery: attending alone (No-RES) vs. attending with resident (RES). Groups were matched using propensity score matching for demographics, surgical procedure, morbidity probability and comorbidities. Outcomes of interest were compared for patients with and without resident participation in surgery (RES vs no-RES). We performed a sub-analysis of RES group by dividing it into junior (PGY 1-3), and senior residents (PGY 4-5), and fellows (PGY ≥ 6).

Results:
26,172 patients met the inclusion criteria, of which 6912 (3456: No-RES, 3456: RES) were matched. Mean age was 58.8 ± 14.3 years, and 46.7% were males. There was no difference in mortality in both groups (p=0.58), however, overall 30-d complication rates were higher in RES group (18% vs. 15.1%, p<0.01). Operative time (OR time) was longer in the RES group (175 min vs. 142 min, p<0.01), while there was no difference of hospital length of stay (HLOS) between the two groups (p=0.17). Table 1 shows the sub analysis based on level of residency. Mortality rate was highest in senior residents (p<0.01), while operative time was highest in operation performed by fellows (p<0.01).

Conclusion:
Resident involvement in surgical management of diverticulitis increases the rate of complications without an increase in mortality. Resident involvement is an important component of surgical residency. Identifying the factors and increased supervision by attendings may lead to improved outcomes. 
 

73.10 Management of Acute Cholecystitis with Significant Risk of Common Bile Duct Stone:The ‘SaFE’ Approach

Posted on January 18, 2018

K. O. Memeh1, S. Jhajj1, K. Tran1, R. A. Berger1,2, T. S. Riall1, A. Aldridge1,2  1University Of Arizona,Surgery,Tucson, AZ, USA 2Flagstaff Medical Center,Surgery,Flagstaff, AZ, USA

Introduction:

About 3-8% of acute calculous cholecystitis (ACC) present with common bile duct stone (CBDS). The 2010 American Society of Gastrointestinal Endoscopy (ASGE) and the 2016 World Society of Emergency Surgery (WSES) guideline on the management of gallstone with significant risk(high risk[HR] and intermediate risk[IR]) of CBDS recommend pre-operative imaging and ERCP for patient with IR and HR for CBDS respectively. Our group adopted a different approach; primary laparoscopic cholecystectomy (LC) with intraoperative cholangiogram (IOC) for all patients HR and IR for CBDS, and then proceed with intra-operative ERCP (IOERCP) for patients with positive IOC, with the intention of reducing length of stay (LOS) and hospital cost (HoC) without negatively impacting outcome.We believe that this approach is Safe, Fast and cost Effective ( ‘SaFE’) and we thus review the outcome of the ‘SaFE’ approach and compares it with the traditional (ASGE/WSES guided) approach.

Methods:

We retrospectively reviewed the medical record of consecutive patients, 18 years and older presenting with ACC with significant risk for CBDS who underwent LC + IOC +/- IOERCP between Jan 2015 and Feb 2017 in our institution. Patients with cholangitis and pre-operative imaging suggestive of CBD mass (other than stone) were excluded. Patients were stratified into ASGE Intermediate risk (ASGE-IR) and ASGE High risk (ASGE-HR) for CBDS based on the published ASGE criteria. We reviewed pre-operative liver function test, total bilirubin and imaging.Complications( cystic duct leak, post ERCP pancreatitis) and hospital charges (HoC) were evaluated. The student t-test was utilized to analyse difference in LOS when compared to similar patients managed prior to the implementation of the SaFE approach.

Results:

A total of 568 patients presented with ACC and suspicion for CBDS, hence had LC + IOC. IOERCP was performed for positive IOC in 87(15%) patients. Of the 87 patients, 34(39%) was ASGE-HR for CBDS.Medain pre-op T bil was 4.1 and 0.8 for ASGE HR and IR respectively.2 IR patients had negative IOERCP. Average LOS was 1.8 days for both HR and IR patient groups. There was no cystic duct leak and no conversion to open cholecystectomy in any of the 87 patients. Two (1 patient per group) had mild post ERCP pancreatitis. Mean HoC was $10,099 per patient.Prior to implementing the SaFE approach( i.e using the  ASGE/WSES guideline),similar cohort of patients had an average LOS of 3.4 days( p < 0.000) , and mean HoC of $14,320 a diffence of $2,941 with estimated cost saving of $255,867 in the 2 year period.

Conclusion:

Our findings suggest that ACC patients who are ASGE-HR, WSES- HR, and ASGE-IR for CBDS could be managed similarly using the ‘SaFE’ approach with significant reduction in both LOS and HoC without any increase in procedure-related morbidity. 

 

 

 

 

 

 

73.07 Trends in Mortality and Cardiac Complications in Major Abdominal Surgery by Operative Volume.

Posted on January 18, 2018

Y. Sanaiha1, Y. Juo1, K. Bailey1, E. Aguayo1, A. Iyengar1, V. Dobaria1, Y. Seo1, B. Ziaeian2, P. Benharash1  1David Geffen School Of Medicine, University Of California At Los Angeles,Cardiac Surgery,Los Angeles, CA, USA 2David Geffen School Of Medicine, University Of California At Los Angeles,Cardiology,Los Angeles, CA, USA

Introduction:

Cardiovascular complications are the leading cause of death following noncardiac surgery. Major abdominal operations represent the largest category of procedures considered to have elevated risk of cardiovascular complications. The current aim was to examine trends in the incidence of mortality, postoperative myocardial infarction, and cardiac arrest after major abdominal operations and to determine the presence of potential volume-outcome relationships. 

Methods:
We performed a retrospective analysis of the Nationwide Inpatient Sample (NIS) for patients having elective open gastrectomy, pancreatectomy, nephrectomy, splenectomy, and colectomy (major abdominal surgery: “MAS”) during 2008-2014. Chi-squared analysis was used to compare demographic and hospital characteristics between groups. Logistic regression was performed to determine predictors of in-hospital mortality, postoperative cardiac arrest (POCA) and myocardial infarction (POMI).  

Results:
Of the 1,300,794 patients undergoing MAS, 49,589(3.70%) experienced in-hospital mortality, 16,542 (1.24%) POMI, and 9,496 (0.76%) POCA. The annual all-cause mortality and POMI rates remained stable while the incidence of POCA steadily rose.  Average Elixhauser score also increased from 1.8 to 2.2 during this study period. Odds of mortality were significantly lower for medium and large volume hospitals compared to small volume hospitals after adjustment (Table). Hospital operative volume did not significantly impact the odds of POMI or POCA. In contrast, larger hospital bedsize was associated with higher odds of mortality and POCA. Subgroup analysis demonstrated lower odds of mortality with higher operative volume over 2008-2014 for all operations except for splenectomy. Significant risk factors for POMI/POCA included age > 65, peripheral vascular disease, and congestive heart failure, while female gender and higher income quartile had decreased odds of these complications (P<0.02). 

Conclusion:
The rate of POCA amongst patients having MAS has increased in the US without a concomitant rise in POMI or mortality. Hospital operative volume appears to reduce odds of postoperative mortality over the entire study period. The effect of operative volume on rate of postoperative cardiac complications is not consistent over time as odds of POCA are significantly lower for higher volume hospitals only in 2008-2011 population. Operative volume does not significantly impact risk of POMI or POCA in the 2012-2014 subgroup. Increased odds of mortality and POCA at larger hospitals by bedsize could reflect patient or hospital factors that are not well represented in NIS. Non-ischemic causes of POCA need further investigation to delineate opportunities for quality improvement. 
 

73.08 Local Referral of High-Risk Patients to Reduce Surgical Costs

Posted on January 18, 2018

M. Smith1,2, U. Nuliyalu2, S. P. Shubeck1,2,3, J. B. Dimick1,2, H. Nathan1,2  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,Center For Healthcare Outcomes & Policy,Ann Arbor, MI, USA 3University Of Michigan,National Clinician Scholars Program,Ann Arbor, MI, USA

Introduction: Improving the value of healthcare delivery is a major focus of healthcare reform. Previous studies have documented substantial cost savings for surgical care delivered in high quality hospitals, with particularly large cost differences for high-risk patients. Practically, shifting high-risk patients to high-quality hospitals must be done within small geographic areas. We sought to determine the availability of high-quality hospitals, the distribution of high-risk patients, and the potential benefit of referral of high-risk patients for surgery within small geographic areas.

Methods: Using 100% Medicare claims data for 2012-2013, we identified elderly patients undergoing elective colectomy (Col), lung resection (Lung), total hip arthroplasty (THA), and total knee arthroplasty (TKA). Risk- and reliability-adjusted hospital rates of serious complications were assessed using a hierarchical logistic regression model, and hospitals were grouped into quintiles; lowest complication rate = high quality. A similar model was used to stratify patients into quintiles of high and low risk for complications. Price-standardized, risk-adjusted Medicare payments were calculated for the entire “surgical episode” from index admission through 30 days after discharge. The geographic units of analysis were Metropolitan Statistical Areas (MSAs), which consist of a relatively high population density (≥50,000) and include surrounding areas that roughly mirror typical commuting distances.

Results: The proportion of MSAs containing a high quality hospital ranged from 47% (Lung) to 58% (THA). A minority of MSAs contained both a high quality and low quality hospital (n=79, 22% Lung; 118, 30% Col; 120, 31% TKA; 122, 32% THA). In these MSAs, 25% of high-risk patients received care at the lowest quality hospitals (TKA 23%, THA 24%, Lung 26%, Col 27%), and 38% of high-risk patients were treated at high quality hospitals (34% Col, 38% TKA, 39% Lung, 39% THA). There was wide variation in costs between high and low quality hospitals within MSAs, and this difference was particularly large for high-risk patients (Figure). Referral of a high-risk patient from a low to high quality hospital within a MSA would generate an average savings of $13,840 for Lung ($31,659 vs $45,499), $8,981 for Col ($29,230 vs $38,211), $2,583 for THA ($20,954 vs $23,537), and $1,936 for TKA ($19,992 vs $21,928, all P <0.001).

Conclusion: In small geographic areas containing high and low quality hospitals, 25% of high-risk patients received care at the lowest quality hospitals. Triaging of high-risk patients to high quality hospitals within small geographic areas may serve as a template for strategic local referral as a means of reducing costs in Medicare.

73.05 Surgical Coaching Relationships: Early Evidence from the Michigan Bariatric Surgical Collaborative

Posted on January 18, 2018

S. P. Shubeck1,2,3, A. E. Kanters1,2, G. Sandhu1, C. C. Greenberg4,5, J. B. Dimick1,2  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,Center For Healthcare Outcomes & Policy,Ann Arbor, MI, USA 3University Of Michigan,National Clinician Scholars Program,Ann Arbor, MI, USA 4University Of Wisconsin,Department Of Surgery,Madison, WI, USA 5University Of Wisconsin,Wisconsin Surgical Outcomes Research Program,Madison, WI, USA

Introduction: There has been an increased focus on building effective surgical coaching programs for practicing surgeons to develop their technical skills. In this context, we sought to evaluate early coaching conversations in the Michigan Bariatric Surgery Collaborative compared to existing models for effective surgical coaching.

Methods: This qualitative study evaluated 10 video coaching conversations between 20 bariatric surgeons at the Michigan Bariatric Surgery Collaborative meeting in October 2015. Using grounded theory approach, the coaching encounter transcripts were coded in an iterative process with comparative analysis in order to identify emerging themes. For this analysis, we focused on the dynamics between participants and content of coaching conversations.

Results: Two major themes emerged in our analysis when comparing early coaching conversations to existing models. (1) While the roles of coach and coachee were defined before the coaching exercise, participants often did not adhere to assigned roles. For example, there were repeated instances in these interactions when a coach would defer to the coachee, indicating they felt less qualified in a particular technique or procedure. (2) The coaching conversations tended to have limited direct coaching, but rather an emphasis on bidirectional exchange of ideas with both participants offering expertise when appropriate. For example, the coach and coachee frequently engaged in back and forth conversation about specific techniques, instrument selection, and decision points.

Conclusions: In early coaching conversations among bariatric surgeons in the Michigan Bariatric Surgery Collaborative, we observed a propensity for participants to gravitate toward a peer to peer dynamic. Future programs aimed at improving technical skill through surgical coaching should explicitly consider the role of bidirectional feedback. 

73.06 The True Cost of Laparoscopic Cholecystectomy with Routine Intraoperative Cholangiography

Posted on January 18, 2018

N. Cortolillo1, J. Parreco1, R. Rattan1, A. Castillo1, R. Kozol1  1University Of Miami,General Surgery Residency Program,Miami, FL, USA

Introduction:

Many prior comparisons of outcomes and costs associated with intraoperative cholangiography (IOC) have been reported. However, prior studies have been limited to initial hospitalizations or readmissions to single institutions. The purpose of this study was to compare outcomes and costs of hospitals performing routine IOC to hospitals performing non-routine IOC including readmission cost across hospitals in the US.

Methods:
The Healthcare Cost and Utilization Project’s (HCUP) Nationwide Readmission Database for 2013-2014 was queried for all patients aged 18 years or older undergoing laparoscopic cholecystectomy. Hospitals performing intraoperative cholangiography in 90% or more of cases were identified as routine and compared to non-routine hospitals. Total charges and costs were calculated according to HCUP standards. Univariable logistic regression was performed for the outcomes of interest using ten different hospital and patient variables. The variables with p<0.05 were used for multivariable logistic regression. Results were weighted for national estimates.

Results:
There were 628,280 inpatient laparoscopic cholecystectomies during the study period with 2.0% occurring in hospitals performing routine IOC. The mortality rate was 0.4%, length of stay was >7 days in 11.0%, and readmission within 30 days occurred in 6.9%. Multivariable logistic regression revealed there was no statistically significant different risk for these outcomes between routine and non-routine IOC hospitals. Table 1 shows the mean age of patients at hospitals performing routine IOC was older, but had a lower Charlson Comorbidity Index and shorter length of stay. Non-routine IOC hospitals had higher mean index total charges but lower mean index total cost. Readmission charges were similar between the groups while readmission cost was higher in routine-IOC hospitals.

Conclusion:
While outcomes are similar, non-routine IOC hospitals charge more than routine IOC hospitals. Despite this, the costs are higher in routine IOC hospitals suggesting an unnecessary cost burden placed on hospitals performing routine IOC.

73.04 Perforated Peptic Ulcer Surgery: No Difference in Mortality Between Laparoscopic and Open Repair.

Posted on January 18, 2018

V. Gabriel1, A. Grigorian1, S. Schubl1, M. Pejcinovska1, E. Won1, M. Lekawa1, N. Bernal1, J. Nahmias1  1University Of California – Irvine,Division Of Trauma, Burns & Surgical Critical Care,Orange, CA, USA

Introduction:  The lifetime prevalence of perforated peptic ulcer (PPU) in patients with peptic ulcer disease is estimated at 5%. Reported mortality rates after surgery for PPU have ranged from 1 to 24%. A recent meta-analysis by Tan et al demonstrated equivalent morbidity and mortality when comparing laparoscopic repair (LR) to open repair (OR).  However, LR was shown to have lower operative time, less pain, shorter length of stay (LOS), and a lower rate of surgical site infection. We hypothesized a decrease in morbidity and mortality with LR from 2011-2015 compared to 2005-2010. Additionally, we hypothesized a decrease in morbidity and mortality for LR versus OR for the entire duration of 2005-2015.

Methods:  Patients undergoing operative repair of PPU between 2005- 2015 were identified in the NSQIP database by CPT code. Patients with definitive acid-reducing operations were excluded. A comparison of OR from 2005-2010 versus 2011-2015 was performed. A similar comparison was performed for LR. Additionally, a comparison between LR and OR for the entire duration (2005-2015) was conducted. Primary outcomes were the differences in 30-day mortality and overall morbidity. After controlling for significant covariables such as age, American Society of Anesthesiologists class, functional status, pre-operative albumin and creatinine, steroid use, liver disease, time to surgery, and presence of malignancy, a multivariate regression analysis was performed.

Results: 5,413 patients between 2005-2015 were included in the study. From 2005-2010 there were 86 LR cases and 1,924 OR cases.  Between 2011-2015 there were 221 LR cases and 3,182 OR cases. LR demonstrated no difference in 30-day mortality or overall morbidity between the two time periods (p>0.05). There was no significant difference in 30-day mortality for patients undergoing OR between the two time periods. However, overall morbidity (odds ratio (OR), 1.99; 95% CI, 1.71-2.33, p<0.05), development of sepsis (p<0.05), and septic shock (p<0.05) were all more prevalent in patients undergoing OR from 2011-2015. Comparing LR versus OR from 2005-2015, patients undergoing LR had a shorter length of stay (p<0.05), and were less likely to exhibit failure to wean from the ventilator at 2 days (OR, 0.34; 95% CI, 0.18-0.65, p<0.05). 

Conclusion: While a 2.5% increase LR utilization was seen, there was not a decreased morbidity and mortality associated with more recent LR from 2011-2015. This may be secondary to increasing utilization of LR in more debilitated patients over time. When LR was compared to OR there was a significant decrease in LOS. Future prospective research is needed to confirm this finding and evaluate the safety of more widespread adoption of LR for PPU.

 

73.02 Percutaneous Cholecystostomy in Acute Cholecystitis – Predictors of Recurrence & Cholecystectomy

Posted on January 18, 2018

M. N. Bhatt1, M. Ghio1, L. Sadri1, S. Sarkar1, G. Kasotakis1, C. Nasrsule1, B. Sarkar1  1Boston Medical Center,Department Of Trauma And Acute Care Surgery,Boston, MA, USA

Introduction:  Acute cholecystitis (AC) is a common acute illness, with the preferred treatment being cholecystectomy. However, in high-risk patients, a less invasive option of percutaneous cholecystostomy tube placement (PC) is preferable. Patients can subsequently either undergo interval cholecystectomy (IC) or PC can be utilized as definitive treatment. Currently, there is little evidence to guide patient care after PC. We sought to demonstrate the clinical outcomes of PC and identify the predictors of recurrent disease as well as successful IC.

Methods:  A retrospective chart review of patients undergoing PC for AC between 2008 and 2016 at a single tertiary care center was performed. Basic patient demographics, laboratory & imaging findings, and patient outcomes including mortality, readmissions, hospital length of stay (LOS), Intensive Care Unit (ICU) LOS, recurrence, and IC were collected. Univariate and multivariate analyses were performed using logistic regression, Wilcoxon Rank, and multi-variable logistic regression models.

Results: Of 145 patients, 96 (67%) had calculous and 47 (33%) had acalculous cholecystitis. PCs were performed in these patients due to their high preoperative risks; 72 (49%) had chronic prohibitive risks and 73 (51%) had acute prohibitive risks. There were 55 (38%) peri-procedural complications, 44 of which were PC dislodgment. Mean duration of PC was 93 days. Recurrence rate for AC was 18%; median duration to recurrence was 65 days. Patients with calculous cholecystitis were more likely to have AC recurrence (OR = 3.24, p = 0.018), whereas length of antibiotics course or duration of PC had no significant correlation with AC recurrence. 41 (28%) patients underwent IC. Patients with acute prohibitive risks and shorter antibiotics course (≤ 7 days) were more likely to undergo IC (OR = 6.66 & 2.10, p = <0.001 & 0.048), and most were completed laparoscopically (OR = 6.84, p = <0.0001). There were only two peri-operative complications and no peri-operative mortality. Mean hospital and ICU LOS were longer for patients with acalculous cholecystitis compared to calculous (22 vs. 11 days, p = <0.0001). 30-day readmission rate was 29%. Patients with acalculous cholecystitis had higher 30-day readmission rate (OR = 2.42, p = 0.020). 30-day mortality after PC was 9%. The follow up was for 26(3-53) months and survival analysis revealed that patients receiving IC had greater survival compared to PC as a definitive option.

Conclusion: PCs are a viable option for high-risk patients with AC. Calculous cholecystitis is a strong predictor of AC recurrence after PC. A longer (>7 days) antibiotics course is not associated with lower recurrence and should be avoided. Patients undergoing IC have better overall survival. PCs, although safe, should not be considered as a definitive treatment, especially in patients with acute critical illness where a successful IC can be performed laparoscopically with minimal complications.

 

73.03 Opioid Use after Surgery among Preoperative Intermittent Users

Posted on January 18, 2018

E. Harker1, C. A. Keilin1, R. Ahmed1, C. Katzman1, D. C. Cron1, T. Yao3, H. Hu1, J. S. Lee1, C. M. Brummett2, M. J. Englesbe1, J. F. Waljee1  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 2University Of Michigan,Department Of Anesthesiology,Ann Arbor, MI, USA 3University Of Michigan,School Of Public Health,Ann Arbor, MI, USA

Introduction:  A significant number of surgical patients intermittently take opioids prior to elective surgery. Understanding the clinical trajectory of this large number of patients is critical to optimizing their care. We hypothesize that a longer duration of preoperative opioid use will be correlated with a longer duration of postoperative use.

Methods:  We used a national employer-based insurance claims dataset to identify adults age 18 to 64 who were preoperatively either opioid-naïve or intermittent opioid users and who underwent a general, gynecologic, or urologic surgical procedure between January 2010 and March 2014 (N= 309,096). We defined preoperative intermittent opioid users as patients who filled ≤120 days’ supply of opioids between 365 and 31 days before surgery. Our primary explanatory variable was preoperative opioid exposure, measured as the number of months during which an opioid prescription was filled in the year prior to surgery (opioid-naïve, 1 month, 2-3 months, 4-6 months, 7-9 months, >9 months). Our outcome was time until last postoperative opioid script (considered the date of opioid discontinuation). We used survival analysis techniques, including Kaplan-Meier curves to compute estimated proportion of patients continuing to fill opioids postoperatively.

Results: In this cohort, 27% of patients used opioids intermittently in the year before surgery, and the majority of these patients (62%) filled opioids during 1 month preoperatively. Patients with a longer duration of preoperative opioid exposure continued to fill opioids for longer durations postoperatively (Figure). Most patients discontinued opioids after the initial prescription, but the remaining patients continued filling opioids long after surgery. Compared to patients with 1 month of opioid fills preoperatively, patients with >9 months of preoperative opioid fills had a 4-fold longer adjusted mean time until opioid discontinuation (326 vs. 84 days, P<0.001). The estimated proportion of patients continuing to fill ≥1 opioid script beyond 180 days was 90% among patients with >9 months of preoperative opioid use, 23% among patients with 1 month of preoperative use, and 15% among opioid-naïve.

Conclusion: Patients who intermittently use opioids prior to surgery are particularly vulnerable to prolonged postoperative opioid use. The surgical event should be considered an opportunity to wean opioid users postoperatively. Such strategies may have significant positive impact on the overall health and wellness of these surgical patients.

72.10 Predictive Value of GEC for Thyroid Cancer after NIFTP Reclassification

Posted on January 18, 2018

A. R. Marcadis1, B. A. Shah2, D. A. Kerr2, O. Picado1, S. Liu1, J. I. Lew1  1University Of Miami,Division Of Endocrine Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA 2University Of Miami,Department Of Pathology,Miami, FL, USA

Introduction: Thyroid nodules with Atypia of Undetermined Significance/Follicular Lesion of Undermined Significance (AUS/FLUS, Bethesda III) on fine needle aspiration (FNA) pose a management dilemma for clinicians, and molecular assays have been developed in order to better predict thyroid malignancy or benignity. The Gene Expression Classifier (GEC) is one commonly used molecular test, with suspicious results corresponding to a 40% malignancy risk. Recently, encapsulated, non-invasive follicular variants of papillary thyroid carcinoma were reclassified as benign Non-Invasive Follicular Thyroid neoplasms with Papillary-like nuclear features (NIFTP). With this reclassification, such neoplasms previously considered malignant are now benign, which may alter the positive predictive value (PPV) of suspicious GEC results for malignancy. This study examines the impact of NIFTP reclassification on the PPV of GEC for thyroid malignancy.

Methods:  A retrospective, single-institution review of 75 surgical patients with AUS/FLUS thyroid cytology and suspicious GEC was conducted. For all patients, preoperative neck ultrasound and FNA reports were reviewed, and the lobe (right/left/isthmus), location (upper/middle/lower), and size of the suspicious thyroid nodule were correlated with final pathology. All encapsulated, non-invasive follicular variants of papillary carcinoma were re-evaluated by an endocrine pathologist and re-classified as NIFTP when appropriate. The PPV of GEC for malignancy in AUS/FLUS thyroid nodules was calculated both before and after NIFTP reclassification.   

Results: Of the 75 patients with AUS/FLUS thyroid nodules and suspicious GEC results, 61 (81%) were female, and 14 (19%) were male. 58 (77%) underwent total thyroidectomy, while 17 (23%) underwent thyroid lobectomy. On final pathology of the GEC suspicious nodule, 7 patients (9.3%) had encapsulated non-invasive follicular variants of papillary thyroid carcinoma which on pathology re-review were classified as NIFTP. The other 68 patients had final pathology which did not change after NIFTP reclassification; 25 of whom (33%) had malignancy (21 papillary thyroid cancer, 3 follicular thyroid cancer, 1 papillary microcarcinoma), and 43 (57%) of whom had benign pathology. Before NIFTP reclassification, the PPV for malignancy in AUS/FLUS nodules with suspicious GEC was 42% (32/75 malignant), whereas after NIFTP reclassification, the PPV was 33% (25/75 malignant). This decrease in PPV for malignancy after NIFTP reclassification was not statistically significant (p >0.05).

Conclusion: NIFTP reclassification as a benign thyroid neoplasm lowers, but does not cause a statistically significant change in the PPV of suspicious GEC results for malignancy in AUS/FLUS thyroid nodules. Surgeons and other clinicians should take this into consideration when evaluating AUS/FLUS thyroid nodules with suspicious GEC results. 

73.01 A 3 year Follow-up of Nonoperative Management in Ventral Hernia Patients With Comorbidities

Posted on January 18, 2018

K. Bernardi1, J. L. Holihan1, D. V. Cherla1, J. R. Flores1, L. S. Kao1, T. C. Ko1, M. K. Liang1  1University Of Texas Health Science Center At Houston,General Surgery,Houston, TX, USA

Introduction:
Individuals with comorbid conditions (e.g. obesity or smoking) are not only at increased risk to develop a ventral hernia but are at markedly increased risk for complications (including recurrence) following repair.  There is limited high-quality prospective data on the safety and efficacy of non-operative management of patients with ventral hernias.  Our objective was to determine the long term clinical and patient reported outcomes of non-operative management of patients with comorbidities also suffering from ventral hernias.
 

Methods:
This is the 3-year follow-up to a prospective observational single institution study of patient with comorbidities and ventral hernias.  Patients were contacted by phone to complete a standardized interview. Primary outcome was proportion of patients who underwent urgent or emergency surgery. Secondary outcomes were the change in quality of life (QoL) from their baseline interview and proportion of patients undergoing elective or emergent repair.  QoL was measured utilizing the modified activities assessment scale (AAS), a validated, hernia-specific QoL survey.  The minimal clinically important difference was considered a change of 7 points on a scale of 1-100 where 1=poor QOL and 100=perfect QOL.
 

Results:
Overall, 60 patients were followed to completion (Table below).  At the end of 3 years, 3 (5%) patients had died due to non-hernia related causes, 16 (26.7%) patients had at least one emergency room visit related to their hernia, 4 (6.7%) patients underwent urgent/emergent ventral hernia repair, and 15 (25%) patients underwent elective ventral hernia repair.  On average, non-operatively managed patients experienced no change in their QoL, while those who crossed over to operative management experienced a substantial improvement in their QoL.
 

Conclusion:
Non-operative management for patients with ventral hernias appears to be safe; however, there was a substantial crossover to operative intervention. For most patients who successfully completed non-operative management, their QoL did not change over 3 years.  On the other hand, patients who underwent ventral hernia repair had a major improvement in their QoL.

72.07 5-factor replacement index for the 11 factor modified frailty index in NSQIP

Posted on January 18, 2018

S. Subramaniam1, J. J. Aalberg1, R. P. Soriano2, C. M. Divino1  1Icahn School Of Medicine At Mount Sinai,Division Of General Surgery, Department Of Surgery,New York, NY, USA 2Icahn School Of Medicine At Mount Sinai,Department Of Geriatrics And Palliative Medicine,,New York, NY, USA

Introduction:  The modified frailty index (mFI-11) is a NSQIP based 11-factor index that has been proven to adequately reflect frailty and predict mortality and morbidity. These 11 factors, made of 16 variables, map to the original 70 item Canada Study of Health and Aging Frailty Index. In the past years, certain NSQIP variables have been removed from the database; as of 2015, only 5 out of the original 11 factors remain. The predictive power and usefulness of these five factors in an index (mFI-5) have not been proven in past literature. The goal of our study was to compare the mFI-5 to the mFI-11 in terms of value and predictive ability for mortality, post-operative infection and unplanned thirty-day readmission for future research and clinical use. 

Methods: The mFI-5 is made up of the following factors: functional status, diabetes, history of COPD, hypertension, and history of CHF and was calculated by dividing the number of  factors present for a patient by the number of available factors for which there were no missing data. Spearman’s Rho was calculated in order to compare mFI-5 and mFI-11 value. Predictive models, using both unadjusted and adjusted logistic regressions were created for each of the three chosen outcomes using 2012 NSQIP data, the last year all mFI-11 variables existed. Adjusted models were controlled for ASA classification, wound class, age, transfer status, surgical complexity represented by RVU, inpatient status, anesthesia type, and emergency type. Both adjusted and unadjusted models using mFI-5 were run on 2015 data to validate results. All above methods were conducted for the following nine surgical subspecialties including general surgery, cardiac surgery, neurosurgery, gynecology, orthopedics, otolaryngology, plastic surgery, thoracic surgery, urology, vascular surgery and then completed for all surgical subspecialties combined

Results: Correlation between the mFI-5 and mFI-11 were above 0.9 across all surgical specialties except for cardiac and vascular surgery. Adjusted and unadjusted models showed similar C-statistics for mFI-5 and 11 and strong predictive ability for mortality and post-operative complications. Predictive value for thirty day readmission was weak for both the mFI-11 and the mFI -5. 

Conclusion:The mFI-5 is an equally effective predictor as the mFI-11 in all subspecialties and is a strong predictor of mortality and post-operative complication. It has credibility for future use to study frailty within the NSQIP database. It also has potential in other databases and for clinical use.    

 

72.08 Laparoscopic Gastropexy in Elderly Patients with Large Paraesophageal Hernias

Posted on January 18, 2018

A. D. Newton1, D. A. Herbst1, K. R. Dumon1, D. T. Dempsey1  1Hospital Of The University Of Pennsylvania,Surgery,Philadelphia, PA, USA

Introduction: The optimal technique for paraesophageal hernia (PEH) repair has been debated. For the past several years, our surgical treatment algorithm for elderly patients with large symptomatic PEH has been formal laparoscopic repair if gastroesophageal reflux (GER) symptoms predominate, and laparoscopic anterior gastropexy alone if mechanical symptoms predominate. Our goal was to evaluate outcomes with this approach.

Methods: We retrospectively reviewed all first-time operations for large PEH (40% or more intrathoracic stomach) in patients ≥ age 65 performed by a single attending surgeon from 2011-2016. Primary outcome measures were perioperative morbidity and mortality, presence of herniated stomach or GER on upper gastrointestinal radiograph (UGI) 3 months postop, and subjective symptom improvement.

Results:  A total of 83 patients (mean age 76.9 years, 84% female) had a primary laparoscopic operation for large PEH (type 3, n=75; type 4, n=8). Thirty patients had formal repair (sac removal, posterior crural repair, partial fundoplication, gastropexy) and 53 had gastropexy alone. There were no open or esophageal lengthening operations and one 30-day reoperation. Median intrathoracic stomach percentage was 50% vs. 90% for formal repair vs. gastropexy. Mean operative time was 161.7 vs. 100.6 minutes (P<0.0001) for formal repair vs. gastropexy, and mean postoperative length of stay was no different (2.6 vs. 2.8 days). ASA was ≥ 3 for 53% vs. 70% (P=0.133) for formal repair vs. gastropexy. Overall 90-day morbidity was 15.7% (16.7% with formal repair vs. 15.1% with gastropexy, P=0.85). There was one post-discharge 30-day mortality. On UGI 3 months postop, one patient (3%) had > 10% of stomach above the diaphragm after formal repair compared to 59% after gastropexy (P<0.001), and 69% had demonstrable GER on UGI after gastropexy compared to 24% after formal repair (P<0.001). However, 71% were asymptomatic and 98% had improvement in preop symptoms after gastropexy; 76% were asymptomatic and 92% had improvement in preop symptoms after formal repair.

Conclusion: Laparoscopic gastropexy alone is a reasonable treatment for large PEH in elderly patients with predominately mechanical symptoms while formal repair gives good results when GER symptoms predominate. Esophageal lengthening is unnecessary in most patients. Postop UGI findings often do not correlate with clinical symptoms in this group.

72.09 Clinical Significance of NQO1 in Non-neoplastic Squamous Epithelium of Esophageal Cancer Patients

Posted on January 18, 2018

Y. Muneoka1, H. Ichikawa1, S. Kosugi2, T. Hanyu1, T. Ishikawa1, Y. Kano1, N. Sudo1, M. Nemoto1, Y. Shimada1, M. Nagahashi1, J. Sakata1, T. Kobayashi1, H. Kameyama1, T. Wakai1  1Niigata University Graduate School Of Medical And Dental Sciences,Division Of Digestive And General Surgery,Niigata, NIIGATA, Japan 2Uonuma Institute Of Community Medicine, Niigata University, Medical And Dental Hospital,Department Of Digestive And General Surgery,Niigata, NIIGATA, Japan

Introduction:  NAD(P)H:quinone oxidoreductase-1 (NQO1) is an antioxidant protein. Low expression of NQO1 contributes to high response to anticancer agents, particularly to oxidative stress inducers such as cisplatin (CDDP) or 5-fluorouracil (5-FU) in malignant tumors. It was reported that NQO1 expression is constitutively reduced in non-neoplastic esophageal squamous epithelium of patients with single nucleotide polymorphism of NQO1 (C609T). The aim of this study is to elucidate the clinical significance of NQO1 expression in the non-neoplastic squamous epithelium of patients with esophageal squamous cell carcinoma (ESCC) who underwent preoperative chemotherapy with CDDP and 5-FU (CF) followed by a radical esophagectomy.

Methods:  We retrospectively analyzed the cases of 43 patients who underwent preoperative chemotherapy with CF followed by a radical esophagectomy for ESCC between 2001 and 2012. NQO1 expression in non-neoplastic squamous epithelium of the surgically resected specimens were examined by immunohistochemistry. The expression was defined as negative when basal cells and vascular endothelial cells were not stained with anti-NQO1 antibody. We analyzed the associations between NQO1 expression and the patient demographics, tumor characteristics, histological response to CF therapy, and relapse-free survival. The median follow-up period of the relapse-free patients was 51 months.

Results: Twenty-two patients (51%) had non-neoplastic squamous epithelium with negative NQO1 expression (NQO1-negative patients). No histological evidence of primary tumor or pathological T1 (pT1) tumor was more frequent in NQO1-negative patients than in NQO1-positive patients (41% vs. 5%; P < 0.01). Overall, downstaging of the primary tumor was achieved in 46% of NQO1-negative patients and in 10% of NQO1-positive patients (P = 0.02). There was no significant difference in the histological response to preoperative CF therapy between the two groups. The three-year relapse-free survival of NQO1-negative patients was significantly better than that of NQO1-positive patients (76% vs. 48%, P = 0.02). Other significant prognostic factors were pT, pN, and lymphovascular invasion in a univariate analysis. Multivariate analysis demonstrated that negative NQO1 expression (hazard ratio [HR], 0.30; 95% confidence interval [CI], 0.10-0.92; P = 0.04) and lymphovascular invasion (HR, 4.39; 95%CI, 1.43-13.5; P = 0.04) were independent prognostic factors.

Conclusion: NQO1 expression in non-neoplastic squamous epithelium of ESCC patients could be a promising biomarker to predict treatment outcomes after preoperative CF therapy followed by a radical esophagectomy.

 

72.05 Identifying Predictors of Prolonged Levothyroxine Dose Adjustment After Thyroidectomy

Posted on January 18, 2018

T. S. Atruktsang1, J. R. Imbus1, N. A. Zaborek1, D. F. Schneider1  1University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction:

Synthroid (levothyroxine) is one of the most prescribed drugs in the US. Despite its widespread use, and multiple dosing schemes, many patients struggle to achieve euthyroidism after thyroidectomy and suffer symptoms of hyper- or hypothyroidism. The purposes of this study are to describe time required for dose adjustment prior to achieving euthyroidism and to identify predictors of prolonged dose adjustment (PDA+) after thyroidectomy.

 

Methods:

This is a retrospective cohort study of patients from a single institution who achieved euthyroidism between 2007 and 2017 after undergoing total thyroidectomy or completion thyroidectomy for benign disease. Levothyroxine doses were calculated using our published BMI-based dosing algorithm; a single provider adjusted doses at 6 intervals. PDA+ was defined as needing at least 3 dose adjustments (top quartile) prior to achieving euthyroidism. We compared patient and disease characteristics of PDA+ patients to the remaining patients (PDA-) using Wilcoxon Rank Sum test or Chi-squared test where appropriate. Multivariate logistic regression was used to identify predictors of PDA+.

 

Results:

The 605 patients in this study achieved euthyroidism in a median of 116 days (range 14 – 863) and 1 dose adjustment (range 0 – 7). Only 222 (36.69%) patients were euthyroid without any dose adjustments. The 508 (83.97%) patients who were PDA- achieved euthyroidism in a median of 101 days (range 14 – 627) and 1 dose adjustment (range 0 – 2). The 97 (16.03 %) patients who were PDA+ achieved euthyroidism in a median of 271 days (range 52 – 863) and dose adjustments (range 3 – 7). PDA+ patients required more than twice the median number of days to achieve euthyroidism (271 vs. 101 days, p<0.001).

Compared to the PDA- group, the PDA+ group did not differ significantly in the proportion of patients with Graves’ disease or Hashimoto’s. However, PDA+ patients were more likely to have chronic renal insufficiency (5.2% vs. 1.6%, p=0.026). More than 3 times as many patients in the PDA+ group were taking iron (6.2% vs. 1.8%, p = 0.010). Similarly, nearly twice as many patients in the PDA+ group were taking multivitamin with minerals (22.7% vs. 11.6%, p = 0.003). When controlling for all other factors, iron supplementation (OR = 4.4, 95% C.I. = 1.43 – 13.55, p = 0.010) and multivitamin with mineral supplementation (OR = 2.4, 95% C.I. = 1.3 – 4.3, p = 0.004) were independently associated with PDA+. However, plain multivitamins were not associated with PDA+. Age, gender, preoperative thyroid disease, and co-morbidities did not independently predict PDA+. 

 

Conclusion:

After thyroidectomy at a high-volume center, achieving euthyroidism can take nearly four months. Iron and mineral supplementation are associated with PDA+. This information can be useful when counseling patients preoperatively and suggests that education about proper levothyroxine administration and interfering supplements may expedite achieving euthyroidism.

72.06 Stricter ioPTH Criterion for Successful Parathyroidectomy in Stage III CKD patients with pHPT

Posted on January 18, 2018

S. Liu1, A. Yusufali1, R. Teo1, M. Mao1, Z. F. Khan1, J. C. Farra1, J. I. Lew1  1University Of Miami Leonard M. Miller School Of Medicine,Division Of Endocrine Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA

Introduction:
The effect of altered parathormone (PTH) metabolism in renal insufficiency on intraoperative parathormone (ioPTH) monitoring during parathyroidectomy (PTX) for primary hyperparathyroidism (pHPT) remains unclear. A stricter >50% ioPTH drop with return to normal range criterion, rather than the classic >50% ioPTH drop criterion alone, may be needed to achieve optimal operative success in this patient population with renal disease. This study compares operative outcomes using classic and stricter >50% ioPTH drop criteria in patients with mild or moderate renal insufficiency undergoing PTX guided by ioPTH monitoring for pHPT.

Methods:
A retrospective review of prospectively collected data in 605 patients undergoing PTX guided by ioPTH monitoring for pHPT was performed. All patients had elevated calcium and PTH levels, with ≥6 months of follow up and a mean follow up of 45 months. Glomerular filtration rate (GFR) was estimated with the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. The National Kidney Disease Outcomes Quality Initiative (KDIGO) staging was used to define the stages of CKD based on estimated GFR (eGFR): Stage I with normal or high GFR (GFR>90 ml/min), Stage II Mild CKD (GFR= 60-89 ml/min), Stage III Moderate CKD (GFR = 45-59 ml/min). Patients with overt secondary hyperparathyroidism (CKD Stage IV and V) were excluded. Patients were further subdivided into patients with >50% ioPTH drop only criterion (classic) and patients with a >50% ioPTH drop to within normal range (<65 pg/mL) criterion (stricter). Operative outcomes including the rates of operative success, failure, recurrence, bilateral neck exploration (BNE) and multiglandular disease (MGD) were compared across the three CKD groups.

Results:
Of 605 patients, 38% (230/605) had normal renal function or stage I CKD, 44% (268/605) had Stage II CKD, and 18% (107/605) had Stage III CKD. In patients with Stage I and II CKD, there was no statistical differences in rates of operative success, failure, recurrence, BNE and MGD between patients with classic compared to those with the stricter criterion. However, in Stage III CKD patients, there was a significant difference in operative success rates between those patients who had >50% ioPTH drop alone and those who had >50% ioPTH drop and return to normal range, (92% vs. 100%, respectively, p<0.05). There was no difference in recurrence, BNE, or MGD rates in Stage III CKD patients between those who had classic >50% ioPTH drop compared to those with the stricter criterion. 

Conclusion:
PTX guided by ioPTH monitoring using the classic >50% ioPTH drop criterion is performed with the highest operative success in patients with normal renal function, Stage I, and Stage II CKD. However, in patients who have Stage III CKD, a stricter >50% ioPTH drop with return to normal range criterion may lead to improved rates of operative success, and should be used during PTX in this patient population with renal disease. 
 

72.04 Adrenal Incidentaloma Follow-up is Influenced by Patient, Radiological and Medical Provider Factors

Posted on January 18, 2018

D. I. Maher1, E. Williams1, S. Grodski1,2, J. W. Serpell1,2, J. C. Lee1,2  1Alfred Hospital,Monash University Endocrine Surgery Unit,Melbourne, VIC, Australia 2Monash University,Department Of Surgery,Melbourne, VIC, Australia

Introduction: The majority of adrenal incidentalomas (AI) are benign, although some are large, functional or malignant, and may require surgery. Therefore, all require follow-up. This case-control study aims to determine the pattern of AI follow-up in a level 1 trauma centre in Melbourne Australia, focussing on the factors that influence whether follow-up is facilitated.

Methods: Patients with CT-detected AIs between January 2010 and September 2015 at The Alfred Hospital were included. Case files were identified using a key word search of electronic CT reports. Patients were excluded if the primary purpose of the CT was to investigate adrenal disease, or if the patient had a history of known adrenal mass. Cases were assessed by two authors and reviewed for demographics, managing unit, CT indication and findings, and follow-up arrangements. To consistently determine if “follow-up” occurred, a strict definition of the term was applied. Statistical analysis using t-test, Chi-squared test and logistic regression was performed using Stata SE v14, with a p-value of < 0.05 set as significant.

Results: A total of 38 848 chest and abdominal CTs were performed in the study period, yielding 804 patients with AIs who met inclusion criteria (mean age 65, 58 % male). The mean size of AI was 23 mm. Univariate analysis demonstrated that follow-up was more likely to occur in younger patients (mean age 62 vs 66, p < 0.001); in larger lesions (mean size 26 mm vs 21 mm, p < 0.001); if the CT suggested follow-up (p < 0.001); or if the CT report suggested a diagnosis (p < 0.001). Follow-up arrangements were most likely to be made by the trauma unit (39 %, p = 0.01).

A multivariable analysis supported the significance of these findings and indicated that the CT report and managing unit strongly influence follow-up rates. When a diagnosis was suggested by the CT report, follow-up was more likely to be facilitated (odds ratio 0.63, 95 % CI 0.45 – 0.88; p < 0.01). Additionally, more cases in the follow-up group had a follow-up recommendation in the CT report (2.88, 1.95 – 4.26; p < 0.01). A large difference in the frequency of follow-up was noted between the Trauma Unit compared to other units (1.77, 1.09 – 2.89; p < 0.02). This variance is possibly due to the introduction of a dedicated adrenal lesion protocol.

Follow-up arrangements were made for 245 cases (30 %). In 36 % of these cases (N = 88) follow-up occurred at The Alfred Hospital. Seven cases (8 %) required surgical intervention. Histopathology confirmed four adrenal cortical tumours, two metastatic melanomas and one phaeochromocytoma. 

Conclusions: This study highlights that AI follow-up is often overlooked, and that approaches need to be developed to ensure that all cases receive the review they require. This study demonstrates that follow-up is influenced by patient, radiological and medical provider factors. An adrenal lesion follow-up protocol may improve follow-up rates, but requires further research.

72.03 Clinical Significance of BRAF Non-V600E Mutations in Colorectal Cancer

Posted on January 18, 2018

Y. Shimada1, Y. Tajima1, M. Nagahashi1, H. Ichikawa1, M. Nakano1, H. Kameyama1, J. Sakata1, T. Kobayashi1, Y. Takii2, S. Okuda3, K. Takabe4,5, T. Wakai1  1Niigata University Graduate School Of Medical And Dental Sciences,Division Of Digestive And General Surgery,Niigata, , Japan 2Niigata Cancer Center Hospital,Department Of Surgery,Niigata, , Japan 3Niigata University Graduate School Of Medical And Dental Sciences,Division Of Bioinformatics,Niigata, , Japan 4Roswell Park Cancer Institute,Breast Surgery,Buffalo, NY, USA 5University At Buffalo Jacobs School Of Medicine And Biomedical Sciences,Department Of Surgery,Buffalo, NY, USA

Introduction: Recent advances of comprehensive genomic sequencing (CGS) enables to detect not only BRAF V600E mutation but also BRAF non-V600E mutations in a single assay. While it has been proved that BRAF V600E mutation in colorectal cancer shows poor prognosis and poor response to anti-EGFR therapy, clinical significance of BRAF non-V600E mutation has not been fully investigated. The present work aimed to describe clinicopathological characteristics and clinical outcome of BRAF non-V600E mutant type compared with BRAF wild-type and BRAF V600E mutant-type.

Methods:  One-hundred-eleven Stage IV CRC patients were analyzed. We investigated genetic alterations using 415-gene panel, which includes BRAF V600E and non-V600E mutations. The differences of clinicopathological characteristics and genetic alterations were analyzed among BRAF wild-type, BRAF V600E mutant-type, and BRAF non-V600E mutant-type using Fisher’s exact test. Overall survival (OS) and Progression-free survival (PFS) in response to targeted therapies were analyzed among the 3 groups using log-rank test. 

Results: CGS revealed that 98 patients (88%), 7 patients (6%), and 6 patients (6%) were BRAF wild-type, BRAF V600E mutant-type, and BRAF non-V600E mutant-type, respectively. The variants of BRAF non-V600E in each 6 patients were as follows: G469A, G469A and V502I, D594G, I326V, N581Y, D594G. BRAF V600E mutant-type were more frequently right-sided, histopathological grade 3, mucinous type, and with multiple peritoneal metastases distant from primary lesion. BRAF non-V600E mutant-type were more frequently left-sided, non-mucinous type, and with bilateral multiple lung metastases. While BRAF V600E mutant-type showed significantly worse OS than BRAF wild-type and non-V600E mutant-type (P < 0.001 and P = 0.038, respectively), BRAF non-V600E mutant-type showed no significant difference compared with BRAF wild-type. Two of 6 patients with BRAF non-V600E mutation underwent R0 resection and showed no evidence of disease at final follow-up. In 47 patients with anti-EGFR therapy, while BRAF V600E mutant-type showed significantly worse PFS than BRAF wild-type (P = 0.013), BRAF non-V600E mutant-type showed no significant difference compared with BRAF wild-type. In 73 patients with anti-VEGF therapy, there was no significant difference on PFS among the 3 groups.

Conclusion: BRAF non-V600E mutant-type demonstrates different clinicopathological characteristics and clinical outcome from BRAF V600E mutant-type. Further preclinical and clinical investigations are needed to clarify the role of BRAF non-V600E mutation in colorectal cancer.

 

72.01 PTEN Mutation Is Associated With Worse Prognosis In Stage III Colorectal Cancer

Posted on January 18, 2018

Y. Tajima1, Y. Shimada1, M. Nagahashi1, H. Ichikawa1, H. Kameyama1, M. Nakano1, J. Sakata1, T. Kobayashi1, H. Nogami2, S. Maruyama2, Y. Takii2, S. Okuda3, K. Takabe4,5, T. Wakai1  1Niigata University Graduate School Of Medical And Dental Sciences,Division Of Digestive And General Surgery,Niigata, NIIGATA, Japan 2Niigata Cancer Center Hospital,Department Of Surgery,Niigata, NIIGATA, Japan 3Niigata University Graduate School Of Medical And Dental Sciences,Division Of Bioinformatics,Niigata, NIIGATA, Japan 4Roswell Park Cancer Institute,Breast Surgery,Buffalo, NEW YORK, USA 5The State University Of New York,Department Of Surgery, University At Buffalo Jacobs School Of Medicine And Biomedical Sciences,Buffalo, NEW YORK, USA

Introduction:
he PI3K/AKT/mTOR pathway is related with cell proliferation and frequently activated in many human cancers. On the other hand, PTEN is a tumor suppressor gene inhibiting PI3K-initiated signaling. Loss of PTEN can be occurred in various types of tumor and associated with progression and worse prognosis. However, the association between PTEN mutation and prognosis in colorectal cancer (CRC) remains unclear. Our aim was to analyze the clinical impact of PTEN mutation in patients with colorectal cancer.

Methods:
Two-hundred-one Stage I–IV CRC patients who underwent colorectal resection were analyzed. We investigated genetic alterations associated with CRC using 415-gene panel. The association between PTEN mutation status and clinicopathological characteristics was analyzed using Fisher’s exact test. The association between PTEN mutation status and relapse-free survival (RFS) was analyzed using log-rank test and Cox proportional hazards model.

Results:
Fifty-five (27%) of 201 patients had PTEN mutation. Tumor diameter < 50 mm, lymphatic invasion, venous invasion, distant metastasis, poorly differentiated cluster grade 2/3 and Ki67 < 60 % were significantly associated with PTEN mutation (P < 0.001, P = 0.036, P = 0.003, P = 0.002, P = 0.009 and P = 0.003, respectively). Univariate analysis showed that PTEN mutation was significantly associated with the worse RFS in patients with Stage III CRC (P = 0.002) (Fig.1). On the other hand, PTEN mutation was not significantly associated with the RFS in patients with Stage I/II CRC and the overall survival in patients with Stage IV CRC (Fig.1). Of 415 genes, 18 genes had mutations in over 10% of patients with Stage III CRC. Those 18 genes were ACVR2A (10.9%), APC (71.7%), BRAF (10.9%), BRCA2 (10.9%), CDH1 (10.9%), CIC (10.9%), ERBB2 (13.0%), FAT1 (10.9%), FBXW7 (23.9%), KRAS (41.3%), PIK3CA (15.2%), PTEN (15.2%), RNF43 (19.6%), SMAD2 (10.9%), SMAD4 (21.7%), SPEN (13.0%), STK11 (15.2%), TP53 (78.3%). Among the 18 genes, PTEN mutation was significantly associated with CIC mutation (P = 0.020). Univariate analysis in patients with Stage III CRC showed that the RFS was significantly worse in mucinous type, CIC mutation, ERBB2 mutation and PTEN mutation (P = 0.005, P = 0.009, P = 0.037, P = 0.002, respectively). Multivariate analysis in patients with Stage III showed that only PTEN mutation was significantly affected the RFS (hazard ratio 6.18, 95% confidence interval 1.63–23.5, P = 0.007).

Conclusion:
PTEN mutation was associated with worse prognosis in Stage III CRC. We speculate that PTEN is one of potential driver genes in CRC.
 

72.02 Unplanned Reoperation in Patients Undergoing Surgery for Rectal Cancer

Posted on January 18, 2018

L. V. Saadat1, A. C. Fields1, H. Lyu1, R. D. Urman1, E. E. Whang1, J. Goldberg1, R. Bleday1, N. Melnitchouk1  1Brigham And Women’s Hospital,Boston, MA, USA

Introduction: The rate of unplanned reoperation can provide information about surgical quality and the incidence and management of postoperative complications. There has been a paucity of studies assessing reoperation rates after rectal cancer surgery and the morbidity after such procedures remains largely unknown. The goal of this study was to determine the factors associated with unplanned reoperation following low anterior resection (LAR) and abdominoperineal resection (APR) for patients with rectal cancer and outcomes following these reoperations. 

 

Methods: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients who underwent elective LAR and APR for rectal cancer from 2012-2014. The primary outcomes were 30-day reoperation rates and postoperative complications. Bivariate and multivariate analyses were conducted to assess risk factors for reoperation.

 

Results: A total of 11,297 patients were identified; 7,714 patients underwent LAR and 3,583 patients underwent APR. 454 LAR patients (5.9%) and 289 APR patients (8.1%) required reoperation within 30 days of their index operation. The most common reasons for reoperation were infection, bleeding, and bowel obstruction. The mean time to reoperation was 10.6 days and 13.1 days for LAR and APR, respectively. Multivariate analysis revealed that female sex (OR: 1.5, 95%CI: 1.19-2.01, p value: 0.001), poor functional status (OR: 2.2, 95%CI: 1.03-4.50, p value: 0.04), operation time (OR: 1.001, 95%CI: 1.00-1.002, p value: 0.01), and low preoperative albumin (OR: 0.79, 95%CI: 0.62-0.99, p value: 0.04) were independent risk factors for reoperation after LAR. Smoking (OR: 1.7, 95%CI: 1.2-2.4, p value: 0.001), COPD (OR: 1.8, 95%CI: 1.1-3.1, p value: 0.03), poor functional status (OR: 2.1, 95%CI: 1.1-4.3, p value: 0.032), operation time (OR: 1.003, 95%CI: 1.002-1.004, p value: <0.001), low preoperative albumin (OR: 0.69, 95%CI: 0.53-0.90, p value: 0.007), and laparoscopic approach (OR: 1.5, 95%CI: 1.1-2.1, p value: 0.02) were independent risk factors for reoperation after APR. Postoperative complication rates are high for those undergoing reoperation and patients are significantly more likely to have a non-home discharge (p <0.001) if reoperation takes place.  

 

Conclusion: Reoperation following LAR and APR for rectal cancer is not uncommon. This study highlights the common causes of reoperation, potentially modifiable preoperative risk factors for reoperation, and the morbidity associated with such operations.

 

 

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