54.01 The impact of a prior history of cancer upon trauma related outcomes.

Posted on January 31, 2019

C. Parker1, T. J. Miner1, D. S. Heffernan1  1Brown University School Of Medicine,Department Of Surgery,Providence, RI, USA

Introduction: Trauma remains a leading cause of death and, among survivors, long term disability and organ dysfunction. Underlying medical comorbidities are significant drivers of trauma related complications. A history of having survived a prior cancer diagnosis is also a common finding among the general population. Cancer survivors often display long term depressed physiologic and/or immunologic reserve. Given that robust immune and physiologic systems are critical to trauma survival, we hypothesize that trauma patients with a history of a prior cancer will display markedly worsened compared to patients with no prior malignancy.

Methods: This is a retrospective review of 4 years of prospectively collected data from a Level 1 trauma center. Charts were reviewed for patient characteristics, injuries sustained and injury severity score (ISS), medical history, with a focus on prior malignancy, presence of DNR/DNI upon presentation, hospital course, and trauma related outcomes, including mortality and discharge disposition. Patients were divided into those with a History of Cancer (HxC) versus those with no prior Cancer (noC). Given the considerable age difference between groups, from among the noC patients, we selected an age matched cohort for comparison.

Results: Among the trauma population as a whole HxC patients were older (73.4 vs 59.2 years; p<0.001). HxC patients, compared to the selected aged matched control displayed no difference in male gender (50.5% vs 49.3%;p=0.9) or ISS (11.2 +/-0.8 vs 10.2+/-0.1; p=0.2). HxC patients had higher average number of non-cancer medical comorbidities (3.1 +/-0.2 vs 2.5+/-0.02; p=0.005). With respect to specific comorbidities, there was no difference in CHF (10.1% vs 7.9%;p=0.5) but HxC patients had significantly higher rates of COPD (23.6% vs 10.6%; p<0.001) and were markedly more likely to be DNR/DNI upon initial presentation following the traumatic injury (27% vs 10.6%; p<0.001). There was no difference in overall hospital length of stay (5.7 +/-0.3 vs 6.4+/-0.1 days; p=0.3). HxC patients had overall greater mortality (13.5% vs 5.4%; p=0.002). Among survivors, HxC patients were less likely to be discharged home (25.9% vs 44.7%; p=0.002) and were markedly more likely to discharged to a hospice (11.7% vs 2.2%; p<0.001). 

Conclusion: Among our trauma population, patients with a prior history of a malignancy present with higher rates of DNR and exhibit overall lower survival and higher rate of discharge to hospice. It is possible that having survived a major cancer diagnosis, HxC patients cannot tolerate the physiologic or immunologic “second hit” burden of a major traumatic injury. We further speculate that our data may have uncovered an unconscious lack of motivation to undergo extensive lifesaving measures after being exhausted by a cancer diagnosis.  

 

53.20 Effect of Surgical Day of Week on Postoperative Outcomes with Robotic-Assisted Pulmonary Lobectomy

Posted on January 31, 2019

T. Chambers2, F. Velez-Cubian2, C. Moodie1, J. Garrett1, J. Fontaine1,2, E. Toloza1,2  1Moffitt Cancer Center And Research Institute,Tampa, FL, USA 2University Of South Florida College Of Medicine,Tampa, FL, USA

Introduction:   The purpose of this study was to assess if patients who underwent surgery received immediate postoperative care at the beginning of the week (Monday through Wednesday [M-W]) had different outcomes than patients who had surgery and immediate postoperative care at the end of the week (Thursday and Friday [Th-F]).  In theory, surgical patients at the end of the week would receive different care due to their postoperative care being given by a partial weekend staff as compared to the full staff during the work week.  This is important to this practice because if there is a difference in outcomes, hospital staffing for weekend care should be adjusted accordingly.

Methods:   Patients, who underwent robotic-assisted pulmonary lobectomy from 2010 to 2016, were divided into the M-W group or the Th-F group according to their surgical day of the week.  Patient demographics, tumor histopathology, intraoperative and postoperative complications, and perioperative outcomes were assessed and compared between groups using independent samples t-test, Pearson Chi-square analysis, Levene’s test, Mann-Whitney U test, and Fisher’s exact test, with significance at p≤0.05.

Results:  There were 344 patients in the study cohort.  After analysis of each of these variables, the Th-F groups had a median skin-to-skin operative time that was 23 minutes longer than that for the M-W group and a median total operative time that was 27 minutes longer than that for the M-W group.  There were significantly more non-small cell lung cancer (NSCLC) and larger tumors resected in the M-W than in the Th-F group.  There were no significant differences between the two groups in the other variables assessed.

Conclusions:  NSCLC tumors were more common in the M-W group and tended to be larger tumors; however, these tumors took less time to resect.  These differences in outcomes based on surgical day of the week could be due to differences in surgeon and/or surgical team performance during different days of the week.  Surgical team schedules should be varied to allow more veteran surgical members to be distributed evenly among the week, which can help lower median surgical times and the amount of anesthesia exposure needed for each case.  Future studies can look to see if this finding continues across other procedures.

53.18 Nodal Skip Metastasis and Outcomes after Robotic-Assisted Pulmonary Lobectomy for Lung Cancer

Posted on January 31, 2019

R. Gerard2, D. Nguyen2, F. Velez-Cubian2, C. Moodie1, J. Garrett1, J. Fontaine1,2, E. Toloza1,2  1Moffitt Cancer Center And Research Institute,Tampa, FL, USA 2University Of South Florida College Of Medicine,Tampa, FL, USA

Introduction:   We sought to evaluate both short- and long-term postoperative outcomes between patients with continuous nodal metastasis (NoSkip) compared to those with nodal skip-metastasis (Skip).

Method:   We retrospectively analyzed patients who underwent robotic-assisted video-thoracoscopic (RAVT) pulmonary lobectomy by one surgeon between September 2010 and May 2017.  Patients with final pathology reporting pulmonary metastasis or benign lesion were excluded.  Inclusion criteria consisted of obligatory pathologic mediastinal nodal (pN2) classification.  Patients were then stratified into two groups:  Skip or NoSkip.  Patients’ demographics, perioperative outcomes, perioperative complications, and overall survival (OS) were compared.

Results:  Of a total of 423 patients who underwent RAVT lobectomy, 390 patients had non-small cell lung cancer (NSCLC).  While 319 patients with NSCLC were pN0 or pN1, 71 patients had pN2 disease, of which 18 (25.3%) were Skip and 53 (74.7%) were NoSkip.  Mean age, gender distribution, and body habitus were similar between groups (p=0.617, p=0.194 and p=0.091, respectively).  Patients with Skip had lower mean pre-operative forced expiratory volume in 1 second as percent of predicted (FEV1%; 79.5±3.5% vs. 89.7±2.8%), but this difference was not quite significant (p=0.053).  Albeit not significant, patients in the NoSkip group had slightly more intraoperative complications (15.1% vs. 5.6%) and slightly more often required conversion to thoracotomy (15.1% vs. 5.6%) compared to the Skip group (p=0.293 and p=0.293, respectively).  Incidence of postoperative complications were similar between groups (p>0.05).  Patients in both groups had similar median estimated blood loss (EBL; 200 mL vs. 200 mL), operative time (214.5 min vs. 197 min), chest tube duration (4.5 d vs. 4 d), and hospital length of stay (LOS; 5 d vs. 5 d) (p=0.734, p=0.178 and p=0.973, respectively).  Mean number of N1 lymph node (LN) stations reported and mean number of N1 LNs evaluated were similar between groups (1.9±0.1 vs. 1.7±0.1 [p=0.226] and 7.6±0.6 vs. 6.7±0.6 [p=0.441], respectively).  Mean number of N2 LN stations reported and mean number of N2 LNs evaluated were also similar between groups (3.7±0.0 vs. 3.4±0.2 and 11.4±1.1 vs. 9.4±1.4, respectively).  Patients with nodal skip metastasis (Skip group) had slightly less favorable 1-yr (50.7%±13.8% vs. 80.0%±6.4%) and 3-yr OS (42.2%± 13.9% vs. 57.1%±9.2%) (p=0.077).

Conclusion:  Mean patient age, gender distribution, and body habitus did not differ between groups.  Patients with Skip had reduced FEV1% pre-operatively, but the number of postoperative complications remained similar between groups.  No significant differences were noted in EBL, operative times, chest tube duration, and hospital LOS.  Skip is associated with worse OS compared to patients with NoSkip.

53.17 Indocyanine Green for Ureter Identification During Robotic Colectomy: A Single Center Study

Posted on January 31, 2019

S. B. Bryczkowski1, J. E. Glanville2, A. H. Khosravi3, A. S. Rosenstock1, G. Mazpule1, S. G. Pereira1  1Hackensack University Medical Center,Surgery,Hackensack, NJ, USA 2Hospital Corporation of America,Surgery,Richmond, VA, USA 3St. Joseph Hospital,Surgery,Tustin, CA, USA

Introduction: Robotic surgery has gained favor across specialties. There is an ongoing effort to make colorectal surgery safer. Urologists have used indocyanine green (ICG) dye to identify ureters during robotic ureterolysis, but no studies existed on ICG use during robotic colectomy. We hypothesized that intraureteral ICG would decrease the time to identify the ureters during robotic sigmoid colectomy.

 

Methods: A retrospective review of prospective data at a single academic center. The use of ICG for ureteral identification reflected a change in practice. Patients either had ureteral stents with intraureteral ICG or stents alone (no ICG). Colectomies were performed by one of three attending surgeons and assisted by one of three robotic fellows. The primary outcomes were time to identify ureters and operative (OR) time. Secondary outcomes were complications of ureteral injury, leak, and infection. All adults (>18) who presented for elective robotic sigmoid colectomy between Oct ’15 – Aug ‘17 were included. Exclusion criteria were pregnancy, age ≤18, and emergency surgery. Data collection included demographics (age, gender), surgical indication (complicated or recurrent diverticulitis or neoplasm), and clinical data (number (n) diverticulitis episodes, n previous surgeries). Data were analyzed using student t test, chi square analysis, or one-way ANOVA.

 

Results: Of 151 patients admitted for colectomy, 30 met criteria. Of those, 16 received ICG and 14 did not (no ICG). There were no differences in age between ICG and no ICG, [presented as mean (m), ± standard deviation (sd)] (59 ± 15 vs. 63 ± 10, p=0.21) or gender, [% female] (50% vs. 71%, p=0.23). There was a statistically significant decrease in the time to identify the ureters in the ICG group [m ± sd] (10min ± 12 vs. 38 ± 81, p=0.04). There were no differences in OR time (264min ± 63 vs. 281 ± 52, p=0.11), n diverticulitis episodes (4 ± 3 vs. 5 ± 9, p=0.39), n previous abdominal surgeries (0.9 ± 0.8 vs. 0.5 ± 0.8, p=0.06), cases of complicated diverticulitis, [n, %] (6, 38% vs. 6, 43%, p=0.76), or in rate of ureteral identification (16, 100% vs. 13, 93%, p=0.14).

 

Conclusion: This single center study demonstrated that intraureteral ICG allowed faster ureteral identification during robotic sigmoid colectomy. Although overall OR time did not differ between the groups, all ureters were identified when ICG was used. Early ureteral identification with ICG could lead to safer colorectal surgery by preventing injury to the ureters. Future studies should focus on whether early ureteral identification using ICG leads to decreased incidence of ureteral injury during robotic colectomy.

53.16 Cement Volume, Height Restoration and Outcomes Following Kyphoplasty

Posted on January 31, 2019

J. H. Mooney1, J. Amburgy1, M. Self1, P. Pritchard1, B. Agee1, M. R. Chambers1  1University Of Alabama at Birmingham,Neurosurgery,Birmingham, Alabama, USA

Introduction:

Kyphoplasty is a minimally invasive surgery developed to restore height and stabilize painful vertebral compression fractures (VCFs). There is an abundance of published data illustrating reduction of pain, disability and improved quality of life following kyphoplasty.  However, there has been no clear correlation between patient outcomes and the volume of cement injected or degree of vertebral height restoration.  The objective of this analysis is to determine if cement volume or height restoration following kyphoplasty correlate with improvements in pain, disability, and quality of life.

Methods:

In this case series, we assessed outcomes following kyphoplasty in 136 Medicare-eligible patients with 1 to 3 painful VCFs between T5 and L5 due to osteoporosis or cancer. The total volume of bone cement injected at each level was recorded for each patient.  Anterior, middle, and posterior vertebral body heights were measured in fifty-nine patients pre and post-operatively utilizing computerized lateral thoracic and/or lumbar radiographs. Patient outcomes were evaluated before and after surgery. The Visual Analog Scale (VAS, range: 0(none) – 10(worst)) was used to prospectively measure back pain preoperatively in all patients.  Pre and post-operative measurements of disability and quality of life were retrospectively collected using the Roland Morris Disability Questionnaire (RMDI, range: 0(no disability) -24(high disability)) and EuroQol 5-Domain scale (EQ5D, range: -0.11(poor quality of life) – 1.0(perfect health)).  Pearson correlations as well as linear regression models were derived for association of total cement volume and vertebral height restoration with patient outcomes. 

Results:

For VAS, RMDI, and EQ5D improvements, neither Pearson correlations (r= 0.042, 0.167, and 0.091), respectively, nor multiple linear regression models (R²= 0.002, 0.029, 0.023), respectively, reveal either a correlation or an association with total cement volume.  Additionally, neither Pearson correlations (r coefficients ranging from 0.001-0.152) nor linear regression models (R² values ranging from 0.0002-0.1133) reveal either correlation or association between anterior, middle, or posterior vertebral body height improvements with VAS, RMDI or EQ5D improvements. 

Conclusion:

This is the largest known study to assess associations of vertebral body height improvements and cement volumes with patient outcomes.  Most patients improved regardless of the vertebral height improvements or cement volumes injected.

 

53.15 The optimal surgical management for colorectal liver metastases in the era of multidisciplinary treatment.

Posted on January 31, 2019

T. Ochiai1, T. Shigeno1, M. Sakano1, T. Igaki1, R. Matsumoto1, N. Chiyonobu1, I. Saito1, K. Saito1, S. Yamazaki1  1Ohta Nishinouchi General Hospital,Suregry,Koriyama, FUKUSHIMA, Japan

Introduction:  Recent advances in chemotherapy have expanded the resectability of colorectal cancer with liver metastases (CRLM), optimal surgical management for the patients with CRLM is controversial. We studied treatment results in the patients with CRLM since molecular target-based agent was approved in Japan since 2008. 

Methods: Based on data collected retrospectively, we analyzed the demographics, clinical data, operative findings, chemotherapy, and outcomes of 285 consecutive CRLM patients treated between 2008 and 2017. To investigate the optimal surgical management, we devided the observation periods into 2 periods, 2008-2011 and 2012-2017, and analyzed resectability and response rate of chemotherapy. 

Results:The 1-, 3-, and 5-year overall survival rates for the entire CRLM patient and 109 patients who underwent liver resection were 80.4%, 48.4%, and 30.0%, and 94.3%, 72.5%, and 52.8%, respectively. Out of synchronous/metachronous, neo-adjuvant and adjuvant chemotherapy, repeat liver resection, only perioperative chemotherapy revealed significant difference in resected 109 patients. The resectability of whole CRLM was 38.2% in 2008-2017, 46.2% in 2008-2011, and 33.5% in 2012-2017. The response rate of patients with unresectable or neoadjuvant chemotherapy were 43.8% in 2008-2017, 43.1% in 2008-2011, and 45.0% in 2012-2017. The 1-, 3-, and 5-year overall survival rates for the entire CRLM patient and 101 patients who underwent liver resection were 74.8%, 48.4%, 32.6%, and 93.7%, 80.7%, 55.5% in 2008-2011, and 84.0%, 47.1%, 25.2%, and 94.9%, 71.1%, 49.5% in 2012-2017. Three cases of initially unresectable CRLM converted to complete resection with neoadjuvant chemotherapy. 

Conclusion:Although development of various molecular target-based agents has improved short-term survival of CRLM patients, liver resection is the key of long-survival. Neither neoadjuvant nor adjuvant chemotherapy is not significantly different in survival, but perioperative chemotherapy is effective in this study. To improve survival of the patients with CRLM, aggressive surgery and perioperative chemotherapy without missing the timing of hepatectomy are required. 

 

53.14 Influence of Tumor Distance from Carina on Outcomes with Robotic-Assisted Pulmonary Lobectomy

Posted on January 31, 2019

J. Bennett1,2, F. Velez-Cubian2, C. Moodie1, J. Garrett1, J. Fontaine1,2, E. Toloza1,2  1Moffitt Cancer Center And Research Institute,Tampa, FL, USA 2University Of South Florida College Of Medicine,Tampa, FL, USA

Introduction:   Tumor location can vary within the lung, and the location of a tumor has an impact on the surgical approach used during a minimally invasive thoracic surgery.  This study investigated the relationship between the location of lung tumors and post-surgical hospital length stay.

Methods:   We retrospectively analyzed clinical data from patients who underwent robotic-assisted pulmonary lobectomy for non-small-cell lung carcinoma.  Hospital length of stay was assessed through chart reviews.  Location of tumor (distance from the carina) was assessed using a direct measurement tool in a computerized tomography (CT) scan image-viewing program.  Student’s t-test, Kruskal-Wallis median test, and Chi-square test were used to compare variables, with significance at p≤0.05.  Multivariable regression analysis was performed to assess the relationship of tumor distance from carina, age, gender, body mass index (BMI), and hospital length of stay. 

Results:  Among 299 patients (mean age, 67.2 ± 0.6 yr; median age, 68.0), there was one patient excluded from the study due to incomplete data.  Mean distance from the center of the tumor to the carina was 9.0 ± 0.2 cm.  The patient cohort exhibited a gender distribution of 55% female and 45% male, with a mean BMI was 27.6 ± 0.3 kg/m2.  Length of stay was found to have a mean of 5.3 ± 0.3 days and median of 4.0 days.  Although univariate analysis of the variables demonstrated that gender was a significant indicator of hospital length of stay, multivariable regression analysis, adjusting for variables of age, BMI, and tumor distance discounted the notion that gender was significant in predicting hospital length of stay.  Age significantly predicted hospital length of stay, while adjusting for tumor distance, gender, and BMI [F(4, 281) = 2.475, p=.045, R2 = .020].  Tumor distance from the carina was not a significant predictor of hospital length of stay (p= 0.530).

Conclusion:  Given these findings, we do not believe that tumor distance from the carina is an effective indicator for hospital length of stay for pateints undergoing robotic-assisted pulmonary lobectomy.  Instead, age was the best independent predictor of hospital length of stay.

53.13 Two Port plus Teleflex Minigrasper Transabdominal preperitoneal (TAPP) Inguinal Hernia Repair

Posted on January 31, 2019

H. J. Bonatti1, H. Bonatti1  1Meritus,Surgical Specialists,Hagerstwon, MD, USA

Introduction: Transabdominal preperitoneal (TAPP) inguinal hernia repair requires a 10mm and two 5mm trocars. When using a transverse peritoneal flap, a rather long incision is required. Tacks for MESH fixation and re-approximation of the flap may be associated with pain and are costly.

Methods: A two port technique was used replacing one 5mm instrument with a Teleflex minigrasper. The peritoneal flap was created from a 5-10cm vertical incision in the infraumbilical peritoneum and re-approximated with a running suture or tacks. Dissection of the inguinal region was done in a reduced size pocket.

Results: Median age of the 17 men and five women was 64.4 (range 29.5-84.8) years; there were 16 unilateral and six bilateral inguinal hernias (including three recurrent hernias and two incarcerated hernias). Two patient had large inguinoscrotal hernias. Tacks for the flap were used in four of the first seven cases; in the last 15 suture closure was used in all patients. Various techniques to suture the flap were tried out, the V-lock turned out to be the easiest option and was made standard. In eight patient only two 5mm trocars were used, in two patients a 5mm and an 8mm trocar was inserted and in 12 patients a 5mm and a 10mm trocar was used. Progrip MESH without tacks was placed in 20 patients. TAPP was done as outpatient procedure in 50% of cases, six patients required 23 hours extended recovery; only five patients with severe co-morbid conditions required admission. Complication included seroma (n=2), bladder injury (n=1) and urinary retention (n=2); two patients with preexisting groin pain had ongoing symptoms post TAPP. No recurrence was observed during a median follow up of 722 (range 14-1299) days.

Conclusion: Creation of the peritoneal flap from a midline incision and re-approximation using a running suture is technically feasible. The created preperitoneal pocket is smaller than in conventional TAPP but still allows good exposure. TAPP can be done with two 5mm ports and the Teleflex minigrasper. The minigrasper can be used for laparoscopic suturing.

 

53.12 Risk Factors for and Associations of Prolonged Air Leak after Robotic-Assisted Pulmonary Lobectomy

Posted on January 31, 2019

R. Gerard2, R. Patel2, D. Nguyen2, F. Velez-Cubian2, C. Moodie1, J. Garrett1, J. Fontaine1,2, E. Toloza1,2  1Moffitt Cancer Center And Research Institute,Tampa, FL, USA 2University Of South Florida College Of Medicine,Tampa, FL, USA

Introduction:   Prolonged air leak (PAL) is the most common complication following partial lung resection and an important determinant of hospital length of stay (LOS).  This study sought to identify risk factors for developing PAL after robotic-assisted video-thoracoscopic (RAVT) pulmonary lobectomy.

Methods:   We retrospectively analyzed prospectively-collected data from patients who underwent RAVT lobectomy by one surgeon between September 2010 and May 2017.  Patients were grouped based on having or not having PAL, defined as an air leak persisting >5 days, during the postoperative period.  Patients’ demographics, intraoperative complications, perioperative outcomes, and postoperative complications were compared.

Results:  Of 423 total patients who underwent RAVT lobectomy, 89 patients (21%) experienced PAL.  Patients with PAL had lower mean body mass index (BMI) compared to patients with no PAL (26.9 kg/m2 vs. 28.7 kg/m2, p=0.045).  Patients who developed PAL postoperatively were more likely to have chronic obstructive pulmonary disease (COPD) (33% vs. 16%, p<0.001) or history of previous pneumonia (14% vs. 7%, p=0.045).  Patients with PAL had lower pre-operative forced expiratory volume in 1 second as percent of predicted (preopFEV1%) (81.2% vs. 87.4%, p=0.010).  Patients with repeat pulmonary surgery were more likely to experience PAL postoperatively, with 50% of those 14 patients developing PAL.  Patients who had intraoperative tracheobronchial injury were also at higher risk for PAL (p=0.032).  Patients with PAL experienced greater median estimated-blood-loss (EBL) (200 mL vs. 150 mL, p=0.013) and greater median operative time (208 min vs. 172 min, p=0.001).  Patients with PAL had longer median hospital LOS (9 d vs. 4 d, p<0.001).

Conclusion:  Decreased BMI, decreased preopFEV1%, COPD, previous pneumonia, re-do surgery, and intraoperative bronchial injury were identified as being risk factors for the development of PAL during the postoperative period.  These patients also experienced increased EBL, operative time, and had longer hospital LOS.

53.11 Effect of Insurance Type on Postoperative Outcomes after Robotic-Assisted Pulmonary Lobectomy

Posted on January 31, 2019

P. Deol2, J. Sipko2, A. Kumar2, A. Tsalatsanis2, F. Velez-Cubian2, C. Moodie1, J. Garrett1, J. Fontaine1,2, E. M. Toloza1,2  1Moffitt Cancer Center,Tampa, FL, USA 2University Of South Florida College Of Medicine,Tampa, FL, USA

Introduction:   Underinsured patients reportedly are less likely to undergo surgical treatment for lung cancer.  We studied the effect of insurance type on patient outcomes following minimally invasive pulmonary lobectomy.

Methods:   We retrospectively analyzed patients who consecutively underwent robotic-assisted pulmonary lobectomy by one surgeon over an 80-month period.  Perioperative outcomes as well as intraoperative and postoperative complications were noted.  Disposition at discharge after surgery (favorable, e.g. transfer to home with self-care or home health nursing and/or physical therapy, vs. unfavorable, e.g. long-term acute care or rehabilitation facility, hospice, or expired) and 5-year overall survival (5-yr OS) were also recorded.  We used Pearson Chi-square (X2), Analysis of Variance (ANOVA), and Kruskal-Wallis test to compare variables, and Cox regression for survival analysis, with statistical significance established at P<0.05.

Results:  Of 433 study patients, 107 patients had private insurance (mean age 57.5 yr), 118 had public insurance [Medicare or Medicaid (mean age 70.3 yr)], 196 patients had combination insurance plans [Medicare plus a privately supplied supplemental plan (mean age 71.8 yr; P<0.001)], and 12 patients had no insurance (excluded due to low sample size).  There were more current smokers in the public insurance group, more former smokers in the combination insurance group, and more nonsmokers in the private insurance group (P=0.03).  There were more comorbidities in the public and combination insurance groups vs. the private insurance group, including gastroesophageal reflux disease (P=0.003), hypertension (P=0.01), and hyperlipidemia (P<0.001).  The groups had no differences in tumor size or pathologic stage.  There were a higher rate of intraoperative conversions to open lobectomy in the private and public insurance groups vs. the combination insurance group (P=0.001).  The private and combination insurance groups had more cases of favorable disposition at discharge after surgery compared to the public insurance group (P<0.001).  Multi-variable regression analyses identified private insurance type as an independent predictor of favorable disposition at discharge [public vs. private plan; odds ratio (OR): 0.43 [95% confidence interval (CI): 0.22 – 0.85], P=0.02] as well as 5-yr OS [(combination vs. private plan; hazard ratio (HR): 2.68 (95% CI: 1.26 – 5.67), P=0.01), (public vs. private plan; HR: 2.84 (95% CI: 1.37 – 5.89), P=0.01)].

Conclusions:  Although public or combination insurance type was associated with greater risk of all-cause 5-yr mortality, and public insurance type was associated with overall conversion to open lobectomy and less favorable disposition at discharge after surgery, insurance type was not associated with increased intraoperative complications, hospital length of stay, or in-hospital mortality following minimally invasive robotic-assisted pulmonary lobectomy.

53.10 Guidelines for Symptom Recurrence in Achalasia: Defining ‘Failed Myotomy’

Posted on January 31, 2019

E. H. Bruenderman1, R. C. Martin1, M. P. Fox2, V. H. Van Berkel2, S. B. Block1, F. J. Kehdy1  1University Of Louisville,Department Of Surgery,Louisville, KY, USA 2University Of Louisville,Department Of Cardiovascular And Thoracic Surgery,Louisville, KY, USA

Introduction: Current treatments of achalasia aim to relieve the outlet obstruction at the gastroesophageal junction (GEJ) but cannot address the progressive degeneration of neurons affecting esophageal motility.  Heller myotomy provides excellent short-term relief, however, long-term symptom recurrence is common.  The term ‘failed myotomy’ is often used to reference symptom recurrence but has no universally accepted definition and is not addressed in SAGES guidelines, last updated in 2011. Standardizing the approach to symptom recurrence will delineate what constitutes a ‘failed myotomy’ versus progressive peristaltic failure.

Methods: Patients with achalasia who underwent laparoscopic Heller myotomy at a single center between 2013 and 2018 were reviewed and data extracted.  Patient demographics and characteristics were compared.  Patients with symptom recurrence were noted.  Follow-up imaging studies were reviewed for objective evidence of GEJ outflow obstruction versus none.  Results were used to compose an algorithm to address symptom recurrence and define ‘failed myotomy.’

Results: A total of 59 patients with a median age of 50 (range 13 to 91) years, 26 (44.1%) were male, median BMI was 27.76 (range 16.13 to 49.03), 18 (30.5%) had undergone prior Botox injection, 30 (50.8%) had undergone prior dilation.  Fundoplication was performed on 21 (35.6%) patients.  Median follow-up was 3 (range 0.5 to 60) months.  Symptom recurrence occurred in 23 (39.0%) patients, with a median interval to recurrence of 13 (range 0.5 to 45) months.  Of those with symptom recurrence, 15 (65.2%) underwent repeat upper gastrointestinal series (UGI), with 7 showing narrowing at the LES. Of 17 (73.9%) who underwent repeat EGD, 4 showed narrowing at the LES.  Of 5 (21.7%) who underwent repeat high resolution manometry (HRM), 1 revealed impairment of LES relaxation.  One (4.3%) patient was lost to follow-up prior to undergoing repeat imaging.  A total of 7 (30.4% of recurrence cohort, 11.9% of total cohort) patients with symptom recurrence required repeat intervention – 4 dilations, 1 dilation and subsequent POEM, 1 redo Heller myotomy, and 1 lost to follow-up before intervention.  A diagnostic algorithm for recurrence was created, defining ‘failed myotomy’ as symptom recurrence after myotomy, with objective findings confirming GEJ outflow obstruction, either on HRM alone, or on UGI and subsequent EGD.

Conclusion: Treatment of achalasia aims to relieve a hypertensive LES.  Symptom recurrence occurs frequently, underscoring the importance of distinguishing a true ‘failed myotomy’ from the progressive degeneration of peristalsis that characterizes achalasia.  Objective evidence of GEJ outflow obstruction in the form of UGI with EGD, and/or HRM, is crucial to label recurrence as a ‘failed myotomy’ and direct further treatment.  We propose updated guidelines to reflect this common issue in the treatment of achalasia.

53.09 Effect of Smoking on Atrial Fibrillation following Robotic-Assisted Video-Thoracoscopic Lobectomy

Posted on January 31, 2019

J. Sipko2, P. Deol2, T. Reljic2, F. Velez-Cubian2, C. Moodie1, J. Garrett1, J. Fontaine1,2, E. Toloza1,2  1Moffitt Cancer Center And Research Institute,Tampa, FL, USA 2University Of South Florida College Of Medicine,Tampa, FL, USA

Introduction:   Patients’ smoking history, including smoking status and length of smoking cessation prior to surgery, have been reported as risk factors for post-operative (post-op) atrial fibrillation (A-fib) after non-cardiac thoracic surgery.  However, no research to date has determined if smoking history serves as a risk factor for A-fib following lobectomies performed via the minimally invasive robotic-assisted technique.  The present study sought to determine the effect of patients’ smoking history and length of smoking cessation prior to surgery on the risk of developing A-fib following robotic-assisted video-thoracoscopic (RAVT) lobectomy to allow for more appropriate dispositioning of patients.

Methods:   This study is a retrospective, cross-sectional, observational study, in which data was collected by chart review of 450 consecutive eligible patients who underwent RAVT lobectomy by a single surgeon between October 2010 and August 2017.  The presence of new onset post-op A-fib was analyzed in patients who never smoked, currently smoke (including those who quit within two months prior to surgery), quit smoking between 2-12 months prior to surgery, and quit smoking >12 months in order to identify an optimal timeframe for smoking cessation.  Odds ratios were calculated using logistic regression, with a 95% confidence interval.

Results:  Our cohort consisted a median age of 68 yr (IQR 61-74), a median BMI of 27.35 kg/m2 (IQR 24-31), and a median BSA of 1.87 m2 (IQR 1.71-2.04), with only 9.75% of patients developing post-op A-fib.  A univariate logistic regression yielded a statistically significant association between smoking status and post-op A-fib (P=.013), but this association was lost when adjusting for age, hypertension, and FEV-1.  However, patients who quit smoking >12 months prior to surgery demonstrated increased odds of developing A-fib compared to those who never smoked, even while adjusting for age, hypertension, and FEV-1 (OR 4.74 (95%CI 1.05-21.35), P=0.04).  Current smokers and patients who quit smoking 2-12 months prior to surgery also had increased odds of developing A-fib when compared to those who never smoked; however, these results were not statistically significant (OR 2.65 (95%CI 0.49-14.28), P=0.26) and (OR 3.90 (95%CI 0.59-26.64), P=0.17).  Former smokers who quit >12 months also possessed more pre-operative comorbidities (median 3, mean 2.96, P=0.04) compared to current smokers (median 2, mean 2.44, P=0.04) and former smokers who quit between 2-12 months prior to surgery (median 2, mean 2.57, P=0.04). 

Conclusions:  Former smokers who quit greater than 12 months prior to surgery were associated with an increased risk of post-op A-fib compared to never smokers, current smokers, and smokers who quit between 2-12 months prior to RAVT lobectomy.  This finding may be explained by former smokers who quit >12 months prior to surgery having a greater number of comorbidities compared to the other 3 groups.

53.08 Intraoperative Fluids and Post-Operative Atrial Fibrillation after Robotic Pulmonary Lobectomy

Posted on January 31, 2019

D. Holliday2, R. Gerard2, F. Velez-Cubian2, C. Moodie1, J. Garrett1, J. Fontaine1,2, E. Toloza1,2  1Moffitt Cancer Center And Research Institute,Tampa, FL, USA 2University Of South Florida College Of Medicine,Tampa, FL, USA

Introduction:   We investigated whether intraoperative fluids given to patients during robotic-assisted pulmonary lobectomy correlate with frequency of postoperative atrial fibrillation (PostOp Afib).

Method:   We retrospectively studied all patients who underwent robotic-assisted pulmonary lobectomy from September 2010 through May of 2017 by one surgeon.  A total of 419 patients were analyzed for types and volumes of intraoperative fluids received, such as intravenous (IV) crystalloid, colloid, packed red blood cells (PRBC), fresh frozen plasma (FFP), platelets, and phenylephrine, for fluids that were lost during surgery, such as estimated blood loss (EBL) and urine output (UOP), and for the calculated balance of these fluids.  These patients were then analyzed based on whether they had PostOp AFib (n=39) or not (n=380).  We also grouped patients by level of intraoperative crystalloids given (<1500 mL, n=86; 1500-2500 mL, n=211; >2500 mL, n=122) and analyzed differences in demographics and in perioperative complications and outcomes.  Statistical significance was defined as p-value≤0.05.

Results:  Patients who had PostOp Afib had a significantly higher mean fluid balance than those without PostOp AFib (2273±499 mL vs 1532±100 mL; p=0.034), while none of the IV fluids given, including PRBC, FFP, platelets, or phenylephrine, nor EBL or UOP significantly differed between the two groups.  When grouped by IV crystalloid volume received, proportionately more females receive <2500ml IV crystalloid, while proportionately more males received >2500 ml (p=0.012).  Higher IV crystalloid volumes correlated with higher rates of intraoperative complications (p<0.001), which was mainly bleeding (p<0.001) during the robotic portion of the procedure (p<0.001), higher rates of overall conversions (p<0.001), emergent conversions due to bleeding (p<0.001), and elective conversions due to pleural or tumor adhesions (p=0.001), and higher rates of postoperative complications regardless of whether these were solely cardiac complications (p=0.003), solely pulmonary complications (p=0.012), or combined pulmonary and cardiac complications (p=0.001), but no individual complications correlated with IV crystalloid volume received (all p>0.206).  Higher IV crystalloid volumes also correlated with EBL (p<0.001), skin-to-skin operative time (p<0.001), chest tube duration (p=0.006), and hospital length of stay (LOS; p=0.004)

Conclusion:  Occurrence of PostOp Afib was associated with greater positive fluid balances after robotic-assisted pulmonary lobectomy, but not with greater volumes of  crystalloid, colloid, PRBC, FFP, platelets, or phenylephrine received nor with EBL or UOP.  Higher IV crystalloid volumes received were associated with higher conversion rates, EBL, and operative times, increased pulmonary and/or cardiac complication rates, and longer chest tube duration and hospital LOS.

53.07 Prevalence and Impact on Quality of Life of Hernias Among Patients Undergoing Computed Tomography

Posted on January 31, 2019

O. A. OLAVARRIA1, K. Bernardi1, A. Milton1, N. B. Lyons1, P. Shah1, T. C. Ko1, L. S. Kao1, M. K. Liang1  1McGovern Medical School at UTHealth,General Surgery,Houston, TX, USA

Introduction:
Two thirds of all Americans are overweight or obese and one half will receive a computed tomography (CT) scan in their lifetime. With the growing obesity epidemic and widespread use of advanced imaging there is a pressing need to quantify the prevalence and impact of hernias among these individuals. Our aim was to determine the prevalence of abdominal wall hernias (clinical and radiographic) among patients undergoing CT scans and their impact on patients’ quality of life.

Methods:
Consecutive patients undergoing elective CT scans of abdomen/pelvis from a single institution were enrolled. In general, CT scans were performed with oral and intravenous contrast with 5 mm cuts. Brief history was obtained in the radiology suite and quality of life (QoL) was measured through the modified Activities Assessment Scale, a validated, hernia-specific survey. On this scale, 1 is poor QoL and 100 is perfect; a change of 7 is the minimum clinically important difference. Standardized abdominal and groin examinations were performed by a surgeon blinded to the CT scan results. Three surgeons blinded to the results of the physical examination reviewed the CT scans for the presence of ventral or groin hernias. The number of patients and their QoL scores were determined for four groups of patients: no hernia, clinical or radiographic hernias, clinically apparent hernias, and occult hernias or hernias only seen on radiographic imaging. Pairwise differences between groups were compared using a Mann-Whitney U test.

Results:
A total of 246 patients were enrolled of whom 76 (30.8%) were overweight and 105 (42.6%) were obese. Physical examination detected a ventral hernia in 50 (20.3%) patients and a groin hernia in 17 (6.9%) patients while CT scan revealed 128 (52.0%) and 64 (26.0%) respectively. Of patients with a hernia on CT scan, 85 (34.5%) had an occult ventral hernia and 40 (16.2%) had an occult groin hernia. The QoL, median (IQR), of patients with no clinical or radiographic hernia was 84 (46), while the QoL of those with a clinical hernia was 62 (55) and 77 (57) among those with an occult hernia (Table).

Conclusion:
In the era of the obesity-epidemic and widespread use of radiographic imaging, hernias are extremely common. One fourth of individuals undergoing CT abdomen and pelvis scans have a clinical hernia while over 40% have an occult hernia. These hernias have a substantial impact on an individual’s QoL. Compared to individuals with no hernias, patients with a clinically apparent hernia and patients with occult hernias have significantly lower median QoL (by 22 and 7 points respectively). Randomized trials are needed to determine if operative repair can result in a clinically significant improvement in QoL.
 

53.06 Intrahepatic Cholangiocarcinoma Tumor Burden to Predict Prognosis Following Resection

Posted on January 31, 2019

J. Cloyd2, F. Bagante2,6, G. Spolverato2, M. Weiss1, S. Alexandrescu3, H. P. Marques4, L. Aldrighetti5, S. K. Maithel7, C. Pulitano8, C. Pulitano8, T. W. Bauer9, F. Shen10, G. A. Poultsides11, O. Soubrane12, G. Martel13, B. G. Koerkamp14, A. Guglielmi6, E. Itaru15, T. M. Pawlik2  1Johns Hopkins Hospital,Surgery,Baltimore, MD, USA 2The Ohio State University Wexner Medical Center,Surgery,Columbus, OH, USA 3Fundeni Clinical Institute, Bucharest,Surgery,Bucarest, -, Romania 4Curry Cabral Hospital,Surgery,Lisbon, -, Portugal 5Ospedale San Raffaele,Surgery,Milan, -, Italy 6University of Verona,Surgery,Verona, -, Italy 7Emory University School Of Medicine,Surgery,Atlanta, GA, USA 8Royal Prince Alfred Hospital,Surgery,Sydney, -, Australia 9University Of Virginia,Surgery,Charlottesville, VA, USA 10Eastern Hepatobiliary Surgery Hospital,Surgery,Shanghai, -, China 11Stanford University,Surgery,Palo Alto, CA, USA 12Beaujon Hospital,Surgery,Clichy, -, France 13University Of Ottawa,Surgery,Ottawa, Ontario, Canada 14Erasmus University Medical Centre,Surgery,Rotterdam, -, Netherlands 15Yokohama City University School of Medicine,Surgery,Yokohama, -, Japan

Introduction: We sought to investigate the impact of total tumor-burden (i.e. size and number) on patient prognosis following resection of ICC.

Methods: Patients who underwent curative-intent resection for ICC at one of the 15 participating institutions between 2005-2016 were identified.

Results:Among 1,278 patients who underwent surgery for ICC, 423 (33.1%) patients had no lymph-node metastasis (N0), while 224 (17.5%) had nodal disease (N1); 631 (49.4%) did not have a lymphadenectomy (Nx). Median tumor size was 6 cm (inter-quartile range [IQR], 4-8). While 1,016 (81.8%) patients had a single ICC, 226 (18.2%) patients had multifocal disease. On multivariable analysis, after adjusting for lymph-node status, tumor size (logarithmic transformation: HR 1.35) and number of ICC (logarithmic transformation: HR 1.51) demonstrated a strong non-linear association with overall survival (OS)(Log-model; Figure 1). Log-model (AUC 0.588) out-performed both tumor size (c-index 0.572) and number of tumors (c-index 0.539) in predicting OS. Among N0 patients, 5-year OS of patients with a single ICC ranged from 80-70% among patients with ICC <3 cm to 50% for patients with ICC >6 cm. Conversely, among N1 patients, 5-year OS of patients with a single ICC ranged from 60-50% for patients with ICC <3 cm to 40-30% for patients with ICC 3-6 cm and 20% for patients with ICC >6 cm.

Conclusion:Tumor size and number of ICC demonstrated a strong non-linear association with survival following resection of ICC. A log-model tumor burden score may be a better tool to estimate prognosis of patients undergoing curative-intent resection of ICC.

 

53.05 Usefulness of Fluorescence Imaging for Laparoscopic Liver Resection and Complex Biliary Surgery

Posted on January 31, 2019

Y. Kawaguchi1,2, Y. Nomura1, M. Nagai1, N. Tanaka1  1Asahi General Hospital,Department Of Surgery,,Asahi, CHIBA, Japan 2the University of Tokyo,Hepato-Biliary-Pancreatic Surgery Division,Bunkyo, TOKYO, Japan

Introduction: A fluorescence imaging technique using indocyanine green (ICG) as a fluorophore has been increasingly used for hepatobiliary surgery, and visualizes liver cancer and the bile duct as fluorescence. However, the usefulness of the technique for laparoscopic liver resection and complex biliary surgery remains unclear. We aimed to evaluate the identification of liver cancer in laparoscopic approach and the visualization of the bile duct during complex biliary surgery in open approach using ICG-fluorescence imaging.

Methods: (1) Visualization of liver cancer was evaluated in 6 patients (13 lesions) who underwent laparoscopic liver resection. As a fluorophore of the technique, ICG was injected intravenously at a dose of 0.5 mg/kg as a routine liver function test within 2 weeks before surgery. (2) Visualization of the bile duct was evaluated in 7 patients who underwent complex biliary surgery. ICG was administered by intrabiliary (IB) injection (0.025 mg/mL) or by intravenous (IV) injection (2.5 mg). The values of fluorescence intensity (FI) of the bile duct and the liver were calculated using a luminance analyzing software.

Results:(1) Of the 13 lesions, there were hepatocellular carcinoma (n=3) and colorectal liver metastasis (n=10). Fluorescence imaging visualized 8 (61.5%) lesions, which were invisible on the surface but were located less than 10 mm from the liver surface (Figure 1A). In contrast, the other 5 were located more than 10 mm from the liver surface and were not visualized as fluorescence. (2) Fluorescence imaging technique with the IB injection method was used for 6 patients with severe inflammation (n=3), abnormal biliary anatomy (n=2), and perforation of the bile duct (n=1). In contrast, the IV injection method was used for 1 patient with abnormal biliary anatomy. When using the IB injection method, the liver did not provide fluorescence as it showed fluorescence using the IV injection method. The fluorescence of the bile duct was clearly visualized on the low FI of the surrounding structures using the IB injection method (Figure1B) compared to fluorescence imaging using the IV injection method (Figure 1C). The median (range) FI ratio of the bile duct to the liver was 19.1 (5.0-67.7) using the IB injection method while it was 1.4 using the IV injection method.

Conclusion:ICG-fluorescence imaging is useful to visualize liver cancers which were not visible from the liver surface during laparoscopic liver resection. The IB injection method provided clear contrast between the bile duct and the surrounding structures compared with the IV injection method. The IB injection method is useful for recognizing the biliary anatomy, especially when biliary drainage tubes were inserted as an intervention of severe biliary tract infection.

 

53.04 Psychotropic Medications May Lead to Altered Presentation for Gastroesophageal Reflux Disease

Posted on January 31, 2019

M. McNally1, P. Belle1, A. D. Jalilvand1, K. A. Perry1  1The Ohio State Wexner Medical Center,Division Of General And Gastrointestinal Surgery,Columbus, OH, USA

Introduction:  Recognition and treatment of gastroesophageal reflux disease (GERD) is largely dependent on self-reported symptoms and quality of life assessment. Underlying psychiatric diagnoses and associated therapies may alter this presentation. As such, the primary goal of this study is to determine if baseline psychotropic medications impact the presentation of GERD, while secondary objectives included comparing disease-specific quality of life and symptom scales. 

Methods:  All patients who presented for elective surgical management of GERD from 2011 to 2016 at a single academic institution (n=359) were reviewed. Demographic data, presenting symptoms, objective work-up, and baseline scores on the gastro-esophageal reflux symptom scale (GERSS) and quality of life (GERD-HRQL) were obtained through chart review. Patients were grouped based on baseline (at the time of intake evaluation) usage of either a serotonin-modulating medication (SMM) or benzodiazepine (BZM) medication, as a proxy for major depression and anxiety disorders. Differences in presenting symptoms, GERSS and GERD-HRQL scores were carried out using Mann-Whitney U, Chi2, or Fisher’s Exact, as appropriate; a p value of <0.05 was considered statistically significant. 

Results: One hundred and sixty-three patients (45.3%) were on psychotropic medications; SMM use accounted for 80% (n=131), followed by BZM (24%, n=62), and 19% were utilizing both SMM/BZM (n=31). Compared to those not on any psychotropic medications, patients on SMM experienced significantly higher rates of chest pain (29% vs 19%, p=0.03), had higher GERD-HRQL scores for dysphagia (3 (1-4) vs 2(0-4), p=0.03) and bloating (4 (2-5) vs 3 (2-4), p=0.05) Patients on BZM presented more often with regurgitation (77 % vs 55%, p <0.005) and trended towards more chest pain (29% vs 19%, p=0.09), while also scoring significantly worse on the GERD-HRQL (33 (25-41) vs 29 (19-36), p=0.02) and GERSS (45.5 (31-54) vs 38 (22-50), p=0.02). Similarly, patients on SMM/BZM also demonstrated higher rates of regurgitation (81% vs 52%,p=0.003) and scores significantly worse on GERD-HRQL (38 (28-43) vs 29 (19-36), p=0.004) and GERSS (48 (31-63) vs 38 (22-50), p=0.02). Compared to the control group, patients on SMM, BZM, or both SMM/BZM demonstrated no difference in motility or pH testing.

Conclusion: Patients on SMM or BZM who present with GERD have higher rates of regurgitation and chest pain and worse scores on disease specific quality of life and symptom scales, Further studies are needed to evaluate how these medications and their associated psychiatric diagnoses impact outcomes after antireflux surgery. 

 

53.03 Perineural Invasion as a Prognostic Factor in Pancreatic Ductal Adenocarcinoma

Posted on January 31, 2019

H. Takahashi1, E. Katsuta1, K. Takabe1  1Roswell Park Cancer Institute,Surgical Oncology,Buffalo, NY, USA

Introduction:

Perineural invasion (PNI) is the process of neoplastic invasion of nerves, and is a morphologic feature observed in various malignancies. It serves as one of the pathologically determined poor prognostic factors along with lymphovascular invasion, and also can be a source of distant metastasis for some tumors. PNI is widely prevalent in patients with pancreatic ductal adenocarcinoma (PDAC). Although the exact mechanism of invasion to nerve still remains unclear, several signaling pathways in tumor microenvironment (TME) have been reported to date. Since PNI is relatively subjective pathological evaluation, there have been some conflicting reports of utility of PNI in the management of PDAC. Therefore, in the present study, we aimed to identify biological factors that are associated with PNI in PDAC using publicly available large data set The Cancer Genome Atlas (TCGA).  

Methods:

Genomic and clinical data of patients with PDAC were obtained from TCGA through cBioportal. Pathological information associated with TCGA was obtained through TIES. Using Kaplan-Meier survival curve and Cox proportional hazards model, clinical and oncologic parameters were analyzed. Gene Set Enrichment Analysis (GSEA) was also conducted between the groups based on PNI status.

Results:

There were 154 patients with PDAC in TCGA. The mean age of the cohort was 65.1 years old, with 83 (54%) patients being male. PNI was positive in 109 patients (71%), negative in 13 (8%), and unknown in 32 (21%). There was no significant difference in overall survival (OS) based on PNI status in TCGA cohort. Median OS was 17.8 months in PNI positive, and 19.9 months in negative (p=0.30). Subsequently, in order to identify the risk factors for OS, univariate analysis was performed with multiple clinical parameters. There was significantly longer OS in the patients who underwent adjuvant radiation therapy or targeted molecular therapy (p=0.002 and p<0.001, respectively). With multivariate analysis, absence of targeted molecular therapy (Hazard Ratio (HR): 4.76, p<0.001), absence of adjuvant radiation (HR: 2.58, p=0.02), and positive PNI (HR: 8.28, p=0.02) were found as independent risk factors of poor prognosis in patients with PDAC.

Furthermore, the PNI positive group was identified to enrich angiogenesis gene set by GSEA (NES: 1.67, p=0.002).

Conclusion:

Positive PNI was one of independent risk factors of poor prognosis in patients with PDAC in this study. It might be due to the associated angiogenesis and possible distant metastasis. 

53.02 Hospital Factors Strongly Influence Robotic Use in General Surgery

Posted on January 31, 2019

C. L. Stewart1, S. Dumitra1, C. Nota1, P. H. Ituarte1, L. Melstrom1, Y. Woo1, G. Singh1, Y. Fong1, H. Nathan2, S. G. Warner1  1City Of Hope National Medical Center,Surgical Oncology/Surgery,Duarte, CA, USA 2University Of Michigan,Hepatobiliary Surgery/Surgery,Ann Arbor, MI, USA

Introduction:   Although the use of robotics in general surgery is increasing in the United States, hospital and patient-level factors driving adoption are sparsely studied.  We hypothesized that general surgeons are more likely to use a robotic surgical platform at hospitals where more urologic and gynecologic robotic surgeries are performed, suggesting that hospital related factors are important for platform choice.

Methods: We queried the Nationwide Inpatient Sample from 2010-2013 for patients who underwent surgery on the gallbladder, pancreas, stomach, spleen, colon, or rectum (general surgery), the prostate or kidney (urologic surgery), and ovaries or uterus (gynecologic surgery).  Operations were classified as robotic if any ICD-9-CM robotic procedure code was used.  Hospitals were grouped into quartiles according to percentage of total volume of urologic or gynecologic surgeries that were performed robotically (0-20%, 21-40%, 41-60%, >60%). Multivariable logistic regression modeling was used to determine independent variables associated with robotic surgery. 

Results:  Survey-weighted results represented 461,368 (47.6%) open, 479,783 (49.5%) laparoscopic, and 27,620 (2.6%) robotic general surgical operations.  For general surgery patients, robotics use increased with each subsequent year studied (5.4% by 2013), and was most commonly performed for rectal surgery (7.0%), on patients with private insurance (3.2%) and higher household income (3.3%, all p<0.001).  Robotic operations were also more frequently performed at urban teaching hospitals (3.4%), compared to rural and non-teaching hospitals (p<0.001).  The odds of a general surgery patient receiving a robotic operation increased directly with increased use in urologic and gynecologic surgery at the hospital (Figure 1, *p<0.001).  General surgery patients treated at a top quartile hospital for robotic urologic surgery had 4 times greater odds of receiving a robotic operation compared to an open or laparoscopic operation (confidence interval 3.0-5.4, p<0.001). This finding was independent of study year, surgical site, insurance type, household income, and hospital type, and also persisted when only comparing laparoscopic to robotic procedures.   

Conclusions:  The use of robotics in general surgery is directly and independently related to its use in urologic and gynecologic surgery at a hospital.  Our study suggests that hospital factors strongly influence robotic use in general surgery. 

53.01 Clinical impact of anatomical resection for HCC treatable with partial resection

Posted on January 31, 2019

T. Gocho1, K. Nakashima1, Y. Shirai1, R. Marukuchi1, J. Yasuda1, H. Shiozaki1, K. Furukawa1, S. Onda1, H. Shiba1, Y. Ishida1, K. Yanaga1  1Jikei University School of Medicine,Department Of Surgery,Tokyo, Japan

Introduction:

Anatomical resection (AR) for hepatocellular carcinoma (HCC) has been reported to have better outcome compared to non-anatomical resection (NR). However, the specific benefit of AR for HCC judged treatable with partial resection remains unclear. The aim of this study is to evaluate the clinical impact of anatomical resection for HCC treatable with partial resection.

Patients and

Methods:
Two-hundred and sixty three patients were treated with primary hepatectomy for HCC between May 1997 and December 2016 at Jikei University Hospital. Of those, 80 patients with solitary tumor which were judged treatable by partial hepatectomy based on preoperative imaging were retrospectively reviewed. We divided such patients into two groups according to the types of resection (anatomical resection (AR) group (n = 28) treated by subsegmentectomy and non-anatomical resection (NR) group (n = 52) treated by partial hepatectomy) and patient factors (age, sex, viral status, ICG R15, Child-Pugh (C-P) grade), tumor factors (size, preoperative AFP and PIVKA-II values and portal vein (PV) invasion), operative factors (operative time, blood loss and blood transfusion) and outcomes (overall (OS) and disease-free (DFS) survival and complications) were assessed.

Results:

The following variables were comparable: sex, HBV infection, HCV infection, ICG 15, C-P grade, Preop. AFP, tumor size, pathological PV invasion, blood loss, blood transfusion and complications. However, AR group had older patients (≥ 65 years) (60% vs. 28.8%, p <0.05), higher preop. PIVKA-II (≥ 100 mAU/ml) (71% vs. 46.2%, p < 0.05) and longer operative time (≥ 360 min) (61% vs. 45%, p < 0.05), which were not independent risk factors related to DFS and OS after primary hepatectomy. There were no statistical difference in 5-year DFS and 5-year OS between AR group and NR group (53% vs. 36%, p = 0.096 and 70% vs. 67%, p = 0.714, respectively). However, for HCC 2 cm or larger, statistically higher 5-year DFS was achieved in AR group as compared with NR group (53% vs. 31%, p = 0.041), while no significant difference was observed in 5-year OS (73% vs. 64%, p = 0.488). Twenty seven of 52 patients in NR group developed intrahepatic recurrence, whose recurrence was in the same subsegment in 9 (33%) and in the other segment in 18 (67%) patients. There was no statistical difference in 5-year OS after recurrence between those with recurrence in the same subsegment and the other subsegment (p = 0.764).

Conclusion:

Anatomical resection (subsegmentectomy) seems to improve DFS of patients with HCC 2 cm or larger in diameter.

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