48.16 Single Center Outcome with a Percutaneous Right Ventricular Device in Right Ventricular Failure

Posted on January 31, 2019

B. Badu1, M. T. Cain1, Z. R. Laste2, L. Durham1, L. Joyce1, D. Ishizawar3, M. Saltzberg3, N. Gaglianello3, A. Mohammed3, D. L. Joyce1  1Medical College Of Wisconsin,Cardiothoracic Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,Radiology,Milwaukee, WI, USA 3Medical College Of Wisconsin,Cardiology/Medicine,Milwaukee, WI, USA

Introduction:

Severe right ventricular (RV) failure requiring right ventricular assist device (RVAD) implantation is encountered following severe acute pulmonary hypertension secondary to acute respiratory distress syndrome or pulmonary embolism, and left ventricular assist device (LVAD) implantation.  Mortality at 1-year reach 30% and 40%, respectively1. Percutaneous RVAD technology is emerging, but understudied2.

Methods:

Patient charts were retrospectively reviewed for demographic and perioperative cardiac hemodynamic data, etiology of RV failure, and comorbid conditions in all patients receiving percutaneous RVAD support at our academic institution between April 2017 and August 2018. The primary outcomes we assessed were in-hospital mortality, duration of RVAD support, ICU length of stay, and device related complications such as bleeding, stroke, and the need for surgical revision.

Results:

Percutaneous RVAD was used in 23 patients (16 men, 70%); median age, 58 [19 to 66] years). Indications for implantation included RV failure post LVAD implantation (n=11, 48%), acute respiratory distress syndrome (n=5, 22%), myocardial infarction (n=5, 22%), post cardiac transplant (n=1, 4%), and viral cardiomyopathy (n=1, 4%).  Median duration of support was 14 (3 to 23) days and 18 (78%) patients were successfully weaned or underwent cardiac transplantation. Overall in-hospital mortality was 34.8%. In-hospital mortality among patients with RV failure after permanent LVAD was 0 % with 1 late death at 150 days.  Mortality among patients with primary pulmonary etiology was 40%. There was no mortality with RV failure post-transplant or after viral cardiomyopathy. Severe postoperative bleeding requiring reoperation was noted in 3 (13%) patients. Superior vena cava obstruction occurred in 2 (8%) patients and device migration in 1 (4%) patient. No device-related infection or pulmonary emboli were noted.

Conclusion:

Percutaneous RVAD support appears to be a versatile and effective tool in treating patients with severe RV failure, with particular benefit after LVAD implantation. These findings support the need for additional investigation into the benefits of this device.

 

References:

1. Kirklin JK, Naftel DC, Pagani FD, Kormos RL, Stevenson LW, Blume, et al. Seventh INTERMACS annual report: 15,000 patients and counting. J Heart Lung Transplant. 2015;34;1495-504.

2. Ravichandran AK, Baran DA, Stelling K, Cowger JA, Salerno CT. Outcomes with the Tandem Protek Duo dual-lumen percutaneous right ventricular assist device. ASAIO J. 2018;64:570-2.

48.17 The Impact of Hospital Teaching Status on Clinical Outcomes After Major Cardiac Surgery

Posted on January 31, 2019

A. A. Haider2, A. Azim2, M. Bravo2, R. Latifi2, J. Goldberg2  2New York Medical College,Department Of Surgery,Valhalla, NY, USA

Introduction:  Surgical residents and medical student play a major role in patient care at teaching hospitals with varying degrees of involvement. It is often feared that trainee involvement in patient care may adversely affect clinical outcomes. The effect of trainee involvement on patient clinical outcomes after major cardiac procedures remain unknown. The aim of our study was to evaluate if trainee involvement in major cardiac surgery such as coronary artery bypass graft (CABG) is associated with worse outcomes.

Methods:  The National Inpatient Sample was abstracted for 3 years for all patients (≥18 years) who underwent CABG. Data was abstracted for patient demographics (age and gender), disease severity, co-morbidities, nature of admission (elective versus emergent), and hospital volumes (low, medium, and high). Patients were divided into two groups: Teaching hospital (TH) and non-teaching hospitals (non-TH). Outcome measures were mortality and failure-to-rescue (death after a complication). Multivariate logistic regression analysis was performed.

Results: A total of 141,392 patients from 589 hospitals were included. Mean age was 65.9 ± 10.8 years, 72.3% were male, and mean Charlson Comorbidity Index was 1.39 ±1.42. 58.1% (n=80,688) patients were treated at TH and 41.9% (n= 58,128) were treated at non-TH. Overall mortality rate in the population was 2.5 % and failure-to-rescue rate was 2.1%. Unadjusted mortality rate (2.6% vs. 2.4%; p=0.04) and FTR (2.1% vs. 2.0%; p=0.04) at TH was higher compared to non teaching. However, after adjusting for confounders with multivariate regression analysis, the odds of mortality (OR: 1.02; CI: 0.95- 1.10) and FTR (OR: 1.02 ; CI: 0.94-1.11) were similar between TH and non-TH.

Conclusion: Unadjusted rates of mortality and failure to rescue at teaching hospitals are slightly higher compared to non-teaching hospitals. This difference may likely be due to difference in disease severity and hospital volume as this effect disappears after adjusting for these factors. With adequate supervision, teaching hospitals can achieve similar outcomes to non-teaching hospitals after major cardiac procedures such as CABG.

 

48.15 Outcomes of Primary Repair of Tetralogy of Fallot in Adolescents and Adults

Posted on January 31, 2019

A. H. Siddiqui1, H. Fatima2, F. Safi2, M. Amanullah1  1Aga Khan University Medical College,Department Of Surgery,Karachi, Sindh, Pakistan 2Aga Khan University Medical College,Medical College,Karachi, Sindh, Pakistan

Introduction:
Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease in the world, and survival into adulthood is well known. Patients with untreated disease seldom present in the developed world; however, it is not uncommon in developing countries. Over time the development of comorbidities give rise to a major surgical challenge. We aimed to establish the relationship between pre-operative characteristics and post-operative course in these patients.

Methods:
We conducted a retrospective chart review of all patients older than the age of 10 years who underwent surgical repair of TOF between July 2006 and February 2017. Primary outcome measures were early (30-day) and late (greater than 30-day) mortality, morbidity, and need for reintervention. Data was analyzed using SPSS v 21.

Results:
A total of 59 patients meeting the inclusion criteria underwent surgical repair of TOF. The mean age at repair was 18.81 (±5.53) years. 6 (10.0%) patients had a pre-operative New York Heart Association (NYHA) functional class of I, 29 (48.3%) were NYHA class II, 12 (20.0%) were NYHA class III and 3 (5.0%) were NYHA class IV. All patients had atrial and ventricular arrythmias on electrocardiogram. Cyanotic spells were seen in 30 (50.8%) patients. 11 (18.6%) patients reported pre-operative palpitations, 11 (18.6%) had chest pain, whereas 9 (15.3%) had a history of infective endocarditis. 11 patients had undergone a previous Blalock-Taussig shunt (BT shunt) procedure.

There was 1 (1.69%) 30-day mortality seen, which was due to a ventricular arrythmia. No late mortalities were seen. The most common post-operative complication was pneumonia, seen in 8 (13.6%) patients, followed by sepsis seen in 6 (10.2%) patients. The mean length of ICU stay was 2.5 (±2.1) days. 3 (5.08%) patients needed a reintervention: one for severe post-operative pulmonary stenosis, one for residual ventricular septal defect (VSD) and pulmonary regurgitation and one for residual atrial septal defect (ASD).

Conclusion:
A significant number of adults with Tetralogy of Fallot are surgically treated in Pakistan, as in other developing countries. The overall morbidity and mortality of surgical intervention in this cohort is acceptable at our institution and comparable to that reported in other studies.

48.14 "Impact of a Thoracic Multidisciplinary Cancer Conference on Lung Cancer Care"

Posted on January 31, 2019

A. C. Sykes1,2, C. Gaudioso3, P. E. Whalen3, K. Attwood3, C. Nwogu4  1Upstate Medical University,Syracuse, NY, USA 2Roswell Park Comprehensive Cancer Center,Summer Research Experience Program In Cancer Science,Buffalo, NY, USA 3Roswell Park Comprehensive Cancer Center,Biostatistics & Bioinformatics,Buffalo, NY, USA 4Roswell Park Comprehensive Cancer Center,Thoracic Surgery,Buffalo, NY, USA

Introduction:  Lung Cancer, as the leading cause of cancer deaths in the U.S. remains a major health challenge. With the increasing complexity of lung cancer care, the multidisciplinary approach has taken on an increasingly prominent role in the care of lung cancer patients. This study aims to capture how a thoracic multidisciplinary conference (MDC) impacts lung cancer care and survivorship, to determine if there is a quantifiable advantage of applying formalized multidisciplinary care. 

Methods:  All patients registered with ICD 10 codes C34.0-9 “lung cancer” between January 1, 2010 and December 31, 2016 were identified from the cancer registry system. A total of 936 patients presented at the MDC were compared to a matched subset of the patients not discussed at the MDC. We used the REDCap electronic data capture tools hosted at Roswell Park Comprehensive Cancer Center (RPCCC). From the entire cohort, the top 600 patients with matched demographics and clinical presentations were used to generate intervention and control groups of 300 patients each. The survival rates and treatment plans of patients in both groups were retrospectively reviewed to quantify the benefits of the thoracic MDC. To objectively compare the quality of each treatment plan, the National Comprehensive Cancer Network (NCCN) guidelines were used to define the standard of care at each stage of the treatment process. The changes made to each treatment plan after the MDC were documented and compared to the final treatment plan to determine how the MDC influenced each case.

Results: There was an improvement in overall survival for lung cancer patients discussed at the Thoracic MDC (p<0.03). However, there was no significant improvement in lung cancer specific survival rates for these patients (p=0.12). MDC discussion made a statistically significant difference in the NCCN guidelines compliance rate of the final treatment received by patients (Table 1). 82 of 185 patients (44.3%) underwent treatment plan changes by the MDC, including 18 patients whose treatment plans were ‘uncertain’ prior to the MDC. Post-MDC recommendations included changes in the type of systemic therapy, surgical procedure, radiotherapy or a change in the sequence of multimodality therapy. 

Conclusion: A large proportion of patients had their treatment plans altered after MDC discussion. The final treatments that patients received were more compliant with NCCN guidelines after such discussions. Though our results showed an improvement in overall survival for the lung cancer patients discussed at the Thoracic MDC, an improvement in lung cancer specific survival as a result of MDC discussion could not be demonstrated in this limited cohort of matched patients. 
 

48.13 Predictors of 30-Day Outcomes Following Mitral Valve Repair

Posted on January 31, 2019

A. Reisman1, A. Thomas1, P. Boateng1, I. Leitman1  1Icahn School of Medicine at Mount Sinai,New York, NY, USA

Introduction: Mitral valve repair has been established as the preferred treatment option in the management of degenerative mitral valve disease. Compared with other surgical treatment options, mitral valve repair is associated with increased survival and decreased rates of both complications and reoperations. However, among patients undergoing mitral valve repair, little is known about the predictors of postoperative outcomes. The purpose of this study was to identify preoperative patient risk factors associated with morbidity and mortality within 30 days of mitral valve repair.

 

Methods:  Data were derived from the American College of Surgeons National Surgical Quality Improvement Program database to assess patients who underwent mitral valve repair from 2011 through 2016. Preoperative risk factors were analyzed to determine their association with a variety of postoperative 30-day outcome measures.

Results: One thousand two hundred and thirty-four patients underwent mitral valve repair; 763 (61.8%) males and 471 (38.2%) females. Ages ranged from 18 to 89 years, with a median age of 65 years. The overall 30-day mortality was 3% (37 patients). Among the 12 identified risk factors associated with increased mortality, pre-operative hematocrit level was the only variable significantly correlated with mortality after undergoing multivariate analysis. 235 patients (19.2%) were discharged to a location other than home, an outcome associated with 21 identified risk factors. Among these risk factors, female gender, age, hypertension requiring medication, dialysis, pre-operative serum sodium, and pre-operative serum albumin remained statistically significant following multivariate analysis. 121 patients (9.8%) experienced unplanned readmission. This outcome was associated with eight risk factors, of which only dyspnea upon mild exertion was significant on multivariate analysis. Reoperation occurred in 99 patients (8.1%). Of the 6 identified variables associated with reoperation, patient age was the only independent predictor on multivariate analysis. 49 patients (4.0%) underwent reintubation, which was associated with 13 identified risk factors. Among them, patient age and pre-operative INR value were predictive of reintubation on multivariate analysis. 

Conclusion: Outcomes are good following mitral valve repair. Although a substantial number of risk factors were found to be associated with adverse outcomes, only a small subset remained significantly significant following multivariate analysis. Identification of these risk factors may help guide clinical decision making with respect to which patients are the best candidates to undergo mitral valve repair. 
 

48.12 Redo Lung Transplantation: Is Age a Factor in Survival Outcome?

Posted on January 31, 2019

J. N. Levy1, M. A. Kashem1, N. Shigemura1, J. Gomez-Abraham1, S. Keshavmurthy1, Y. Toyoda1  1Temple University,Cardiovascular Surgery,Philadelpha, PA, USA

Introduction:
Currently, the number of elderly recipients for lung transplantation (LTx) is increasing. However, fewer patients receiving primary single or double LTx with graft failure outcome are sometimes offered redo-LTx. We investigated the survival outcome of single or double redo-LTx in elderly recipients analyzing the UNOS database.  

Methods:

We reviewed the UNOS database and included patients who received single and/or double redo- LTx based on three different age cohorts from 1987 to 2014: recipient age – ≤69, 70-74, and ≥75 years old. Kaplan-Meier survival outcome was compared among the different age cohorts using variables such as age, gender, ethnicity, BMI, length of stay (LOS), ECMO, blood type, and transplantation procedure. Using SAS program, data were expressed as Mean ± standard deviation and p<0.05 was considered significant.

Results:

There were 594 had double and 498 had single redo-LTx out of total 1,092 redo-LTx patients. Demographics data showed 52% male, 87% white, 6% black, 5% Latino, and 2% others, mean age (50±5) years, BMI (20±5) kg/m2, median LOS 15 days, and blood groups: O-46%, A-40%, B-10%, AB-4%, ECMO-4%. Within the age cohorts, 1,069 patients were ≤69 years of age, 20 patients were 70-74 years old, and 3 patients were over ≥75 years old. Log-rank test for equality of survival between the three different age groups showed no significant difference in survival for single redo-LTx (p=0.89), but demonstrated significance between the age cohorts for double redo-LTx (p=0.004). There was no significant age discrimination between individuals receiving single redo-LTx based on age: ≤69 vs. 70-74 years old (p=0.63), ≤69 vs. ≥ 75 years old (p=0.94), 70-74 vs. ≥75 years old (p=0.91).

Conclusion:
Age was not a factor in survival outcome of the elderly patients undergoing single redo-LTx, but was statistically significant in double redo-LTx. Further study is warranted due to limited number of patients.

48.11 Outcomes after CABG or Valvuloplasty are Worse in Cardiac Transplant Centers?

Posted on January 31, 2019

M. M. Jamil1, W. Qu1, F. C. Brunicardi1, M. M. Nazzal1, J. Ortiz1  1University Of Toledo Medical Center,Surgical Education,Toledo, OH, USA

Introduction:

The purpose of the study is to determine if the outcomes after CABG or valvuloplasty are different among centers that perform cardiac transplant and centers that do not.

Methods:

Centers performing cardiac transplants during 2008-2014 were identified from the National Inpatient Sample. All CABGs and valvuloplasties within this period were stratified by whether they were performed at a cardiac transplant center (CTC) or a non-transplant center (NTC). Demographics and comorbidities were extracted using ICD-9 codes. Outcomes were in-hospital mortality, acute stroke, acute renal failure (ARF), deep sternal wound infection (DSWI), reoperation, and length of stay (LOS) >14 days. Χ2, Mann Whitney tests were used for comparison. The effect of being in CTC vs NTC on each outcome was derived from logistic regression and expressed as Odd’s ratio (OR) with 95% confidence interval (CI), after adjustment for covariates. 

Results:

2,003,765 cases of CABGs or valvuloplasties were identified. 18% (n=366,877) of these were in CTC and 82% (n=1,636,888) in NTC. The mean age in CTC vs. NTC was 65 and 66 years, respectively.  33% of cases in CTC were females vs. 31% in NTC (p<0.01). African Americans comprised of 9.3% of cases in CTCs and 6.5% of cases in NTCs (p<0.01). Among comorbidities, cases in CTC had higher rates of congestive cardiac failure (2.2% vs. 1.3%), renal failure (16% vs. 14%), atrial fibrillation (38.1% vs. 32.5%), with all p<0.01. Cases in CTC had lower rates of obesity (16.6% vs. 19.6%), HTN (71.6% vs 74.3%), COPD (18.6% vs. 22.1%), and diabetes (25.5% vs. 31.1%) compared to NTC (all p<0.01). Fewer cases in CTC had intra-aortic balloon pump (6.6% vs. 8.5%, p<0.01). NTC had more emergent cases (47.5% vs. 41.8%, p<0.01) than CTC. Cases in CTC had a higher in-hospital mortality (3.2% vs. 2.7%, p<0.01) than NTC. The adjusted OR for mortality for cases in CTC was 1.13 (95% CI 1.07-1.18). CTC cases also had a higher rate of ARF (17.4% vs. 15.3%, p<0.01) with adjusted OR 1.05 (95% CI 1.03-1.08, p<0.01); reoperation (2.6% vs. 2.0%, p<0.01) with adjusted OR 1.19 (95% CI 1.13-1.26, p<0.01); deep sternal wound infection (1.1% vs. 0.8%, p<0.01) with adjusted OR 1.35 (95% CI 1.24-1.46, p<0.01); and LOS>14 days (23.3% vs. 16.8%, p<0.01) with adjusted OR 1.47 (95% CI 1.44-1.50, p<0.01). CTC cases had a lower rate of acute stroke (7.8% vs. 8.1%, p<0.01), but adjustment for covariates revealed an OR of 1.00 (95% CI 0.97-1.04, p=0.82).

Conclusion:

CABGs and valvuloplasties performed in CTCs have worse outcomes than those in NTCs with higher rates of in-hospital mortality, acute renal failure, reoperation, deep sternal wound infection, and LOS>14 days.

 

48.10 Ivor-Lewis vs McKeown Esophagectomy: Analysis of Operative Outcomes from the ACS-NSQIP Database

Posted on January 31, 2019

M. J. Sabra1, h. Xu1, A. D. Cassano1, L. G. Wolfe1, B. Kaplan1, R. D. Shah1  1Virginia Commonwealth University,Surgery,Richmond, VA, USA

Introduction:
The decision to perform an Ivor Lewis or a McKeown technique for esophagectomy is usually based on surgeon’s preference and their comfort level with the two procedures, usually based on their training and personal experience. In this study we aim to compare these 2 approaches.

Methods:
We identified patients who underwent either approaches to esophagectomy in the American College of Surgeons?National Surgical Quality Improvement Project (ACS?NSQIP) database (2005-15). We compared both groups using a bivariate analysis.

Results:
We identified 4283 patients with esophagectomy and divided them into 2 groups based on whether they received a Mckeown (1279; 29.86%) or an Ivor Lewis (3004; 70.14%) esophagectomy. Basic preoperative characteristics including age, race, gender, BMI, hemoglobin, albumin, creatinine, weight loss, comorbidities, and functional status were not different between groups. General surgeons performed 65% of the Mckeown operations vs. only 50% of the Ivor Lewis operations (p <.0001). The Mckeown operation group had a higher mean operative time (415 vs 393 minutes, p <.0001), higher frequency of sepsis (9.61% vs 7.35%, p= .0129), more patients with prolonged intubation (15.31% vs 12.01%, p= 0.0035), higher rate of re-intubation (14.92% vs 11.68%, p=0.0035), and higher re-admission rate (25% vs 20.92%, p=0.0108). The mortality rate and hospital length of stay (LOS) were not different

Conclusion:
Both techniques are comparable in 30-day mortality and LOS. However, McKeown esophagectomy is a longer operation and it is associated with more unplanned intubation, increased difficulty weaning from the ventilator, more sepsis, and higher chance of readmission.
 

48.09 Opioid and Adjunct Pain Medication Utilization after Robotic Versus Open Transhiatal Esophagectomy

Posted on January 31, 2019

L. R. Franko2, C. M. Gilbert2, A. A. Brescia1, J. Caceres2, L. Azzouz2, A. A. Mazurek2, A. C. Chang1, P. W. Carrott1, J. Lin1, W. R. Lynch1, M. B. Orringer1, R. M. Reddy1, K. H. Lagisetty1  1University Of Michigan,Thoracic Surgery,Ann Arbor, MI, USA 2University Of Michigan,Medical School,Ann Arbor, MI, USA

Introduction:
Transhiatal esophagectomy (THE) can be performed via an open or robotic-assisted (RA) approach. The reported benefits of RA THE include more complete lymph node sampling and direct visualization during dissection. However, the impact of RA THE on postoperative acute pain management is unknown. This study compares the impact of RA THE versus open THE on postoperative pain management. 

Methods:
All patients undergoing THE at our institution between 03/2017-03/2018 were identified (n=57). Retrospective chart review and our institutional STS database were utilized to collect data regarding surgical approach, demographics, complications and pain management. Patients undergoing McKeown or Ivor Lewis esophagectomies were excluded. Pain management strategy and utilization, including opioids, adjuncts, epidural, and patient controlled analgesia (PCA), were recorded from postoperative day (POD) 0-10 as well as day prior to discharge. The mean oral morphine equivalents (OMEs) per POD were based on OMEs taken (oral and IV rescue dose) after epidural, PCA, or opioid infusion was discontinued. Descriptive data were analyzed, and 2-tailed t-test or Chi-squared was utilized as appropriate. 

Results:
Open THE was performed in 41 patients with 3 conversions to open. RA THE was successful in 16 patients. An epidural was utilized in 38 (92.7%) of open patients versus only 1 (6.3%) RA patient (p<0.001). Of note, 15 (93.8%) RA patients received a PCA compared to 18 (43.9%) open (p<0.001), 3 of whom did not also receive an epidural. PCA and/or epidural was discontinued on POD 4.6 for open and 3.8 for RA patients (p=0.003). Mean daily OME use from POD 3-10 on average trended higher in RA patients with only POD 8 showing a significant difference (p=0.015; Figure 1). On the day prior to discharge, mean OME per patient was significantly higher in the RA group (35.1) versus open (17.3; p=0.029). Age, procedure time, length of stay, postoperative event rate, prior benzodiazepine or opioid use, number of adjunct doses per day, gabapentin or lidocaine patch use, discharge prescription OME, and number of patients requiring refills did not differ.  

Conclusion:
This study demonstrated mean daily OME use for the first ten PODs after THE did not differ between the open or RA; however, day prior to discharge OME use was higher in the RA cohort. This suggests that opioid use following RA THE may equal or exceed opioid use following open THE.  Further investigation with a larger cohort of patients is needed to identify risk factors for higher use in RA patients, such as lack of epidural use.

 

48.08 Minimally-Invasive Single Vessel Coronary Bypass: Outcomes from a Single-Institution STS Database

Posted on January 31, 2019

N. J. Smith1, M. Cain1, B. Miles1, P. Pearson1, L. Joyce1, L. Durham1, G. Raikar1, C. Rokkas1, D. Joyce1  1Medical College Of Wisconsin,Cardiothoracic Surgery,Milwaukee, WI, USA

Introduction:  Coronary artery bypass grafting (CABG) can be performed through a variety of approaches. Minimally invasive, non-sternotomy CABG has been proposed as a technique to reduce perioperative morbidity. Early data demonstrate improvements in perioperative metrics, however, adoption has been limited due to limited institutional experience.

Methods:  The Society of Thoracic Surgeons (STS) database at a single academic institution was queried for all isolated single-vessel left internal mammary to left anterior descending artery (LIMA-LAD) bypass procedures performed between January 2011 and March 2018. Patients were grouped based on operative approach, comparing conventional sternotomy to non-sternotomy (minimally-invasive) approaches. Patients who underwent concomitant valvular, aortic, or ablative procedures were excluded. Patient characteristics, perioperative variables, and short term outcomes were compared between groups. Primary outcome included mortality and major adverse cardiac events, with postoperative morbidity as secondary outcomes.

Results: A total of 48 minimally-invasive and 68 conventional sternotomy single-vessel LIMA-LAD CABG procedures were performed. Minimally-invasive approaches were more often elective (81.3 vs 52.9%, p=0.002). Patient characteristics were similar between groups. STS predicted risk scores demonstrated similar predicted mortality between groups with significantly lower predicted rates of prolonged ventilation, renal failure, and long length of stay in the minimally-invasive group. No significant difference was noted in major adverse cardiac events (0.0 vs 7.4%, p=0.076), STS composite morbidity (2.1 vs 8.6%, p=0.237), and postoperative myocardial infarction (4.2 vs 1.5%, p=0.569). Minimally-invasive approach was associated with fewer pulmonary (0.0 vs 10.3%, p=0.040) complications and decreased ICU (34.95 vs 58.7 hours, p<0.001) and total length of stay (4.54 vs 8.04 days, p<0.001). There were no observed strokes or graft occlusion reoperation in either group. There was a trend toward reduced 30-day mortality (100 vs 92.6%, p=0.076). These are consistent with previous experiences.

Conclusion: Minimally-invasive single-vessel LIMA-LAD CABG demonstrates improved perioperative outcomes regarding length of stay and pulmonary complications while performing comparably to conventional sternotomy in mortality and major adverse cardiac events. In select patients, minimally-invasive approaches to single-vessel grafting may be beneficial and a safe alternative to conventional approaches.   

 

48.07 Thymectomy Modality Impacts Readmission and Length of Stay: A National Cancer Database Study

Posted on January 31, 2019

B. S. Hendriksen1, M. F. Reed1, C. S. Hollenbeak2, M. D. Taylor1  1Penn State Health Milton S Hershey Medical Center,Hershey, PA, USA 2Pennsylvania State University,University Park, PA, USA

Introduction:  
Minimally invasive thymectomy operations are increasing and the impact on readmission and hospital length of stay merits contemporary evaluation. This study assessed surgical modality and other risk factors associated with 30-day unplanned readmission and hospital length of stay following thymectomy.

Methods:
The National Cancer Database was used to identify patients 18 years and older who underwent thymectomy between 2010 and 2015. Patient characteristics were compared using analysis of variance. Logistic regression and generalized linear modeling were used for multivariable analysis. Propensity score matching was used to control for covariate imbalance between modalities.

Results: 
3,145 patients underwent thymectomy: 2,360 open, 379 VATS, and 406 robotic assisted. VATS and robotic approaches were less likely to have readmissions compared to open (OR=0.32, p=0.015, and OR=0.30, p = 0.0110, respectively). Length of stay for VATS was 1.2 days less than for open (p < 0.0001) and robotic had a length of stay 1.3 days less than open (p < 0.0001). Propensity score matching corroborated that unplanned readmission was increased in open vs VATS (p = 0.0100) and decreased in robotic vs open (p = 0.0180). Length of stay was significantly shorter for robotic compared to open (p = 0.0070).

Conclusion: 
Minimally invasive surgery offers important benefits when compared to an open approach for thymectomy. VATS is associated with fewer readmissions and a robotic-assisted approach is associated with a shorter length of stay and fewer readmissions.

 

 

48.06 Surgery for Recurrent Pulmonary Metastases of Sarcoma Versus Non-Sarcoma

Posted on January 31, 2019

G. J. Haro1, J. Reza3, A. Sammann1, M. Hudnall2, K. Jones1, D. Jablons1, M. J. Mann1  1University Of California – San Francisco,San Francisco, CA, USA 2Northwestern University,Chicago, IL, USA 3Florida Hospital,Orlando, FL, USA

Introduction:

Pulmonary metastases frequently recur after metastasectomy.  There is limited evidence to guide surgical decision-making following recurrence, but a particularly aggressive approach to metastasectomy has been advocated for sarcoma. We studied outcomes associated with an aggressive surgical approach to recurrent pulmonary metastases from sarcoma and other primary malignancies.

Methods:

We retrospectively identified 556 consecutive pulmonary metastasectomies at our center between 1991-2015 among 192 sarcoma and 252 non-sarcoma patients.  The most common non-sarcoma subtypes were colorectal adenocarcinoma (n=80), melanoma (n=49), and renal cell carcinoma (n=34).  Indications for initial metastasectomy were substantially more liberal for sarcoma than non-sarcoma.  Patients were all followed with standard surveillance imaging.  Kaplan-Meier analysis with a right-censored dataset assessed recurrence and overall survival from time of metastasectomy.  Multivariable Cox proportional hazards models were developed in sarcoma and non-sarcoma patients with recurrent pulmonary metastasis based upon age, sex, race, non-sarcoma cancer type, number/size lesions, time to recurrence, surgery date, anatomic resection, minimally invasive procedure, and chemo/radiotherapy.

Results:

Median survival was 3.1 (95% CI 2.4-3.9) years for sarcoma and 4.7 (95% CI 3.6-6.8) years for non-sarcoma.  Seventy percent (135/192) sarcoma and 42.1% (106/252) non-sarcoma patients recurred and sarcoma patients recurred with a greater number of lesions (mean 4.5 vs 2.5).  Median time to recurrence was 7.2 (95% CI 4.8-9.6) and 10.8 (95% CI 8.4-13.2) months in sarcoma and non-sarcoma, respectively.  In those who recurred, 49.6% (67/135) sarcoma and 38.7% (41/106) non-sarcoma underwent repeat metastasectomy.  Sarcoma patients whose recurrences remained resectable experienced similar survival to those who did not recur (Figure, P=0.47), whereas those with resectable recurrence from non-sarcoma had worse survival (P=0.02).  Multivariable models identified recurrence <6 months (HR 2.7 95% CI 1.8-4.1) and need for anatomic resection (HR 1.7 95% CI 1.0-2.9) as predictors of worse survival among sarcoma patients.  Delayed recurrence >2 years (HR 0.2 95% CI 0.1-0.5; HR 0.4 95% CI 0.2-0.8) and largest lesion <2cm (HR 0.5 95% CI 0.3-0.7; HR 0.6 95% CI 0.4-0.9) were associated with improved survival in sarcoma and non-sarcoma, respectively.

Conclusion:

Although recurrences of pulmonary metastasis tend to be more virulent in sarcoma, aggressive repeat resection when possible may better preserve survival in patients with sarcoma compared to non-sarcoma.  Patients with a longer time to recurrence and smaller lesions may be more likely to benefit from repeat surgical resection

48.05 Surgical Outcomes After CABG in Octogenarians: Does Higher Experience Equate Better Outcomes?

Posted on January 31, 2019

A. A. Haider1, A. Azim1, M. Bravo1, R. Latifi1, J. Goldberg1  1New York Medical College,Department Of Surgery,Valhalla, NY, USA

Introduction: As the US population ages, the number of octogenarian (≥80 years) population with coronary artery disease undergoing coronary artery bypass graft (CABG) is increasing. Studies have suggested that centers who manage a higher proportion of these patients may have better outcome for this high risk population. The aim of this study was to determine if centers that manage higher proportion of octogenarian patients undergoing CABG have better outcomes.

Methods:  The National Inpatient Sample was abstracted for all patients undergoing CABG for 3 years. Hospitals were divided into 4 groups of quartiles based on the percentage of their total CABG patient’s ≥80 years. Outcome measures were mortality and failure-to-rescue (death after a complication) and overall complications (Stroke, UTI, pneumonia, respiratory failure, DVT, PE, iatrogenic PTX etc). Multivariate regression models were created adjusting for age, gender, Charlson comorbidity index, disease severity, hospital volume, and nature of admission (elective/emergent).

Results: A total of 141,392 patients from 589 hospitals were included. Mean age was 65.9 ± 10.8 years, 72.3% were male, and mean Charlson Comorbidity Index was 1.39 ±1.42. Overall 10.8% (n=15,265) of the population that underwent CABG was octogenarian. The proportion of octogenarian patients in these hospitals undergoing CABG ranged from 6.7% in the lowest quartile group to 18.3% in the highest quartile group. The overall mortality rate in the octogenarian group was 5.1% and failure-to-rescue rate was 4.2%. Odds of mortality (OR, 0.97; 95% CI, 0.91–1.07) and FTR (OR, 0.99; 95% CI, 0.91–1.09) after CABG were similar at centers with lowest proportion of octogenarian patients compared with centers with higher proportion of octogenarians. Unadjusted rate of complications was higher in centers with higher proportion of octogenarian patients (43.7% vs. 39.8%; p=0.03) however, using multivariate analysis, the adjusted odds of complications remained similar (OR, 1.02; 95% CI, 0.98–1.07)

Conclusion: The overall proportion of octogenarian patients that undergo CABG at a center does not significantly affect its outcome for this group of patients. Octogenarian patients who are managed at hospitals that manage a lower proportion of these patients have similar outcomes. This evidence does not support the need for treating octogenarian patients at centers with higher proportion of CABG patients.

48.04 Are Post-Cardiac Surgery Outcomes Worse in End-Stage Renal Disease or Acute Kidney Injury Patients?

Posted on January 31, 2019

P. D. Kohtz1, B. R. Griffin2, S. Faubel2, S. Ambruso2, J. Teixeira2, M. Bronsert3, M. Wells1, C. Matter1, M. J. Weyant1, T. Reece1, J. D. Pal1, D. A. Fullerton1, J. C. Cleveland1, M. Aftab1  1University Of Colorado Denver,Cardiothoracic Surgery,Aurora, CO, USA 2University Of Colorado Denver,Division Of Nephrology,Aurora, CO, USA 3University Of Colorado Denver,Adult And Child Consortium For Health Outcomes Research And Delivery Science And Surgical Outcomes And Applied Research,Aurora, CO, USA

Objective: Patients with End Stage Renal Disease (ESRD) requiring hemodialysis are increasing worldwide. Cardiac surgery is reluctantly offered to these patients. ESRD is an established risk factor for patients undergoing surgery requiring cardiopulmonary bypass. Acute Kidney Injury (AKI) after cardiac surgery leads to a significant increase in post-operative mortality and morbidity. The objective of this study is to evaluate the influence of ESRD on post-operative outcomes. We further compared adjusted complications rates in ESRD patients to matched counterparts without any kidney disease, as well as to those who develop severe AKI following cardiac surgery.

Method: Using our local STS database from 2011-2016, we identified 2,536 surgical cases, of which 1,584 met inclusion criteria (Figure 1A).Within this group, 35 patients had ESRD at the time of surgery and 102 patients developed severe AKI (doubling of creatinine) following surgery. We performed unadjusted, multivariate, and propensity matched analyses comparing ESRD patients to those without renal injury and those who developed severe AKI following surgery. A 2:1 greedy match was used. All statistical tests were considered to be significant at a 2-sided p < .05.

Results: The in-hospital mortality was 2.9%. vs 2.5% (p = 0.9) in patients with and without ESRD. On bivariate analysis, there were no significant differences in preoperative cardiogenic shock (p=0.5), mean Charlson comorbidity index (p=0.9) and cardiopulmonary bypass time (p=0.7) between the groups. In both models, propensity matching was successful, as defined by standard error values < 0.1 in all variables. There was no difference in propensity matched post-surgical infection (p=0.46), intensive care unit (ICU) length of stay (p=0.77), or 30-day readmission rate (p=0.58) in the ESRD patients compared to those with normal renal function. When compared to patients with severe AKI following surgery, on propensity-matched analysis, ESRD patients had dramatically lower risks of post-surgical infection (p=0.005) and ICU LOS (p=0.03) (Figure 1B-C). Median follow up of ESRD group was 21.5 months (Range: 1-71 months) and 5-year KM-estimated survival for ESRD patients was 61% (Figure 1D).

Conclusion: In dialysis dependent patients with ESRD, major cardiac surgery procedures can be performed with acceptable perioperative risks and early mortality. There is no significant difference in post-surgical complications compared to those with normal renal function or post-operative AKI. ESRD patients had much lower rates of infections and ICU length of stay compared to those who developed severe post-operative AKI following surgery.

48.02 Satisfaction after Lung Cancer Surgery: Do Clinical Outcomes Affect HCAHPS Scores?

Posted on January 31, 2019

E. S. Singer1, S. D. Moffatt-Bruce2, D. M. D’Souza2, L. Luo2, R. E. Merritt2, P. J. Kneuertz2  1The Ohio State University, Wexner Medical Center,Department Of Surgery,Columbus, OH, USA 2The Ohio State University, Wexner Medical Center,Thoracic Surgery Division, Department Of Surgery,Columbus, OH, USA

Introduction: Hospital consumer assessment of health care providers and systems (HCAHPS) surveys capture patients’ hospital experience and satisfaction, and are used as a patient-centered quality metric by CMS and hospital administrators. The effects of clinical outcomes on HCAHPS ratings following thoracic surgery are ill defined. We hypothesized that increased length of hospital stay (LOS) and postoperative complications negatively affect HCAHPS scores.

Methods:  Patients undergoing lung resection for cancer at a single academic cancer center between years 2014-2018 were analyzed. Clinical data were derived from the institutional Society of Thoracic Surgeons (STS) database and supplemented with HCHAPS survey data. The endpoints were overall top-box satisfaction scores, as well as domain-specific scores in communication with physicians and nurses. Multivariate regression analysis was used to test the association between clinical outcomes and HCAHPS top-box scores.

Results: In total, 181 out of 478 (38%) patients who underwent pulmonary resection for lung cancer completed HCAHPS surveys. Patient median age was 65 years, and most underwent lobectomy (94%). Median LOS was 4 days (IQR 3-6 days). The rate of top-box rating for the overall hospital experience, communication with doctors, and communication with nurses were 92%, 84%, and 69%, respectively. Patient factors associated with lower satisfaction scores with doctors included Asian/Other race and never-smoking status (p=0.02 and p=0.03, respectively). Increasing LOS was associated with worse satisfaction with doctors’ communication (Figure). Overall and major complication rates were 43% and 3% and were not associated with top-box HCAHPS scores. In multivariate analysis adjusted for patient factors, increasing LOS remained independently associated with worse patient satisfaction in the domains of communication with physicians and nurses. Specifically, patients with LOS >6 days compared to LOS <4 days were less likely to endorse top-box scores reflecting that doctors gave understandable explanations (OR 0.15, 95%CI 0.04-0.56) and nurses listened carefully (OR 0.11, 95%CI 0.06-0.69).

Conclusion: Overall HCHAPS satisfaction scores following lung cancer surgery were high and negatively associated with increasing length of stay, but not by postoperative events. Thoracic surgeons should be aware that patient satisfaction may be impacted more by the perception of effective communication during prolonged hospitalizations than by complications.

 

48.01 A Modern Propensity Score Matched Analysis Of Transthoracic Versus Transhiatal Esophagectomy

Posted on January 31, 2019

C. Takahashi1, R. Shridhar2, J. Huston3, K. Meredith4  1National Naval Medical Center,Surgery,Portsmouth, VIRGINIA, USA 2Florida Hospital Cancer Institute,Radiation Oncology,Orlando, FLORIDA, USA 3Sarasota Memorial Institute for Cancer Care,Gastrointestinal Oncology,Sarasota, FLORIDA, USA 4Florida State University College Of Medicine/ Sarasota Memorial Institute for Cancer Care,Gastrointestinal Oncology,Sarasota, FL, USA

Introduction: Surgical resection has become a mainstay of therapy for esophageal cancer and can increase survival significantly. With the advancement of minimally invasive surgery, there is still debate on the best approach for esophagectomy. We report a modern analysis of outcomes with transthoracic (TT) versus transhiatal (TH) esophagectomy.

Methods: A prospectively managed esophagectomy database was queried for patients undergoing transthoracic or transhiatal esophagectomy between 1996 and 2016.  Propensity score matching was perfomred based upon age and stage. Statistical analysis was performed using SPSS® version 23.0 (IBM®, Chicago, IL). Continuous variables were compared using the Kruskal Wallis or the ANOVA tests as appropriate. Pearson’s Chi-square test was used to compare categorical variables. Unadjusted survival analyses were performed using the Kaplan-Meier method comparing survival curves with the log-rank test.

Results: We identified 846 patients who underwent esophagectomy with a mean age of 64  ± 10 years. There was no difference in EBL for TT and TH, but the mean OR times were longer for TT vs. TH  (p<0.001) and the number of retrieved lymph nodes was higher for TT vs. TH (p<0.002).  Post-operative complications occurred in 207 (29.0%) patients who underwent a TT approach versus 59 (44.7%) who underwent a TH approach, (p<0.001).  The most common complications in TT versus TH techniques respectively were anastomotic leaks: 4.3% versus 9.8%, (p=0.01), anastomotic stricture 7% versus 26.5%, (p<0.001) and pneumonia 12.6% versus 22.7%, (p<0.002). Other outcomes that were also improved in TT vs. TH were aspiration (p<0.001), wound infections (p=0.004), and pleural effusions (p<0.001). Median survival was also significantly improved in patients undergoing TT (62 months) vs TH  (39 months) p=0.03. After matching there were 131 in the TT and 131 in the TH groups.  Post-operative complications remained lower in the TT (32.1%) vs TH (44.3%), p=0.04. Among these, anastomotic strictures (p<0.001), pulmonary complications (p=0.006), aspirations (p<0.001), and pleural effusions (p<0.001) were all lower in the transthoracic cohorts. There were lower incidences of anastomotic leaks in the TT 6 (4.6%) vs TH 13(9.9%), p=0.09 and wound infections: TT 6 (4.6%) vs TH 14(10.7%) p=0.06 which did not reach significance.

Conclusion: In this modern propensity score matched analysis of transthoracic versus transhiatal esophagectomy we found that a transthoracic approach was associated with lower pneumonias, anastomotic leaks, wound infections and strictures with an improvement in nodal harvest.  Survival was also significantly improved in patients who underwent transthoracic esophagectomy.

 

47.20 Implant Sparing Nipple Sparing Mastectomy

Posted on January 31, 2019

E. E. Burke1, C. Laronga1, W. Sun1, S. J. Hoover1, N. Khakpour1, J. V. Kiluk1, M. C. Lee1  1Moffitt Cancer Center,Breast Oncology,Tampa, FL, USA

Introduction: Nipple sparing mastectomy has become an option for the treatment and prevention of breast cancer in selected women. Our experience with implant sparing mastectomy suggests that this is a safe and effective option for women with previous retropectoral implant augmentation. We aimed to explore outcomes of patients that underwent concurrent implant and nipple sparing mastectomy (ISNSM) at our institution.

Methods:  A retrospective review of patients undergoing ISNSM for either prevention or treatment of breast cancer from 2009 until 2017 was performed at a single institution. Data including patient and tumor characteristics, stage, systemic and radiation therapy use, 90-day complication rates, additional reconstruction, and disease recurrence was collected.

Results: A total of 11 patients were identified after ISNSM; the average BMI was 22.8kg/m2 (range 18.6-30.9). Four (36.4%) had breast cancer in the breast undergoing ISNSM, 3 (27.3%) had a known pre-operative diagnosis of invasive breast cancer or ductal carcinoma in situ (DCIS) in the contralateral breast for which the nipple was excised, and 4 (36.4%) had no disease in either breast. The mean age of the cohort was 48 years, with mean of 52.1 years in those with breast cancer and 41 years in those without breast cancer. Average tumor size was 15mm in breasts treated with ISNSM; all had negative margins of resection, negative analysis of nipple base, and none had disease recurrence after average follow up of 34.9 months (range 0.4-80 months). Final pathological stage was stage 0 for 1 patient, Ia for 3 patients, IIa for 1 patient and IIb for 1 patient. In the 4 disease free patients, 2 were BRCA1+, 1 was BRCA2+, and 1 had a PALB2 mutation. There have been no diagnoses of breast cancer in the 7 patients that pursued implant and nipple sparing mastectomy in breasts without cancer after an average of 33.5 months (range 7-63 months). Ninety-day complication rates in this group were low overall. There was no nipple necrosis, 1 patient developed wound dehiscence with skin flap loss requiring operative intervention, 1 patient required takeback to OR for hematoma and 1 patient had a wound infection requiring antibiotics. Of the 11 patients, 9 (81.8%) have undergone delayed reconstruction requiring only implant exchange. One has not required implant exchange and one has not yet undergone implant exchange. Average time to exchange was 12.5 months (range 3-52 months).  None of these patients required delayed flap reconstruction. 

Conclusion: ISNSM was effective and well tolerated in this highly selected group of patients with acceptable oncologic outcomes and low complication rates. Patients undergoing this procedure pursued delayed reconstruction and none required flap reconstruction. Further investigation into this option for the treatment and prevention of breast cancer is warranted.   
 

47.19 Is Excision of Radial Scar Identified on Core Needle Biopsy (CNB) Necessary?

Posted on January 31, 2019

K. Nimtz1, K. Hookim2, A. Sevrukov3, T. Tsangaris1, A. Willis1, A. Berger1, M. Lazar1  1Thomas Jefferson University,Surgery,Philadelphia, PA, USA 2Thomas Jefferson University,Pathology,Philadelphia, PA, USA 3Thomas Jefferson University,Radiology,Philadelphia, PA, USA

Introduction: Quantifying the risk of upgrade to malignancy with radial scars has been an ongoing challenge in the breast cancer research community. Previous reviews show radial scars account for 5-9% of findings on core needle biopsy. The upgrade rate varies from 0-40% making management of radial scars controversial.  Multiple studies have investigated the association of radial scar and malignancy, with recent studies indicating lower rates. The lack of consensus on the optimal management highlights the need for further analysis of radial scar and its risk of upgrade to malignancy. We sought to identify our institutional upgrade rate of radial scar identified on core needle biopsy.

Methods: An IRB approved retrospective review of pathology and radiology databases from 2010 to 2017 was performed to identify radial scar found on core needle biopsy.  We excluded patients with malignancy associated with radial scar and those who did not undergo surgical excision. The initial imaging findings prompting the core needle biopsy as well as the upgrade rate to malignancy (invasive ductal/lobular carcinoma and ductal carcinoma in situ) on surgical excision were assessed. 

Results: We identified 127 patients with radial scar on a core needle biopsy.  Due to malignancy associated with radial scar, no surgical excision or incomplete records, we excluded 75 patients leaving 52 patients for analysis. Of these, 4 of 52 (7.7%) patients had an upgrade to malignancy upon surgical excision of the radial scar—2 with DCIS and 2 with invasive ductal cancer.  All 4 of these patients had findings on both mammography and ultrasound.  Eight patients had atypia associated with radial scar on core needle biopsy, two of which were upgraded to malignancy at the time of surgical excision.  The rate of upgrade for radial scar alone on core needle biopsy was 2 of 44 (4.5%).  Of the 44 patients with radial scar alone on core needle biopsy, 15 (34%) were found to have atypia (6 with flat epithelial atypia, 5 with atypical ductal hyperplasia, 2 with lobular carcinoma in situ, one with atypical lobular hyperplasia and one with both atypical ductal and lobular hyperplasia) on surgical excision.

Conclusion: With the increasing use of digital tomosynthesis, it is possible that more radial scars will be identified on core needle biopsy.  Although  the upgrade rate to malignancy was only 4.5%, there was a substantial upgrade rate of pure radial scar to some type of atypia which could alter subsequent management. Additionally, one-quarter of radial scars with atypia upgraded to malignancy on excision. For these reasons, careful consideration should be given to re-excision of core needle biopsy showing radial scar with and without atypia.

 

47.18 Is Cervical Node Ultrasound Useful for Indeterminate or Malignant Subcentimeter Thyroid Nodules?

Posted on January 31, 2019

F. B. Karipineni1, Z. Sahli2, J. Canner3, A. Mathur3, J. Prescott3, R. Tufano4, M. Zeiger2  1UCSF Fresno,Department Of General Surgery,Fresno, CALIFORNIA, USA 2University Of Virginia,Department Of General Surgery,Charlottesville, VA, USA 3The Johns Hopkins University School Of Medicine,Department Of General Surgery,Baltimore, MD, USA 4The Johns Hopkins University School Of Medicine,Department Of Otolaryngology,Baltimore, MD, USA

Introduction:
Preoperative neck ultrasound (US) in patients with thyroid cancer can detect suspicious lymph nodes that may in turn result in a change in surgical management. However, in patients with indeterminate or malignant subcentimeter thyroid nodules, the role of neck ultrasound and extent of surgery is controversial. Our study evaluates the utility of preoperative neck ultrasonography in this subset of patients.

Methods:
Medical records of patients with biopsy-proven, unifocal Bethesda III, IV, V or VI thyroid nodules ≤ 1.0 centimeter between January 2006 and December 2016 were retrospectively reviewed. Patients with multifocal papillary thyroid carcinoma (PTC) or medullary carcinoma, those who did not undergo preoperative cervical US, and those who underwent prophylactic central lymph node dissection (CLND) were excluded. Clinical, radiologic, cytologic, and pathologic variables were analyzed to determine change in clinical management or operative approach based on US findings of suspicious cervical lymph nodes.

Results:
The records of 217 patients met study criteria. A total of 14 (6.5%) patients had suspicious lymphadenopathy on US, 5 (2.3%) in the central neck and 9 (4.1%) in the lateral neck. Of the 5 patients with suspicious central nodes, none underwent biopsy prior to surgery. Only 2 (0.9%) who had obvious lymphadenopathy at surgery underwent CLND; the other 3 had negative frozen section analysis and therefore did not undergo CLND. Of the 9 patients with suspicious lateral neck nodes, only one (0.4%) had a positive aspiration biopsy and underwent lateral selective neck dissection. 

Conclusion:
Surgical approach was altered in only three patients (1.4%) as a result of preoperative neck ultrasonography in our cohort, thus challenging the need for routine preoperative neck US to evaluate for the presence of lymph node metastases in this patient population. The identification of cervical lymph node metastases in the 2 patients with positive central neck US in our cohort would have likely been achieved without the use of US. Further studies are needed to delineate whether performing routine neck US in patients with unifocal, subcentimeter indeterminate or malignant nodules is cost-effective.
 

47.17 An Analysis of Factors Resulting in Thyroid Reoperations

Posted on January 31, 2019

T. Longoria Dubocq1, M. Serpa1, A. Lugo1, E. Santiago1, A. Gonzalez1, W. Mendez-Latalladi1  1University Of Puerto Rico School Of Medicine,Endocrine Surgery Section. Department Of Surgery,San Juan, Puerto Rico, USA

Introduction: Thyroid surgery has been practiced for many years by General Surgeons to treat benign and malignant disease. However, the development of new surgical sub-specialties have demonstrated that treating thyroid disease at a high volume center (HVC) improves outcomes in this kind of patients. Many studies have showed that thyroid reoperations have a higher complication rate when compared to single thyroid surgery. We studied the incidence of causes for surgery reoperation and if whether the initial surgery was performed at a low volume center (LVC) or HVC.

Methods: This is a retrospective study were we analyzed all thyroid reoperations from 2013 to 2018 at a HVC institution. HVC was defined as hospital that performed more than 100 thyroid surgeries per year and surgeons with more than 25 thyroid surgeries per year. Data from previous surgeries, and reasons for reoperation was gathered and evaluated statistically. Reoperation was defined as a patient who had thyroid surgery with previous history of thyroid surgery. Patients were also divided into two groups depending on where their first surgery took place: LVC (Group 1) or HVC (Group 2). SPSS statistical software and Pearson’s Chi-Square test used for analysis and comparison. To establish statistical significance a p-value ≤ 0.05 was utilized.

Results: We examined 786 records of which 105 (7.49%) had undergone a previous thyroid surgery. Five were excluded due to lack of information. There were 86% (86/100) females and 14% (14/100) male in our study. The most common overall reason for re-operation was completion thyroidectomy due to previous lobectomy pathology positive for cancer 35% (35/100); followed by recurrence of malignant disease 34% (34/100) overall. Reoperation for benign disease was 23% (23/100) overall. Group 1 consisted of 40% (40/100) of patients while Group 2 had 60% (60/100) of patients. In Group 1, the most common reason for reoperation was malignant disease recurrence with 47.5% (19/40). In Group 2, the incidence of malignant disease recurrence occupied 25% (15/60) of the cases which was significant when compared between the two groups (p=0.001). Group 2 most common reason for reoperation was a malignant lesion requiring completion thyroidectomy with 53.33% (32/60).

Conclusion: The most common reason for reoperative thyroid surgery was a previous lobectomy with incidental malignancy and indications for a completion thyroidectomy. When the first surgery was performed in a LVC, the most common reason for reoperation was recurrence of malignancy.

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