47.16 Does thyromegaly with tracheal deviation or substernal extension pose high risk of acute airway compromise?

Posted on January 31, 2019

Y. Qudah1, J. Crystal1, J. Wade1, T. Davidov1  1Robert Wood Johnson – UMDNJ,General Surgery,New Brunswick, NJ, USA

Introduction:   Thyromegaly with tracheal deviation and substernal extension is an indication for surgery in part because of concerns over airway compromise.  However, the exact risk is unclear.

Methods:   CT scans of the neck or chest from 2009-2017 performed at a single hospital were queried for findings of thyromegaly with substernal extension, tracheal deviation, or tracheal compression. The charts of these patients were retrospectively reviewed to determine whether acute airway compromise with sudden intubation or urgent surgical intervention was required.

Results: A total of 682 scans were queried, revealing 209 patients whose scans demonstrated  substernal extension or tracheal deviation or compression. Of 209 patients, 125 patients (60%) were asymptomatic with CT findings incidentally discovered.  Eighty-four patients (40%) presented with symptoms including dyspnea, dysphagia, chest pain, neck pain, or visible neck mass.  Nineteen patients that had these CT findings required intubation during their hospital stay, of which 18 intubations were emergent.  Of these 19 patients, 18 had confounding cardiopulmonary problems. No patients required cricothyroidotomy or urgent tracheostomy. There were no mortalities related to sudden airway compromise.  Five patients progressed to surgery, one of whom required sternotomy.

Conclusion: While thyromegaly with substernal extension or tracheal deviation may an indication for thyroidectomy in part to prevent sudden airway compromise, the majority of patients with these CT findings are asymptomatic and only rarely do these patients sustain an airway emergency requiring an intervention.

 

47.15 Si vs. Xi Robot for Adrenalectomy: A 10-year experience

Posted on January 31, 2019

A. Lucy1, E. Malone1, J. Richman1, J. Owen1, J. R. Porterfield1  1University Of Alabama at Birmingham,Surgery,Birmingham, Alabama, USA

Introduction: Over the last decade, robotic adrenalectomy has been increasingly used for surgical management of adrenal masses. The da Vinci Xi robot was introduced in 2014 as a more versatile upgrade to their Si robot with the goal of promoting OR efficiency and multi-quadrant access. The specific benefits of the Xi robot have only been addressed in a limited number of specialties and procedures. The aim of this study was to compare the outcomes of the Xi vs. the Si system for robotic adrenalectomy in a high-volume center.                                                         

Methods: All patients at a single institution undergoing adrenalectomy between June 2008 and May 2018 were captured prospectively (n=515). We excluded patients who had an adrenalectomy by a non-robotic approach and who were <18 years old (n=212). Demographic, clinical, pathological, and operative variables were collected from electronic medical records. An adjusted negative binomial regression model was used to examine the change in total operating room time by robot type adjusting for all covariates significantly associated with room time in bivariate tests. These included diabetes, facility (main hospital vs. outpatient surgery center), robot type, and final pathology. Chi-square or Fisher's Exact Tests and t-tests were used to examine differences in categorical and continuous variables by robot type.

Results: Robot type was documented for 99% of 212 cases (n=209). There were no significant differences in patient demographics or preoperative comorbidities by the robot type. Median total room time using the Xi was 215 minutes (IQR: 190-254) vs. 235 (IQR 203-279) for the Si system (p=0.03). Other perioperative and pathological variables were similar. In adjusted models, total room time was 11% longer for diabetic patients vs. non-diabetics (IRR 1.11, 95% CI: 1.03-1.20), procedures done at our outpatient surgery center were 22% shorter vs. our main facility (IRR 0.78, 95% CI 0.68-0.89), and Xi robot procedures were 9% shorter than those done with the Si robot (IRR 0.91, 95% CI 0.83-0.99).

Conclusion: In adjusted analyses, the Xi robot has shorter adrenalectomy times compared to the Si robot. We attribute this decrease in operative time to the improved instrumentation, ease and efficiency in docking and patient positioning. More multi-institutional studies with larger groups of patients are needed to document the effect of advancing technology and carefully track and publish outcomes.

 

47.14 Clinical Significance of Increased Body Mass Index in Breast Cancer Patients

Posted on January 31, 2019

S. R. Kaslow1, C. Cartier1, M. L. Plasilova1  1New York University Langone Health,Department Of Surgery,Brooklyn, NY, USA

Introduction:
Multiple studies have associated increased body mass index (BMI) with more aggressive breast cancer tumor biology and worse clinical outcomes, however, many of these studies were conducted with primarily non-Hispanic white patients. We aimed to compare the clinical outcomes and breast cancer tumor biology of patients with increased BMI (≥25) and normal BMI (18-25) at New York University Langone Health (NYULH), which serves a racially and ethnically diverse patient population. 

Methods:
We extracted data on geography, race/ethnicity, breast cancer recurrence rates, and tumor biology from the NYULH Institutional Breast Cancer Database, which contains sociodemographic and clinical information for breast cancer patients who received first definitive surgery at New York University Langone Medical Centers in Manhattan and Brooklyn.

Results:
Our data included 3,091 patients with invasive breast cancer and ductal carcinoma in situ. Breast cancer patients living in Brooklyn had increased BMI compared to breast cancer patients living in Manhattan (p=0.013). There was no statistically significant difference in breast cancer recurrence in patients with increased BMI relative to those with normal BMI (p>0.5). Our data show a higher proportion of ethnic minorities diagnosed with breast cancer in Brooklyn compared to Manhattan, including African Americans (35.2% vs. 17.6%) and Asian Americans (12.1% vs. 8.5%). We did not find a significant difference in breast cancer recurrence when comparing White and non-White patients with increased BMI.

Conclusion:
Despite differences in ethnic minority status between two study sites and statistically significant differences in BMI based on residence, breast cancer patients treated within NYULH with increased body mass index did not have statistically significant different breast cancer recurrence rate.
 

47.13 Standardization of Oncotype DX Ordering By Surgery at a Safety Net Hospital: Pilot Study

Posted on January 31, 2019

A. Keshinro1, E. Johnson1, E. Horowitz1, E. Warnack1, K. Joseph1  1NYU School of Medicine,Surgery,New York, NEW YORK, USA

Introduction:

Oncotype DX is a useful assay that helps oncologists and patients determine whether patients should undergo adjuvant chemotherapy or hormonal therapy. Testing for Oncotype may lead to delays in chemotherapy that can lead to clinically adverse outcomes. In order to decrease the delays in ordering the test as well as the turn around time, and as a result, initiation of chemotherapy, we implemented a new ordering protocol at Bellevue Hospital involving pathology, breast surgery to standardize the criteria for ordering Oncotype DX.  

Methods:  

As part of a quality improvement process to standardize the ordering process for Oncotype DX post-operatively, pathology and breast surgery met with representatives of Genomic Health to determine new workflows to improve the ordering process for Oncotype DX. In addition, methods for communicating pathology results and insurance status were identified. After new workflows were put in place, any patient that fit the criteria for Oncotype DX testing was ordered by breast surgery as soon as the final pathology was received (May-August 2018). Time from surgery to order, time from surgery to report, number of Oncotype DX orders, method by which oncotype dx is ordered, and type of insurance were examined.

 

Results:

There was a significant decrease in the overall turnaround time from surgery to Oncotype DX result from 64 days to 29 (55% reduction) (p<0.05). Implementation of the new workflow had the largest impact on reducing time from surgery to ordering the test (50 days to 17 days), a 66% reduction (p<0.05). 72% of the orders are now being placed by portal vs 6% before standardization, 14% by paper vs 88% before standardization, 14% by fax vs 6% before standardization. In addition, the payor mix has changed to include 11.3% Medicare vs 0% before standardization. Total number of Oncotype orders for 2017 were 16 (eligible cases 41), and cases YTD 2018-18.

Conclusions:

Implementation of a new ordering process has allowed access to individualized treatment planning to more eligible patients; 12.5% increase over 2017 orders within 7 months into the year (16 orders in 2017 vs. 18 orders by July 2018), ordering by portal helps to improve efficiency of ordering and receiving results.

Less than half of eligible patients were offered Oncotype DX in 2017, before adoption of the new protocol. By implementing this protocol more eligible patients will receive appropriate management.

Given the medically underserved population that our clinic serves (64% are immigrants and 73% have Medicaid or self pay), we can improve the level of care to our patients.

As we continue the protocol we will examine the impact on reduction on chemotherapy wait times.

 

 

 

47.12 Quilting Suture in Closure of Mastectomy Skin Flaps for Locally Advanced Breast Cancer in Myanmar

Posted on January 31, 2019

S. Myint1, T. Lwin1, W. Yee1, H. Thuya1, A. Myat1, Y. Kyaw1, K. Nyunt1, K. Khaing1, T. Lwin1  1University of medicine (1), Yangon,Department Of Surgery,Yangon, YANGON, Myanmar

Introduction: Seroma formation is the most frequent postoperative complication after breast cancer surgery. In 2015 surgery for breast cancer at the Yangon General Hospital amounted to 17.12% (229) of all the elective major operations. In 2016, 244 cases of modified radical mastectomy (MRM) were carried out and 32.38 % of locally advanced breast cancer patients developed seroma post operatively. Seroma cause discomfort, and wound complications.Seroma prolonged hospital stay and delayed adjuvant therapy. It can leads to poor prognosis. We explored whether quilting sutures could reduce seroma occurrence. Quilting sutures aim to prevent shearing between skin flaps and chest wall and to reduce the dead space.

Methods: Twenty five breast cancer patients from 1st July 2017 to 31st December 2017 were included in this descriptive study. All underwent modified radical mastectomy. After MRM  quilting sutures were applied to approximate  skin flaps to underlying pectoral muscle at an interval of 2 to 3 cm. Customized, strategically placed, multiple alternating interrupted quilting sutures are put with 3/0 vicryl at various parts of the flaps. A close drainage tube was usually inserted into the axilla. The skin was closed with two layer techniques. Drainage tube was removed when the 24 hour drain amount was less than 30mls in two consecutive days. Patients were followed up in the outpatient clinic and the clinically significant seroma were detected by clinical examination and ultrasoung examination. 

Results: The average time to insert quilting suture is 12 mins. None of the cases develop permanent skin dimplings one month after operation. Post-operatively,mean amount of drainage tube output is 274.9 ml. Five patients (20%) developed clinically significant seroma in follow-up visits and underwent needle aspiration. The mean number of needle aspiration is 3 times. Mean amount of seroma aspirated is 300 ml. None of the patients develop wound sepsis or wound gaping.   

Conclusion:MRM is frequently performed at the Yangon General Hospital and seroma is a common complication. It can prolong hospital stay and can lead to frequent visits to clinic and delay adjuvant therapy. Quilting suture reduced the incidence of seroma formation from 32% to 20%. This technique is cost effective and can be performed by general surgeons. We feel that this may be an important technique for breast cancer surgery in low resource settings and warrants further investigation.

 

47.11 Postoperative Hypomagnesemia Levels Predict Post-thyroidectomy Hypocalcemia

Posted on January 31, 2019

B. M. Launer1, R. McIntyre1, L. J. Helmkamp1, C. D. Raeburn1, M. B. Albuja-Cruz1  1University of Colorado School of Medicine,GI, Tumor And Endocrine Surgery,Aurora, CO, USA

Introduction
Hypocalcemia is a frequent complication of thyroidectomy. Magnesium (Mg) and calcium metabolism are closely related. There is a paucity of studies evaluating the role of preoperative and postoperative Mg levels in post- thyroidectomy hypocalcemia. 

Methods
Retrospective review of prospectively collected data of 389 patients who underwent thyroidectomy.  We followed a standard protocol to manage hypocalcemia. Calcium, albumin, PTH and magnesium levels were checked immediately after surgery.  Patients were stratified into 3 categories: high, intermediate, and low risk of hypocalcemia.  High risk patients were started on oral calcitriol and calcium.  Intermediate risk patients were given only oral calcium and low risk received no supplementation.  Hypocalcemia was defined as corrected calcium level (CCL) < 8 mg/dl.   Severe hypocalcemia was defined as a CCL < 7 mg/dl.  Hypocalcemia event was defined as an episode of hypocalcemia at any point after the operation.  Symptomatic hypocalcemia was defined as CCL <8 mg/dl plus symptoms of hypocalcemia.  Hypomagnesemia was defined as Mg level <1.7mg/dl.  Patients with and without hypomagnesemia preoperatively and immediately postoperatively were compared.  Data were analyzed for demographics, operative procedure, calcium levels, PTH levels and complications of hypocalcemia.

Results
Seventy-eight patients (23%) had preoperative hypomagnesemia and 106 patients (37%) had postoperative hypomagnesemia.  There was no difference in biochemical or symptomatic hypocalcemia, severity of symptoms of hypocalcemia, need for IV calcium, emergency department (ED) visits, readmissions, and permanent hypocalcemia between normal preoperative Mg and low preoperative Mg groups.  Patients with low postoperative Mg levels had a significant higher risk of hypocalcemia (28% vs. 16%, p 0.007).  Patients with low postoperative Mg levels also had a significantly higher rate of requiring I.V calcium (9% vs. 3%, p 0.023) based on our protocol.  However, there was no difference between these two groups in regards to symptomatic hypocalcemia, severity of hypocalcemia, severity of symptoms of hypocalcemia, ED visits, readmissions, or permanent hypocalcemia.  On multivariate analysis, postoperative hypomagnesemia was an independent predictor of hypocalcemia with 1.71 risk ratio (1.09, 2.68; 95% CI).

Conclusion
Postoperative hypomagnesemia is seen in more than one third of patients after thyroidectomy and it is associated with a significantly higher risk of hypocalcemia and need for I.V calcium.  The risk of hypocalcemia is doubled for those patients with immediate postoperative hypomagnesemia.  Therefore, postoperative Mg levels should be closely monitored and replaced as necessary in patients after thyroidectomy.

 

47.09 Epidural anesthesia is safe in open resection of pheochromocytoma and abdominal paraganglioma

Posted on January 31, 2019

D. Wiseman1, J. McDonald1, D. Patel1, E. Kebebew3, K. Pacak2, N. Nilubol1  1National Cancer Institute,Bethesda, MD, USA 2National Institute of Child Health and Human Development,Bethesda, MD, USA 3Stanford University,Surgery,Palo Alto, CA, USA

Introduction:

The most common side effect of epidural anesthesia (EA) is hypotension. Because hypotension frequently occurs after a removal of pheochromocytoma-paraganglioma (PPGLs) from the alpha-adrenergic blockade and the abrupt reduction of catecholamine production, we aimed to determine if EA is associated with an increased risk of postoperative hypotension and complications from postoperative fluid overload.

Methods:

We performed a retrospective review of a prospectively collected cohort of patients who underwent open resections of PPGLs from 2009-2018.  The EA infusion started before patient transfer to ICU. Clinical characteristics, tumor burden, and perioperative parameters were analyzed by the use of EA. The primary endpoint was postoperative hypotension.

Results:

Of 66 patients who underwent open resections of PPGLs, 52 (78.8%%) received EA. No differences in patient demographics and clinical characteristics were found by the use of EA except the significantly lower rate of EA used in patients with von Hippel-Lindau disease due to the presence of spinal hemangioblastoma (0% vs. 82.5%, p=0.008) and a higher rate of EA use in patients undergoing reoperation (85.7% vs. 58.8%, p=0.035). We found that postoperative hypotension was common following open resections of abdominal PPGLs (56.9%). However, there was no difference in the rates of postoperative hypotension by the use of EA (58.8% in EA group vs. 50.0% in non-EA group, p=0.561), the need for postoperative vasopressor (p=1.00) or diuretics (p=0.111), postoperative weight gain (p=0.436), hypoxia (p=0.703), or the volume of IV fluid in the first 24 hours postoperatively (p=0.903). EA was stopped because of postoperative hypotension in 13.6% of patients.

Conclusion:

Although postoperative hypotension is common after open resection of PPGLs, EA is safe as it was not associated with increased risk of postoperative hypotension or fluid overload.
 

47.08 Breast Cancer Treatment Patterns in Women Age ≥ 80: A Report from the National Cancer Database

Posted on January 31, 2019

J. Frebault1, C. Bergom2, M. Shukla2, Y. Zhang3, C. Huang3, A. Kong1  1Medical College Of Wisconsin,Department Of Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,Department Of Radiation Oncology,Milwaukee, WI, USA 3University of Wisconsin-Milwaukee,Zilber School Of Public Health,Milwaukee, WI, USA

Introduction:
Women aged ≥80 are an increasing proportion of patients diagnosed with breast cancer in the US. There are no established guidelines for decision making in this population, particularly due to consideration of performance status and competing comorbidities. This study aims to identify national treatment patterns and survival outcomes in breast cancer patients aged 80 and over.

Methods:
Women aged ≥80 diagnosed with ductal carcinoma in situ (DCIS) or stage I-III invasive breast cancer from 2005-2014 were identified in the National Cancer Database. We excluded cases with incomplete staging and treatment details. Kaplan-Meier curves and Cox proportional hazard models were used to evaluate survival outcomes. Chi-square and logistic regression models were used to identify demographic, disease, and facility factors that influenced receipt of breast surgery.

Results:
We identified 62575 women with invasive cancer and 6070 with DCIS. Of the invasive cases, 94% received breast surgery. Age <85, white race, lower stage, and smaller tumor size were associated with receipt of surgical treatment (p<0.0001 for all). Those who received breast surgery were more likely to be estrogen receptor (ER)+ (p=0.001), HER2- (p<0.0001), and healthier, with a comorbidity score of 0 or 1 (p<0.0001). They were also more likely to have axillary surgery (p<0.0001), chemotherapy (p=0.0009), and radiation (p<0.0001). Among DCIS patients, 98% had breast surgery. White patients (p=0.003) and those <85 years old (p<0.0001) were more likely to receive surgery. Those who had surgery were more likely to receive radiation (p<0.0001). When compared to academic programs, surgical management was more likely to be performed in community cancer centers for both invasive cancer (p<0.0001) and DCIS (p=0.04). On multivariate analysis of invasive cancer patients, those with white race, age <90, lower stage, ER-, or fewer comorbidities were more likely to have surgery (all p<0.0001). On multivariate analysis of DCIS patients, those age <90 were more likely to have surgery (p<0.0001). Black women were half as likely to receive surgery (p=0.02). In both groups, overall survival was higher for those who received surgery compared to those who did not (p<0.0001), with a hazard ratio of 3.3 [95% CI 3.18-3.46] for invasive cancer (Fig. 1) and 2.2 [95% CI 1.72-2.83] for DCIS.

Conclusion:
The vast majority of breast cancer patients age ≥80 in this nationwide dataset received primary surgical management, which was associated with a significant survival advantage for both invasive and non-invasive disease. Surgical intervention should be considered in patients with few comorbidities and favorable tumor characteristics.

47.06 Impact of Geographic Dispersal of National Accreditation Program for Breast Centers on Quality Care

Posted on January 31, 2019

A. C. Alapati1, L. A. Riba1, R. B. Davis2, T. A. James1  1Beth Israel Deaconess Medical Center,Surgery,Boston, MA, USA 2Beth Israel Deaconess Medical Center,Medicine,Boston, MA, USA

Introduction: The National Accreditation Program for Breast Centers (NAPBC) is dedicated to the improvement of quality of care for patients with breast disease. Geographical distribution of healthcare resources is an important dimension of quality. Little has been published about breast center allocation patterns with respect to demand and impact on population health outcomes. The purpose of this study is to analyze incidence and mortality rates of breast cancer in relation to NAPBC distribution in the US.

Methods: The incidence and mortality rates of breast cancer per state in 2014 were retrieved from the Center for Disease Control and Prevention.  We determined the number of NAPBC centers in each state per 1000 cases of breast cancer. Data were analyzed by spearman (non-parametric) correlation.

Results:The total number of NAPBC centers is 570. Across the US there is an average of 2.8 centers/1000 cases of breast cancer; standard deviation 1.9, range from 0 to 8.7.  A positive correlation (r = 0.45) exists between breast cancer incidence and the number of centers (p=0.0009). The correlation between mortality and centers/1000 cases is weakly negative (r=-0.20), (p=0.16).

Conclusion:Our study demonstrates that NAPBC centers are adequately distributed according to breast cancer incidence in the US. However, the presence of NAPBC centers did not impact mortality rates. Additional strategies are warranted to control population mortality rates for breast cancer.

 

47.05 Optimizing Opioid Prescribing Practices Following Parathyroidectomy

Posted on January 31, 2019

A. Sada1, D. S. Ubl2, C. A. Thiels1, B. M. Dy1, M. L. Lyden1, G. B. Thompson1, T. J. McKenzie1, E. B. Habermann2  1Mayo Clinic,Department Of Surgery,Rochester, MN, USA 2Mayo Clinic,Surgical Outcomes Program, Robert D And Patricia E Kern Center For The Science Of Health Care Delivery,Rochester, MN, USA

Introduction:
With the increased awareness of the U.S. opioid epidemic, several initiatives have attempted to limit overprescribing of opioids. As the opioids requirements differ based on the procedure and patient specific factors, we conducted a large initiative that resulted in prescribing guidelines for different procedures. The aim of this study is to refine our guidelines for parathyroidectomy.

Methods:
Patients undergoing parathyroidectomy at three academic centers were asked to complete a 28-question telephone survey at 21-35 days post-discharge as part of a larger initiative. Surveys captured opioid consumption and patient experience while patient characteristics were abstracted. Discharge opioids were converted into Morphine Milligram Equivalents (MME) and reported as median and interquartile range (IQR). Univariate comparisons were used. Consumption was dichotomized into top quartile users (Q4), who consumed between 20-217 MME vs standard users (Q1-Q3), who consumed between 0-15 MME.

Results:
A total of 103 patients completed the survey; mean age was 65±12 years, 83% were female and 89% were opioid-naive. At discharge, opioid prescriptions were provided to 86% of patients. While the median prescribed was 75 (IQR 75-125, range 0-375) MME, the median consumed was 0 (IQR 0-20). Half (51%) of patients did not consume any, while only 11% consumed >50 MME. Patients who did not consume opioids reported a median last pain score before discharge of 1 (IQR 0, 2) while patients who did consume opioids reported a median score of 2 (IQR 2, 3), p<0.001.
There was no difference in opioids consumption between unilateral neck exploration (n=71), bilateral exploration (n=26) or thyroidectomy and parathyroidectomy (n=6) (p=0.10).
Overall, 98% of patients were satisfied with their pain control. While 31% reported being prescribed too much opioid, no patients reported they were not prescribed enough. All 4 patients requiring an opioid refill reported it was very easy to get a refill. Of those receiving a prescription, 95% had left-over opioids at the time of survey, resulting in 81% of prescribed opioids being unused. Only 6% of patients disposed of left-over opioids.

Conclusion:
While the majority of patients undergoing parathyroidectomy received opioids after discharge, over half of them did not consume any, and very few consumed more than a day or two of opioid medication. Moreover, surgical approach did not change consumption, illustrating that these guidelines are applicable to thyroidectomy given similarity between incisions and techniques. We recommend prescribing non-opioid analgesics for patients undergoing parathyroidectomy and thyroidectomy and considering less than 40 MME for patients with high pain scores.
 

47.04 Survival Outcomes of Early-Stage Hormone Receptor Positive Breast Cancer in the Elderly

Posted on January 31, 2019

A. Nayyar1, K. K. Gallagher1, P. D. Strassle1, C. G. Moses1, K. P. McGuire2  1University Of North Carolina At Chapel Hill,Department Of Surgery,Chapel Hill, NC, USA 2Virginia Commonwealth University,Department Of Surgery,Richmond, VA, USA

Introduction:
Women ≥70 years old form a significant proportion of patients affected by breast cancer (BC). Treatment decisions for this patient population are complicated given presence of comorbidities, reduced tolerability of therapy and limited enrollment in clinical trials. A growing body of evidence suggests equivalent outcomes in elderly patients with hormone receptor positive, early-stage BC patients receiving primary endocrine therapy only or surgery with subsequent endocrine therapy. Whether these results are reproduced in the larger BC population outside of a clinical trial, currently remains unclear.

Methods:
Women ≥70 years old, diagnosed with early-stage invasive BC between January 2008 and December 2013, with tumor size T1 or T2 and minimal nodal involvement (N0 and N1), endocrine and/or progesterone receptor positive, and started endocrine therapy within a year of diagnosis were identified using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked datasets. Endocrine therapy use was identified using outpatient prescription fills for Anastrozole, Exemestane, Fulvestrant, Letrozole, Raloxifene, Tamoxifen, and Toremifene. Surgical intervention included either breast conserving surgery or mastectomy. Trends in the use of primary endocrine therapy only were assessed using Poisson regression. Multivariable Cox proportional hazard regression was used to estimate the association between undergoing surgery within a year of diagnosis and 5-year all-cause mortality, after adjusting for patient demographics, comorbidities, and clinical cancer characteristics. Similar methods were used to assess 5-year cancer-specific mortality, where non-cancer mortality was treated as a competing risk. 

Results:
Overall, 8,968 women were included in the analysis; 8,146 (91%) received surgery with endocrine therapy and 832 (9%) received primary endocrine therapy alone. The proportion of women not receiving surgery remained consistent between 2008 and 2013, p=0.24. The 5-year mortality was 7% (n=660), and 21% of all deaths were due to cancer causes (n=140). After adjustment, 5-year mortality was lower among women undergoing surgery (HR 0.55, 95% CI 0.44, 0.67, p<0.0001) (Figure). Similar results were found when looking at 5-year cancer-specific mortality (HR 0.35, 95% CI 0.22, 0.56, p<0.0001).

Conclusion:
Elderly BC patients with early-stage, hormone receptor positive disease receiving primary surgical intervention plus endocrine therapy had improved survival compared to those receiving primary endocrine therapy alone. This study reflects the importance of surgical intervention for elderly BC patients and warrants further investigation to evaluate whether surgery may be omitted safely in subsets of elderly patients.

47.03 Implant Sparing Mastectomy: A Novel and Safe Surgical Approach for Breast Cancer

Posted on January 31, 2019

E. E. Burke1, C. Laronga1, W. Sun1, B. J. Czerniecki1, S. J. Hoover1, N. Khakpour1, J. V. Kiluk1, M. C. Lee1  1Moffitt Cancer Center,Breast Oncology,Tampa, FL, USA

Introduction:   In women undergoing mastectomy for breast cancer with prior retropectoral implant-based augmentation, implant sparing mastectomy has been reported. In this study, the safety and feasibility of this novel surgical approach was evaluated.

Methods:  A retrospective review of all patients undergoing implant sparing mastectomy from 2006 to 2018 for either breast cancer treatment or prevention at a single institution was performed. Data including patient and tumor characteristics, stage, use of systemic therapy and radiation therapy, 90-day complication rates, type of reconstruction, and recurrence of disease was collected.  

Results: A total of 74 women were identified with implant sparing mastectomy from 2006 to 2018.  Of these, 49 (66.2%) underwent bilateral mastectomy. A total of 66 (89.2%) received mastectomy after diagnosis of invasive breast cancer or ductal carcinoma in situ (DCIS) while 8 (10.8%) elected mastectomy for prophylaxis. Among 66 breast cancer patients, resection margins were negative in 53 (80.3%), negative but close (DCIS < 2mm) in 10 (15.2%), and positive in 3 (4.5%). Five (7.6%) of these breast cancer patients had a documented recurrence; 4 at distant sites, and 1 local recurrence in the chest wall despite adjuvant chemotherapy and radiation therapy in the setting of node positive disease for which axillary lymph node dissection was declined. No new breast cancer diagnoses were reported in the 8 patients that underwent implant sparing mastectomy for prophylaxis alone. Ninety-day complication rates for all patients were low; 1 patient (1.4%) had a seroma requiring aspiration, 1 patient (1.4%) had a wound infection requiring antibiotics, and 4 (5.4%) had a hematoma requiring operative intervention. Three patients (4.1%) had wound dehiscence and 8 (10.8%) had flap loss. Of those patients with flap loss, 6 required debridement in the operating room (OR), and 1 of these patients required OR for free flap loss that was performed immediately after implant sparing mastectomy. The only complication rate higher than expected based on the literature was that of hematoma requiring operative intervention.  The vast majority, 64 (86.5%) underwent delayed reconstruction. Of these, only 7 required flap reconstruction, the remainder of patients underwent implant exchange only. 

Conclusion: For patients with previous implant-based augmentation pursuing mastectomy for breast cancer treatment or prevention, implant sparing mastectomy is a novel surgical approach with local recurrence and overall complication rates comparable to skin-sparing mastectomy with the exception of a slightly increased hematoma rate.  Finally, delayed reconstruction for these patients often requires no more than implant exchange with a low rate of need for flap reconstruction. As such this study suggests that implant sparing mastectomy is a safe and reasonable approach for selected patients.

 

47.02 Are Tc-99m-Sestamibi Scans in Secondary Hyperparathyroidism Needed?

Posted on January 31, 2019

B. A. Jones1, B. Lindeman1, H. Chen1  1University Of Alabama at Birmingham,Department Of Surgery,Birmingham, Alabama, USA

Introduction:  Parathyroidectomy for patients with secondary hyperparathyroidism (2HPT) generally required a 4-gland exploration. Some groups have strongly recommended routine pre-operative Tc-99m-sestamibi scans to guide intraoperative planning and to potentially identify ectopic parathyroid glands. Others, including our team, practice scanning for only selected patients. In order to determine the utility of sestamibi scans in this patient population, we reviewed our experience.

Methods:  We performed a retrospective review of patients who underwent parathyroidectomy for 2HPT by one surgeon between 2000 and 2018. Data reviewed included patient demographics, laboratory results, pathology and radiology reports, and clinical and operative notes.

Results: Of the 72 patients in the cohort, mean age was 47.2 ± 15.6 and 50% were female. The pre-operative mean calcium and parathyroid hormone levels were 9.6 ± 1.1 mg/dl and 1192.1 ± 914.1 pg/ml, respectively. Sestamibi scans were performed in 21 patients (29%). Of these, 17 were re-operative cases. In the sestamibi cohort, only 4 patients had ectopic glands identified on the scan (2 retroesophageal, 1 thymic, 1 undescended). Among the 61 patients without pre-operative imaging, 16 had ectopic glands (12 thymic, 2 intrathyroidal, 1 carotid sheath, 1 undescended) (26.2% of non-imaged patients, 27.8% of all 2HPT patients). All of these 16 ectopic glands were found by the surgeon at the time of operation without the need for pre-operative imaging. All patients in the series were cured with a minimum follow-up of 6 mos.

Conclusion: Ectopic parathyroid glands are commonly seen in patients undergoing parathyroidectomy for 2HPT. The majority of ectopic glands were successfully identified during the operation without preoperative sestamibi scan. Therefore, routine pre-operative Tc-99m-sestamibi scans are not needed for successful parathyroidectomy for 2HPT.

47.01 Breast Reconstruction Disparities Remain Despite Affordable Care Act Medicaid Expansion

Posted on January 31, 2019

A. N. Cobb1, E. Eguia1, U. Maduekwe2, C. Godellas1, P. C. Kuo3  1Loyola University Medical Center,General Surgery,Maywood, IL, USA 2Loyola University Medical Center,Plastic Surgery,Maywood, IL, USA 3University Of South Florida College Of Medicine,Tampa, FL, USA

Introduction:

Following the implementation of Medicaid expansion via the Affordable Care Act (ACA), more women had access to cancer surgical care. However, the rates of reconstruction following mastectomy remain low. This study aims to evaluate the impact of Medicaid expansion on the utilization of breast reconstruction following mastectomy for breast cancer.

Methods:

We conducted a retrospective review using the Healthcare Cost and Utilization Project (HCUP) State Inpatient Database (SID) for the years pre (2010-2013) and post (2014) Medicaid expansion.  We compare the incidence of breast reconstruction in Medicaid expansion states (MD, NY, WA) vs. non-expansion (FL) states. Reconstruction was defined as the observed procedure rate per 1,000 cancer admissions. A generalized linear model with a Poisson distribution and logistic regression was used with incidence rate ratios (IRR) and difference-in-differences (DID).   

Results:

We identified 65,178 females diagnosed with breast cancer. Of those 13,161 (16%), underwent breast reconstruction.   Patients in non-expansion states were slightly older with a mean age of 49 (8.6) [vs 48 (8.6) p<.001] and had lower Elixhauser comorbidity indices at 2.0 (1.1) [vs. 2.1 (1.2) p<.0001]. Both groups were predominantly white (65%) and had Medicaid insurance, though there were a higher proportion of Medicaid patients in non-expansion states (86.1% vs. 84.5%). The rates of breast reconstruction did not significantly increase in expansion states, even when adjusting for age, comorbid disease and race (IRR=1.04 95% CI [.75,1.44]). Additionally, living in a Medicaid expansion state post-implementation did not increase patients’ odds of getting reconstructive surgery (OR 1.16 95% CI .82-1.65). African-American women were 30% (OR .68 95% CI .64-.72) less likely to get reconstruction than their white counterparts while Hispanic women had increased odds of reconstruction overall (OR 1.16 95% CI 1.08-1.24).

Conclusion:

The rates of breast reconstruction have remained virtually unchanged pre and post Medicaid Expansion in both expansion and non-expansion states. Disparities in breast reconstruction remain after the ACA's expansion of Medicaid and may disproportiontely impact African American women . 

 

46.20 Routine Syncope Evaluation in the Neurologically Intact Trauma Patient

Posted on January 31, 2019

N. L. Bandy1, T. J. Novosel1, J. R. Burgess1  1Eastern Virginia Medical School,Dept Of Surgery,Norfolk, VA, USA

Introduction:
Falls represent a significant portion of the US trauma population. The etiology of a fall is often ambiguous. Frequently concern exists for a syncopal event which can lead to extensive diagnostic testing. Previously published data have demonstrated limited utility for routine syncopal evaluation. However, the practice remains common in many trauma centers. This study evaluates the utility of routine carotid duplex ultrasound and echocardiogram in trauma patients with a GCS of 15 who were admitted after a fall.

Methods:
The trauma patient registry from a level one trauma center was retrospectively analyzed. Patients were included if they had a GCS of 15, diagnosis of fall, carotid duplex ultrasound, and a trans-thoracic echocardiogram ordered during the evaluation for suspected syncope. Patients who were not admitted to the trauma service were excluded. 50 patients were included in the study. Medical co-morbidities were compared between those with positive findings on diagnostic testing and the overall study population.   

Results:
405 admissions were reviewed to capture 50 patients who met inclusion criteria. Of these, 14 (28%) had significant findings on duplex ultrasound. However, none of these patients required inpatient intervention and only four (8%) were referred for outpatient follow up. None of the lesions discovered on carotid duplex ultrasound were felt to be causative of syncope. Of the 50 echocardiograms, 10 (20%) had hemodynamically significant pathology. Two of these patients (4%) required inpatient intervention and four (8%) were referred for outpatient follow up only. Only one patient was discovered to have a lesion on echocardiogram considered to be reasonably causative of a syncopal event. There were no significant differences in baseline co-morbidities between the study population and those with positive findings on duplex ultrasound or echocardiogram.

Conclusion:
Routine carotid duplex and echocardiogram studies continue to be ordered frequently on the neurologically intact trauma patient with possible syncope despite low diagnostic utility. More stringent care protocols are needed to better allocate resources within the trauma system and increase the positive predictive value when advanced imaging studies are obtained.
 

46.19 Sarcopenia Predictive of Long-Term Outcomes for Elderly Patients after Trauma?

Posted on January 31, 2019

D. Proksch1, K. Kelley1, S. Shaw1, J. Burgess1  1Eastern Virginia Medical School,Norfolk, VA, USA

Introduction: Relative to the general population, trauma injuries in elderly patients are linked to increased incidence of morbidity and mortality. A previously reported surrogate measure of sarcopenia is psoas muscle size—an established predictor of in-hospital outcomes, but its association with long term outcomes is unknown. The purpose of this prospective study is to assess the predictive power of psoas muscle size on functional status and survival of elderly trauma patients 3 and 6 months after intensive care unit admission.

Methods: Trauma intensive care unit patients over the age of 50 were recruited to the study. The patient or their caregiver completed a questionnaire regarding pre-admission functional status. Attendings, residents, and nurses completed prognostic surveys regarding their patient’s 3 and 6-month survival and disposition. Chart review included cross-sectional psoas area measurements on computerized tomography scan which were used to stratify patients into sarcopenic and non?sarcopenic groups. Finally, patients received phone calls 3 and 6 months post-trauma to determine overall health and functional status.

Results: The 72 study participants had an average age of 70 and a corrected psoas area of 388 ± 101 mm2/m2. Sarcopenia was defined as below the study median (380 mm2/m2). Injury Severity Score distribution was similar for the sarcopenic and non?sarcopenic groups (17.7 ± 9.2). Patients also had similar pre-injury activities of daily living, walking device use, and co-morbidities. Sarcopenic patients had a higher incidence of recent weight loss (p=0.009). Hospital courses were similar except that non?sarcopenic patients were more likely to go to the operating room at least once (p=0.0007). Forty-one and twenty?six patients completed a phone survey at 3 and 6 months, respectively. There was not a significant difference in overall health, independence, and hospital re-admission. Medical provider surveys predicted that the sarcopenic patients would be less likely to survive 3 and 6 months post-trauma (p<0.05). Six-month survival prediction accuracy was the same for both groups (p=0.95). In-hospital mortality was not statistically significant but trended toward an increase in the sarcopenic patients (9% vs. 19%, p=0.22); 3-month mortality showed similar trends (14% vs. 24%, p=0.29).

Conclusion: While sarcopenia has a reported association with worse outcomes in elderly trauma patients, our prospective study did not show a significant difference in complication rates during hospitalization. It is unclear why sarcopenic patients were less likely to undergo operative intervention, perhaps due to provider perception of surgery tolerance. While not statistically significant, there was a trend towards decreased post-discharge survival. The lack of significant results may be attributed to lower numbers. Additional long-term studies are needed to determine the true impact of sarcopenia on elderly trauma patients.

 

46.18 Evaluation of AIM2 Inflammasome Expression in Sporadic Ascending Aortic Dissection.

Posted on January 31, 2019

W. Ageedi1, P. Ren1, Y. Wang1, J. Guo1, J. Coselli1,2,3, Y. Shen1,2,3, S. LeMaire1,2,3  1Baylor College Of Medicine,Division Of Cardiothoracic Surgery, Michael E. DeBakey Department Of Surgery,Houston, TX, USA 2Texas Heart Institute,Cardiovascular Surgery,Houston, TX, USA 3Baylor College Of Medicine,Department Of Molecular Physiology And Biophysics,Houston, TX, USA

Introduction: Ascending thoracic aortic aneurysms and dissections (AAD) are extremely lethal conditions. No effective medical treatment to prevent AAD currently exists. Identifying the biological pathways responsible for aortic destruction is critical for developing effective treatment. We have recently shown that NLRP3 (nucleotide oligomerization domain–like receptor family, pyrin domain containing 3)–caspase-1 inflammasome cascade degrades smooth muscle cell contractile proteins, leading to aortic biomechanical dysfunction and AAD development. Increasing evidence suggests that Absent In Melanoma 2 (AIM2), another member of the inflammasome family with cytosolic DNA sensing ability, is critically involved in tissue inflammation and destruction.We hypothesized that patients with ascending AAD have elevated aortic tissue levels of AIM2 

Methods: Ascending aortic tissues were obtained from patients with ascending aortic dissection (n=6), patients with ascending aortic aneurysm without dissection (n=6) and organ-donor controls without aortic disease (n=6). We excluded patients with heritable aortic diseases, such as Marfan syndrome. AIM2 expression levels were determined by western blot and immunofluorescence analyses and compared between the three groups. 

Results: Western blot analysis showed that while AIM2 was barely detectable in control and non-dissection aortic aneurysm tissues, AIM2 was markedly increased in aortic dissection samples. Double immunofluorescence analysis showed a significant amount of AIM2 in the aortic media and adventitia of aortic dissection tissue, particularly in smooth muscle cells.

Conclusions: The expression of AIM2 inflammasome is increased in sporadic ascending aortic dissection. Further studies are needed to confirm this finding in larger samples, and to determine the role of AIM2 in aortic inflammation, extracellular matrix destruction, smooth muscle cell dysfunction, and AAD development.

46.17 Cardioscope: A New Innovation for Visualization of Intracardiac Pathology

Posted on January 31, 2019

A. Alotaibi1, G. A. Al-Dossari1, P. T. Roughneen1  1University Of Texas Medical Branch,Cardiovascular And Thoracic Surgery,Galveston, TX, USA

Introduction: Currently, cardiologists and cardiac surgeons visualize intracardiac anatomy through the echocardiography and cardiac catheterization or by open-heart surgery. The concept of cardioscopy, or endoscopy of the heart, dates back to the early 20th century with the first cardioscope developed by Drs. Rhea and Walker in 1913. The first published article was in 1922 by Drs. Allen and Graham. Since then, several attempts have been made to design the ideal cardioscope. Cardioscopy, however, has not advanced as rapidly as other forms of endoscopic surgery because of problems with visualization through blood within the beating heart. We present a novel endoscopic technique in performing a direct visualization of intracardiac anatomy in a porcine heart utilizing carbon dioxide (CO2) and normal saline (NS), and we describe its use as a diagnostic and therapeutic treatment to advance the future of the cardiovascular disease.

Methods: Our model involves cardioscope access in a porcine heart and great vessels with the use of CO2 and NS. During the first trial in 2016, a flexible endoscopy machine was used to visualize intracardiac anatomy. We expanded our work in 2017 and present the data herein. Purse strings were applied on both the right heart side (right atrium and pulmonary artery) and left heart side (aorta and left atrium). The pulmonary veins, the superior vena cava, and the inferior vena cava were closed with 3-0 Prolene sutures to allow the heart to fill with the NS and CO2. A flexible Olympus bronchoscope was used. This endoscope has outside diameters of approximately 5-6 mm, with an ability to flex 180 degrees and extend 120 degrees. The endoscope was inserted through the harvested porcine aortic artery, and CO2 was utilized to inflate the heart.

Results: We were able to view intracardiac structure through different heart axis views (the left and right heart axes). However, despite rotation and flexion of the 180-degree endoscope, it was not possible to see the mitral valve; although, other areas in the left ventricle were visualized.

Conclusion: Cardioscopy has potential as a diagnostic and therapeutic technique. However, the design of a cardioscope should include 360 degrees of rotational capacity and a side arm, the capability for therapeutic intervention, and improved optic visualization through blood utilizing digital subtraction technology.

 

46.16 The Molecular Signature of Deep Partial and Full Thickness Burns

Posted on January 31, 2019

A. S. Karim1, Z. Wang2, C. Kendziorski2, A. L. Gibson1  1University Of Wisconsin,Department Of Surgery,Madison, WI, USA 2University Of Wisconsin,Department Of Biostatistics & Medical Informatics,Madison, WI, USA

Introduction: Thermal injury can result in substantial morbidity and mortality. The most important determinant of burn wound healing and the need for surgical intervention is burn depth. There is a gap in our knowledge of how burns progress and if they possess the regenerative capacity needed at various depths of injury to heal the wounds without skin grafting. This is in part due to our incomplete understanding of the interplay between inflammation and the regenerative response. In this study, we sought to characterize the wound microenvironment in deep partial (DPT) and full thickness (FT) burns using high throughput RNA sequencing in order to identify pathways for therapeutic interventions.

Methods: Non-burned (NB; n=6), DPT (n=5), and FT (n=5) tissue biopsies were obtained at the time of burn excision on days 5-10 (median: 6 days) after burn injury then submitted for RNA sequencing. After mapping and normalization, probabilities with a false discovery rate of 5% were calculated to determine differentially expressed genes (DEG). Gene sets of genes that are involved in inflammation, reactive oxygen species (ROS), regeneration, apoptosis and necroptosis were created from the list of DEG and compared in DPT and FT samples normalized to NB. One-sided, Paired t-tests of log2 transformed fold changes were used to compare the two conditions.

Results: 5416 DEG in FT and 4131 DEG in DPT tissues were identified. 1442 of the DEG were different in DPT versus FT. There were no significant differences between DPT and FT with regards to apoptosis and necroptosis (p=0.0763), but there were significant changes with regards to regenerative potential, inflammation and ROS. DPT had greater regenerative potential than FT (p<0.0001), while FT had greater inflammatory response and ROS than DPT (p<0.0001).

Conclusion: In this study we present findings suggesting that there are differences in gene expression profiles between DPT and FT burn tissues that were operatively managed. Genes that are involved in inflammation, ROS, apoptosis and necroptosis were upregulated in FT and DPT relative to NB. Regenerative capacity was significantly lower in FT compared with DPT burns. Overall, this points to an imbalance between the inflammatory and regenerative capacity which is leading to apoptosis, necroptosis and cellular senescence. Gene set enrichment analysis of the mechanisms leading to this imbalance suggests mitochondrial stress and ROS (specifically the NAPDH oxidase system) as some of the biggest mediators. Targeting ROS and preventing mitochondrial depletion may be a viable therapeutic target aimed at preventing burn wound progression and accelerating healing of burn wounds. This will ultimately reduce the need for skin grafting in these patients.

46.15 Tension Influences Small ncRNA Regulatory Landscape of MSC-derived Exosomes During Wound Healing

Posted on January 31, 2019

D. Colchado1, H. V. Vangapandu1, N. Templeman1, H. Li1, Y. Ning1, A. Blum1, P. Bollyky2, S. Keswani1, M. Robertson1, C. Coarfa1, S. Balaji1  1Baylor College Of Medicine,Houston, TX, USA 2Stanford University,Palo Alto, CA, USA

Introduction: Mesenchymal stem cells (MSCs) have a huge therapeutic potential in wound healing. While it is known that the extracellular environment affects the MSC secretome, the role of mechanical tension on the bioactive extracellular vesicles, namely exosomes, released by MSCs, is not known. We hypothesized that mechanical tension regulates MSC exosome production and influences wound healing via paracrine effects on dermal fibroblasts.

Methods: Human MSCs were cultured on silicone membranes +/-10% tonic strain for 24h and analyzed for phenotypic changes (morphology, alpha-SMA, and fibrosis PCR-array) and genes important in exosome biogenesis  (RAb27a-b;SMPD3). Exosomes were isolated and analyzed for size and quantity (Zetasizer). The exosome protein level was quantified (BCA Assay) and Westernblotting (CD63,HSP70,CD9) and Next-Gen Sequencing were performed. Exosomes were labeled by Exo-Glow before use in a primary human dermal fibroblast (FB) migration assay. p-values by ANOVA; (n=3/group).

Results:Tension resulted in the loss of the characteristic morphology of the MSC spindle shape and increased alpha-SMA staining in MSCs. There was a significant change (>2-fold) in ~ 30/77 fibrotic genes with tension. Tension upregulated the expression of IL-10 and IL13RA2, which are also involved in anti-inflammatory cytokine processes. In contrast, pro-fibrotic and pro-inflammatory genes such as Acta-2 and Ccl-2 were downregulated by tension. Additionally, genes encoding fibrinolytic enzymes such as PLAT and growth factors (EGF, VEGFA, and CTGF) were downregulated under tension. Tension downregulated the expression of both RAb27a-b (p<0.01) in MSCs, and there was a corresponding phenotype of perinuclear reorganization of exosomes with an increase in size distribution and protein levels under tension (p<0.05). The three exosome surface markers were verified by Western blotting. Exosomes were enriched for small RNAs as expected. The abundance of tRNA was increased, whereas the miRNAs and lincRNAs in the MSC-derived exosomes were reduced under tension. KEGG analysis of the gene targets and pathways of down regulated miRNAs showed enrichment of intracellular and extracellular wound healing processes. Interestingly, MSC-derived exosomes under static conditions slowed the migration of FB in a scratch wound assay, whereas those derived under tension increased FB migration (p<0.05), but there was no effect of the complete MSC-conditioned media from either static or tension conditions on FB migration.

Conclusion:Mechanical tension induces a fibrogenic and inflammatory phenotype in MSCs. Given that the production and composition of bioactive cargo in MSC exosomes is regulated by tension and can influence FB behavior, we propose that MSC-derived exosomes are a likely target for extracellular communication during wound healing. These insights provide a key role in the development of exosome-based clinical therapies in the context of wound healing and fibrosis.

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