10.17 Predictors for Discharge to SNF for Community Dwellers Following Emergency General Surgery

Posted on January 31, 2019

M. E. Villarreal1, A. Z. Paredes1, A. T. Malik2, S. Strassels1, H. P. Santry1, C. D. Jones2, D. Vazquez1  1Ohio State University,Department Of Surgery, Division Of Trauma, Critical Care And Burn,Columbus, OH, USA 2Ohio State University,Department Of Orthopaedics,Columbus, OH, USA 3Johns Hopkins University School Of Medicine,Department Of Surgery, Division Of Acute Care Surgery,Baltimore, MD, USA

Introduction:  Emergency general surgery (EGS) can have a devastating impact and be functionally debilitating even for previously independent patients. We sought to characterize the differences in clinical and perioperative characteristics between previously community dwelling EGS patients who were and were not discharged to skilled nursing facility (SNF) after index hospitalization.

Methods:  The ACS-NSQIP database was queried from 2012-2016 for adults, >18 years old, who presented for evaluation from home, as a transfer from an outside hospital or from an outside emergency department and who emergently underwent one of the 7 procedures which account for the most admissions, deaths, complications and inpatient costs within 48 hours of presentation. Patients admitted from SNFs or other long-term care facilities were excluded. Bivariate comparisons were conducted to measure differences in clinical characteristics (e.g. age, number of comorbidities), perioperative characteristics (e.g. operative time, transfusion requirement), and type of intervention (e.g. high risk vs. low risk) between patients discharged to SNF versus home. Multivariable logistic regression analysis was conducted to determine factors associated with discharge to SNF.

Results: Overall, 151,440 patients met inclusion criteria. Median age was 43yrs (IQR 29-59). The majority were female (52%), white (72%), and of pre-operative independent functional status (98%). 87% of patients underwent a high-risk operation. The majority of patients (96%) returned home after EGS as opposed to discharge to SNF (4.5%). Patients discharged to SNF were more likely to be >80 years old (37% vs 3.0%), totally dependent (2.0% vs 0.2%) and have an ASA class >II (91% vs 25%) (all p<0.001). Patients discharged to home were more likely to have an operative time between 0-60min (21% vs 62%) and have low-risk surgery (14% vs 5.6%) (both p<0.001). Patients discharged to SNF were 2.5 times and 30 times more likely to be readmitted (14% vs 5.3%) or die (6.2% vs 0.2%) within 30 days, respectively (both p<0.001). On multivariable analysis age >66, presence of comorbidities such as congestive heart failure (OR 1.5, 1.3-1.9) or disseminated cancer (OR 1.3, 1.2 – 1.5), and sepsis (OR 1.3, 1.2-1.4), dirty surgical wound (OR 1.4, 1.2-1.6), operative time >120min (OR 1.78, 1.6-1.9) and any pre-discharge complication (OR 2.7, 2.5-2.9) were predictive of discharge to SNF.

Conclusion: Baseline patient characteristics and complexity of hospital course are associated with discharge to SNF after EGS care for those who were previously community dwellers. Though patients discharged to SNF made up a minority of EGS patients in our cohort, their higher rates of re-admission and other post discharge complications suggest a need for improved discharge planning processes and post-discharge care plans for the sickest EGS patients.

10.16 Hospital Level Diagnostic Radiology Associated Outcomes for Acute Cholecystitis

Posted on January 31, 2019

K. B. Ricci1, A. Z. Paredes1, A. P. Rushing1, D. Ayturk2, A. Diaz1, V. T. Daniel2, H. E. Baselice1, S. Strassels1, A. M. Ingraham3, H. P. Santry1  1Ohio State University,Department Of Surgery, Division Of Trauma, Critical Care And Burns,Columbus, OH, USA 2University Of Massachusetts Medical School,Department Of Quantitative Health Sciences,Worcester, MA, USA 3University Of Wisconsin,Surgery,Madison, WI, USA

Introduction: Cholecystitis is a common cause of acute abdominal pain for which early operation is recommended. The effect of diagnostic radiology and endoscopic resources on timing of operation and associated clinical outcomes is unknown. We sought to evaluate the relationship between hospital resources, timing of operation, and outcomes for patients with acute cholecystitis with and without choledocholithiasis.

Methods: 2,811 U.S. hospitals were surveyed on emergency general surgery practices, including diagnostic radiology structures and processes (e.g. computerized tomography scan type, timeliness of results) and endoscopic retrograde cholangiopancreatography (ERCP) resources. 1,690 hospitals (60%) responded. Survey data from 510 hospitals was linked to corresponding 2015 Statewide Inpatient Sample data using American Hospital Association identifiers. Patients admitted emergently with a primary diagnosis code of acute cholecystitis were included. Radiology/ERCP resources associated with early cholecystectomy (≤72hrs) were analyzed using univariate and multivariable modeling. Differences in systemic or surgical complications between patients undergoing early (< 72hrs) vs late (>72hrs) operation were similarly analyzed.

Results: Of 24,339 acute cholecystitis patients, the majority were white (64%), with a median age of 57yr (IQR 40-72) and >3 comorbidities (39%). 88% had uncomplicated cholecystitis. Most presented to a hospital with CT scan  (96%) and ultrasound (US) (98%) availability. Nearly half presented to a hospital with overnight teleradiology (46%), and round the clock US technicians (49%). 74% had an operation; 92% (N=16,535) early and 8% (N=1,494) late. Late-operation patients were older (62yr, IQR 46-75 vs 53yr, IQR 37-68), white (68% vs 63%) and had  > 3 comorbidities (59% vs 32%) and choledocholithiasis (23% vs 13%) compared to early-operation patients (all p <0.001). Late-operation patients also had higher frequency of >2 systemic (5% vs. 2%) and >2 surgical (1.4% vs 0.9%) complications (both p<0.001). On multivariable analyses, patients cared for at hospitals lacking overnight teleradiology and CT technicians had 18% (aOR 0.82, 0.73-0.94) and 44% (aOR 0.56, 0.38-0.83) decreased odds of an early operation. Also, late-operation patients had 1.8 (95% CI 1.6-2.0) higher odds of systemic complication and longer length of stay (aOR 4.07, 3.92- 4.22). Age ≥65 (aOR 2.45, 1.91-3.14; aOR 2.09, 1.71-2.56) and black race (aOR 1.24, 1.04-1.48; aOR 1.25, 1.08-1.45) were also associated with major surgical and systemic complication, respectively.

Conclusion: Few radiologic or endoscopic resources were noted to affect timing of cholecystectomy. These data highlight the possible effect of late operations. Our findings have implications to optimize time to surgery for patients with acute cholecystitis to reduce risk of complications. Efforts to improve measures to reduce time to operative intervention should be further investigated.

10.15 High Risk Emergency Laparotomy In Australia: Comparing NELA, P-POSSUM And ACS-NSQIP Calculators

Posted on January 31, 2019

D. D. Eliezer1,2, M. Holmes1, G. Sullivan2,3, J. Gani1,2, P. Pockney1,2  1John Hunter Hospital,Department Of Surgery,Newcastle, NSW, Australia 2University of Newcastle,School Of Medicine And Public Health,Newcastle, NSW, Australia 3John Hunter Hospital,Department Of Anaesthesia,Newcastle, NSW, Australia

Introduction:

Emergency laparotomies performed in high risk patients can lead to significant morbidity and mortality. The National Emergency Laparotomy Audit (NELA) has highlighted the importance of identifying these high risk patients and providing them with the appropriate level of care. The NELA risk prediction calculator (NRPC) has been developed by data collected in England and Wales to look at 30-day mortality and morbidity risk and is one of several risk calculators, including P-POSSUM and ACS NSQIP. NRPC has not been tested outside of this context, though comparison has been made to P-POSSUM. In our study, we seek to validate NRPC in the Australian population and compare NRPC to P-POSSUM and ACS-NSQIP for predicting mortality in high risk patients.

Methods: A retrospective review of all emergency laparotomies undertaken at four different sized Australian surgical centres was performed between January 2016 and December 2017. Patient demographics, pre-operative clinical findings, haematology and biochemistry results, intra-operative data and post-operative course documentation were extracted from records. NRPC, ACS NSQIP and P-POSSUM calculators were used to estimate 30-day mortality risk. The previously established NELA high risk category score, ≥10% was chosen to assess the sensitivity of NRPC and compare its positive predictive value (PPV) to that of P-POSSUM and ACS NSQIP calculators. The McNemar test was used to identify statistical significance.

Results: There were 562 patient charts reviewed during the study period. Patient demographics included 261 males (46.4%), mean age: 66 years, median ASA: 3, average LOS: 13.65 days. There were 59 patients who died within 30 days (10.5%). NRPC was able to identify 52 (sensitivity = 88.1%) of these as being within the high risk group. Using the ≥10% risk level, NRPC identified 205 patients, P-POSSUM identified 228 patients and ACS NSQIP identified 201 as high risk. Fifty-two of 205 (25.4%) NRPC-scored patients died compared to 45 out of 228 (19.7%) for P-POSSUM and 46 out of 201 (22.9%) for ACS NSQIP. When using the McNemar test, there was no significant difference between NRPC and P-POSSUM (p=0.07) or NRPC and ACS NSQIP (p=0.18).

Conclusion: The NRPC is a sensitive test for predicting mortality in high risk emergency laparotomy patients within the Australian context which has a different healthcare model and population density when compared to England and Wales. When comparing the PPV of NRPC to that of P-POSSUM and ACS-NSQIP, no statistical difference was noted. Further validation in different populations, including more remote and regional areas of Australia and analysis of different risk categories is warranted.

 

10.14 Intraoperative Cholangiogram – an Analysis of Trends and Outcomes for Management of Cholecystitis.

Posted on January 31, 2019

K. Zhang1, V. Natkha1, J. Mccauley1, M. L. Warren1, J. Luo3, Y. Zhang2,3, K. Y. Pei1  1Texas Tech University Health Sciences Center,Surgery,Lubbock, TX, USA 2Yale School of Medicine,Section Of Surgical Outcomes And Epidemiology,New Haven, CT, USA 3Yale School of Public Health,Environmental Health Sciences,New Haven, CT, USA

Introduction:

 

Common bile duct injury and retained stones continue to be rare, but potentially catastrophic outcomes of laparoscopic cholecystectomy.  Although still controversial and unsettled, there is some evidence that intraoperative cholangiography during laparoscopic cholecystectomy may mitigate such complications.  Despite multiple national practice management guidelines espousing liberal use of intraoperative cholangiography, it is unknown practice patterns among US surgeons.

 

Methods:

 

The ACS NSQIP database was queried for patients undergoing laparoscopic cholecystectomy with (CPT code 47563) and without (CPT code 47562) intraoperative cholangiography for diagnosis of cholecystitis (identified by ICD 9 and ICD 10 codes) from 2005 to 2016. Patients undergoing cholangiogram for known common bile duct stones were excluded.  Trends and practice patterns were evaluated as percentages of total procedures performed from NSQIP participating hospitals.  Standard descriptive statistics were analyzed using student t test, chi-squared as indicated.  Multivariable logistic regression was utilized to compare outcomes of interest including complications, mortality or reoperation.

 

Results:

 

A total of 19,636 procedures (80.3% without cholangiography) were included for analysis.  There were no significant differences among patient characteristics between the 2 groups.  Among NSQIP participating hospitals, majority of surgeons do not perform intraoperative cholangiogram and there appears to be an increasing trend to forgo cholangiography during the study period (Figure 1).  After adjusting for patient characteristics, there were no differences in overall complications [OR 0.86 95% CI (0.74-1.00)], 30-day mortality [OR 0.95 95% CI (0.59-1.52)],or reoperation [OR 1.16 95% CI (0.31-4.35)].

Conclusion:

 

Most surgeons do not perform intraoperative cholangiography during laparoscopic cholecystectomy for cholecystitis.  There were no significant differences in overall complications, mortality, or reoperative risk.

10.13 Transfusion Rates in Emergency General Surgery – High but Modifiable

Posted on January 31, 2019

A. J. Medvecz1, A. Bernard3, C. Hamilton3, K. Schuster2, O. Guillamondegui1, D. Davenport3  1Vanderbilt University Medical Center,Nashville, TN, USA 2Yale University School Of Medicine,New Haven, CT, USA 3University Of Kentucky,Lexington, KY, USA

Introduction:  Transfusion of red blood cells (RBC) increases risk-adjusted morbidity and mortality in surgical patients. Blood management programs have been developed to reduce rates of transfusion. However, emergency general surgery cases are at inherent risk for transfusion given case complexity and patient acuity. We sought to examine the rate of transfusion in emergency general surgery and whether it has changed over time. 

Methods:  This is a retrospective review of ACS NSQIP data from 3 academic medical centers that are also Level I Trauma Centers. Operations performed by general surgeons on adults (age ≥ 18 years) were selected. Data were analyzed from two periods, calendar years 2011 to 2013 and 2014 to 2016. We grouped procedures by the first four digits of the primary procedure CPT code. Groups with fewer than 100 cases and fewer than 10 total transfusions were combined into an “Other” group resulting in 40 procedure groups. Transfusion is defined as any transfusion of RBC during or < 72 hours after the operation. Composite morbidity was defined as any ACSNSQIP complication within 30 days of the operation that was not present prior to the operation.

Results: Between period 1 and 2 overall general surgery transfusion rates decreased from 6.4% to 4.8% of cases (emergent: 16.6% to 11.5%; non-emergent 4.9% to 3.7%; Fisher’s exact p’s < 0.001), Table). Among patients transfused, the number of units received also decreased slightly (median 2 U [IQR 2-3] to median 2 U [IQR 1-3], Mann-Whitney U p = 0.005). Morbidity decreased over the same period from 13.8% to 12.3% (p = 0.001); with emergent cases decreasing from 26.3% to 20.6%, p < 0.001. Mortality did not change by period. (emergent 6.6%, 6.7%; non-emergent 1.4%; 1.5%).

Conclusion: Rates of RBC transfusion have decreased over time. EGS requires twice the rate of transfusion of elective general surgery. However, efforts to reduce transfusion have also been successful in the EGS population. Morbidity improved over the same time period while mortality was unchanged.

10.12 Elective General Surgery Can Be A BridgeTo Transplant In Advanced Heart Failure (LVAD) Patients

Posted on January 31, 2019

E. Neidich1, S. Shah1, A. Vest2, L. Chen1, M. Kiernan2, J. Yoo1  1Tufts Medical Center,Surgery,Boston, MA, USA 2Tufts Medical Center,Medicine,Boston, MA, USA

Introduction:   Advanced heart failure patients with a left ventricular assist device (LVAD) often have co-existing medical conditions that, without surgical intervention, disqualify them from being listed for heart transplantation.  These patients are high-risk surgical candidates and there is a paucity of data regarding whether elective general surgery interventions can be performed safely and actually lead to cardiac transplantation. A retrospective review of Tufts Medical Center’s institutional heart failure database from 2008 – Present was conducted to assess the outcomes of patients requiring surgical intervention to become eligible for transplantation.  

Methods:   We performed a retrospective study of end stage heart failure patients with a LVAD who were not eligible for transplant listing due to medical co-morbidities.  These patients underwent elective general surgery procedures from 2008 – Present. Patient demographics, the operative procedure, surgical morbidity and mortality rates, and transplant status were reviewed.

Results:  We identified sixteen advanced heart failure patients with a LVAD who were referred for elective general surgery procedures to be eligible for transplantation. A total of seventeen operations were performed on these sixteen patients.  The mean age was 49.6 years and the patients were predominantly male 14/16 (88%). The surgical procedures included laparoscopic cholecystectomy (23%), laparoscopic sleeve gastrectomy (23%), laparoscopic sigmoid colectomy (18%), VATS wedge resection (6%), hernia repair (6%), distal pancreatectomy and splenectomy (6%), lipoma excision (6%), peritoneal dialysis catheter placement (6%) and total thyroidectomy (6%). The overall morbidity rate was 35.3% (6/17 patients).  Complications included post-operative ileus in 11.7% (2/17), surgical site infection in 11.7% (2/17) and post-operative bleeding in 11.7% (2/17). The 30-day mortality rate associated with all general surgery procedures was 17.6%. Of the sixteen patients who were referred for surgery, 81.2% of patients (13/16) became eligible for heart transplantation and 56.2% (9/16) underwent successful heart transplantation.   

Conclusion:  A variety of general surgery interventions are safe and effective in advanced heart failure patients with an LVAD, allowing reactivation to the transplant wait list, and ultimately cardiac transplantation. However, these patients carry a high perioperative risk and close multidisciplinary collaboration is required. This single center retrospective review represents the largest available series of LVAD patients undergoing general surgery procedures to become eligible for cardiac transplantation. As demand for cardiac transplantation rises in the coming years, more data is needed to optimize care for this complex patient population.  

 

10.11 Patient-Provider Trust and Preferred Decision Making Role for Colorectal Cancer Treatment

Posted on January 31, 2019

A. C. De Roo1,2,3, A. W. Trickey4, C. M. Veenstra1,3, S. T. Hawley1,3, S. E. Regenbogen1,2,3, A. M. Morris4  1University Of Michigan,Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA 2University of Michigan,Department Of Surgery,Ann Arbor, MI, USA 3University of Michigan,Institute For Healthcare Policy And Innovation,Ann Arbor, MI, USA 4Stanford University,Stanford-Surgery Policy Improvement Research And Education Center,Palo Alto, CA, USA

Introduction:
Concordance between patients’ desired and actual roles in decision making (DM), especially for multidisciplinary treatment, is a key contributor to decision satisfaction and regret, but patient DM preferences are multifactorial and not static. Understanding sources and influences of preference can help align patients’ preferred DM role and actual DM role. We hypothesized that patients’ trust in their physicians would be associated with preferred DM role.

Methods:
We conducted a population-based survey of all incident stage III colorectal cancer cases in the Surveillance Epidemiology and End Result (SEER) registries of Georgia and metropolitan Detroit between August 2011 and March 2013. We assessed patients’ desired level of personal and physician involvement in DM for treatment, and characterized preferences as patient-led, physician-led, shared (both patient- and physician-led), or neither. We dichotomized the primary predictor, patient-physician trust, into “high” and “low” based on median values of validated 5-point Likert scale question responses. We evaluated associations between trust and preferred DM role using χ2 tests and multinomial logistic regression using the largest preference group, physician-led DM, as the base outcome for comparison. The multivariable model was adjusted for patient age, sex, race, income, education, health literacy, marital status, and presence of a surgical complication.

Results: 
Among 1301 respondents (68% response rate), 1261 indicated DM preference — 569 (45.1%) preferred physician-led DM, 378 (29.9%) preferred shared patient- and physician-led DM, 218 (17.3%) preferred patient-led DM, and 96 (7.6%) preferred neither patient- nor physician-led DM. Patients who indicated low trust in their surgeon were more likely to prefer patient-led DM (Relative risk ratio (RRR) 1.68, 95% CI 1.2-2.4) or neither patient- nor physician- led DM (RRR 1.74, 95% CI 1.1-2.8) over physician-led DM. Patients with low trust in their oncologist also preferred patient led-DM (RRR 1.61, 95% CI 1.13-2.29) or neither (RRR 1.76, 95% CI 1.1-2.9). In the analyses for trust in both surgeon and oncologist, unmarried patients were more likely to prefer patient-led or shared DM, while male and black patients were more likely to prefer physician-led DM.

Conclusion:
Low trust in physicians was independently associated with reduced desire for physician involvement in DM for treatment. A preference for DM without physician input is concerning because it may limit discussion of options and evidence for treatment. This study reports the first numerical data to indicate that establishing and maintaining trust provides an opportunity for physician input into decision making for treatment, should patients desire it.
 

10.10 Implementation Of A Blunt Renal Injury Protocol For Children

Posted on January 31, 2019

M. Raees1, B. Guidery3,5, C. Schelgel1, K. D. Sborov5, C. J. Kelsey6, A. Greeno2, K. F. Collins2, J. M. Ndolo4, G. L. Crane4, C. N. Shannon3, M. E. Danko2, H. N. Lovvorn2  1Vanderbilt University Medical Center,Department Of General Surgery,Nashville, TN, USA 2Vanderbilt University Medical Center,Divison Of Pediatric Surgery,Nashville, TN, USA 3Vanderbilt University Medical Center,Surgical Outcomes Center For Kids,Nashville, TN, USA 4Vanderbilt University Medical Center,Department Of Radiology And Radiological Services,Nashville, TN, USA 5Vanderbilt University Medical Center,Vanderbilt School Of Medicine,Nashville, TN, USA 6Vanderbilt University,Nashville, TN, USA

Introduction:  Non-operative management of blunt renal injury in children is broadly practiced yet remains non-standardized. The aim of this study was to evaluate the implementation of a formal renal injury protocol on our single-center outcomes.

Methods:  After IRB approval, a retrospective analysis was performed of 312 children, 18 years and younger, who presented with blunt renal injury to our institution from 2005-2017. Patients were grouped into 3 categories: those treated pre- or post-implementation of a formalized protocol at a free-standing children’s hospital, and those treated at the adjacent adult hospital. Comparisons were made between groups using the chi-square test of independence, and one-way ANOVA. Statistical significance was set a priori, p<0.05.

Results: 99 patients were treated in the pre-protocol, 63 in the post-protocol, and 150 in the adult-treated groups (Table). The groups were different in terms of age (p=0.000) and race (p=0.040), although grade of renal injury was not. ISS was significantly higher in the adult-treated group (p=0.000). A significant difference in disposition from the ED to floor (p=0.000) and step-down unit (p=0.000) was observed. The adult-treated group had a shorter ED time in hours (1.94±3.2 adult-treated; 4.11±3.5 post; 3.6±3.9 pre, p=0.000), and a longer hospital length of stay in days (8.1±8.3 adult-treated; 7.8±21.7 post; 5.5±5.2 pre, p=0.013). Post-protocol, a significant increase in follow-up with Pediatric Surgery was observed (p=0.000), as was utilization of renal ultrasound at follow-up (p=0.000).

Conclusion: Among children sustaining blunt renal injuries, we found improved follow-up with Pediatric Surgery and increased utilization of ultrasound to monitor renal healing. A decrease in length of stay and an increase in time spent in the ED was observed after the establishment of a children’s hospital. As was observed for reduced blood transfusion post-protocol, further research will be necessary to determine optimal resource utilization among children sustaining blunt renal trauma. 

 

10.09 Evaluating Patient-Reported Outcomes in Inguinal Hernia Clinical Trials

Posted on January 31, 2019

A. R. Wilcox1,2, S. W. Trooboff1,2,3,4, S. L. Wong1,2,3  1Dartmouth-Hitchcock Medical Center,Department Of Surgery,Lebanon, NH, USA 2Dartmouth Medical School,Lebanon, NH, USA 3The Dartmouth Institute for Health Policy and Clinical Practice,Lebanon, NH, USA 4Veterans Health Administration,VA National Quality Scholars Program,White River Junction, VT, USA

Introduction: Patient-reported outcomes (PRO) data are increasingly reported in the surgical literature and are subsequently relied upon for clinical decision making. Adherence to the CONSORT (Consolidated Standards of Reporting Trials) statement is required by major journals for randomized controlled trials (RCTs). In 2013, CONSORT added 5 guidelines for reporting PROs in RCTs, known as the PRO extensions. Although PROs are frequently reported in the inguinal hernia literature as a main outcome of interest, adherence to the PRO extensions is unknown.

Methods: In consultation with a medical librarian, a systematic review of the literature was performed to find RCTs evaluating inguinal hernia repair via Ovid MEDLINE. Our inclusion criteria were RCTs evaluating surgical management of inguinal hernia that included PROs as primary or secondary outcomes, published January 2014-July 2018. Exclusion criteria were non-elective repairs, age < 18, or articles unavailable in English. If a trial’s results were published more than once, we only included the most recent publication. Two researchers graded the articles for compliance with the PRO extensions.

Results: We identified 1548 papers in our initial review, 78 of which met criteria for inclusion in this study. Most RCTs (43/78, 55%) compared different types of mesh or techniques to secure mesh. Only 1 paper (1.3%) met all 5 CONSORT PRO extensions, while 11 (14%) did not meet any of the extensions. The PRO extension requiring “identification of the PROs in the abstract as a primary or secondary outcome” was the most commonly satisfied extension (82%), while the extension requiring “statistical approaches for dealing with missing data are explicitly stated” was the least satisfied (18%) (FIGURE). Pain was the most frequently studied PRO, and a Visual Analog Scale was the most frequently used assessment tool. Of note, only 12 papers (15%) referenced the CONSORT statement and none of these demonstrated full adherence to the extensions.

Conclusion: RCTs evaluating elective inguinal hernia repair demonstrate poor adherence to CONSORT PRO guidelines. PRO data from inguinal hernia trials have been published in numerous studies and meta-analyses; however, the lack of standardization in PRO reporting calls into question the generalizability of these findings. It is also noteworthy that very few studies referenced the CONSORT statement in the design of their RCT. If few studies are following CONSORT, it is unsurprising that there was such poor compliance with the PRO extensions. Further education about and dissemination of these guidelines is necessary to improve PRO reporting and ensure optimal patient-centered care based on high quality evidence.

10.08 It's Not Just An Ileus: Disparities Associated With Ileus Following Ventral Hernia Repair

Posted on January 31, 2019

M. J. Lee1, G. Sugiyama1, J. Nicastro1, A. Alfonso1, G. F. Coppa1, P. J. Chung2,3  1Zucker School of Medicine at Hofstra/Northwell,Department Of Surgery,New Hyde Park, NY, USA 2State University of New York Downstate Medical Center,Department Of Surgery,Brooklyn, NY, USA 3Coney Island Hospital,Department Of Surgery,Brooklyn, NY, USA

Introduction:  Postoperative ileus following abdominal surgery not only causes patient discomfort but leads to increased hospital length of stay (LOS) and cost. We sought to identify risk factors associated with postoperative ileus following ventral hernia repair.

Methods: Utilizing the Nationwide Inpatient Sample (NIS) from 2008-2012, we identified adult patients that underwent either open or laparoscopic hernia repair for umbilical and ventral hernias with a diagnosis of umbilical/ventral hernia. We excluded cases with diagnosis of obstruction and bowel gangrene that underwent bowel resection, or with missing data. Risk variables of interest were age, sex, race, income status, insurance status, elective admission, comorbidity status (using the validated van Walraven Score), morbid obesity, procedure type, conversion to open, mesh use, hospital type (rural, urban non-teaching, urban teaching), bed size, and region (northeast, midwest, south, west). Univariate analysis comparing patients with ileus vs control was performed. We then performed multivariable analysis using logistic regression, adjusting for all the risk variables, with ileus as the dependent variable.

Results: 30,912 patients were identified that met criteria. Of these, 2,660 (8.61%) had postoperative ileus during their stay at the hospital. Univariate analysis showed all risk variables were associated with development of ileus with the exception of income status (p=0.2903), elective admission (p=0.7989), mesh use (p=0.3620), and hospital bed size (p=0.08351). Median length of stay was 7 days in the ileus cohort vs 3 days in control (p<0.0001). Median total charges (adjusted to 2012 dollars) was $54,819 vs $35,058 (p<0.0001). We then performed logistic regression adjusting for all risk variables and found that age (OR 1.73, p<0.0001), conversion to open (OR 1.58, p<0.0001), Black vs White race (OR 1.48, p<0.0001), male sex (OR 1.46, p<0.0001), comorbidity status (OR 1.16, p<0.0001) were independently associated with increased risk of ileus. However laparoscopic vs open (OR 0.73, p<0.0001) and northeast vs south hospital region (OR 0.74, p<0.0001) were independently associated with decreased risk of ileus. 

Conclusion: We performed a large observational study looking for risk factors associated with ileus following ventral hernia repair. Race and region of treatment are independent risk factors associated with ileus following ventral hernia repair, and a potential source of disparities in care and increased admission length and higher cost of care. Further prospective studies are warranted.

 

10.07 An Actionable Risk Model for the Development of Incisional Hernia Following Emergency Surgery

Posted on January 31, 2019

J. Fernandez-Moure1, A. M. Wes2, L. Kaplan1, J. Fischer2  1Hospital Of The University Of Pennsylvania,Traumatology, Surgical Critical Care, And Emergency Surgery,Philadelphia, PA, USA 2Hospital Of The University Of Pennsylvania,Plastic Surgery,Philadelphia, PA, USA

Introduction: Emergency surgery (ES) has been associated with increased rates of ventral incisional hernia (VIH). In high-risk patients, prophylactic mesh (PM) placement and small bite fascial sutures (SBS) have been shown to be safe and effective in preventing VIH. A preoperative risk stratification model for VIH following ES may identify patients who could benefit from PM. This study aims to quantify the incidence of surgically treated VIH in ES patients and develop a clinically actionable risk stratification scheme.  

Methods:  We retrospectively reviewed all patients who underwent abdominal operations requiring fascial incision within an urban academic hospital system from 2005-2013. Comorbidities and operative characteristics were assessed. The primary outcome was surgically treated VIH. We excluded patients having less than 1-year follow-up and patients undergoing elective surgery, planned hernia surgery, or a urologic procedure. Hernia risk was calculated with logistic regression modeling and validated using bootstrapping techniques. Beta (β ) coefficients were calculated to correlate risk. A simplified clinical risk assessment tool was derived by assigning point values to the rounded b coefficients.

Results: 4,400 patients with a 14.5% incidence of surgically treated VIH were identified. The strongest risk factors associated with VIH included hypertension, BMI >30, tobacco use, age >30 yr, prior GI surgery, and peritoneal contamination. Each risk factor was assigned a rounded risk score of 1 based on β  coefficients and 3 risk tiers were stratified. VIH incidence in high risk patients was 10.9% compared with 4% and 1% of medium and low risk patients, respectively (C-statistic=0.68) (Figure 1). Patients with all six risk factors evidenced the highest VIH risk (20%).

Conclusion: Preoperative identification of ES patients at risk for VIH may help guide a preventative strategy to reduce its incidence and aid in pre-operative patient counseling. Given the primary outcome was surgically corrected VIH within the same system the incidence of hernia in this poplulation may be underestimated. At-risk patient identification may be aided by using a clinically relevant 6-factor risk stratification model. Model use may inform the decision to engage in specific VIH reduction strategies that could include prophylactic mesh placement. 

 

10.06 Correlation Between Inpatient Opioid Use and Discharge Prescriptions: Patient-Centered Prescribing

Posted on January 31, 2019

J. Bleicher1, S. M. Stokes1, B. C. Nguyen1, L. C. Huang1,2, B. S. Brooke1, R. E. Glasgow1  1University Of Utah,General Surgery,Salt Lake City, UT, USA 2Huntsman Cancer Institute At The University Of Utah,General Surgery,Salt Lake City, UT, USA

Introduction: As knowledge of the opioid epidemic grows, many have begun to generate guidelines to optimize opioid prescribing. Adherence to blanket guidelines, as opposed to a patient-centered approach to opioid prescribing, may lead to significant problems with over- and under-prescribing of opioids for patients. Patients’ in-hospital narcotic requirements can serve as a valuable way to determine the optimal amount of opioids for discharge. As the first step to developing a patient-centered approach to opioid prescribing, we compared inpatient opioid use during the 24 and 48 hours prior to discharge with the amount of opioids prescribed at discharge.

Methods:  We conducted a retrospective observational study at a single academic tertiary center. All patients with CPT codes for Roux-en-Y gastric bypass, distal pancreatectomy, pancreaticoduodenectomy, colectomy, and abdominal wall reconstruction between July 1, 2016 and June 30, 2018 were included. Patients with chronic pain requiring preoperative methadone and fentanyl patches were excluded from the study. The total 24 and 48 hour pre-discharge opioids used, and the discharge prescription, were convered to morphine milligram equivalents (MME). This was converted to daily MME prescribed by dividing the total discharge prescription by 7 days – based on the Centers for Medicare and Medicaid Services recommendations. Spearman’s rank coefficients were used to measure the correlation between inpatient opioid use and discharge prescriptions. We examined the association between 24 and 48 hour inpatient opioid use with the total discharge prescription MME using hierarchical multiple linear regression models (with clustering by procedure and provider) to examine the association between total discharge MME with 24 and 48 hour pre-discharge opioid use.

Results: Of 631 patients who met the inclusion criteria, 53.1% (335/631) received a prescription for daily MME that exceeded their 24 hour opioid requirement. 130 patients (25.1%) required no pain medications within 24 hours of discharge and 66 patients (12.7%) required no pain medications within 48 hours of discharge who still received a discharge prescription. The 24 hour inpatient (r = 0.33) and 48-hour inpatient (r = 0.35) pain requirement showed low correlation with the discharge MME. Increasing length of stay was associated with a higher total MME prescribed at discharge (+10.1 MME/additional hospital day, p < 0.001).

Conclusion: Opioid prescriptions at discharge do not consistently correlate with actual patient opioid requirements. This leads to significant problems with over- and under-prescribing. Systematic and prescriber educational interventions are needed to create a practice of patient-centered opioid prescribing.

10.05 Palliative Care in Emergency General Surgery Patients in the NIS

Posted on January 31, 2019

S. R. Yelverton1, B. Matthews1, N. Rozario1, C. Reinke1  1Carolinas Medical Center,Surgery,Charlotte, NC, USA

Introduction:
Rates of admissions due to emergency general surgery (EGS) diagnoses are on the rise and emergency surgery is associated with worse outcomes. Patients admitted with an EGS diagnosis benefit from care concordant with their goals, given their disease severity and comorbidities.  Palliative care consults in patients faced with unplanned hospitalization can assist surgeons with communication, provide family and patient support, improve symptom management, and facilitate end of life and goal planning. We hypothesized that utilization of palliative care and discharge to hospice has increased over time and that use of palliative care services is associated with increased utilization of hospice services compared to inpatient mortality.

Methods:
Using the 2002–2011 Nationwide Inpatient Sample and EGS diagnosis codes as defined by the AAST, we identified patients aged ≥18 years with an EGS admission. Patient demographics, hospitalization characteristics, rates of operation, mortality, utilization of palliative care services, and discharge to hospice were identified.  APRDRG Risk of Mortality subclass was used to identify patients with extreme likelihood of dying (ELD).  Multivariable linear regression was used to investigate the association between palliative care consult and discharge to hospice after controlling for patient and disease characteristics. 

Results:
We identified an estimated 25 million non-cardiovascular EGS admissions. During their inpatient stay, 0.3% received palliative care, and among those discharged alive 0.7% were referred to hospice care.  Over time, the rate of inpatient palliative care and discharge to hospice care increased, while rates of inpatient mortality decreased (Figure 1).  In the 4% of patients with ELD, 3% received palliative care, 5% were discharge to hospice and 23% suffered inpatient mortality.  After controlling for age, race, insurance status, and EGS category, the use of palliative care services increased odds of discharge to hospice care compared to inpatient mortality by 80% for all patients and by 100% for the subgroup of patients with ELD.  Of patients with length of stay≥2 days who had an inpatient mortality, only 8% received palliative care services.  

Conclusion:
Despite the known risks associated with EGS diagnoses, palliative care services remain infrequently utilized in this population. Protocols for utilization of palliative care services in the surgical ICU may have contributed to the increased utilization of palliative care services over time.  Care coordination with palliative care services is likely an opportunity for improving patient and family satisfaction and better matching patients with resources. 
 

10.04 Modern Management of Perforated Peptic Ulcers – a Decade Long ACS NSQIP Analysis.

Posted on January 31, 2019

R. Dev1, J. Mccauley1, T. Wyatt1, V. Natkha1, J. Luo3, Y. Zhang2,3, K. Y. Pei1  1Texas Tech University Health Sciences Center,Surgery,Lubbock, TX, USA 2Yale University School Of Medicine,Surgical Outcomes And Epidemiology,New Haven, CT, USA 3Yale School of Public Health,Environmental Health Sciences,New Haven, CT, USA

Introduction:

Decades after the introduction of acid reducers and the recognition of endemic helicobacter pylori infection as the cause of peptic ulcers, medical management has largely replaced surgical therapy.  Nevertheless, a portion of patients will require operative intervention for perforated ulcers.  With the increasing adoption of advance laparoscopic techniques, it is uncertain the practice patterns among US surgeons during the last decade.  This study evaluates the trends and outcomes in management of perforated peptic ulcers.

Methods:

The ACS NSQIP database was queried for patients with diagnosis of peptic ulcer perforation (ICD 10 codes K26.5, K27.2, K26.1 K27.1, and K27.5 and ICD 9 codes 532.1, 532.5, 533.2, 533.5, 533.10)from 2005 to 2016.  Only the index operation identified by the current procedural codes (CPT) was included for analysis.  Based on CPT codes, operations were divided into 3 major groups including: simple open suture repair, laparoscopic repairs, and open suture repair open suture repair with omental patch). Trends and practice patterns were evaluated as percentages of total procedures performed from NSQIP participating hospitals. Standard descriptive statistics were analyzed using student t test and chi-squared as indicated.  Outcomes including complications, mortality or reoperation were evaluated by procedural group.

 

Results:

A total of 2,603 procedures were included for analysis.  There were no significant differences among patient characteristics between the 3 groups. Among NSQIP participating hospitals, majority of surgeons perform simple open suture repair of perforated ulcers (50.0% open suture repair only, 7.8% laparoscopic repairs, 42.2% open suture repair with omental patch) and there appears to be a plateauing of laparoscopic implementation (Figure 1).  Patients undergoing simple open suture repair only had the highest mortality rate (12.25%) whereas laparoscopic repairs had the lowest mortality (7.35%).  Other outcomes of including any complication, reoperation, and length of stay were similar.  Of note, no historical procedures including vagotomy and drainage operations were reported during this study period.

Conclusion:
 

The national experience in management of perforated peptic ulcer is rare and only a small minority of surgeons perform laparoscopic patch repairs.  Surprisingly, the majority of surgeons performed simple open suture repair without patch.  Barriers to implementation of laparoscopic techniques warrants further study.

10.03 Emergent General Surgery (EGS) Operations in Patients with Left Ventricular Assist Devices (LVADs)

Posted on January 31, 2019

Z. M. Bauman1, R. Cunningham1, A. Hodson1, V. Shostrom1, C. Evans1, L. Schlitzkus1  1University Of Nebraska College Of Medicine,Acute Care Surgery,Omaha, NE, USA

Introduction:  The LVAD patient population is rapidly expanding.  Few institutions have experience managing these patients.  The unique characteristics of this patient population complicate the management of acute surgical problems due to lack of knowledge concerning LVADs and the necessary anticoagulation for this device.  EGS intervention is often warranted, but remains poorly described.  We reviewed our EGS cases in LVAD patients to understand this patient population and approach to treatment.

Methods:  Over a 12-year period, 301 LVAD patients were reviewed.   Demographics, comorbidities, reason for EGS consultation, operative intervention, transplantation and mortality were noted.  Continuous variables were analyzed using the nonparametric Wilcoxon test and categorical variables were analyzed using the Fischer Exact and Chi-Square test.  Statistical significance was set at p<0.05.

Results: A total of 139 (46.2%) patients required EGS consultation.  Patients with EGS consults were older (63 vs 57 years, p=0.002), primarily Caucasian (86%) males (83%) with an average pre-implant cardiac index (CI) of 1.84.  Comorbidities were similar between those with and without EGS consults. 

Gastrointestinal (GI) bleeding was the most common reason for consultation (53%), followed by abdominal pain (22%) and bowel ischemia/obstruction (19%).  Unfortunately those requiring EGS consults were taking warfarin (77%) and aspirin (60%).  Procedures were not withheld: 46% required esophagogastroduodenoscopy (EGD) and 30% required colonoscopy. 

Surgical intervention was undertaken in 28% of those with an EGS consults – 49% emergent (within 24 hours), 44% urgent (during hospitalization) and 8% semi-urgent.  The mean time to operation was 48 days post-LVAD placement (interquartile range of 11-273 days).  EGS intervention precluded 7 (18%) patients from heart transplantation and 10 (26%) suffered perioperative mortality.  Only elevated lactic acid at the time of EGS consult was associated with an increased likelihood of mortality.

Conclusion: EGS consultation is necessary in almost half of all LVAD patients.  Most commonly, GI bleeding is the main reason worsened by the anticoagulation required for the LVAD device.  Although EGD or colonoscopy can be safely used to manage the majority of these consultations, one third will require surgical intervention.  At consultation, those patients with a high lactic acid have a higher incident of mortality. Additional analysis of this patient population is required for further assessment to determine the timeliness of the consult, for better preoperative optimization and risk benefit discussion.

 

10.02 Role of Nerve and Muscle Biopsies in Pediatric Patients in the Era of Genetic Testing

Posted on January 31, 2019

K. Yang1, S. T. Iannaccone2,3, L. S. Burkhalter2, J. S. Reisch4, C. Cai5, D. T. Schindel1,2  1University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA 2Children’s Medical Center,Division Of Pediatric Surgery,Dallas, Tx, USA 3University Of Texas Southwestern Medical Center,Department Of Pediatrics,Dallas, TX, USA 4University Of Texas Southwestern Medical Center,Department Of Clincal Science,Dallas, TX, USA 5University Of Texas Southwestern Medical Center,Department Of Pathology,Dallas, TX, USA

Introduction: Neuromuscular disorders (NMDs, disease of muscle, nerve, and neuromuscular junction) occur 1 in 3500 worldwide. NMD often requires extensive workup that may not yield a specific diagnosis. Traditionally, diagnosis depended on operative biopsy, that often gave non-specific results depending on the lab’s expertise. Recent advances in molecular genetics suggest that less invasive genetic testing should be the initial approach, reserving biopsy for later. Additionally, due to various algorithms for different NMD categories, the decision to do biopsy first can be difficult.  Our goals were to demonstrate the diagnostic utility of muscle/nerve biopsy within the pediatric population at an academic center and offer recommendations for genetic testing in relation to biopsy to achieve the highest diagnostic yield.

Methods:   Following IRB approval, we reviewed the EMR of 221 pediatric patients who underwent muscle and/or nerve biopsy for NMD at our center from 1/07 to 3/18. Demographics, family history, clinical presentations, genetic testing and pathology results, complications, clinical diagnoses, and follow up data were collected. Genetic testing included any NMD single gene testing or multiple gene panel testing as well as whole exome sequencing. We compared those who received genetic testing prior to biopsy with those who received genetic testing after biopsy to determine the effect on diagnostic yield. Chi square analysis was done for statistical significance.

Results: 220 patients underwent muscle biopsy and 15 patients underwent nerve biopsy. Not all patients received genetic testing. 119 patients had genetic testing prior to biopsy and 68 patients received genetic testing following biopsy. The average age at time of biopsy was 7.7 years (range 1 month to 18 years), 63% male and 73.7% Caucasian. No surgical or anesthesia complications were noted. Biopsy revealed histological abnormalities in 62.9% (139) and were sufficient to make a specific clinical diagnosis in 33.9% (75).  When genetic testing was done before biopsy, pathogenic variants were found in 7.6% (9) and the biopsy identified histological abnormalities in 64.7% (77). When genetic testing was done after biopsy, pathogenic variants were found in 39.7% (27) and biopsy identified abnormalities in 75% (51). The distribution of biopsy results was comparable and not influenced by the timing of genetic testing (p-value 0.345). Genetic testing yield for pathogenic variants was higher when done after biopsy (p-value<0.001).

Conclusion:Muscle and nerve biopsies are safe and may provide significant diagnostic value. Biopsy helped to rule in or out NMD and to guide genetic testing. Our data suggest NMD genetic testing yield was higher when done after biopsy.

 

09.20 High Incidence of Pheochromocytoma Among Adrenal Incidentalomas

Posted on January 31, 2019

R. L. Deitz1, M. B. Mulder1, M. J. Paonessa1, J. I. Lew1, J. C. Farra1  1University of Miami Miller School of Medicine,Division Of Endocrine Surgery,Miami, FL, USA

Introduction:  Pheochromocytoma is a rare adrenal tumor of catecholamine hypersecretion with known malignant potential. Often found in patients with symptoms such as episodic hypertension, palpitations and diaphoresis among others, pheochromocytomas may present as an adrenal incidentaloma discovered initially on imaging studies performed for indications other than suspected adrenal disease. This study examines the incidence of pheochromocytomas among patients who initially present with an adrenal incidentaloma.

Methods:  A retrospective review of prospectively collected data from patients who underwent adrenalectomies between 1999-2017 at a single institution was performed. All patients with adrenal incidentalomas underwent biochemical evaluation prior to surgical resection. Final pathology was evaluated and compared to preoperative biochemical values and diagnoses. Descriptive statistics analyzing the diagnosis patterns and symptomatology were performed. Differences were assessed at p<0.05.

Results: Of 183 patients, 56 had pheochromocytomas on final pathology and 50% (n=28) of these adrenal tumors were discovered incidentally. All but one were found by CT imaging during workup for other reasons including nonspecific abdominal pain, nephrolithiasis, and shortness of breath. Of the incidental pheochromocytomas, 57% (n=16) were asymptomatic, while 42% (n=12) were symptomatic (p<0.05). Hypertension was common in incidental and non-incidental pheochromocytomas (82% v 75%, p=0.52), with 60% (n=14) of the incidental pheochromocytomas requiring multiple anti-hypertensive medications. All patients underwent laparoscopic (n=23) or open (n=5) adrenalectomy with the diagnosis of pheochromocytoma confirmed by final pathology. 

Conclusion: Pheochromocytoma is found in a significant portion of surgical patients who initially present with adrenal incidentalomas. Although these patients do not demonstrate overt symptoms of pheochromocytoma, most may have significant hypertension requiring multiple anti-hypertensive medications. All patients presenting with an adrenal incidentaloma should undergo full biochemical evaluation, particularly in the presence of idiopathic hypertension.

 

09.19 Primary Hyperparathyroidism and Bone Density in Patients with a History of Roux-en-Y Gastric Bypass

Posted on January 31, 2019

V. Lai1, K. D. Burman2  1Virginia Hospital Center,Arlington, VA, USA 2MedStar Washington Hospital Center,Washington DC, WASHINGTON, DC, USA

Introduction:  Primary hyperparathyroidism (1HPT) affects 1-3% of the population and can negatively impact bone mineral density (BMD), with an increased risk of osteoporosis and fractures.  A much higher percentage of the population has obesity, and rates of Roux-en-Y gastric bypass (RYGB) surgery to correct morbid obesity has increased.  Some have noted that RYGB patients may develop lower BMD, especially at the femur.  Secondary hyperparathyroidism (2HPT) in RYGB patients is common, but 1HPT in RYGB patients has not been well studied, particularly studies of their bone health.  The aim of the study was to compare the BMD of RYGB patients who develop 1HPT to those with 1HPT who have not undergone RYGB.  The hypothesis was that patients with 1HPT and a history of a RYGB would have lower BMD than controls.

Methods: A retrospective review of adult patients with sporadic 1HPT cared for within a multi-site metropolitan health network between 2000-2018 was performed.  Patients with a history of RYGB and 1HPT were identified with ICD and CPT codes, and included if they had BMD data from dual-energy x-ray absorptiometry scans. Cases were matched 1:1 by age, race, and sex to a control group of patients with 1HPT without a history of RYGB. BMD, biochemical, and clinical data were collected.  

Results: Four patients with a history of RYGB who developed 1HPT were identified: 100% were female; 50% were white and 50% were black; the average age at the time of 1HPT diagnosis was 61 years.  The cohort was more likely than the controls to have osteoporosis (75% vs. 25%) and less likely to have any one site with normal BMD (0% vs. 100%).  The worst BMD occurred in the distal radius and lumbar spine in the cohort group, and in the lumbar spine in the control group.  Fractures occurred in 50% of both.  The patients with a history of RYGB with 1HPT tended to have lower serum calcium and higher parathyroid hormone (PTH).  Both groups were vitamin D replete, and the RYGB group was more likely to have taken high-dose supplementation (75% vs. 25%) to achieve vitamin D repletion. All patients in the cohort group underwent parathyroidectomy without significant complications, and with postoperative normalization of serum calcium and PTH.

Conclusion: Patients with 1HPT who have undergone RYGB may present with worse BMD than those with 1HPT who have not undergone RYGB.  The distribution of the bone disease in the patients with 1HPT and a history of RYGB seemed more similar to the pattern of bone disease of typical 1HPT patients than in typical post-RYGB patients, where changes occur in the femur.  They were more likely to have required high-dose supplementation to be vitamin D replete, and they had lower serum calcium and higher PTH levels, which may reflect the influence of 2HPT to the 1HPT picture.  Whether this contributed to the BMD results is possible, and further study on the bone health of these patients would help clarify the results of these initial findings.
 

09.18 Single institution review of Outcomes of Bethesda III and IV Thyroid nodules over a five year period

Posted on January 31, 2019

N. Yepuri1, R. Naous2, R. Acharya3, M. Dhir1  1SUNY Upstate Medical University,General Surgery,Syracuse, NEW YORK, USA 2SUNY Upstate Medical University,Pathology,Syracuse, NEW YORK, USA 3SUNY Upstate Medical University,Medicine,Syracuse, NY, USA

Introduction: Indeterminate thyroid cytology is seen in approximately 25% of thyroid nodule fine needle aspirations (FNA) and 75% of these nodules are ultimately noted to be benign on final histology. The role of molecular tests is to reduce the number of unnecessary surgical procedures performed for benign nodules by improving the diagnostic discrimination between benign vs malignant nodules. Small single institution studies have previously reported that ThyGenX and ThyraMIR can reduce unnecessary surgeries; however more validation studies are needed. Aim of the current study was to determine if molecular testing using ThyGenX and ThyraMIR can alter surgical management in patients with Bethesda 3 and 4 nodules.

Methods: A single institution retrospective analysis of all Bethesda 3 (B3) and 4(B4) thyroid FNAs from 2013 to 2018 was performed after IRB approval. Patients with non-invasive follicular thyroid neoplasm with papillary like nuclear features (NIFTP) were grouped with malignant category as surgery is indicated in these patients.

Results:Of 413 FNAs, 25 (6 %) were diagnosed as B3 and 15 (4 %) were B4. The ThyGenX and ThyraMIR was obtained 4 B3 (16%) cases, and 5 of B4 (33%) cases. Eight patients with B3 underwent surgery and 4 were diagnosed with malignancy (1 PTC, 1 NIFTP, 1 FV-PTC, 1 – paraganglioma) resulting in an institutional malignancy rate of 50%. The remaining 4 patients were bening (2 hurthle cell change/adenoma, 2 nodular hyperplasia). Six patients with B4 underwent surgery and 3 were diagnosed with malignancy (1 FVPTC, 1 FTC, 1 PTC) resulting in an institutional malignancy rate of 50%. As the malignancy rate was similar for B3 and B4 molecular testing results were analyzed together for these nodule categories. Molecular testing results were available for 16 patients (6 B3, 10 B4)– 1 patient with B3 had positive PAX8-PPAR mutation while all others had negative testing. Only 2/16 patients underwent surgery. Patient with PAX8-PPAR B3 was found to have NIFTP whereas B4 patient who opted for surgery despite negative test result had benign final histology. Majority of the patients chose to continue surveillance based on clinical recommendations of negative molecular test.

Conclusion:In our small institutional cohort of B3 and B4 patients the malignancy rate was 50% based on FNA results. More data are needed to evaluate the role of molecular testing in B3 and B4 nodules are our institution.

 

09.17 Adrenal Cavernous Hemangioma:  A Rare Tumor That Mimics Adrenocortical Carcinoma.

Posted on January 31, 2019

M. V. Nishtala1, C. R. McHenry2  1University Of Wisconsin,Department Of Surgery,Madison, WI, USA 2Case Western Reserve University School Of Medicine,Department Of Surgery,Cleveland, OH, USA

Introduction:  Adrenal cavernous hemangioma (ACH) is a rare tumor with approximately 60 cases that have been previously reported. The aim of this study was to determine the frequency of ACH and its clinical significance in our institutional experience.

Methods:  A retrospective review of consecutive patients undergoing adrenalectomy from 1994-2018 was completed to determine the frequency of cavernous hemangioma, its presenting manifestations, characteristic imaging and pathologic features, management, and outcome.

Results: Of 144 consecutive patients who underwent adrenalectomy by a single surgeon, 5 (3.5%) had an ACH. All were incidentally discovered, non-functional adrenal masses varying in size from 6-12 cm with imaging features that were indeterminate in differentiating a benign adenoma from an adrenocortical carcinoma. Attenuation values for the adrenal masses on computed tomography varied from 30-53 Hounsfield units.  All ACHs were large, heterogeneous, complex masses with a variable presence of calcification, hemorrhage, and necrosis. These features, along with rapid enlargement are concerning for adrenocortical carcinoma. During the operation, there was no direct local invasion and all adrenal tumors were successfully removed laparoscopically without tumor rupture or bleeding. All patients had an uneventful postoperative course without complications.

Conclusion: ACH is a rare tumor that can progress to a very large size without symptomatic manifestations, making it difficult to differentiate from adrenocortical carcinoma both clinically and radiographically. ACH can be safely resected laparoscopically despite its large size.

 

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