87.13 Volume of Care Delivered by Pediatric Surgical Specialties through Patient Portal Messaging

Posted on January 18, 2018

K. M. Riera1, J. R. Robinson1, K. J. Van Arendonk1, D. Fabbri2, G. P. Jackson1  1Vanderbilt University Medical Center,Pediatric Surgery,Nashville, TN, USA 2Vanderbilt University Medical Center,Biomedical Informatics,Nashville, TN, USA

Introduction: Patient portals are online applications that allow patients and their caregivers to interact with healthcare systems. Secure patient-provider messaging is one of the most popular functions of patient portals. Prior work has shown that surgeons deliver substantial medical care to adult patients through portal messaging. Adoption of this technology by pediatric surgical patients and providers in a broadly deployed patient portal has not been studied. 

Methods: We obtained all message threads (i.e., sets of messages exchanged between portal users and healthcare providers) initiated on behalf of patients and exchanged with pediatric surgical providers through the Vanderbilt University Medical Center patient portal from June 1 to December 31, 2014. Messages sent for patients of age 21 years and younger were included in analysis to examine the period of transition to adulthood. We collected patient demographics, providers’ surgical specialties, and message content for each thread. We determined the total number of messages in each thread and number of individual messages sent by patients themselves, surrogates (i.e., parents or guardians), delegates (i.e., other individuals authorized to communicate on behalf of the patient), and providers. 

Results: During the study period, 292 message threads were sent to pediatric surgical providers on behalf of pediatric patients. These threads contained a total of 1679 individual messages, 520 patient or caregiver and 1159 provider messages, with an average of 5.8 (SD 5.0) messages per thread and range of 1 to 56 messages per thread. The majority of threads were about male (176, 60.3%) and white (239, 81.8%) patients. Median patient age was 6.0 years (IQR 3-14 years). Messages were sent more frequently regarding younger patients (p = 0.001). Table 1 shows messaging volumes by surgical specialty. Specialties receiving the most message threads were otolaryngology (123; 42.1%), and general surgery (35; 12.0%). Specialties exchanging the largest average number of messages per thread were cardiac surgery (6.9; SD 11.5), and otolaryngology (6.6; SD 4.5). Most message threads involved rich interactions with delivery of substantial care including management of new problems, ordering of tests, changes to treatment regimens, and patient and family education. 

Conclusion: Pediatric surgical specialists deliver substantial care through secure messages in patient portals, but messaging volumes vary across specialties. Institutions adopting patient portals should consider effects on provider workload and models for compensation of online care. Our ongoing research is evaluating the semantic content of messages and determining the complexity of medical care delivered through portal messages.

86.13 Health-Related Needs of Pregnant Women and Caregivers with Prenatal Surgical Fetal Diagnoses

Posted on January 18, 2018

M. E. Danko1, J. R. Robinson1,2, R. K. Skeens3, G. P. Jackson1,2  1Vanderbilt University Medical Center,Department Of Pediatric Surgery,Nashville, TN, USA 2Vanderbilt University Medical Center,Department Of Biomedical Informatics,Nashville, TN, USA 3Vanderbilt University Medical Center,Department Of Pediatrics, Division Of Neonatology,Nashville, TN, USA

Introduction:  Pediatric surgeons are asked to address challenging problems in newborn infants. Congenital anomalies are often diagnosed prenatally, providing an opportunity for early parental education and decision-making. Prior research has shown that many pregnant women and caregivers have unanswered questions during pregnancy. We examined health-related needs of pregnant women and caregivers with prenatal surgical diagnoses to design better educational resources for this population.

 

Methods:  We enrolled English and Spanish speaking adult pregnant women and caregivers in a mixed-methods study of health-related needs during pregnancy. Pregnant women < 36 weeks gestational age were recruited from an advanced maternal-fetal center and group prenatal care practice. Pregnant women could invite caregivers (i.e., anyone significantly involved in the care of mother or baby) to participate. Study subjects completed sociodemographic surveys and semi-structured interviews. Needs were categorized by two research team members by semantic type using a validated consumer health needs taxonomy with four main categories (i.e., informational, logistical, medical, and social/emotional) and the degree to which they were met (i.e., met, partially met, or unmet).

 

Results: One hundred participants (71 pregnant women, 29 caregivers) were enrolled in the study; 29 (20 pregnant women, 9 caregivers) had fetuses with surgical diagnoses, which included congenital heart disease (10), spina bifida (7), gastroschisis (6), hydrocephalus (5), cleft lip/palate (4), omphalocele (1), and congenital diaphragmatic hernia (1). Health-related needs data are shown in Table 1. Participants expressed 323 needs, 240 from pregnant women and 83 from caregivers. The most common need subtype was informational needs about specific therapeutic interventions (31 needs, 9.6%). A total of 101 needs (31.3%) were unmet, with the majority in the informational category (57 needs, 56.4%). The most common specific subtype of unmet needs for all participants was logistical, usually questions pertaining to the healthcare facilities, policies or personnel. The most common subtype of unmet needs was the need for emotional support in pregnant women and logistical needs about healthcare facilities, policies, or personnel for caregivers.

 

Conclusion: Despite receiving care in advanced maternal fetal care settings, pregnant women and caregivers with surgical fetal diagnoses have significant unmet health-related needs during the pregnancy. Pregnant women and their caregivers have differing types of health-related needs. Some unmet needs, such as questions about facilities or details of surgical procedures, can be easily addressed, and meeting them may improve the perinatal experience. 
 

70.06 Neoadjuvant Radiation for Locally Advanced Colon Cancer: A Good Idea for a Bad Problem?

Posted on January 18, 2018

A. T. Hawkins1, T. M. Geiger1, M. Ford1, R. L. Muldoon1, B. Hopkins1, L. A. Kachnic1, S. Glasgow2  1Vanderbilt University Medical Center,Nashville, TN, USA 2Washington University,Colon And Rectal Surgery,St. Louis, MO, USA

Introduction: Compared with lower tumor stages, resection of locally advanced colon cancer (LACC) is associated with poor survival. Few strategies are available to address this disparity. Data on the effect of neoadjuvant radiation therapy (NRT) to improve resectability and survival is lacking. We hypothesized that NRT will result in increased R0 resection, decreased multivisceral resection rates and improved overall survival in patients with LACC.  

Methods: The National Cancer Database (NCDB 2004-2014) was queried for adults with clinical evidence of LACC (defined as clinically evident T4 disease prior to surgery) who underwent curative resection. Patients with metastatic disease or in whom clinical staging data was unavailable were excluded.  Patients were divided into two groups – those who underwent NRT and those that did not.  Bivariate and multivariable analyses were used to examine the association between NRT and R0 resection rate, multivisceral resection and overall survival.  

Results: 15,207 patients with clinical T4 disease who underwent resection were identified over the study period.  195 (1.3%) underwent NRT.  The majority of patients in the NRT group underwent 4500 cGy of radiation in 25 fractions over five weeks (range: 3900- 5040 cGy). Rate of NRT utilization did not change by year. Factors associated with the use of NRT included younger age, male gender, private insurance, lower Charlson comorbidity score, and treatment at an academic/research program.  NRT was associated with superior R0 resection rates (NRT 87.2% vs. No NRT 79.8%; p=0.009) but not lower multivisceral resection rates (NRT 45.6% vs. No NRT 21.5%; p< 0.001).  Five-year overall survival was increased in the NRT group (NRT 62.0% vs. No NRT 45.7%; p< 0.001; PLEASE SEE FIGURE).  The benefit of NRT persisted in a Cox proportional hazard multivariable model containing a number of confounding variables including comorbidity, multivisceral resection and postoperative chemotherapy (OR 1.30; 95%CI 1.01-1.69; p=0.04).  

Conclusion: Younger age, male gender, private insurance, lower Charlson comorbidity score, and treatment at an academic/research program were associated with increased rates of NRT utilization. Although radiation is rarely used in locally advanced colon cancer, this NCDB analysis suggests that the use of neoadjuvant radiation for clinical T4 disease may be associated with superior R0 resection rates and improved overall survival.  NRT should be considered on a case-by-case basis in locally advanced colon cancer. Further research is necessary to identify patients that will benefit the most from this approach. 

 

54.12 Analysis of Intensive Care Unit Admission Data in Urban Teaching Hospital in Maputo, Mozambique

Posted on January 18, 2018

J. Y. Valenzuela1, F. Urci3, L. Niquice3, M. Sidat3, R. G. Valenzuela2, K. McQueen1  1Vanderbilt University Medical Center,Nashville, TN, USA 2Stony Brook University Medical Center,Stony Brook, NY, USA 3Universidade Eduardo Mondlane,Maputo, ., Mozambique

Introduction:  An essential component to improve surgical capacity includes access to intensive care for pre and post operative management for the critically ill. Limited data exist regarding intensive care unit capacity, patient volume, case mix, and mortality rates in Mozambique and sub saharan Africa.

Methods:  Retrospective review of intensive care unit admissions at tertiary referral hospital in Maputo, Mozambique from January 2016 to December 2016.  Most common diagnoses were compiled along with respective mortality rates.

Results: The tertiary referral hospital has a 16 bed unit. In 2016, 1468 patients were evaluated by an intensivist with 965 ICU admissions.  Most common medical conditions requiring ICU care were Diabetes/CAD, stroke, pulmonary edema, hypertensive emergency, and malaria.  Most common surgical diagnoses admitted to ICU were head trauma/intracranial hemorrhage, polytrauma, GI bleed, and eclampsia. Of the surgical conditions, average mortality rate is 30.1%.  

Conclusion: Access to intensive care unit is an essential component of healthcare. Current capacity and demographics is unknown of ICUs in sub saharan Africa.  The primary tertiary hospital in Maputo admits a wide range of mixed medical and surgical conditions. We are in the process of calculating APACHE II scores to determine predicted deaths and compare to actual observed deaths.  Deaths due to surgical conditions warrant further investigation to determine how best to invest limited resources and to develop protocols to reduce mortality.

 

53.20 Outcomes of Abdominal Gunshot Wounds in Patients with Obesity

Posted on January 18, 2018

P. Patalano1, M. C. Smith2, T. Schwartz4, G. Sugiyama3, V. Roudnitsky4  1New York University School Of Medicine,Surgery,New York, NY, USA 2Vanderbilt University Medical Center,Surgery,Nashville, TN, USA 3North Shore University And Long Island Jewish Medical Center,Surgery,Manhasset, NY, USA 4Kings County Hospital Center,Surgery,Brooklyn, NY, USA

Introduction:  Obesity is a public health crisis in the United States, as two thirds of the adult population is overweight or obese. Several studies have demonstrated differences in mortality and length of stay (LOS) according to body mass index (BMI) in blunt trauma, but none have examined this in penetrating trauma. We investigated the association between obesity and overall, as well as ICU LOS following admission for anterior abdominal gunshot wound (GSW).

Methods:  We performed a retrospective chart review of all patients admitted from January 1, 2013 to September 1, 2015 to our urban, Level I Trauma Center. Records were extracted from the trauma registry by mechanism of injury. Patients who were dead on arrival and pregnant patients were excluded.  Variables required to calculate Trauma and Injury Severity Score (TRISS), demographic information, BMI, and information on hospital course were extracted. The TRISS was used to control for injury severity. Our primary outcome was LOS; secondary outcomes were ICU LOS and mortality.

Results: 148 patients were included of which 45 were obese, 46 overweight, 56 normal weight and 1 underweight. There was no significant difference in ISS between obese and normal weight patients (22.38 vs. 22.91, p=0.775). There was a statistically significant increase in LOS for obese patients (21.4 vs. 13.1 days, p=0.032).  There was also an increased ICU LOS in obese patients (11.3 days vs. 5.1 days, p=0.020). Obesity was not associated with increased mortality (6.7 vs. 5.4%, p=0.562).

Conclusion: This data illustrates an association between obesity and increased hospital and ICU LOS in patients admitted with an abdominal GSW. Efforts to curb the epidemics of obesity and violence may lead to a reduced burden on the healthcare system as it relates to this issue. Further prospective studies are warranted to examine specific interventions aimed at decreasing length of stay in patients with obesity.

 

50.10 Can the Laparoscopic Approach Be Employed in Octogenarians with SBO?

Posted on January 18, 2018

E. H. Chang1, P. Chung3, M. J. Lee1, M. Smith5, K. Barrera1, V. Roudnitsky2, A. Alfonso4, G. Sugiyama4  1State University Of New York Downstate Medical Center,General Surgery,Brooklyn, NY, USA 2Kings County Hospital Center,Division Of Trauma And Acute Care Surgery,Brooklyn, NY, USA 3Coney Island Hospital,Department Of General Surgery,Brooklyn, NY, USA 4Hofstra Northwell School Of Medicine,Department Of Surgery,Hempstead, NY, USA 5Vanderbilt University Medical Center,Department Of Trauma Surgery,Nashville, TN, USA

Introduction: The number of octogenarians is projected to increase four-fold by the year 2050. Laparoscopic surgery (LAP) has been associated with decreased length of stay and pain, however the open approach is often employed for small bowel obstruction (SBO). Our aim was to compare laparoscopic surgery (LAP) in the octogenarian population in patients presenting with SBO from adhesive disease with the traditional open exploratory approach. 

Methods:

An observational study utilizing ACS NSQIP from 2006-2014 was performed. Patients ≥80 years of age, who underwent emergency surgery within one day of admission with a postoperative diagnosis of intestinal/peritoneal adhesion with obstruction (ICD9 560.81) were included in the study. Risk variables of interest included: age, sex, race, BMI, preoperative sepsis, ASA classification, length of stay (LOS), postoperative mortality, and postoperative pneumonia. Univariable analysis was performed using Student’s t-test and Wilcoxon Rank Sum Test for continuous variables while Fisher’s Exact Test and Chi-square Test for categorical variables. Multivariable analysis was performed using Logistic Regression. 

Results:

A total of 103 LAP and 692 open cases were identified. There were no significant differences in age (p=0.1518), sex (p=0.7994), BMI (p=0.1151), or race (p=0.3722) between the groups. However, the open group tended to have higher ASA class (p=0.0225) and incidence of preoperative sepsis (p=0.01597). Unadjusted outcomes showed longer LOS in open vs LAP (median 4.0 vs 8.0 days, p<0.0001), higher incidence of postoperative mortality in open vs LAP (p=0.0071), and higher incidence of postoperative pneumonia in open vs LAP (p=0.0032). Logistic regression with postoperative mortality and pneumonia ad dependent variables were performed adjusting for preoperative risk variables and LAP vs Open. Age (OR 1.11, 95%CI 1.01-1.22, p=0.0311) and preoperative sepsis (OR 3.77, 95%CI 1.06-12.02, p=0.0287) were associated with mortality. Male sex (OR 2.68, 95%CI 1.58-4.60, p=0.0003) and open procedure (OR 5.03, 95%CI 1.50-31.34, p=0.0282) were associated with postoperative pneumonia. 

Conclusion:

We compared outcomes after LAP vs open adhesiolysis for adhesive SBO in the octogenarian population. Adjusting for multiple preoperative variables and LAP vs open approach, we found that age and presence of preoperative sepsis, but not procedure type, was associated with mortality. Therefore, octogenarians who present with SBO due to adhesive disease may benefit from an initial laparoscopic approach. Further prospective studies are warranted.
 

5.16 Overview of Florida Genetic Mutation Carriers from the Inherited Cancer Registry (ICARE)

Posted on January 18, 2018

D. A. Henry1, D. Almanza1, C. Lee1, W. Sun1, T. Pal2, C. Laronga1  1Moffitt Cancer Center And Research Institute,Breast Surgical Oncology,Tampa, FL, USA 2Vanderbilt-Ingrahm Cancer Center,Nashville, TN, USA

Introduction: Given the growing list of genetic mutations associated with increased risk for breast cancer, the purpose of this study is to identify Florida enrollees in our Inherited Cancer Registry (ICARE) to better quantify the population for subsequent studies.

Methods: This is a single-institution, IRB-approved international database of subjects recruited from a combination of sources (institutional genetics clinic, external referrals, and social/media outlets) for an inherited cancer syndrome registry. Subjects enrolled from Nov 2000 to Jan 2017 were offered voluntary questionnaires as part of the study. Patients with a Florida zip code and a positive test for one of 11 genetic mutations associated with increased risk for breast cancer (per 2017 NCCN guidelines) were included for analysis. Demographics and questionnaire data were reviewed.

Results: Florida zip codes were identified for 1,247 (55%) of subjects at enrollment. 526/1247 were confirmed carriers of a deleterious mutation, encompassing 8/11 targeted NCCN genes form our study cohort. Median age at enrollment was 48.5 years (range 20-83); 91% were female, 85% self-identified as non-Hispanic Whites. Most patients were BRCA1+ (42%) or BRCA2+ (42%), followed by ATM+ (5%); 374 (71%) of patients had a history of cancer (64% breast; 7% ovarian, 3% both). Questionnaire response rate was 69%. Based on self-reported data, 351/361 (97%) of patients had a high school diploma of which 61% had a college degree or higher; 169/313 (54%) of carriers were the first in their family to have testing.  293/526 (56%) of the cohort, based on zip code, are predicted to fall below the national median household income (MHI) of $54,889; however, where available, questionnaire data placed only 101/314 (32%) below the national MHI.  261 (83%) had private health insurance at the time of genetic testing. 148 (48%) had complete insurance coverage for testing, 98 (32%) received subsidized testing or paid a copay, and 22(7%) paid out of pocket. 161 were treated with surgery for breast cancer; 59 (37%) bilateral mastectomies, 37 (23%) unilateral mastectomies, and 65 (40%) breast-conservation.  72/161 (45%) had genetic testing for surgical decision making, of which 43 (60%) opted for bilateral mastectomy. 89/161 (55%) had genetic testing after surgery, of which 16 (18%) pursued delayed bilateral mastectomy.

Conclusion: Within this educated, insured, and higher income Florida cohort, non-Hispanic White BRCA1/BRCA2 female carriers were the most frequent participants. This is a highly selected group compared to the population of Florida. Genetic test results seemed to influence prophylactic mastectomy choice, as a majority of post-test result cancer patients (59%) elected bilateral mastectomy. This database encompasses a large hereditary cancer syndrome cohort, but is too selected for regional population-based evaluation.

 

43.10 Survival Disparities In Patients With Pancreatic Neuroendocrine Tumors

Posted on January 18, 2018

J. Ousley1, J. A. Castellanos1, C. E. Bailey1, N. Baregamian1  1Vanderbilt University Medical Center,General Surgery,Nashville, TN, USA

Introduction: The incidence of pancreatic neuroendocrine tumors (PNET) is rising, but little is known about the impact of disparities on survival. The aim of our study was to characterize existing disparities in patients with PNET.

Methods:  A retrospective cohort study of patients diagnosed with PNET was performed using the Surveillance, Epidemiology, and End Results (SEER) database between 1988-2012.  Kaplan-Meier and log-rank test were used for survival analysis.  A multivariable (MV) logistic regression model was used to assess demographic and tumor-related factors associated with survival.  

Results: A total of 3,759 patients with PNET were identified.  The mean age at diagnosis was 57.7 + 13.9 years.  The majority of patients were male (54%), white (80.5%), married (64.2%), and presented with distant disease (55.4%).  Median overall survival (OS) for the entire cohort was 52 months.  Median OS was significantly improved for patients who underwent primary tumor resection (PTR) compared to those who did not (64 vs 29 months, p<0.001).  On MV analysis, increasing age, male sex, higher grade tumors, and increasing stage were associated with worse survival, whereas tumor location in the tail of the pancreas and PTR were associated with improved survival (Table).  

Conclusion: Significant survival disparities were found in a cohort of patients with PNET, with improved survival observed in patients who underwent primary tumor resection.  Future studies focusing on access to care, patient education, and socioeconomic factors may help elucidate key factors for improved survival in patients with PNET.
 

39.03 Is the operative autonomy granted to a resident consistent with the operative performance quality?

Posted on January 18, 2018

J. P. Fryer4, B. C. George1, B. D. Bohnen2, S. L. Meyerson4, M. C. Schuller4, A. H. Meier5, L. Torbeck3, S. P. Mandell6, J. T. Mullen2, D. S. Smink7, J. G. Chipman8, E. D. Auyang9, K. P. Terhune10, P. E. Wise11, J. N. Choi3, E. F. Foley13, M. A. Choti12, C. Are15, N. J. Soper4, K. D. Lillemoe2, J. B. Zwischenberger14, G. L. Dunnington3, R. G. Williams3  1University Of Michigan,Ann Arbor, MI, USA 2Massachusetts General Hospital,Boston, MA, USA 3Indiana University School Of Medicine,Indianapolis, IN, USA 4Northwestern University,Department Of Surgery,Chicago, IL, USA 5State University Of New York Upstate Medical University,Syracuse, NY, USA 6University Of Washington,Seattle, WA, USA 7Brigham And Women’s Hospital,Boston, MA, USA 8University Of Minnesota,Minneapolis, MN, USA 9University Of New Mexico HSC,Albuquerque, NM, USA 10Vanderbilt University Medical Center,Nashville, TN, USA 11Washington University,St. Louis, MO, USA 12University Of Texas Southwestern Medical Center,Dallas, TX, USA 13University Of Wisconsin,Madison, WI, USA 14University Of Kentucky,Lexington, KY, USA 15University Of Nebraska College Of Medicine,Omaha, NE, USA

Introduction. Surgical residency training should produce surgeons capable of performing core procedures competently and independently. As residents’ operative performances improve, faculty should allow greater autonomy. In this study we seek to identify and define situations where the operative autonomy levels granted to residents was inconsistent with their operative performance.

Methods.  Surgical faculty provided operative performance ratings for PGY1-5 residents from 14 U.S. general surgery residency programs using the SIMPL smartphone app. For each procedure the supervising surgeon assessed the resident’s operative performance and indicated the level of autonomy that the resident was granted during that procedure. Performance was assessed using an ordinal operative performance scale and autonomy was characterized using the Zwisch autonomy scale. Concordance between performance and autonomy scores was defined as concurrent scores of either “practice ready (performance) or above and meaningful autonomy” (Zwisch) [aka PR/MA] or “not practice ready or above and not meaningfully autonomous” [NPR/NMA]. Discordant scores were “practice ready or above and not meaningfully autonomous” (PR/NMA) as well as “not practice ready or above and meaningfully autonomous” (NPR/MA). The supervising surgeon also indicated the patient-related complexity of the case. Multiple variables were investigated to determine their impact on resident operative autonomy including: resident performance, PGY level, patient-related case complexity, procedure-related complexity, procedure frequency, core vs. specialty procedures.

Results. During the study period 10964 SIMPL assessments that included both a performance score and an autonomy score were collected from 493 different surgeons assessing 615 different residents. 80% of assessments were concordant; including 39% rated as PR/MA and 41% as NPR/NMA. Of the 20% of discordant assessments, most (14.4%) were NPR/MA while the remaining 5.6% were PR/NMA. NPR/MA was the predominant discordant rating in PGY1-4 residents. In PGY5 residents PR/NMA ratings (8.9%) were slightly more frequent than NPR/MA ratings (8.2%). All but 7 surgical attendings (1.4%) provided opportunities for meaningful autonomy on at least one occasion. High volume and easy cases were more frequently performed under meaningfully autonomous circumstances. Operative performance quality accounted for 74% of the variance in the faculty surgeons’ decisions about the level of autonomy allowed (F=341.84; p<0.05).

Conclusions. Faculty autonomy granted to surgical residents was concordant with resident performance in most cases. When discordant, faculty most commonly provided meaningful autonomy when the performance was less than practice ready, a combination to be expected on occasion during training. Few surgical attending surgeons provided no opportunities for autonomous resident operative performance.

38.05 Surgical resident wellness and opportunities for improvement: A single center pilot survey

Posted on January 18, 2018

P. Marincola Smith1, P. N. Chotai1, J. L. Padgett1, S. K. Geevarghese1, K. P. Terhune1  1Vanderbilt University Medical Center,Department Of General Surgery,Nashville, TN, USA

Introduction:  

Surgical residents are at risk of burnout, depression, and poor compliance with health guidelines. We surveyed our trainees to understand their physical and mental health, and compared answers to age-appropriate health guidelines for the population at large.

Methods:  

General surgery residents at a large university-affiliated program were invited to participate in a 34-question, anonymous survey examining factors that affect physical and mental health, including self-reported work hours, compliance with age-appropriate health guidelines, and current diet and exercise habits. Validated depression (PHQ9) and fatigue (Epworth Sleepiness Scale, ESS) scales as well as questions on perceived barriers to health and wellness were included. Data was analyzed using chi-square and Mann-Whitney U tests with SPSS software. 

Results: 

Seventy-two percent of residents participated (n=55, 42% female). Most worked an average 71-80 hours per week (78%) and reported an average of 5 hours of sleep or more per night (75%). Most had at least three hours of leisure time (76.5%) or physical activity (42%), and up to one hour for religious activities (73%) or community activities (80%), per week. Lack of time was the most common (94.5%) barrier to more physical activity. Compliance with recommended primary care physician (PCP), dentist and vision visits was 25%, 23.5% and 42%, respectively. Those who saw their PCP in the last year were more satisfied with their health (p=0.049). Among female residents, 78% complied with cervical cancer screening recommendations. The majority (80%) of residents felt they did not focus enough on health. Barriers to health maintenance visits were time (80%), schedule unpredictability (76%) and appointment availability (67%). Forty-nine percent were interested in participating in work-place wellness programs, including fitness classes(56%), massages(56%), sports teams(49%), ergonomic assessments(36%) and running programs(31%). Although most (71%) reported no mental health concerns, median PHQ9 score was 5 (“mild depression”), and 11% scored in the “moderately severe” or “severe” depression category. The median ESS was 14, corresponding to moderate excessive daytime sleepiness. ESS and PHQ9 scores were positively correlated (p≤0.0001). Male and female residents scored similarly on ESS(p=0.945) and PHQ9(p=0.056) scales. Significant differences in daytime sleepiness were noted among residents in different years of training(p=0.007). Perceived mental health problems correlated with higher scores on ESS(p=0.049) and PHQ9(p≤0.0001) scales.

Conclusion: 

This single-center pilot survey identified barriers to resident wellness as well as opportunities for targeted intervention, a next intended step. Future multi-center collaborations are proposed to further promote wellness among surgical trainees. A specific target should be facilitating trainees’ abilities to meet age-appropriate health guidelines.

33.04 Resection for Anal Melanoma: Is There an Optimal Approach?

Posted on January 18, 2018

A. T. Hawkins1, T. Geiger1, R. Muldoon1, B. Hopkins1, M. Ford1  1Vanderbilt University Medical Center,Colon & Rectal Surgery,Nashville, TN, USA

Introduction:
Anal melanoma is a lethal disease but its rarity makes understanding the behavior and effects of intervention challenging.  Local resection (LR) and abdominal perineal resection (APR) are the proposed treatments for non-metastatic disease and have each gone in and out of favor over the years. We hypothesize that there will be no difference in overall survival between the two types of resection. 

Methods:
The National Cancer Database (NCDB 2004-2014) was queried for adults with a diagnosis of anal melanoma who underwent curative resection. Patients with metastatic disease were excluded.  Patients were divided into two groups – those who underwent local resection (LR) and those who underwent abdominal perineal resection (APR).  Bivariate and multivariable analyses were used to examine the association between resection type and R0 resection rate, short term survival and overall survival.  

Results:
570 patients with anal melanoma who underwent resection were identified over the study period.  The median age was 68 and 59% of patients were female.  383 (67%) underwent LR.  Rate of LR did not change significantly by year. Factors associated with the use of LR included older age, government insurance, and treatment at a high volume center. LR was associated with lower rates of R0 resection rates (LR 73% vs. APR 91%; p<0.001). Overall five year survival for the entire cohort was 20%. There was no significant difference in five-year overall survival (LR 17% vs. APR 21%; p=0.31). (SEE FIGURE)  Even when adjusting for confounding variables including age, gender, comorbidity, and R0 resection in a Cox proportional hazard multivariable model there was no significant survival difference between resection methods (OR 0.84; 95%CI 0.66-1.06; p=0.15).  In addition, there was no improvement in overall survival for patients who underwent R0 resection (OR 1.18; 95%CI 0.90-1.56; p=0.22). 

Conclusion:
Anal melanoma has an abysmal prognosis, with only 1 out of 5 patients alive at five years.  Older age, government insurance, and treatment at a high volume center were associated with local resection. Although local resection was associated with lower rates of R0 resection, there was no discernable difference in overall survival in both unadjusted and adjusted analysis. Given the known morbidity of APR resection, local resection should be considered in cases of anal melanoma.  

Figure- Kaplan-Meier Curve for Overall Survival Comparing Method of Resection

 

29.08 Effect of a Dedicated Pain Management Service on Trauma Patients with Rib Fractures

Posted on January 18, 2018

S. A. Bellister1, R. D. Betzold1, S. E. Nelson1, D. P. Stonko1, R. A. Guyer1, T. J. Hamilton1, J. P. Wanderer1, O. L. Gunter1, O. D. Guillamondegui1, B. M. Dennis1  1Vanderbilt University Medical Center,Division Of Trauma And Surgical Critical Care,Nashville, TN, USA

Introduction:   Rib fractures are a source of significant morbidity. Inadequate pain
control compromises respiratory function which can lead to respiratory complications and
adverse outcomes. A dedicated pain management service provides expertise in
multimodal pain management techniques which may mitigate these events. We sought to
assess the effect of a comprehensive pain service (CPS) on the outcomes of patients with
rib fractures.

Methods: A retrospective analysis on all adult patients (age ≥ 16) with more than 2 rib
fractures at a level 1 trauma center from September 2010 through December 2015 was
executed. 1:1 propensity matching was performed on the likelihood of receiving a CPS
consult. Demographic, injury data and medication use were examined. The primary
outcome was in-hospital mortality, secondary outcomes included pneumonia,
tracheostomy, 30-day ventilator-free days and 30-day ICU-free days. Mortality,
pneumonia and tracheostomy were analyzed using logistic regression, while 30-day
ventilator-free days and 30-day ICU-free days required proportional odds ordinal logistic
regression.

Results: 3,215 patients that met inclusion criteria, with a final matched cohort of 1,022
patients receiving CPS consults and 1,022 without consult. Demographics (mean age)
and injury (ISS and rib fractures) were similar in both groups. CPS consult was associated
with decreased mortality (OR 0.52, 95% CI 0.30-0.88). CPS consultation was associated
with decreased pneumonia (OR 0.58, 95% CI 0.37-0.89), tracheostomy (OR 0.54, 95%
CI 0.36-0.81), and 30-day ICU-free days (OR 0.68, 95% CI 0.58-0.80). There was
increase in 30-day ventilator-free days (OR 1.28, 95% CI 1.03-1.60) with CPS consult.

Conclusion: A comprehensive pain service consultation in rib fracture patients is
associated with a nearly 50% reduction in mortality, as well as reductions in pneumonia
and tracheostomy rates. There also is an increase in ventilator-free days in patients with
CPS consults.

 

23.01 SMAD4 Loss in Patient-Derived Colorectal Cancer Tumoroids Confirms Chemoresistance.

Posted on January 18, 2018

B. Szeglin1, C. Wu9,11, I. Wasserman2, S. Uppada3, X. Chen6, K. Ganesh8, A. Elghouayel7,11, J. Shia5, A. Barlas10, P. B. Paty11, M. R. Weiser11, J. G. Guillem11, G. M. Nash11, K. Manova-Todorova10, P. Dhawan3, R. Beauchamp4, N. E. Kemeny8, J. Garcia-Aguilar11, C. L. Sawyers9, J. Smith9,11  1Albert Einstein College Of Medicine,Bronx, NY, USA 2Icahn School Of Medicine At Mount Sinai,New York, NY, USA 3University Of Nebraska Medical Center,Department Of Biochemistry And Molecular Biology,Omaha, NE, USA 4Vanderbilt University Medical Center,Section Of Surgical Sciences,Nashville, TN, USA 5Memorial Sloan-Kettering Cancer Center,Department Of Pathology,New York, NY, USA 6University Of Miami Miller School Of Medicine,Department Of Bioinformatics And Biostatistics,Miami, FL, USA 7College Of William And Mary,Williamsburg, VA, USA 8Memorial Sloan-Kettering Cancer Center,Department Of Medical Oncology,New York, NY, USA 9Memorial Sloan-Kettering Cancer Center,Human Oncology And Pathogenesis Program,New York, NY, USA 10Memorial Sloan-Kettering Cancer Center,Department Of Molecular Cytology,New York, NY, USA 11Memorial Sloan-Kettering Cancer Center,Colorectal Service, Department Of Surgery,New York, NY, USA

Introduction:
Loss of SMAD4, the central node of the TGF-β  superfamily, occurs in 10-20% of colorectal cancer (CRC) cases. SMAD4 loss in the context of activated Wnt signaling may play a role in disease progression and resistance to standard 5-fluorouracil (5-FU) based chemotherapy, but the underlying mechanisms are poorly understood. Development of relevant CRC models to better study SMAD4 biology and associated chemoresistance is needed.

Methods:
Fresh CRC specimens were obtained at time of resection. Tumors were dissociated to individual cells and seeded within a Matrigel matrix in our 3D tumoroid cell culture model. SMAD4 mutant versus SMAD4-wildtype (wt) tumoroids were injected subcutaneously into immunocompromised mice. The mice were treated with systemic 5-FU and tumors weighed at necropsy. In addition, CRISPR/Cas9 was used to knockdown (kd) SMAD4 in patient-derived tumoroids ex vivo.  SMAD4 expression was restored in SMAD4 mutant SW480 CRC cells. The SMAD4-kd tumoroids, SMAD4-wt tumoroids, and CRC cells with restored SMAD4 expression were treated with 5-FU or FOLFIRI (5-FU, leucovorin, and irinotecan) to determine dose-response differences. In a parallel, exploratory analysis, microarray expression data from 250 CRC patients was used to generate a SMAD4 signature (FDR < 10-7). The Illumina BaseSpace Correlation Engine was used to correlate this signature with compounds that could be used in synergy with 5-FU based chemotherapy in the context of SMAD4 loss.

Results:
Engrafted SMAD4-deficient tumors did not respond to 5-FU treatment, while SMAD4-retained tumors demonstrated decreased tumor weight compared to vehicle (p < 0.02). SMAD4-kd tumoroids treated with either 5-FU or FOLFIRI ex vivo were significantly more resistant to treatment than SMAD4-wt tumoroids (p < 0.01). Conversely, restoration of SMAD4 expression in CRC cells mutant for SMAD4 was associated with significant response to 5-FU based therapy (p < 0.01).  Finally, the SMAD4 signature implicated 3-3-diindolylmethane, a putative Wnt pathway inhibitor, as a lead candidate for use in the context of SMAD4 deficiency and 5-FU based chemotherapy.

Conclusion:
We demonstrate that loss of SMAD4 is associated with chemoresistance to 5-FU and FOLFIRI treatment in in vivo and ex vivo CRC tumoroid models, thereby establishing relevant biological systems to study patient-specific resistance mechanisms. Furthermore, in silico analysis of a SMAD4 gene expression signature reveals 3-3-diindolylmethane as a possible therapeutic compound to target activated Wnt signaling in the context of SMAD4 loss in CRC patients undergoing 5-FU based chemotherapy. 
 

13.17 Pediatric Snakebites: comparing patients in two geographic locations in the United States

Posted on January 18, 2018

P. N. Chotai1, J. R. Watlington2, S. Lewis3, T. Pyo3, A. A. Abdelgawad4, E. Y. Huang5  1Vanderbilt University Medical Center,Department Of Surgery,Nashville, TN, USA 2University Of Tennessee Health Science Center,College Of Medicine,Memphis, TN, USA 3Texas Tech University Health Science Center,School Of Medicine,El Paso, TX, USA 4Texas Tech University Health Science Center,Department Of Orthopedic Surgery,El Paso, TX, USA 5University Of Tennessee Health Science Center,Division Of Pediatric Surgery, Department Of Surgery,Memphis, TN, USA

Introduction:

Management of children with snakebites may vary based on subjective criteria and geographic and climatic factors. We reviewed the incidence and management of snakebite injuries in children at two tertiary referral centers in separate geographic and climatic location to assess differences in management and outcomes of these patients.

Methods:

An institutional review board approved, retrospective chart review was performed for patients ≤18-year-old with ICD-9/E-codes for snakebite injuries at emergency department (ED) of two American College of Surgeons verified trauma centers (2006-2013). One center is located in south-east US and experiences a sub-tropical climate whereas the other is located in south-west US and experiences a semi-arid climate. Demographic and clinical parameters were extracted. Descriptive bivariate analysis using chi-square or Fisher exact test for nominal variables and Mann-Whitney U test for continuous variables was performed.

Results:

A total of 108 patients(59% male), median age of 9y(1y-17 y), were included. Snake type was identified by bystanders in 55.5% cases; copperhead was the most common(37%) subtype. About 30% patients received antivenin. One quarter of all patients were discharged from ED. Of the 83 admitted, 81% were admitted to floor and 19% were observed in the intensive care unit (ICU). Two patients received surgical intervention in 48 hours after presentation (fasciotomy for lower extremity rattlesnake bite and blister removal on thumb from unidentified snake bite). There was one gastrointestinal complication (emesis), one cardiovascular (premature atrial contractions, benign) and one neurologic (paresthesia at bite site). All patients were discharged home with one 30-day re-admission for unrelated trauma. There were no fatalities. Compared to patients who sustained a snakebite in semi-tropical regions, patients in semi-arid areas had shorter bite-to-ED time, presented directly to the referral center, were more frequently bitten by a rattlesnake, had longer length of hospital stay, required antivenin more frequently and at higher doses, and were more frequently admitted to the ICU (table 1). No differences were seen in gender, age at presentation, severity of wound, location of bite, abnormalities in coagulation profile or rate of admission to hospital amongst the two sites.

Conclusion:

Patients sustaining snakebites in semi-arid climates were more commonly exposed to dangerous snake types, resulting in higher antivenin requirement, as well as longer hospital stays and need for intensive monitoring. Although no fatalities were reported in our study, our data support early transfer of snakebite victims to higher centers of care, especially in semi-arid or high-risk areas.

12.01 Maintaining Oncologic Integrity with Minimally Invasive Resection of Pediatric Embryonal Tumors

Posted on January 18, 2018

H. M. Phelps1, G. D. Ayers2, J. M. Ndolo3, H. L. Dietrich4, K. D. Watson5, M. A. Hilmes3, H. N. Lovvorn6  1Vanderbilt University Medical Center,School Of Medicine,Nashville, TN, USA 2Vanderbilt University Medical Center,Division Of Cancer Biostatistics,Nashville, TN, USA 3Vanderbilt University Medical Center,Pediatric Radiology,Nashville, TN, USA 4Vanderbilt University Medical Center,School Of Nursing,Nashville, TN, USA 5Vanderbilt University Medical Center,Pediatric Hematology/Oncology,Nashville, TN, USA 6Vanderbilt University Medical Center,Pediatric Surgery,Nashville, TN, USA

Introduction:  Embryonal tumors arise typically in infants and young children and are often massive at presentation. Treatment is multimodal, and while complete resection is a critical element, surgery can interrupt therapy. When appropriate, minimally invasive surgery (MIS) offers a potential means to minimize treatment delays. However, the use of MIS to resect embryonal tumors remains controversial regarding the oncologic integrity of this approach.

Methods:  A retrospective review of embryonal tumors treated at a single institution over a 15-year period was conducted to: 1) assess candidacy of embryonal tumors for MIS, and 2) evaluate outcomes for patients undergoing MIS versus open resection. Query of the institution’s cancer registry identified pediatric patients treated for intracavitary embryonal tumors from 2002 to 2017. To assess amenability for MIS, tumor volume (TV) and image-defined risk factors (IDRF, neuroblastic tumors only) were measured radiographically at time of diagnosis and immediately before resection. Stage, Children’s Oncology Group risk stratification, procedure-related details, delay to next dose of chemotherapy, relapse-free survival (RFS), and overall survival (OS) were evaluated. Wilcoxon, Pearson chi-square, and log-rank tests were performed.

Results: A total of 201 patients were treated for neuroblastic tumors (NBL, n=101), Wilms tumor (WT, n=66), hepatoblastoma (n=23), rhabdomyosarcoma (RMS, n=10), and pancreatoblastoma (n=1). Among these patients, 175 tumors were resected either open (n=151, 86%) or by MIS (n=24, 14%; 20 NBL, 3 WT, 1 RMS). Of the 174 with complete data at time of analysis, the median TV at resection was 84.8 ml [IQR 20.4, 372.5]. For NBL cases, a significantly greater proportion of MIS resections (n=17, 94%) had no IDRF when compared to open resections (n=31, 48%; p<0.001). For the entire cohort, RFS at 5 years was 0.78 [CI 0.71–0.85] for open resection versus 0.90 [CI 0.78–1.00] for MIS (p=0.463). OS at 5 years was 0.87 [CI 0.81–0.93] for open resection versus 1.00 [CI 1.00–1.00] for MIS (p=0.294). The largest TV resected via MIS was 93.4 ml, so subgroup comparisons were adjusted for TV<100 ml. No significant difference in margin status between open resection (n=68) and MIS (n=23) was observed, and MIS was associated with significantly less blood loss, shorter hospital stays, shorter operating time, and quicker return to the next chemotherapy cycle (Table 1).

Conclusion: For appropriately selected patients, MIS resection of pediatric embryonal tumors, particularly NBL, maintains an acceptable oncologic integrity while minimizing treatment delays, but large tumor volume, vascular encasement, and small patient size limit its broader applicability.

11.16 Perioperative Chemoradiation Does Not Influence Incisional Hernia Formation After Cancer Resection

Posted on January 18, 2018

S. Kavalukas1, R. Baucom2, L. Huang1, S. Phillips1, C. Bailey1, R. Pierce1, M. Holzman1, K. Sharp1, B. Poulose1  1Vanderbilt University Medical Center,Department Of Surgery,Nashville, TN, USA 2Baylor University Medical Center,Dallas, TX, USA

Introduction:  The effect of adjuvant therapy on subsequent ventral incisional hernia (VIH) formation after cancer resection is unknown.  This study assessed the impact of adjuvant therapy on long term VIH formation after tumor resection for abdominal malignancy.

Methods:  Patients undergoing resection of abdominal malignancy were retrospectively identified and followed up to 2 years by computed tomography (CT) scan for VIH formation.  Those who received either chemotherapy and/or radiation 6 months before or after resection (adjuvant therapy, AT) were compared to patients without adjuvant therapy (no adjuvant therapy, NAT).  Cox proportional hazards (CPH) regression was used identify factors associated with VIH formation over time while adjusting for multiple confounding factors.

Results: 485 patients underwent abdominal cancer resections (AT n=105; NAT n=380). The median age was 58 yrs for the AT group and 61 for the NAT group. 40% of the AT group and 41% of the NAT group were female. The clinical cancer stage breakdown was statistically significant between the 2 groups (AT had more stage 4 and NAT had more stage 1 cancers). The proportion of patients free of VIH at 24 months was 46% in the AT group and 39% in the NAT group (Figure, p=0.62).  AT was not found to be associated with increased VIH compared to NAT in the CPH model (HR=0.817, 95% CI: (0.567, 1,177).

Conclusion: The rate of incisional hernia formation after resection for abdominal malignancy does not appear to be influenced by adjuvant chemo- or radiotherapy. Continued evaluation of risk factors and the role of hernia prevention is important to maintain quality of life for cancer survivors.