48.09 Outcome of Different Induction Therapies in Living Donor Renal Transplant in Indian Population

Posted on January 26, 2017

M. K. Lowther3, M. Khan3, S. Bansal3, V. Kher4, H. Raja5, F. Nwariaku2, J. Parekh2, B. Tanriover1, N. Rajora1  1University Of Texas Southwestern Medical Center,Internal Medicine/ Nephrology,Dallas, TX, USA 2University Of Texas Southwestern Medical Center,Sugery,Dallas, TX, USA 3University Of Texas Southwestern Medical Center,Dallas, TX, USA 4Medanta,Transplant Nephrology,Gurgaon, HARYANA, India 5Baylor University Medical Center,Internal Medicine,Dalas, TX, USA

Introduction:  Induction therapy with interleukin-2 receptor antagonist (IL2-RA) is recommended as a first line agent in living donor renal transplantation (LRT). However, comparative outcomes of induction therapy remains controversial in Indian LRT population.

Methods:  A single center (Medanta Medicity, Gurgaon, India) dataset was retrospectively studied for patients receiving LRT from 2010 to 2014 (N=901) to compare effectiveness of IL2-RA to other induction options (no-induction and rabbit anti-thymocyte globulin [R-ATG]). IL2-RA and no-induction were chosen for immunologically low risk patients. R-ATG was primarily given to the recipient with PRA>20% and HLA mismatch > 5 antigen out of 6. Patient charts were analyzed for dates which included follow-up dates with corresponding creatinine levels (at 3 months, 6 months, 1 year, last follow up), date and type of rejection if applicable, graft loss and death. The data used for analysis was the patients’ most recent follow up. The main outcomes were the risk of acute rejection at one-year and overall allograft failure (graft failure or death) post-transplantation through the end of follow-up.

Results: A total of 901 patients were followed with 316 patients on no induction, 550 patients on IL2-RA, and 35 patients on R-ATG. Rejection rates of the recipients were 26.4%, 22.6%, and 8.2% respectively (P = 0.92). Graft failure rates of the recipients were 3.3%, 1%, and 0% respectively (P = 0.11). The mean age of recipients was 38.7 years old. Similar Kaplan Meier curves for overall graft survivals were observed among induction categories. Rejection rate was higher in no-induction and IL2-RA groups (~25%) compared to r-ATG induction. On univariate Cox analysis, compared to no-induction therapy, overall allograft failure were similar among induction categories.

Conclusion: Compared to no-induction therapy, IL2-RA induction was not associated with better outcomes in Indian LRT recipients. R-ATG appears to be an acceptable and possibly the preferred induction alternative for IL2-RA in high rejection risk Indian patients as it offers lower rejection rates and better graft survival long term.

 

48.08 Pathology and Outcomes of Incidental Hepatocellular Carcinoma following Liver Transplantation

Posted on January 26, 2017

C. Ekeke4, C. Hughes1, A. Humar1, A. Tsung3, S. Ganesh1,2, V. Rachakonda1,2, A. D. Tevar1  1Thomas E. Starzl Transplantation Institute,Dept. Of Surgery / Unversity Of Pittsburgh,P, PA, USA 2Division Of Gastroenterology,Hepatology & Nutition / Dept. Of Medicine / University Of Pittsburgh,Pittsburgh, P, USA 3UPMC Liver Cancer Center,Dept. Of Surgery / University Of Pittsburgh,Pittsburgh, PA, USA 4Department Of Surgery,University Of Pittsburgh Medical Center,Pittsburgh, PA, USA

Introduction:   Liver transplant (LT) remains the most effecting treatment modality for management of hepatocellular carcinoma (HCC) in the end-stage liver disease population.  The longterm outcomes of preoperatively known HCC treated with LT have been well characterized.  Less is known about the tumor pathology and outcomes of incidentally discovered HCC found during hepatic explant pathology review. The aim of this study was to determine incidence, patient and pathologic characteristics and outcomes of incidental hepatocellular carcinoma discovered following LT in a large volume center experience.

Methods:   This study retrospectively reviewed patients undergoing liver transplant at the University of Pittsburgh Medical Center from 2002 to 2013.   Review of patient demographics, preoperative radiographic, tumor markers, tumor pathologic characteristics, short and long-term outcomes was performed.

Results:  During the study period, 320 patients underwent LT in which HCC was known preoperatively or found on explant. The average follow up was 2035.6 days.  Incidental HCC was detected in 52 of 1886 (2.8%) patients who underwent LT during that time period.. The most common indication for liver transplantation was hepatitis C.   Patients with incidental HCC versus known HCC shared similarities in age (57.21 vs. 58.09 yrs), sex (78.8% and 80.2% male) and lab MELD at transplant (17.27 vs. 15.01).  Average Peak and pre-transplant alpha fetal protein tumor (AFP) markers were 33.5 and 30.48 in the incidental HCC cohort and 849.2 and 337.45 in the known HCC group. Incidental HCC LT had more moderate to poorly differentiated tumor pathology (71.2% vs. 58.2%, p value = <0.05) and similar numbers of well (23.1% vs. 21.3%) and poorly (5.8% vs. 6.3%) differentiated lesions.  Lack of vascular invasion was similar between the two groups (73.1% vs 66.4% ), in incidental HCC and known HCC, respectively. HCC recurrence was 9.6% in incidental HCC and 12.7% in known HCC.

Conclusion:  We present a large volume experience with incidental HCC found after LT.  Patient demographics, recurrence and survival outcomes were similar in incidental and known HCC LT recipients.  Pathological findings were comparable in size, with evidence of more moderately-poorly differentiated tumors in the incidental HCC group.

 

48.07 Utility of Pre-Liver Transplant Screening Colonoscopy

Posted on January 26, 2017

R. C. Graham1, O. Afolabi1, J. A. Fridell1, C. A. Kubal1, B. Ekser1, R. S. Mangus1  1Indiana University School Of Medicine,Transplant Division, Department Of Surgery,Indianapolis, IN, USA

Introduction:

Solid organ transplant patients are at an increased risk for de-novo malignancies. Based upon existing literature, it is unclear if these patients have an increased risk of colorectal cancer (CRC) compared to the general population. This study reviews the reports for the required pre-transplant colonoscopy for a large number of liver transplant patients, and then assesses the risk of CRC and other cancers post-transplant.

Methods:

The records of all adult patients undergoing liver transplant (LT) at a single center over a 15 year period were reviewed. The protocol for CRC screening at our center requires a colonoscopy within 3 years of listing for LT. There is no specific post-transplant screening protocol, other than the standard of care for the community. Finding of advanced adenomas (polyps with villous histology, serrated histology, or dysplasia) and colon carcinoma are reported as events. Colonoscopy and pathology reports were reviewed for all patients included in the analysis.

Results:

There were 1685 liver transplants performed during the study period, with 1431 having a pre-transplant colonoscopy report available for review (85%). The median time from colonoscopy to transplant was 9 months. Median follow up was 69 months (minimum 12 months) post- transplant. Of those with available colonoscopy reports, 608 patients had a polyp identified (42%), of which 493 were biopsied with an available pathology report (81%). Of the biopsied polyps, 3 were cancerous (0.2% of all patients, 0.5% of patients with a polyp) and 38 were pre-cancerous (2% of all patients, 6% of patients with a polyp).  Among all patients there were 9 individuals who developed post-LT CRC (0.5%). Of these 9 CRC patients, 3 had an abnormal colonoscopy, one with hyperplastic polyps, one with tubular adenomas, and one with a combination of hyperplastic polyps, tubular adenomas, and tubulovillous adenoma; only the last of these three was considered pre-cancerous. Of the 38 patients with pre-cancerous polyps, one developed CRC in the follow up period (3%). There were 9 of the 38 (24%) patients with precancerous polyps who developed other cancers post-transplant including skin (5), breast (1), lung (1), bladder (1), and sarcoma (1). This compares to 16% of patients developing any non-HCC post-transplant cancer.

Conclusion:

These results suggest that screening colonoscopy prior to transplant is effective for exclusion of patients at high-risk for developing CRC post-transplant. Additionally, patients with pre-cancerous colon lesions appear to be at increased risk of developing other cancers post-transplant, but not CRC.

48.06 Improved Utilization and Sharing of Liver Allografts Using a Dedicated Independent Donor Surgeon

Posted on January 26, 2017

S. Gotewal1, C. Hwang1, J. Reese1, M. MacConmara1  1University Of Texas Southwestern Medical Center,Transplant,Dallas, TX, USA

Introduction:  In 2014, a novel approach to organ procurement was initiated by the organ procurement organization (OPO) in the North Texas by hiring a full-time donor surgeon.  The intent was to increase utilization and enhance distribution of organs. The aim of our study was to investigate the impact of the independent OPO surgeon on discard rates and patterns of organ use. 

Methods:  A retrospective review of the OPO donor database identified all procurement cases from the North Texas DSA, between January 1, 2013 and September 30, 2015. Basic donor demographic data, donor serologies and intraoperative variables were collected. Marginal donor status was determined by identifying age >65, macrovesicular fat>30%, cold ischemia time> 8 hrs, HBV status, HCV status, AST enzyme levels>500, sodium levels>170, liver segment use, or donation after cardiac death (DCD) donor. In addition, we calculated the cumulative number of marginal characteristics associated with each donor (marginal liver score). The presence of the OPO surgeon as assistant or primary surgeon was identified.  Organ disposition codes and sharing codes were obtained to evaluate patterns of utilization.

Results: There were 711 liver procurements done during the period of study with a discard rate of 11.7%. There was no difference in the discard rate in the time period before or after the OPO surgeons arrival (12.2% vs. 11.3%).  The OPO surgeon was present for 208 donor surgeries (29.3%), however there was a higher rate of discard when the OPO surgeon was present (13.5% vs. 10.2%, p<0.001) and this was not explained by age, macrovesicular fat content or cold ischemia time differences. The OPO surgeon procured livers from more DCD donors although this represented only small fraction of the total donor surgeries.

Marginal donors were procured by OPO and non-OPO surgeons at equal frequency, however the cases at which the OPO surgeon was present had much greater complexity (as determined by marginal score) and the rate of discard was significantly less when the OPO surgeon was present at these cases (22% vs. 47%, P<0.01) The OPO surgeon was also associated with a higher number of regional and national shared organs (54% vs. 26%).

Conclusion: The addition of a dedicated full-time OPO surgeon has changed the pattern of utilization of the donor livers in North Texas.  It has decreased the discard rate of livers from patients with multiple marginal characteristics and this has lead to 18 additional livers being transplanted per year since initiation of the OPO surgeon.

 

48.05 Gait Speed And Hand Grip Strengh Are Independent Predictors Of Liver Transplant Waiting List Dropout

Posted on January 26, 2017

S. Kulkarni2, H. Chen4, D. A. Josbeno5, A. Schmotzer1,6, C. Hughes1, A. Humar1, V. Rachakonda1,3, M. A. Dunn1,3, A. D. Tevar1  3University Of Pittsburgh,Division Of Gastroenterology, Hepatology & Nutition / Dept. Of Medicine,Pittsburgh, PA, USA 4Department Of Medicine,University Of Pittsburgh Medical Center,Pittsburgh, PA, USA 5Department Of Physical Therapy,University Of Pittsburgh Medical Center,Pittsburgh, PA, USA 6Division Of Gastroenterology, Hepatology & Nutrition,University Of Pittsburgh Medical Center,Pittsburgh, P, USA 1Thomas E. Starzl Transplantation Institute,Dept. Of Surgery / University Of Pittsburgh,Pittsburgh, PA, USA 2Department Of Surgery,University Of Pittsburgh Medical Center,Pittsburgh, PA, USA

Introduction:   Frailty scores have been shown to effectively predict perioperative surgical risk.  In this light, gait speed has been validated as a reproducible metric of patients functional status and facility with activities of daily living. Studies have also validated its role in predicting morbidity and long-term survival. The 5-Meter Walk Test (5MWT), which measures patients’ self-selected gait speed, is a pragmatic and reproducible clinical test that can be easily conducted in an outpatient setting.  Grip strength is another practical outpatient test that can be measured with a hand dynamometer and measures dominant hand isometric grip force in pounds. We propose that the 5MWT and grip strength measurement can accurately capture frailty in liver transplant listed patients, and more specifically, can predict liver transplant waitlist dropout.

Methods:   A retrospective analysis was done of patients undergoing outpatient liver transplant evaluation and successful listing at UPMC between 7/2013 and 7/2016. All of these patients had an averaged 5MWT score calculated after performing the test three times with a one-minute rest in between walks.  In addition, each patient had dominant arm grip strength measured and recorded with a hydraulic hand dynamometer. Patients with waitlist dropout due to progression of HCC were excluded from analysis.  Patient demographics, transplant evaluation data, and outcomes on the waitlist were examined.  Statistical analysis was performed using student t-test and chi-square analysis.

Results:  A total of 197 liver transplant listed patients evaluated as outpatients were reviewed.  The patients had an average age of 57.1 years (range 20 to 74) and were predominantly white (90.4%).  Patients’ most common etiology of liver disease was HCV, 64 (32.5%) of patients had a diagnosis of HCC, 14 (7.1%) of patients had a previous liver transplant, and average MELD score upon listing was 16.0.  Of the 197 patients, 38 (19.3%) were ultimately dropped from the waitlist due to non-HCC related reasons.  Grip Strength was predictive of waitlist dropout (46.14 lbs vs. 59.6 lbs; p<0.005).  In addition, 5MWT times were found to be an independent predictor of waitlist dropout (0.92 m/s vs. 1.03 m/s; p < 0.005).

Conclusion:  The 5MWT and grip strength have been shown to accurately measure frailty, and we show that both independently  predict waitlist dropout among liver transplant listed patients.  The 5MWT and grip strength should be considered valuable tools in the evaluation and maintenance of end stage liver patients listed for transplant.

 

48.04 Living Donor Liver Transplantation for PSC: Timely transplants with Excellent Outcomes

Posted on January 26, 2017

C. Ibarra1, D. C. Mulligan1, P. Yoo1, K. Giles1, K. Cartiera1, G. Babas1, C. DelaSancha1, A. Liapakis1, M. Schilsky1, C. Caldwell1, S. Emre1, M. I. Rodriguez-Davalos1  1Yale University School Of Medicine,Surgery – Transplant,New Haven, CT, USA

Introduction: Primary Sclerosing Cholangitis (PSC) is a chronic cholestatic liver disease secondary to a fibrotic inflammation of the intra and/or extra hepatic biliary tree that progresses to cirrhosis, portal hypertension and liver failure, and in some cases cholangiocarcinoma. Liver transplantation remains the only effective treatment for this disorder. Living liver donor transplant (LDLT) offers an option for timely transplantation of these patients. The aim of this study is to review patient and graft survival in a cohort of patients with PSC who underwent liver transplant at our center

Methods: Retrospective review of data from patients transplanted with LDLT or deceased donor organs for PSC between August 2006 and August 2016.  Demographics, type of donor, relationship between recipient and donor, type of transplant anastomosis and number of ducts, post-operative surgical complications, recurrence, patient and graft survival were analyzed

Results:Of the last 390 transplants at our center over 10 years, 19 transplants (4.8%) in 18 patients were performed for PSC. Eleven (57.8%) were LDLT; [7 Right lobes in 7 adults, 4 Left lobes in 3 adults and one pediatric patient] and eight (42.2%) received deceased donor organs (DD). Two underwent liver transplantation at other institutions and received graft for retransplantation (1-LD, 1-DD). 14 patients were males (77.7%) with a mean age of 39.9 years (9 – 66yr) and 80% were over the age of 18 yr.  IBD was associated in 15 patients; 13 Ulcerative Colitis (72.2%), 2 Crohn’s (11.1%) and 3 patients had no bowel disease (16.6%). Of 19 transplants performed at our institution, 18 survived [median f/u was 48 months, range 10-77 months]. One patient died (due to chronic rejection from non-compliance with immunosuppression) and 1 lost her left lobe donated graft within 90 days from antibody mediated rejection leading to graft loss and small for size syndrome, and was successfully re-transplanted with a DD; 5 year patient and graft survival was excellent at 89 and 90% respectively.  No cases of Cholangiocarcinoma (CCA) were found on explant pathology in this series. Biliary reconstruction was carried out by Roux en-Y hepaticojejunostomy to a single duct in 14 patients (77.7%), and to two ducts in 1 patient (5.5%), with duct-to-duct in 3 patients (16.6%). 

Conclusion:Living Donor Liver Transplantation is a excellent option for patients who have PSC to permit timely liver transplant and prevent severe complications from infections, liver failure or development of CCA.   Right lobe LDLT in adults may offer a greater margin of safety in preventing small for size syndrome with post op complications, however both right and left lobe LDLT was effective for PSC.

 

48.03 Do Objective Assessments Match Adolescent Transplant Patients’ Perceptions of Transition Readiness?

Posted on January 26, 2017

B. Cao1,2, F. C. Njoku1,3, Y. J. Bababekov1, A. King1, B. J. Luby1, D. C. Chang1, H. Yeh1  1Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA 2University Of Rochester,School Of Medicine,Rochester, NY, USA 3University Of California – Irvine,School Of Medicine,Orange, CA, USA

Introduction:
The period of transition from pediatric to adult care in organ transplant patients is associated with increased risk of graft loss, which may be attributed to poor compliance secondary to knowledge gaps. Previous work has largely utilized subjective questionnaire tools to assess patient readiness to transition to the adult health care system. We observed anecdotally that patient perception of readiness did not always correspond to caregiver perception, so we developed a novel objective questionnaire to assess the accuracy of these perceptions.

Methods:
Pediatric kidney and liver transplant patients ≥ 15 years old completed paired subjective and objective transition readiness questionnaires measuring health knowledge, self-management skills, and psychosocial adjustment. Patients completed the surveys while being seen in the transplant clinic or over the telephone. Each paired survey question was considered in “agreement” if the patient’s answers to both the subjective and objective forms of the question matched; “overconfident” if the patient answered the subjective form of the question claiming full knowledge but was unable to answer the objective form of the question accurately; and “underconfident” if the patient answered the subjective form of the question doubting their knowledge but was able to answer the objective form of the question accurately. Non-parametric tests and regression analysis were used to determine differences in survey responses based on age, gender, time since transplant, and type of organ transplant. 

Results:
Of the 47 patients identified as age ≥ 15 years old, 21 completed the survey (44.7%). The patients ranged from age 15 to 25 years old. The median percent of paired questions scored as “agreement,” “overconfident,” and “underconfident” were 68.2% (IQR = 66.7%-77.3%), 18.2% (IQR = 9.1%-27.3%), and 9.5% (IQR = 4.5%-13.6%). Age >18 years old at the time of questionnaire completion and liver transplantation (vs. kidney transplantation) were associated with slightly higher rates of overconfidence, but these differences were not statistically significant. Male gender and greater time since transplant were associated with slightly lower rates of overconfidence, but again, these were not statistically significant.

Conclusion:
Accurately assessing transition readiness among pediatric transplant patients is vital in educating and supporting patients as they prepare to transition to independent care. We found that patients’ perception of their skills agreed with their demonstrated skills less than 70% of the time. This disconnect suggests that not all adolescent and young adult patients may be ready to make informed decisions regarding their care. Moreover, assessment tools depending only on subjective questionnaires may not adequately guide patient education or accurately determine readiness for transition and transfer. 
 

48.01 Access to Healthcare after Living Kidney Donation

Posted on January 26, 2017

W. Summers1, C. R. Baxter1, B. Shelton1, R. Reed1, P. MacLennan1, J. McLeod1, C. Carroll1, J. Locke1  1University Of Alabama,Birmingham, Alabama, USA

Introduction:  Live kidney donors are encouraged to regularly follow up with their primary care physician (PCP) to monitor kidney function and comorbid disease development. The impact of kidney donation on PCP visits and health insurance is unknown. The goal of this study was to explore post-donation trends in health insurance, PCP visits, and comorbid disease development. 

Methods:  Living kidney donors who are part of a multi-center, IRB-approved, cohort study were contacted and distributed a questionnaire designed to assess access to healthcare (defined as number of PCP visits per year and health insurance coverage). Medical records were also reviewed to evaluate development of post-donation comorbid disease (e.g. hypertension, diabetes, kidney disease). We used descriptive statistics to examine trends in access to healthcare pre and post-donation.

Results: 59 adult living kidney donors were studied; median age of 43.3 years (IQR: 38.9-56.7); 54 European American and 5 African American; with median follow-up of 6.6 years (IQR: 4.3-29.2). 19 donors (32.2%) developed post-donation comorbid disease. We observed a 10.2% increase in health insurance coverage from 86.4% before to 96.6% after donation. Although 6.9% of our cohort reported having trouble obtaining new health insurance after donation, 100% of donors who developed post-donation comorbidities were able to obtain health insurance post-donation. There was also an observed increase in utilization of PCP visits post- compared to pre-donation (84.7% vs. 74.6%), particularly among those donors who developed post-donation comorbidities (100%). 

Conclusion: One third of living kidney donors developed comorbid disease post-donation. Development of post-donation comorbidities did not negatively impact access to healthcare. In fact, access to healthcare as measured by PCP visits and health insurance increased after living kidney donation. 

 

30.10 Impact of Neoadjuvant Dose Escalation on Downstaging & Perioperative Mortality in Esophageal Cancer

Posted on January 25, 2017

S. Ji3, S. Thomas5,7, K. Anderson3, J. Frakes2, S. Roman4,7,8, J. A. Sosa4,6,7,8, T. Robinson2  3Duke University Medical Center,School Of Medicine,Durham, NC, USA 4Duke University Medical Center,Department Of Surgery,Durham, NC, USA 5Duke University Medical Center,Department Of Biostatistics And Bioinformatics,Durham, NC, USA 6Duke University Medical Center,Department Of Medicine,Durham, NC, USA 7Duke Cancer Institute,Durham, NC, USA 8Duke Clinical Research Institute,Durham, NC, USA 1Duke University Medical Center,Durham, NC, USA 2Moffitt Cancer Center And Research Institute,Tampa, FL, USA

Introduction:

The addition of neoadjuvant chemoradiation prior to resection of locally advanced esophageal cancer has been shown to improve disease-free and overall survival. However, the optimal radiation dose remains unknown, and conventional U.S. practice has been to use a higher dose (50.4 Gy) than that used in recent European trials (41.4 Gy). Our objective was to characterize current U.S. practice patterns and compare primary tumor and nodal down-staging, perioperative mortality, and overall survival as a function of total radiation dose. 

Methods:

We performed a retrospective analysis of adult patients with non-metastatic esophageal cancer diagnosed between 2004 and 2013 within the National Cancer Data Base treated with neoadjuvant chemoradiotherapy followed by resection. The primary outcome was overall survival. Secondary outcomes included 30- and 90-day mortality and pathologic down-staging. Univariate and multivariate analyses were used to assess the association between selected outcomes and total radiation dose (41.4, 45.0 or 50.4 Gy) after controlling for patient demographic and clinical factors. 

Results: 

A total of 5,835 patients met inclusion criteria: 154 (2.6%) received 41.4 Gy, 1,696 (29.1%) 45 Gy and 3,985 (68.3%) 50.4 Gy. Patient demographic characteristics and comorbidities were balanced among groups. The use of 41.4 and 50.4 Gy both increased substantially (2.1% to 6.3% and 45.1% to 75.4%, respectively), while use of 45 Gy decreased (52.9% to 18.3%) during the study period (p<0.001). Compared with the 41.4 Gy group, patients receiving 45 and 50.4 Gy had higher rates of nodal down-staging (49% and 48% vs. 38%, respectively; p=0.05). Survival outcomes including 30-day, 90-day and overall survival did not vary significantly by radiation dose; however, patients receiving 41.4 Gy had numerically lower rates of 30-day and 90-day (0.0% and 1.3%) mortality compared to those with 45.0 Gy (2.8% and 7.0%) or 50.4 Gy (2.7% and 6.1%; p=0.21 for 30-day; p=0.16 for 90-day mortality, respectively). 

Conclusion:

To our knowledge, this study provides the first nationally representative assessment of neoadjuvant chemoradiation dose escalation practice patterns in the treatment of locally advanced esophageal cancer in the U.S. We observed no statistically significant differences in overall or short-term survival as a function of radiation dose. Although higher radiation doses were significantly associated with improved nodal down-staging, lower dose radiation exhibited a non-significant trend towards lower 30- and 90-day mortality rates. Our study lends support to neoadjuvant approaches that balance lower elective doses (41.4 Gy) to minimize toxicity while maintaining higher doses (50.4 Gy) to gross disease to maximize locoregional control. Further research is warranted to assess the impact of neoadjuvant radiation dose escalation on locoregional disease control, perioperative complications, and overall survival. 

30.09 Stromal MZB1 is a Prognostic Factor of Pancreatic Cancer Resected After Chemoradiotherapy

Posted on January 25, 2017

K. Miyake1, R. Mori1, R. Matsuyama1, Y. Homma1, A. Okayama2, Y. Ota1, K. Taniguchi1, H. Hirano2, I. Endo1  2Yokohama City University,Graduate School Of Medical Life Science And Advanced Medical Research Center,Yokohama, KANAGAWA, Japan 1Yokohama City University,Department Of Gastroenterological Surgery,Yokohama, KANAGAWA, Japan

Introduction: Pancreatic ductal adenocarcinoma (PDAC) is classified to three types following the resectability in NCCN Guidelines, namely Resectable, Borderline resectable (BR), and Unresectable. BR cases invade to surrounding major arteries and/or vein. Therefore, it is not easy to achieve R0 resection by straightforward surgery. Recently, several studies have reported that NACRT for BR-PDAC improves prognosis and resectability, and eradicates micro metastases. Furthermore, it is presumed that NACRT induces antitumor immunity, and the accumulation of tumor infiltrating lymphocytes (TILs) correlate with prognosis. In our department, we have started clinical research of NACRT for BR-PDAC from Jan 2009. In fact, we have already reported that high CD8+ TILs might be a predictive marker of long survival for these cases. However, the feature of cases with high CD8+ TILs has not been clarified. In this study, we have performed proteomic analysis to reveal the predictive marker of high accumulation of CD8+ TILs.

Methods: We studied 72 resected BR-PDAC cases with NACRT from Jan 2009 to Mar 2014. Three matched pairs of high CD8+ TILs with good prognosis and low CD8+ TILs with poor prognosis cases were selected. Shotgun proteomics was performed using the cancerous part and tumor stroma which are extracted from formalin-fixed and paraffin-embedded tissue samples. For validation of identified proteins, immunohistochemistry (IHC) was performed. 44 PDAC cases with straight forward surgery from 2006 to 2014 were evaluated for comparison. Relationships between the identified proteins and NACRT, TILs, clinical outcomes were assessed by statistical analysis.

Results: 369 proteins were identified by shotgun proteomics, and there was statistic difference of expression in 6 proteins. From these candidates, we selected one protein; Marginal zone B and B1 cell specific protein (MZB1), which is known for B lineage cell specific protein. MZB1 expression were detected in only tumor stroma, and tumor cells were negative. IHC showed high expression of stromal MZB1 in long survival cases with high CD8+ TILs as with proteomic analysis. In the NACRT group (n=72), high expression of stromal MZB1 was positively correlated with the accumulation of CD8+ TILs (|R|=0.347, p=0.002). Patients with high accumulation of stromal MZB1 (?207) had a longer overall survival (OS) than others (3 year-survival; MZB1 high : low = 60.2% : 28.6%, p=0.014). Regarding the 36 patients with high CD8+ TILs in the NACRT group, there was statistic significant relationship between high expression of stromal MZB1 and OS (3 year-survival; MZB1 high : low = 72.9% : 42.9%, p=0.003). In straight forward group (n=44), there was no significant relationships between stromal MZB1 and accumulation of CD8+ TILs, or OS.

Conclusion: MZB1 might be a predictive marker of the high CD8+ TILs and long term survival of resected BR-PDAC cases after NACRT. Furthermore, MZB1 might have a promotive effect on anti-tumor immunity.

 

30.08 Malignant Large Bowel Obstruction: Is Less More?

Posted on January 25, 2017

P. J. Chung1, M. C. Smith1, H. Talus3, V. Roudnitsky2, A. Alfonso1, G. Sugiyama1  1State University Of New York Downstate Medical Center,Surgery,Brooklyn, NY, USA 2Kings County Hospital Center,Acute Care Surgery/Trauma,Brooklyn, NY, USA 3Kings County Hospital Center,Surgery,Brooklyn, NY, USA

Introduction:
Colorectal cancer is the fourth most common malignancy in the United States, with over 134,000 new cases expected in 2016. Though many of these cases are early-stage and identified on screening colonoscopy, a subset of patients are detected because they present with large bowel obstruction (LBO). These patients are likely to require urgent or emergent operative therapy. Using a large national database we sought to investigate the outcomes of patients who present with LBO as there are several options for managing this condition.

Methods:
Data was collected from the Nationwide Inpatient Sample (NIS) 2010 – 2012. We included patients with a diagnosis of LBO (560.89, 560.9), with a confirmed diagnosis of colorectal cancer (153 – 154). To identify patients with average risk we excluded patients with familial syndromes (e.g. Familial Adenomatous Polyposis), concurrent neoplasms, age <60 years, and missing race data. We calculated the Elixhauser-Van Walraven score to assess comorbidity status. We identified patients that underwent non-surgical therapy (non-invasive or invasive diagnostic modalities, with resuscitation and/or percutaneous drainage, with or without subsequent chemotherapy), diversion alone, diversion followed by either open or laparoscopic resection, colonic stenting alone, or stenting followed by either open or laparoscopic resection, and either open or laparoscopic resection alone. Multiple imputation was performed. Using inpatient mortality as the outcome variable we performed multivariable logistic regression using age, gender, race, insurance status, income status, elective procedure status, hospital size, urban vs rural hospital setting, geographic region, type of procedure performed, tumor location, presence of perforation, and Elixhauser-Van Walraven score as risk variables.

Results:
6,308 patients met the inclusion criteria of which 473 (7.50%) died. The median age was 74.0 years and 80.23% underwent an emergent procedure. After adjusting for all risk variables, age (OR 1.67 [1.39 – 2.00], p<0.0001), perforation (OR 2.85 [1.97 – 4.11], p<0.0001), Elixhauser-Van Walraven score (OR 1.97 [1.71 – 2.27], p<0.0001), and non-surgical management compared to open resection alone (OR 2.06 [1.60 – 2.65], p<0.0001) were predictive of mortality. However laparoscopic resection compared to open was associated with decreased risk of mortality (OR 0.33 [0.17 – 0.67], p<0.0001).

Conclusion:
In this large observational study of patients presenting with LBO due to colorectal cancer, we found that age, perforation, increasing comorbidities, and non-surgical management were associated with a significantly increased risk of mortality, while undergoing a laparoscopic compared to open resection was associated with decreased risk of mortality. Further prospective studies are warranted to study longer term outcomes and better inform operative planning, particularly as less invasive options become more widely available.
 

30.07 Impact of Peer Support on Colorectal Cancer Patients’ Adherence to Recommended Multidisciplinary Care

Posted on January 25, 2017

A. E. Kanters1, A. M. Morris1, P. H. Abrahamse2, L. Mody3, P. A. Suwanabol1  1University Of Michigan,Department Of General Surgery,Ann Arbor, MICHIGAN, USA 2University Of Michigan,Center For Cancer Biostatistics,Ann Arbor, MI, USA 3University Of Michigan,Department Of Internal Medicine,Ann Arbor, MI, USA

Introduction:  Multidisciplinary care is critical for the successful treatment of Stage III colorectal cancer (CRC), yet postoperative receipt of chemotherapy remains unacceptably low for unclear reasons. Peer support, or exposure to others who have undergone similar diagnoses and treatment, has been proposed as a means to improve patient acceptance of and coping with cancer care. However, the specific impact of peer support on colorectal cancer patients’ attitudes toward and adherence to recommended chemotherapy is unknown. 

Methods:  We conducted a population-based survey of patients in the Detroit and Georgia Surveillance, Epidemiology and End Results regions after surgery for Stage III CRC between 2011- 2013. For this study, we assessed patient-reported exposure to any peer support, adequacy of peer support, and attitudes towards chemotherapy, and analyzed their association with receipt of postoperative chemotherapy using χ2 tests.

Results: Among 1281 patient respondents (68% response rate), 56% reported exposure to some form of peer support. Exposure to peer support was associated with younger age, higher income, and having a spouse or domestic partner (p<0.001, p=0.016 and p<0.001, respectively). Exposure to any peer support was significantly associated with receipt of adjuvant chemotherapy (p<0.001), but amount or adequacy of peer support was not (p=0.74). Respondents reported that exposure to peer support had a primarily positive impact on their attitudes (e.g., 73% indicated that it helped them know what to expect). However, the few who reported negative impact on attitudes (e.g., 11% indicated that it made them more scared or anxious about treatment) were less likely to receive chemotherapy (p=0.020). Male patients and those with lower levels of education found that peer support helped with decision making for use of chemotherapy (p=0.007 and p=0.012, respectively). 

Conclusion: Our study demonstrates that peer support is associated with overall higher rates of postoperative chemotherapy adherence, except in the rare instances of a negative peer support experience. These data suggest that a facilitated peer support program could positively influence treatment decision making and uptake of recommended multidisciplinary care. 

30.06 Hospital Minimally Invasive Surgery Utilization for Gastrointestinal Cancer

Posted on January 25, 2017

M. C. Mason1,2, H. S. Tran Cao2, S. S. Awad1,2, F. Farjah3, G. J. Chang4, C. Chai2, N. N. Massarweh1,2  1Michael E. DeBakey VA Medical Center,Houston VA Center For Innovations In Quality, Effectiveness, And Safety,Houston, TX, USA 2Baylor College Of Medicine,Michael E. DeBakey Department Of Surgery,Houston, TX, USA 3University Of Washington,Department Of Surgery And Surgical Outcomes Reseach Center,Seattle, WA, USA 4The University Of Texas MD Anderson Cancer Center,Department Of Surgical Oncology And Health Services Research,Houston, TX, USA

Introduction: Laparoscopic and robotic techniques are applied across surgical specialties. However, the extent to which these minimally invasive surgery (MIS) techniques are applied for gastrointestinal (GI) cancer resection has not been well defined and the impact of receiving care at high MIS utilizing hospitals is unclear.

Methods: Retrospective cohort study of 137,581 surgically resected esophageal, gastric, pancreatic, hepatobiliary, colon, and rectal cancer patients within the National Cancer Data Base (2010-2013). Disease-specific, reliability-adjusted MIS utilization and conversion to open rates were calculated for each hospital and used to stratify hospitals into quartiles. Among gastric, pancreatic, and colon patients for whom AC was indicated, the association between days to AC and hospital MIS utilization was examined using generalized estimating equations.  The association with risk of death was evaluated with multivariable Cox regression.

Results: While disease-specific MIS use increased significantly (42.0-68.3% increase; trend test, p<0.001 for all but hepatobiliary [p=0.007]), most hospitals remained low MIS-utilizers. High MIS utilization is associated with increased lymph nodes examined (p<0.001 for all) and shorter LOS (p<0.001 for all). Among colon and rectal patients, mortality at 30 days (colon—0.7% lowest MIS quartile vs 0.4% highest quartile; trend test, p<0.001; rectal—1.1% vs 0.8%; trend test, p=0.018) and 90 days (colon—2.6% vs 2.0%; trend test, p=0.002; rectal—2.4% vs 1.6%; trend test, p=0.002) was lower at higher MIS utilizing hospitals. Except for colon, case volume was highest at hospitals in the lowest and highest conversion to open quartiles. However, hospital conversion rates were not clearly associated with worse perioperative outcomes. For gastric cancer, each 10% increase in hospital MIS utilization is associated with 3.3[95% CI, 1.2-5.3] fewer days to AC initiation. While this association was not observed for pancreatic or colon patients overall, time-to-AC was decreased by 3.3[0.7-5.8] days for gastric and 1.1 [0.3-2.0] days for colon patients who had open resection.  Relative to the lowest quartile hospitals, care at higher MIS utilizing hospitals was associated with a lower risk of death for colon (Q2–Hazard Ratio 0.96[0.89-1.02]; Q3–HR 0.91[0.86-0.98]; Q4–HR 0.87[0.82-0.93]) and rectal cancer patients (Q2–Hazard Ratio 0.89[0.76-1.05]; Q3–HR 0.84[0.72-0.97]; Q4–HR 0.86[0.74-0.98]).

Conclusions: Although MIS use for GI cancer has increased, most hospitals remain low utilizers. Shorter LOS at high utilizing hospitals and the lack of a clear association between hospital conversion rates and perioperative outcomes potentially reflect the real world effectiveness of MIS.  As data regarding MIS for GI cancer resection evolve, MIS utilization may help identify hospitals with infrastructure and care processes that can be used to facilitate multimodality cancer care.

30.05 Postoperative Outcomes From Rectal Cancer Resection in the U.S.: Still Room For Improvement

Posted on January 25, 2017

L. Gregorian1, E. Vo1, L. Haubert1,2, E. Choi1,2, S. S. Awad1,3, A. Artinyan1,2  1Baylor College Of Medicine,Houston, TX, USA 2Baylor St. Lukes Medical Center,Houston, TX, USA 3Michael E. DeBakey Veterans Affairs Medical Center,Houston, TX, USA

Introduction:
Colorectal cancer is a leading cause of cancer death in the US. We have previously described changes in cancer-specific rectal cancer treatment and long-term survival over the last 4 decades. The aim of our current study was to describe changes in early postoperative outcomes after curative-intent surgery for rectal cancer in the US. We hypothesized that postoperative outcomes such as length of stay (LOS), mortality, and postoperative complications have improved over time.

Methods:
The National Inpatient Sample and the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality data were queried in 5 year intervals from 1993-2013 for patients with rectal adenocarcinoma, older than 18 years of age, who had undergone curative-intent surgery (n=16,419). Baseline characteristics (age, gender, type of operation) and postoperative outcomes (LOS, inpatient mortality, discharge disposition, and postoperative complications) were described. Clinical/demographic characteristics and postoperative outcomes were compared by discharge year. Continuous variables were compared using the 1-way analysis of variance (ANOVA) or non-parametric tests, and categorical variables were compared using the chi-square test.

Results:
The mean age of the entire population was 65.6±13.1 years. 58.7% of patients were male and median LOS was 8 (IQR 4-11) days. Mean age of diagnosis has decreased with time (68.3±12.1 in 1993 to 62.6±13.0 years in 2013, p<0.001). The proportion of male patients has increased in the same time period (56% to 62%, p<0.001). As in our prior study, sphincter-preserving operations increased significantly over time (51% in 1993 to 60.5% in 2013, p<0.001). During the same time period, perioperative hemorrhage and inpatient mortality decreased from 3.6% to 1.6% (p<0.001) and 1.9% to 0.7% (p<0.001), respectively. There was no clinically significant change in the surgical site infection (SSI) rate (4.3% to 4.6%, p<0.001), whereas anastomotic leak and digestive complications increased over time (9.8% to 12.7%, p<0.001). Median LOS decreased significantly from 10 (IQR 7-13) to 6 (IQR 4-9) days (p<0.001). However, non-home discharges and home-health use increased from 8.3% to 11.4% and 23.5% to 42.7%, respectively (p<0.001).

Conclusion:
The treatment of rectal cancer continues to evolve, with a greater emphasis on sphincter-preserving surgery, as well as decreases in perioperative hemorrhage and inpatient mortality. However, the rate of SSIs has not changed meaningfully and the risk of anastomotic and other digestive complications has increased, potentially secondary to anatomically lower pelvic anastomoses. Although LOS has decreased, there has been an increase in transitional care and home-health service needs. A shift toward organ-preserving strategies is likely necessary to further improve post-operative outcomes from rectal cancer surgery.

30.04 Age is an Important Risk Stratifier for Lymph Node Metastasis in Patients with Thin Melanoma

Posted on January 25, 2017

A. J. Sinnamon1, M. G. Neuwirth1, R. L. Hoffman1, D. E. Elder2, X. Xu2, R. R. Kelz1, R. E. Roses1, D. L. Fraker1, G. C. Karakousis1  2Hospital Of The University Of Pennsylvania,Department Of Pathology,Philadelphia, PA, USA 1Hospital Of The Univerity Of Pennsylvania,Endocrine And Oncologic Surgery,Philadelphia, PA, USA

Introduction:
While the association of age with nodal metastases and outcomes in patients with melanoma has been recognized and variably reported upon, the influence of age on nodal positivity in patients with thin melanoma has been less well studied, limited by few events in institutional experiences.  Using a large national dataset we study the association of age and nodal positivity in thin melanoma and its implications on current recommendations for sentinel lymph node biopsy in this patient population.

Methods:
Patients with clinical stage I 0.50-1.0mm thin melanoma diagnosed from 2010-2013 who underwent wide excision and had any LNs pathologically evaluated were identified using the National Cancer Data Base (NCDB). Nodes were defined as either positive or negative based on presence of any metastatic disease. Age was categorized as <40 years, 40-64 years, and ≥65 years. Clinicopathologic factors associated with LN positivity were identified using chi-square or Fisher exact method as indicated. Multivariable logistic regression was performed to identify predictors of LN positivity.

Results:
From 2010-2013, 8772 patients underwent wide excision and had evaluation of regional LNs. Of these, 333 were found to have nodal spread, for an overall positivity rate of 3.8%. Median age was 56y (IQR 46-67y) in those with negative LNs and 52y (IQR 41-61y) with LN disease (p<0.001). By multivariable analysis, age≥65 years, thickness≥0.76mm, increasing Clark level, mitoses, ulceration, and acral lentiginous or epithelioid histology were independently associated with LN positivity. Age was found to reliably stratify patients for LN positivity among other high risk features, namely tumor depth, mitogenicity, and ulceration status (figure).  Patients <40yo with T1a tumors<0.76mm (who would not generally be recommended SLN biopsy) had LN positivity rate of 5.56% (18/324 patients); conversely, patients ≥65yo with T1b tumors ≥0.76mm (who would generally be recommended for SLN biopsy) demonstrated LN positivity rate of 3.87% (37/956).  This pattern remained unchanged if including Clark level IV/V as a worrisome feature in addition to mitogenicity and ulceration.

Conclusion:

Current guidelines for SLN biopsy in patients with thin melanoma focused on tumor variables may be too restrictive in young patients and overly permissive among patients ≥65 years using a 5 percent threshold for LN positivity; patient’s age should be an important factor when counseling these patients for lymph node evaluation.

30.03 Impact of Time to Surgery in Patients with Clinical Stage I-II Pancreatic Adenocarcinoma

Posted on January 25, 2017

D. S. Swords1, C. Zhang2, A. P. Presson2, M. A. Firpo1, S. J. Mulvihill1, C. L. Scaife1  1University Of Utah,Department Of Surgery,Salt Lake City, UT, USA 2University Of Utah,Study Design And Biostatistics Center,Salt Lake City, UT, USA

Introduction:  Timeliness is a domain of healthcare quality, and wait times for cancer surgery have increased in recent years. Time to surgery (TTS) from diagnosis in pancreatic adenocarcinoma (PDAC) may be delayed due to the need for biliary decompression, multi-disciplinary review, or medical optimization. Existing data on the clinical impact of TTS have been conflicting.

Methods:  The National Cancer Database was reviewed from 2004-2012 for patients undergoing upfront resection of clinical Stage I-II PDAC with data on TTS. TTS was defined as time from diagnosis to resection. Patients with TTS of 0 or > 120 days and those that received neoadjuvant therapy were excluded. Patients with unknown clinical stage were excluded if pathologic stage was III-IV. Overall survival (OS) began at time of surgery and was the primary outcome. Multivariable Cox regression with TTS modeled as a restricted cubic spline was used to evaluate the relationship between TTS and mortality in order to define TTS groups. OS was evaluated with unadjusted Kaplan-Meier analysis and multivariate Cox regression analysis. Secondary outcomes were rates of positive margins, nodal positivity, and upstaging from clinical to pathologic stage; they were examined using logistic regression models adjusted for demographic and clinical characteristics.

Results: There were 15,945 patients available for analysis. Patients with TTS ≤ 2 weeks had the highest risk of mortality with a gradual decrease to 40 days, and then a gradual increase to 120 days. We thus defined TTS as: short (1-14 days, N=5,465), medium (15-42 days, N=8,241), and long (43-120 days, N=2,239). Adjusted odds of positive margins, nodal positivity, and upstaging were not significantly different between TTS groups. On unadjusted survival analysis, short TTS patients had slightly worse survival than medium and long (P<0.001, Log-rank). Survival differences between TTS groups were most pronounced in Stage I patients; long TTS  had superior survival to medium TTS, which was superior to short TTS (P<0.001 for both, Log-rank, Figure). On multivariate Cox proportional hazard analysis, short vs. medium TTS was associated with modestly increased hazards of mortality (Hazard ratio [HR] 1.07, 95% confidence interval [CI] 1.02-1.11, P=0.003) but long vs. medium was not (HR 0.95, 95% CI 0.9-1.01, P=0.12).

Conclusion: Moderately longer TTS was not associated with worse outcomes and short TTS was associated with higher mortality, especially in Stage I disease. These findings should reassure patients and providers that reasonable delays are likely safe. However, we could not account for patients who initially were planned for resection but progressed on repeat imaging or who were unresectable on exploration.

30.02 Disparities in Managing Emotions when Facing Breast Cancer: Results of Couples Distress Screening

Posted on January 25, 2017

S. Dumitra1, V. Jones1, C. Vito1, J. Rodriguez1, C. Bitz1, E. Polamero2, M. Loscalzo2, R. Obenchain2, L. Kruper1, S. G. Warner1  1City Of Hope National Medical Center,Department Of Surgery,Duarte, CA, USA 2City Of Hope National Medical Center,Department Of Populational Sciences,Duarte, CA, USA

Introduction: Distress screening and referral is now required for cancer center accreditation. Understanding patient and caregiver stress is critical to successful cancer care. This study examines the perceived emotional impact of breast cancer on both patients and partners.

Methods: From March 2011 to February 2016, patients and partners underwent an electronic 48-point distress screen during their initial surgical clinic visit. Distress was measured via self-reported concerns on a five-point Likert scale. Respondents were also asked about preferred interventions. Patient and partner ability to manage emotions was assessed in relation to education, ethnicity, fatigue, anxiety and depression using ordered logistic regression.

Results: Of the 665 individuals screened, 51.7% (n=344) were patients while 48.3% (n=321) were partners. Patients were more distressed than partners regarding fatigue, anxiety, depression, and worrying about the future (p<0.005). Partners requested information regarding “managing emotions” less often than patients (19.7% vs. 46.3%).  In the univariate analysis for managing emotions, being partner was protective against self-reported distress (OR 0.49 (95%CI 0.34–0.70), p<0.000) as was holding an advanced degree (OR 0.36 (95%CI 0.14–0.93),p=0.035). In the multivariate ordered logistic regression, having at least some college remained protective against difficulty in managing emotions, while being a partner was not(OR 0.93 (95%C I0.62–1.39, p=0.789). Financial concerns, anxiety, depression, and worrying about the future remained significantly associated with increased difficulty in managing emotions (Table 1). After correcting for known variables, partners were found to ask for information or help less than patients(OR 0.28 (95%CI 0.17–0.48), p<0.000).

Conclusion: While partners have similar concerns as patients, they do not seek information or help in managing emotions. Both patients and partners with less education and increased financial distress were more likely to report difficulty managing emotions. This study identifies groups who would benefit from supportive measures even in the absence of a request for help.

30.01 Can Medicaid Expansion Decrease Disparity in Surgical Cancer Care at High Quality Hospitals?

Posted on January 25, 2017

D. Xiao1,2,3, C. Zheng1,2,3, M. Jindal1,2,3, C. Ihemelandu1,2,3, L. Johnson1,2,3, T. DeLeire2,3, N. Shara1,2,3, W. Al-Refaie1,2,3  1MedStar Georgetown University Hospital,Washington, DC, USA 2MedStar Georgetown Surgical Outcomes Research Center,Washington, DC, USA 3Georgetown University Medical Center,Washington, DC, USA

Introduction:  Skepticism on Medicaid program’s ability to provide quality care has contributed to the debate on Affordable Care Act’s (ACA) Medicaid expansion. It is unknown whether Medicaid expansion can improve access to high-quality surgical cancer care for poor Americans. To address this gap, we examined the effects of the largest pre-ACA expansion in Medicaid eligibility, which occurred in New York in 2001. We hypothesized that this policy decreased disparity in access to surgical cancer care at high-quality hospitals (HQH) by insurance type and by race.

Methods:  We identified 67,685 non-elderly adults 18-64 years old from the 1997-2006 New York State Inpatient Database who underwent one of nine major cancer resections. HQHs were defined as either high-volume hospitals (HVH, assigned yearly as hospitals of highest procedure volumes that treated 1/3 of all patients) or low-mortality hospitals (LMHs), whose observed-to-expected mortality ratio were < 0.7. Analysis examining access to HVH was restricted only to patients of procedures with strong volume-outcome relationship (esophagus, liver, stomach, pancreas, and urinary bladder; N=10,737).   

Disparity was defined as the model-adjusted difference in percentage of patients operated at HQH by insurance type (Medicaid/uninsured vs privately insured) or by race (blacks vs whites). Consistent with published literature, we combined Medicaid and uninsured patients to capture changes in access to care due to newly gained Medicaid coverage by an otherwise uninsured patient. Covariates included age, sex, procedure type and emergency admission. Levels of disparity were calculated quarterly for each pair of comparison, then regressed using interrupted time series to evaluate the impact of Medicaid expansion.

Results: Overall, 15.0% of our study cohort were Medicaid/self-pay and 12.1% were blacks. The disparity in access to HVH by insurance type was reduced by 0.61 percentage points per quarter following the expansion (p=0.003) (Figure). Meanwhile, the Medicaid/uninsured beneficiaries had similar access to LMH as the privately insured; no significant change was detected around the expansion. Conversely, racial disparity has increased by 0.86 percentage points per quarter (p<0.001) in access to HVH (Figure) and by 0.48 percentage points per quarter (p=0.005) in access to LMH after the expansion.

Conclusions: The pre-ACA Medicaid expansion reduced the disparity in access to surgical cancer care at HQH by insurance type. However, it was associated with an increased racial gap in access to HQH for surgical cancer care. Further investigations are needed to explore whether Medicaid expansion may aggravate racial disparity in surgical cancer care.

09.20 Misdiagnosing Pediatric Appendicitis: Clinical, Economic, and Socioeconomic Implications

Posted on January 25, 2017

G. Dubrovsky2, J. Rouch2, N. Huynh2, S. Friedlander1, Y. Lu1, S. L. Lee1,2  1Harbor-UCLA,Surgery And Pediatrics,Torrance, CA, USA 2UCLA,Surgery And Pediatrics,Los Angeles, CA, USA

Introduction: ~~Misdiagnosing appendicitis may lead to unnecessary surgery. The study evaluates the risk factors for negative appendectomies, as well as the clinical, financial and socioeconomic consequences of negative appendectomy (NA) across 3 states.

Methods: ~~Data were obtained from the California, New York and Florida State Inpatient Databases 2005-2011. Patients (<18 years) who underwent non-incidental appendectomies (n=156,660) were evaluated with hierarchical and multivariate negative binomial regression analyses on outcomes including hospital cost, length of stay (LOS) and associated morbidity.

Results:~~Overall rates of negative appendicitis (NA), where a normal appendix was found at operation, have decreased over time (3.2% in 2005 to 1.8% in 2011, p <0.01) (Fig 1). Perforated appendicitis (PA) has also decreased (25.6% in 2005 to 24.1% in 2011, p <0.01). This reflects an increase in true acute non-perforated appendicitis (ANPA). However, certain subpopulations are at higher risk for undergoing surgery for NA. Age (<5 years), whites, females, use of laparoscopy, having private insurance and care at a low volume hospital were all significant risk factors for NA. In contrast, significant risk factors for PA include age (<5 years), African Americans, males, having open surgery and having public or no insurance. Compared to ANPA, NA patients are associated with increasing hospital stay, greater cost and higher morbidity. LOS for patients with NA showed a 5.6% increase over time (3.0 to 3.3 days), relative to a 13.7% decrease (2.0 to 1.7 days) for patients with ANPA, p <0.01 (Fig 1). Hospital costs averaged over time for NA are greater than ANPA ($6,926 vs $6,492 per patient, p <0.01) and morbidity is significantly higher (2.5% for NA vs 1.3% for ANPA, p <0.01). An estimated average of $4.6 million in total hospital costs/year resulted from admissions related to NA in California, New York and Florida. Of the three states, California had higher rates of NA and PA, as well as a significantly higher complication rate and median cost.

Conclusion:~~Despite a low incidence, NA is associated with longer LOS, higher cost and greater morbidity than ANPA. Whites, females and privately insured patients were associated with higher NA rates while those at an increased risk for PA were African Americans, males and those with public or no insurance. The highest rate of NA and PA was in California, which also had the highest median cost and the highest rate of complications. Further research is needed to understand what drives such disparities and to inform efforts to improve quality of hospital care across all groups of patients.

 

09.19 Safety of Peri-operative Ketorolac Administration in Pediatric Appendectomy

Posted on January 25, 2017

R. M. Dorman1,2, H. Naseem2, G. Ventro1,2, D. H. Rothstein1,2, K. Vali1,2  1State University Of New York At Buffalo,Department Of Surgery,Buffalo, NY, USA 2Women And Children’s Hospital Of Buffalo,Department Of Pediatric Surgery,Buffalo, NY, USA

Introduction: We sought to evaluate the impact of peri-operative ketorolac administration on outcomes in pediatric appendectomy. 

Methods:  The Pediatric Health Information System database was queried for patients aged 5-17 with a primary diagnosis of appendicitis and a primary procedure of appendectomy during the period 2010-2014. Patients with procedures suggesting incidental appendectomy, those records with data quality issues, deaths, and extra-corporeal membrane oxygenation (ECMO) were excluded. Variables recorded included age, sex, race, ethnicity, discharge year, complex chronic conditions (CCC), geographic region, intensive care unit admission, mechanical ventilation, and whether appendicitis was coded as complicated. The exposure variable was ketorolac administration on the day of or day after operation. The primary outcomes of interest were any surgical complications during the initial encounter, postoperative length of stay (LOS), total cost for the initial visit, any readmission to ambulatory, observation, or inpatient status within 30 days, and readmission with a diagnosis of peritoneal abscess or other postoperative infection or with transabdominal drainage performed.

Results: 78,926 were included in the analysis cohort.  Mean age was 11.4 years (SD 3.3 years), the majority were male (61%), white (70%), and non-Hispanic (65%). Few had a CCC (3%) or required mechanical ventilation (2%) or an ICU admission (1%).  Patients with complicated appendicitis comprised 28% of the cohort. Most (73%) received ketorolac on postoperative day 0-1; those with complicated appendicitis were less likely to receive ketorolac. In all, 2.6% of the cohort had a surgical complication during the index visit, 4.3% were readmitted within 30 days, and 2% had a post-operative infection or transabdominal drainage (1% in the uncomplicated group, 5% in the complicated group). Median post-operative LOS was 1 day and mean cost was $9,811 ±  $9,509. On bivariate analysis, ketorolac administration was associated with a decrease in same-visit surgical complications (p=0.004) and cost ($459 decrease, p<0.001) but was not associated with readmission, post-operative LOS, or post-operative infection. On multivariate analysis, ketorolac administration was associated with a significant decrease in any complication (adjusted odd ratio 0.89, 95% C.I. 0.80-0.99) and cost (ANOVA p<0.001) but was not associated with readmission, post-operative LOS, or post-operative infection.  

Conclusion: Based on a large, contemporary data set of children’s hospitals, ketorolac administration in the immediate post-operative period after appendectomy for appendicitis is common and was not associated with an increase in post-operative LOS, post-operative infection, or any-cause 30-day readmission. Ketorolac was, however, independently associated with a lower overall rate of post-operative complications and cost in this population. 

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