44.01 Greater Lymph Node Retrieval and Lymph Node Ratio Impacts Survival in Resected Pancreatic Cancer

Posted on January 26, 2017

K. A. Mirkin1,2, C. S. Hollenbeak1,2, J. Wong2  1Penn State University College Of Medicine,Department Of Public Health Sciences,Hershey, PA, USA 2Penn State University College Of Medicine,Department Of Surgery,Hershey, PA, USA

Introduction:
Surgical resection is the mainstay of pancreatic cancer treatment, however, the ideal lymphadenectomy remains unsettled.  Several meta-analyses have concluded that extended lymphadenectomies do not impact survival.  The objective of this study was to determine if number of examined lymph nodes (eLN), a proxy for lymphadenectomy, and lymph node ratio (LNR) impact survival.

Methods:

The U.S. National Cancer Data Base (2003-2011) was reviewed for patients with clinical stage I and II resected pancreatic adenocarcinoma.  Patients who received neoadjuvant therapy were excluded.  Patients were stratified by eLN: 0-6, 7-12, 13-15, and >15, and LNR (LNR= #positive nodes/ #eLN):0, 0-0.2, 0.2-0.4, 0.4-0.8, and >0.8.  Univariate and multivariate survival analyses were performed.

 

Results:

14,807 patients with clinical stages I-II resected pancreatic adenocarcinoma were included.  Of these, 15.6% (N=2,309) of patients had 0-6 eLN, 27.1% (N=4,012) had 7-12, 13.4% (N=1,977) had 13-15, and 38.6% (N=5,709) had >15 eLN.  The majority of patients underwent pancreaticoduodenectomy (N=7,720, 55.1%), while the remainder underwent distal pancreatectomy (N=1,833, 13.1%), total pancreatectomy (N=1,850, 13.2%) and other (N=2,604, 18.6%).  Patients who underwent pancreaticoduodenectomy had a median eLN of 11, while those who underwent distal or total pancreatectomy or another procedure had 14. Patients with >15 eLN had significantly improved survival over the other cohorts in both node negative and node positive disease (P<0.001, both).   After controlling for patient, disease, and treatment characteristics, patients with 7-12, 13-15, and >15 eLN had improved survival relative to patients with 0-6 eLN (HR 0.87, p<0.001, HR 0.89, p=0.002, HR 0.82, p<0.001, respectively).

32.6% (N=4,829) of patients had a LNR of 0, 29.8% (N=4,414) £0.2, 9.2% (N=2,843) 0.2-0.4, 11.0% (N=1,643) 0.4-0.8, and 1.9% (N=278) had a LNR >0.8.  Patients with LNR 0 had improved survival in T1-T3 disease (P<0.01).  After controlling for patient, disease and treatment characteristics, higher LNR was negatively associated with survival (LNR 0-0.2: HR 1.44, p<0.001, LNR 0.2-0.4: HR 1.82, p<0.001, LNR 0.4-0.8: 2.03, p<0.001, LNR >0.8, p<0.001).

Even when a suboptimal number of lymph nodes were examined (eLN £6 or £12), higher LNR remained an independent predictor for mortality.

Conclusion:

Greater lymph node retrieval in stage I & II pancreatic adenocarcinoma appears to have therapeutic and prognostic value, even in node-negative disease, suggesting a comprehensive lymphadenectomy is beneficial.  Lymph node ratio is inversely related to survival and may be useful when suboptimal lymph node retrieval is performed.

43.20 Functional Recovery in Transfemoral Versus Transapical Transcatheter Aortic Valve Replacement

Posted on January 26, 2017

N. K. Asthana1, A. Mantha4, G. Vorobiof3, P. Benharash2  1University Of California – Los Angeles,Los Angeles, CA, USA 2University Of California – Los Angeles,Cardiothoracic Surgery,Los Angeles, CA, USA 3University Of California – Los Angeles,Cardiology,Los Angeles, CA, USA 4University Of California – Irvine,Orange, CA, USA

Introduction: Transcatheter aortic valve replacement (TAVR) has greatly improved treatment options for severe aortic valve stenosis patients (AS) at high surgical risk. Typically, a transfemoral (TF) approach is preferred due to being less invasive than a transapical (TA) approach. However, in patients where peripheral access is limited due to tortuosity, size, or calcification, a TA approach is preferred. This study assessed whether myocardial functional recovery differed significantly post-TAVR between patients who received a TF approach vs. a TA approach.

Methods: Echocardiograms of all severe AS patients that underwent TAVR at Ronald Reagan UCLA Medical Center from 2012-2016 were evaluated. Parameters that were assessed include left ventricular ejection fraction (LVEF), left ventricular internal diameter (LVID), interventricular septal thickness at end-diastole (IVSd), and posterior wall thickness at end-diastole (PWd). Moreover, left ventricular segmental longitudinal strains and global longitudinal strain (GLS) were measured using two-dimensional speckle tracking echocardiography (2D-STE). Echocardiograms were evaluated pre-TAVR (mean: 20.1 d), post-operatively (mean: 2.5 d), and at a 1-month follow-up (mean: 32.7 d). Statistical analysis was conducted using a repeated measures analysis of variance (rANOVA), where p < .05 was considered significant.

Results: Of the 216 patients assessed, 42 patients had complete data available. Patients that underwent TAVR with a TF approach (N = 31, 67% male, 81.6 y in age) were compared to those that underwent a TA approach (N = 11, 55% male, 87.3 y in age). For the entire cohort, between the pre-TAVR baseline and the 1-month follow-up: (i) There were no significant changes in LVEF, LVID, IVSd, or PWd (p > .05). (ii) Segmental longitudinal strains significantly increased in the apex (from -18.9 to -21.5%, p < .0001), anterior segments (from -15.5 to 18.3%, p < .0001), lateral segments (from -14.0 to -17.1%, p < .0001), inferior segments (from -14.9 to -18.1%, p < .0003), and septal segments (from -14.2 to -16.9%, p < .0002). (iii) GLS significantly improved (from -15.6 to ?18.2%, p < .001). When comparing the TF and TA groups, there were no significant differences in LVEF, LVID, IVSd, PWd, GLS, and anterior, lateral, inferior, and septal segmental longitudinal strains (p > .05). However, there was a significant difference in longitudinal strain at the apex between the TF and TA groups (TF vs. TA at 1-month follow-up: -22.3 +/- 7.63% vs. -15.9 +/- 7.47% respectively, p < .05).

Conclusion: Patients that underwent a TF approach showed significantly greater post-TAVR improvement in apical longitudinal strain, although myocardial functional recovery did not significantly differ between TF vs. TA groups otherwise. Additionally, it appears that myocardial strains measured by 2D-STE are more sensitive in detecting subclinical functional changes compared to more customary measures of cardiac remodeling.

 

43.19 Patterns of Mediastinal Metastasis after Robotic-Assisted Lobectomy for Non-Small Cell Lung Cancer

Posted on January 26, 2017

R. Gerard4, F. O. Velez-Cubian2, E. P. Ng4, C. C. Moodie1, J. R. Garrett1, J. P. Fontaine1,2,3, E. M. Toloza1,2,3  1Moffitt Cancer Center,Thoracic Oncology,Tampa, FL, USA 2University Of South Florida Morsani College Of Medicine,Surgery,Tampa, FL, USA 3University Of South Florida Morsani College Of Medicine,Oncologic Sciences,Tampa, FL, USA 4University Of South Florida,Morsani College Of Medicine,Tampa, FL, USA

Introduction:   Many thoracic surgeons perform mediastinal lymph node (LN) sampling (MLNS) in order to minimize morbidity believed to be associated with complete mediastinal LN dissection (MLND).  In order to focus attention of MLNS to the most likely LN levels involved for a given lung cancer, we sought to determine the patterns of mediastinal LN metastasis found after robotic-assisted video-thoracoscopic pulmonary lobectomy for non-small cell lung cancer (NSCLC).

Methods:   We retrospectively analyzed prospectively collected data for all patients who underwent robotic-assisted pulmonary lobectomy for NSCLC by one surgeon over 69 months.  Clinical stage was determined by history & physical examination, computerized tomography, positron-emission tomography, brain imaging studies, and/or endobronchial ultrasonography. Pathologic stage was based on intraoperative findings and final pathology. The pulmonary lobe resected and any mediastinal LNs involved by metastasis were noted.

Results:  Of 303 NSCLC patients (pts), mean age was 69±0.5 yr (range 39-98 yr), with most common histologies being adenocarcinoma (66%), squamous cell carcinoma (21%), and neuroendocrine carcinoma (10%).  Tumors were located in the right lung in 198 (65.3%) pts and in the left lung in 105 (34.7%) pts.  The three most common anatomic locations were right upper lobe (RUL; 39.6%), left upper lobe (LUL; 21.8%), and right lower lobe (RLL; 18.5%).  Frequencies of stage-3 disease were similar for left NSCLC compared to right NSCLC (p=0.59), but the frequency of stage-2 disease was higher for left NSCLC (28.6%) compared to that for right NSCLC (17.2%; p=0.02).  Of stage-3A right NSCLC, 56.8% were in the RUL, while 69.6% of stage-3A left NSCLC were in the LUL.  Among N1 LNs, level 11 involvement was more common than level 10 involvement for all right and left NSCLC combined (72/103, 69.9% vs. 20/103, 19.6%; p<0.0001).  Mediastinal LN involvement was highest in level 4R (23/198; 11.6%), level 5 (11/105; 10.5%), level 7 (25/303; 8.3%), and level 2R (10/198; 5.1%).  Stage-3A RLL NSCLC most commonly metastasized to level 7 (12/26; 46.2%), while stage-3A left lower lobe NSCLC metastasized most commonly to level 9L (3/6; 50.0%).

Conclusion:  After robotic-assisted pulmonary lobectomy, mediastinal LN metastatic disease was similarly frequent for right versus left NSCLC, while stage-2 disease was more frequent with left NSCLC.  Among N1 LNs, interlobar LNs were more commonly involved than hilar LNs.  For stage-3A NSCLC, there was upper lobe predominance on both sides.  Level 4R LNs were the most frequently found to be positive with right NSCLC, mostly due to RUL NSCLC, while level 5 LNs were most frequently found to be positive with left NSCLC, mostly due to LUL NSCLC.  These patterns of N1 and mediastinal LN involvement should assist in guiding thoracic surgeons to perform a more focused MLNS or a more complete MLND for more accurate NSCLC staging.

43.17 Tumor Size and Perioperative Outcomes after Robotic-Assisted Pulmonary Lobectomy

Posted on January 25, 2017

R. Gerard4, F. O. Velez-Cubian2, E. P. Ng4, C. C. Moodie1, J. R. Garrett1, J. P. Fontaine1,2,3, E. M. Toloza1,2,3  1Moffitt Cancer Center,Thoracic Oncology,Tampa, FL, USA 2University Of South Florida Morsani College Of Medicine,Surgery,Tampa, FL, USA 3University Of South Florida Morsani College Of Medicine,Oncologic Sciences,Tampa, FL, USA 4University Of South Florida,Morsani College Of Medicine,Tampa, FL, USA

Introduction:   Tumor size is one factor that determines whether lobectomy is performed via open or minimally invasive approach.  We investigated whether tumor size affects perioperative outcomes after robotic-assisted video-thoracoscopic (RAVT) pulmonary lobectomy.

Methods:   We retrospectively studied all patients (pts) who underwent RAVT pulmonary lobectomy between September 2010 and May 2016 by one surgeon at our institution.  Patients were grouped by greatest tumor diameter on pathologic measurement of lobectomy specimens.  Perioperative outcomes, including estimated blood loss (EBL), skin-to-skin operative time, conversion to open lobectomy, intraoperative and postoperative complications, chest tube duration, hospital length of stay (LOS), and in-hospital mortality were compared.  Chi-square test, Student’s t-test, and Kruskal-Wallis test were used, with p≤0.05 as significant.

Results:  We identified and grouped 359 pts by greatest tumor diameter being ≤10mm, 11-20mm, 21-30mm, 31-50mm, or ≥51mm.  Tumor histology was comprised of NSCLC (89.4%), SCLC (1.9%), and pulmonary metastases (8.6%), with the most common NSCLC histology being adenocarcinoma (63.8%), squamous cell (21.5%), and neuroendocrine (9.7%).  No differences were noted in mean age, female:male ratio, or mean body surface area among the groups, but mean body mass index was lowest in pts with tumors ≥51mm.  Lobar distribution of lung tumors did not differ among the groups (p>0.14), but extent of resection differed by pts with tumors ≥51mm having a lower rate of simple lobectomies (p<0.001) and a higher rate of en bloc chest wall resection (p<0.001).  Neither overall intraoperative complications nor overall or emergent conversion to open lobectomy differed among the groups (p>0.21), but pulmonary artery (PA) injury occurred in as high as 7.2% of pts in groups with tumors ≥21mm (p=0.014).  While median EBL was higher in pts with tumors ≥51mm (p≤0.003) and median operative time was higher in pts within groups with tumors ≥31mm (p≤0.019), median chest tube duration and median hospital LOS did not differ among the groups (p>0.37).  Neither overall total postoperative complications nor overall pulmonary or cardiovascular complications differed among the groups (p>0.23), but pneumothorax after chest tube removal and requiring intervention was more frequent in pts who had tumors ≤10mm (p=0.03).  In-hospital mortality did not differ among the groups (p=0.60).

Conclusions: Patients who undergo RAVT lobectomy for tumors ≥51mm are associated with lower BMI and are less likely to have simple lobectomies and more likely to require en bloc chest wall resection.  Patients with larger tumors also are at increased risk of PA injury, higher EBL, and longer operative times, but are at lower risk for pneumothorax after chest tube removal and that require intervention.  However, tumor size does not affect chest tube duration, hospital LOS, or in-hospital mortality.

43.16 Weekend Discharge and Readmission Rates After Cardiac Surgery

Posted on January 25, 2017

G. Ramos1, R. Kashani1, Y. Juo1, A. Lin2, N. Satou1, R. J. Shemin1, P. Benharash1  1David Geffen School Of Medicine, University Of California At Los Angeles,Division Of Cardiac Surgery,Los Angeles, CA, USA 2David Geffen School Of Medicine, University Of California At Los Angeles,Division of General Surgery,Los Angeles, CA, USA

Introduction:  Unintended rehospitalization within 30 days serves as a quality metric for institutions and may lead to financial penalties. Few studies have examined the implications of weekend discharges on readmission rates. Limited care coordination and cross coverage of surgeons are known challenges of weekend hospital function and may lead to less comprehensive post-discharge care plan. Based on this knowledge, we hypothesized that patients discharged on weekends would be more likely to be readmitted. 

Methods:  Using the institutional Society of Thoracic Surgeons (STS) database, all adult patients (>18) undergoing cardiac surgery between 2008 and 2015 were identified. 44 demographic and perioperative characteristics were collected and accounted for in a multivariate model. Emergency, transplant and mechanical assist patients were excluded. Weekday discharge was defined as being discharged on Monday through Friday while weekend discharge was limited to Saturdays and Sundays. The primary outcome variable was any readmission within 30 days of discharge. 

Results: Of the 4416 patients included in the study, 3632 (82%) were discharged on a weekday, and 783 (18%) were discharged on a weekend; 495 (11%) patients were readmitted within 30 days. The readmission rates for the weekday and weekend cohorts were similar (10% vs.11%, p=0.4). After adjustment for other risk factors of readmission, there was no association between discharge day of the week and readmission (adjusted odds ratio [AOR]= 1.08, 95% CI=0.83-1.42, p=0.6).  Significant risk factors for readmission included receiving dialysis (AOR=1.6, 95% CI=1.09-2.30, p=0.016), undergoing an urgent operation (AOR=1.24, 95% CI=1.01-1.53, p=0.04), and taking preoperative Coumadin (AOR=1.43, 95% CI=1.04-1.97, p=0.03) or beta-blockers (AOR=1.32, 95% CI=1.07-1.63, p=0.01).

Conclusion: In this study, weekend discharge status was not associated with an increased risk of readmission after cardiac surgery. However, patients having an urgent surgery, receiving dialysis, or taking preoperative Coumadin or beta-blockers were more likely to be readmitted. Our findings suggest that readmission reduction programs should focus on patient factors rather than providing additional weekend coverage beyond existing care coordination resources. 

 

43.13 The Use of Peri-operative Ketorolac in Surgical Treatment of Pediatric Spontaneous Pneumothorax

Posted on January 25, 2017

R. M. Dorman1,2, G. Ventro1,2, S. Cairo1, K. Vali1,2, D. H. Rothstein1,2  1Women And Children’s Hospital Of Buffalo,Pediatric Surgery,Buffalo, NY, USA 2State University Of New York At Buffalo,Pediatric Surgery,Buffalo, NY, USA

Introduction:
The effect of post-opertative anti-inflammatory medications on pleurodesis success after treatment of spontaneous pneumothorax is uncertain. We sought to determine if the use of post-operative ketorolac is associated with an increased risk of recurrence in the surgical treatment of primary spontaneous pneumothorax in children.

Methods:
The Pediatric Health Information System database was queried for all patients age 10-16 years discharged ibetween 2004-2014 with a primary diagnosis of pneumothorax or pleural bleb and a thoracotomy, thoracoscopy, or lung resection procedure. Deaths, encounters representing readmission after previous operative treatment of pneumothorax in the prior year, patients requiring extra-corporeal life support, and patients with diagnoses or concurrent procedures that may lead to secondary or iatrogenic pneumothorax were excluded. Variables included basic demographics, discharge in the first or second half of the study period, chronic renal or hematologic disease, intensive care unit admission or post-operative mechanical ventilation, and whether a lung resection or plication was coded. The primary predictor of interest was ketorolac administration any time in the period from post-operative day 0 to 5. The primary outcomes of interest were thoracentesis, thoracostomy, thoracotomy, thoracoscopy, lung resection or plication, or pleurodesis within 1 year of the index admission. Bivariate analyses were carried out for all outcomes and multivariate logistic regression analyses were then performed for reintervention and readmission.  

Results:
1,678 records met inclusion criteria. Three hundred ninety-five (23%) were subsequently excluded (227 readmissions and the remainder for one of the above-listed criteria), leaving 1,283 patients for analysis. The cohort was predominately male (79%), white (74%), and older (mean age 15.5 ± 1.2 years). Most patients had some lung resection recorded (78%), a majority were administered ketorolac (57%), and few required reintervention (20%) or readmission (18%). Mean postoperative length of stay was 5.2 ± 3.8 days and mean cost was $17,649 ± $10,599. Older patients and those in the earlier years of the study were more likely to receive ketorolac. There was significant variation in frequency of ketorolac administration by geographic region, ranging from 32% to 68%. On multivariate analysis, no variable was predictive of reintervention, and only lung resection correlated with readmission (adjusted odds ratio 0.63 [95% C.I. 0.45-0.90]). 

Conclusion:
Post-operative ketorolac administration was not associated with an increased likelihood of reintervention or readmission within 1 year of operative treatment of primary spontaneous pneumothorax, suggesting that it may be used safely as part of a post-operative pain control regimen. Effects on postoperative length of stay and cost, however, were not demonstrated.
 

43.12 Acute Retrograde Type A Aortic Dissection: Morphological Analysis and Clinical Implications

Posted on January 25, 2017

B. L. Rademacher1, P. D. DiMusto2, J. L. Philip1, C. B. Goodavish3, N. C. De Oliveira3, P. C. Tang3  1University Of Wiscosin,Department Of Surgery, Division Of General Surgery,Madison, WISCONSIN, USA 2University Of Wisconsin,Department Of Surgery, Division Of Vascular Surgery,Madison, WISCONSIN, USA 3University Of Wiscosin,Department Of Surgery, Division Of Cardiothoracic Surgery,Madison, WISCONSIN, USA

Introduction: Numerous studies have described thoracic stent graft induced retrograde type A dissections (rTAD), however, much less is known about acute spontaneous rTAD with tears originating past the left subclavian without prior aortic instrumentation. This study compares the morphology of acute rTAD with both acute antegrade type A dissection (aTAD) with primary tears in the ascending aorta and acute type B dissection.

Methods: From 2000 to 2016, there were 12 acute rTAD, 96 aTAD, and 92 acute type B dissections with available imaging that underwent operative intervention at our institution. Dissection morphology along the length of the aorta was characterized using 3-dimensional reconstruction based on computerized tomography angiography (CTA) images. We examined primary and secondary tear characteristics, true lumen area as a fraction of the total lumen area, and false lumen contrast intensity as a fraction of the true lumen contrast intensity.  Features of presentation and operative parameters were compared between rTAD and aTAD.

Results: Compared with acute type B dissections, primary rTAD tears were more common in the distal arch (75% vs 43%, p=0.04), and the false lumen to true lumen contrast intensity ratio at the mid-descending thoracic aortic level was lower (0.46 vs 0.71, P=0.02) indicating more sluggish blood flow or thrombosis in the false lumen. rTAD cases had less decompression of the false lumen compared with acute type B dissections such that there were fewer aortic branch vessels distal to the subclavian that were either exclusively perfused through the false lumen or through both the false and true lumen (0.40 vs 2.19, P<0.001). Compared with aTAD, rTAD had a tendency for less root involvement where true lumen as a fraction of total lumen area at the root level was higher (0.88 vs 0.76, P=0.081). rTAD had a lower false lumen to true lumen contrast intensity ratio compared to aTAD at the root (0.25 vs 0.57, P<0.05), ascending aorta (0.25 vs 0.72, P<0.001), and proximal arch (0.39 vs 0.67, P<0.05) indicating more sluggish flow or greater tendency to thrombose. rTAD patients were more likely to undergo aortic valve resuspension (100% vs 74%, P=0.044) than aortic valve replacement, and tend to have lower aortic cross-clamp times (83 vs 108 min, P=0.066) (Table 1).

Conclusion: This study suggests that retrograde propagation of the false lumen to the arch and ascending aorta tends to occur when the primary tears that occur distal to the left subclavian are in close proximity to the aortic arch and when false lumen decompression through the distal aortic branches are less effective. Compared to aTAD, rTAD tends to have less root involvement and successful aortic valve resuspension is more likely.

43.10 Are Non-Emergent Cardiac Surgeries Performed During Off-Time Associated with Worse Outcome?

Posted on January 25, 2017

R. Ou1, G. Ramos1, Y. Juo1, R. J. Shemin1, P. Benharash1  1David Geffen School Of Medicine, University Of California At Los Angeles,Division Of Cardiac Surgery,Los Angeles, CA, USA

Background:

With the implementation of value-based healthcare, it is of increasing interesting to understand whether performing elective surgeries during off-time impacts surgical outcomes. In cardiac surgery, interdisciplinary coordination in the operating room is crucial. Factors such as end of day fatigue, care team transitions, and physiologic changes in patients can negatively affect coordination and precipitate adverse events in patient care. We hypothesized that “off-time” cases, including late start and weekend operations, are associated with higher postoperative mortality and major adverse events in patients receiving elective cardiac operations. 

Methods:

The institutional Society of Thoracic Surgeons (STS) database was used to identify all adult elective cardiac operations performed between January 2008 and December 2015 at a university hospital. Patients receiving transplants and extracorporeal mechanical circulatory support were excluded. ”Off-time” was defined as either operation “late starts,” i.e. an incision time after 3PM, or procedures occurring during the weekends. Univariate and multivariate logistic regression were performed to examine its impact on in-hospital mortality and major adverse events (MAE). MAE were defined as postoperative atrial fibrillation, stroke, transient ischemic attack, myocardial infarction, renal failure, surgical site infection, sepsis, prolonged respiratory support, and unplanned reoperations. Available cost data was directly obtained from the departmental BIOME database.

Results:

Of the 3,399 non-emergent cardiac operations included in the study, 468 (13.8%) were performed during off-time. After adjusting for patient and operative characteristics, cases performed off time were not associated with increased in-hospital mortality (P=0.58, CI 95%  0.99—1.02), readmissions (P=0.20, CI 95%  0.99—1.07), or MAE (P=0.10, CI 95%  0.99—1.11). Cost data were available in 1650 (48.5%) patients. Of the patients with cost data available, late start operations were associated with a 16.4% increase in total cost (P<0.01), however after adjusting for patient comorbidities this was no longer significant (P=0.17).

Conclusions:

These findings suggest that cases performed during off time are not associated with increased mortality or other complications in a tertiary-care academic medical center. Our findings should be considered during operative scheduling in order to optimize resource distribution and patient care strategies.

43.08 Lobectomy, Segmentectomy or Wedge Resection for T1a NSCLC: a Systematic Review and Meta-analysis

Posted on January 25, 2017

M. A. IJsseldijk1,2, M. Shoni3, C. Siegert5, J. Seegers2, T. Van Engelenburg2,5, T. Tsai3, A. Lebenthal3,4,5, R. Ten Broek1,2  1Radboud University Medical Center,General Surgery,Nijmegen, GELDERLAND, Netherlands 2Slingeland Hospital,Surgery,Doetinchem, GELDERLAND, Netherlands 3Brigham And Women’s Hospital,Surgery,Boston, MA, USA 4Harvard School Of Medicine,Brookline, MA, USA 5VA Boston Healthcare System,West Roxbury, MA, USA

Introduction:
The optimal treatment of small (T1a) non-small cell lung cancer (NSCLC) remains subject to debate. Lobar resection is considered the standard of care. However, recent studies indicate sublobar resection (segmentectomy or wedge resection) as a promising, parenchymal sparing treatment yielding comparable oncological outcomes. We conducted a systematic review and meta-analysis to compare oncological outcomes after lobar resections and parenchymal sparing resections in T1a NSCLC.

Methods:
We searched MEDLINE, PubMed, EMBASE, Web of Knowledge and CENTRAL to identify studies reporting overall survival (OS) or disease-free survival (DFS) following lobar resection or parenchymal sparing resections in early-stage NSCLC. Two researchers independently identified  studies and extracted data. Oncological outcomes after lobar resection and parenchymal sparing resections were compared using the Mantel-Haenszel method and outcomes were pooled for each surgical modality using the inverse variance method. 

Results:
A total of 8781 studies were identified, from which 24 articles were included. There was no difference in 5-year OS in pT1a tumors when lobar resection was compared to a lung parenchymal sparing resection (Relative Risk=0.90 (95%CI 0.80-1.02)). Moreover, there was no difference in 5-year DFS for pT1a tumors or 5-year OS for cT1a tumors between lobar surgery and a lung parenchymal sparing resection. Strikingly, there was a minor difference in 5-year DFS favoring a parenchymal sparing resection over lobar surgery for cT1a tumors.
The point estimates of 5-year OS of both comparative and non-comparative studies for pT1a tumors were 86% (95% CI: 84-89%) following lobar resection (n=1538), 83% (95%CI: 75- 91%) following segmentectomy (n = 402) and 71% (95% CI: 65 – 76%) following wedge resection (n = 65). There were no differences in pooled estimates for 5-year OS in cT1a tumors and 5-year DFS for pT1a tumors.

Conclusion:
This systematic review and meta-analysis shows that parenchymal sparing surgery in the form of segmentectomy yields equivocal results in terms of 5-year OS or DFS compared to lobar surgery for T1a NSCLC tumors. However, nodal upstaging is present in approximately 10% of patients.

 

43.07 Outcomes of Acute Renal Failure Evolved During Veno-Venous ECMO for Severe ARDS Patients

Posted on January 25, 2017

R. Devasagayaraj1, N. Cavarocchi1, H. Hirose1  1Thomas Jefferson University,Philadelphia, PA, USA

Introduction:  Patients who develop severe acute respiratory distress syndrome (ARDS) with stable hemodynamics may be placed on veno-venous extracorporeal membrane oxygenation (VV ECMO) to support respiratory recovery.  Survival outcomes remain unclear in those who develop acute kidney injury (AKI) requiring continuous veno-venous hemodialysis (CVVHD).

Methods:  A retrospective chart review (2010-2016) of patients who underwent VV ECMO for ARDS was conducted with IRB approval.  Patients supported by veno-arterial ECMO due to cardiac failure or hemodynamic instability were excluded. Analyses of patient demographics, clinical risk factors, respiratory parameters, and laboratory data were conducted.  AKI was defined by receiving CVVHD, which was used for patients with oliguria despite administration of diuretics, acute renal failure, severe metabolic acidosis, and/or uncontrollable fluid overload.  VV ECMO was performed via right internal jugular access using dual lumen ECMO cannula, while CVVHD was performed via groin access using a separate dialysis catheter.  Patients on VV ECMO were divided by development of AKI into two groups, AKI and non-AKI and survival analysis was performed.

Results: We identified 54 ARDS patients (aged 45 ± 13y, 33 males) supported by VV ECMO (mean ECMO days 12 ± 6.7) including 16 (29.6%) in AKI group and 38 (70.4%) in non-AKI group.  No patients had previous renal failure, and serum creatinine was similar between AKI and non-AKI group at the time of ECMO initiation (1.8 ± 1.1 mg/dl in AKI group vs. 1.4 ± 0.7 mg/dl in non-AKI group, p=0.194).  Survival of AKI group (56.3% [9/16]) was inferior to the non-AKI group (86.8% [33/38]), p=0.013.  At the time of initiation of ECMO, patients demographics, lung, renal, and liver functions were similar between AKI and non-AKI group.  However, at the time of decannulation of ECMO, AKI group showed higher lactate (5.2 ± 5.1 mmol/L in AKI group vs 2.1 ± 1.2 mmol/L in non-AKI group, p=0.046), metabolic acidosis (bicarbonate level, 23 ± 3.4 mmol/L vs. 27 ± 9.9 mmol/L, p=0.032), despite similar creatinine levels (1.2 ± 0.6 mg/dL vs. 1.0 ± 0.5 mg/dL, p=0.272).  AKI group showed greater incidence of complications during ECMO including liver failure (37.5% [6/16] vs. 5.2% [2/38], p=0.002) and internal hemorrhage (68.8% [11/16] vs. 21% [8/38], p<0.001). Among the survivors of ECMO, 79.2% [38/48] survived hospital stay and 43.8% [7/16] recovered renal function without need of permanent dialysis.

Conclusion: In our experience, patients initially placed on VV ECMO for single organ injury due to ARDS when complicated by AKI showed decreased survival.  Patients developing AKI are likely to develop hepato-renal syndrome and internal bleeding, all which may lead to multi-organ failure.  VV ECMO alone successfully manages patients with severe ARDS; however, other end-organ function needs careful monitoring and appropriate treatment to improve outcome.

43.06 Meta-analysis of Thromboelastography for Postoperative Hemorrhage After Cardiac Surgery

Posted on January 25, 2017

J. Parreco1, M. Eby1, A. A. Kurian1, C. Faber1, R. Kozol1  1University Of Miami,Miami, FL, USA

Introduction:
Thromboelastography (TEG) has been used since the 1940s and the first use in cardiac surgery was reported in the 1980s. The purpose of this meta-analysis was to evaluate and compare the results of implementing TEG in the routine monitoring for postoperative bleeding after cardiac surgery.

Methods:
Studies involving TEG and cardiac surgery were systematically reviewed. Studies comparing TEG to conventional assessments were included in this meta-analysis and analyzed using random or fixed effect models to determine the mean difference or odds ratio.

Results:
Six studies were identified and included 1,770 patients undergoing cardiac surgery. This included 880 patients having TEG testing performed and 890 control patients without TEG testing performed. The patients undergoing the TEG assay were less likely to require transfusions of red blood cells (RBC), plasma or platelets. For these transfusions the odds ratios (OR) with confidence interval (CI) were: 0.58 (95% CI 0.46 to 0.73, p<0.01) for RBC, 0.57 (95% CI 0.45 to 0.72, p<0.01) for plasma and 0.60 (95% CI 0.48 to 0.74, p<0.01) for platelets. The number of patients requiring reexploration for bleeding was also less in the patients having TEG testing with an OR of 0.38 (95% CI 0.22 to 0.67, p<0.01). The chest tube drainage amounts were also less in the TEG patients with a mean difference (MD) of -450.1 (95% CI -875.5 to -24.7, p=0.04).

Conclusion:
Transfusion requirements for patients undergoing cardiac surgery with TEG testing were significantly less than patients undergoing conventional assessments for postoperative hemorrhage. The rate of reexploration and chest tube drainage was also significantly less for patients undergoing TEG testing.
 

43.05 Robotic-Assisted Lobectomy Outcomes for Early vs. Late Pathologic Stages of Primary Lung Cancer

Posted on January 25, 2017

B. Montane4, F. O. Velez-Cubian2, K. Toosi4, R. Gerard4, C. C. Moodie1, J. R. Garrett1, J. P. Fontaine1,2,3, E. M. Toloza1,2,3  1Moffitt Cancer Center,Thoracic Oncology,Tampa, FL, USA 2University Of South Florida Morsani College Of Medicine,Surgery,Tampa, FL, USA 3University Of Sough Florida College Of Medicine,Oncologic Sciences,Tampa, FL, USA 4University Of South Florida,Morsani College Of Medicine,Tampa, FL, USA

Introduction:   Surgical resection is still the gold standard for early stages of primary lung cancers.  More advanced stages, including nodal involvement, are approached with a multimodality therapy.  The purpose of our investigation was to determine the surgical outcomes of robotic-assisted video-thoracoscopic (RAVT) surgery for early versus late primary lung cancer stages.

Methods:   We retrospectively analyzed perioperative outcomes of consecutive patients with primary lung cancer and who underwent RAVT lobectomy by one surgeon at our institution during a 6-year period.  Patients were grouped by pathologic stage (pStage) into 4 groups:  pStage1, pStage2, pStage3, and pStage4.  Patient characteristics, operative times, intraoperative estimated blood loss (EBL), lymph node (LN) dissection, perioperative complications, chest tube duration, hospital length of stay (LOS), and in-hospital mortality were compared among the pStage groups.  Chi-square test, Student’s t-test, and Kruskal-Wallis or Mood’s median test were used, with p≤0.05 as significant.

Results:  A total of 359 patients underwent RAVT lobectomy by one surgeon between September 2010 and May 2016.  Thirty-one patients had pulmonary metastases or benign lesions and were excluded.  A cohort of 328 patients was analyzed in our study.  Patients’ characteristics differed only by pStage4 having lower body mass index (BMI; p=0.04).  Neither overall intraoperative complications nor conversion to open lobectomy differed among pStage groups (p≥0.09), although recurrent laryngeal nerve injury was highest in pStage3 (p=0.02).  Overall postoperative complications did not differ among pStage groups (p≥0.18), with the most common postoperative complication being prolonged air leak >5 days (20.5% vs. 19.4% vs. 25.0% vs. 44.4%, respectively, for pStage1 through pStage4; p=0.57).  Median EBL and median operative times were lowest for pStage1 (150 mL, p<0.001, and 162 min, p<0.001, respectively), but chest tube duration, hospital LOS, and in-hospital mortality did not differ among pStage groups (p≥0.15).  Efficacy of LN dissection was best for pStage2 and pStage3 for numbers of individual N1 (p≤0.02) and N2 (p≤0.002) LNs harvested, respectively, but did not differ among pStage groups for numbers of LN stations assessed (p≥0.16).

Conclusions:  Robotic-assisted lobectomy is feasible not only for early stages, but also as part of multi-modality treatment for more advanced primary lung cancers.  More advanced pStage, particularly LN involvement, resulted in increased EBL and longer operative times, but did not result in increased perioperative complication risk, hospital LOS, or in-hospital mortality.  Robotic-assisted lobectomy should be considered for the surgical component for multi-modality treatment of resectable advanced-stage primary lung cancers.

43.03 Incidence of Cerebral Microemboli in Single-Dose vs Multi-Dose Cardioplegia in Adult Cardiac Surgery

Posted on January 25, 2017

L. Mukdad1, S. Barajas1, K. Kim1, W. Toppen1, R. Gevorgyan2, H. Laks1, P. Benharash1  1David Geffen School Of Medicine, University Of California At Los Angeles,Cardiac Surgery,Los Angeles, CA, USA 2University Of California – Los Angeles,Los Angeles, CA, USA

Introduction:  Cerebral microemboli have been associated with neurocognitive deficits after cardiac operations using cardiopulmonary bypass (CPB). Interventions by the perfusionist and alterations in flow account for a large proportion of previously unexplained microemboli. This study compared the incidence of microemboli during cardiac operations using conventional (multi-dose) and Del Nido (single-dose) cardioplegia delivery. 

Methods:  Transcranial Doppler ultrasonography was used to detect microemboli in bilateral middle cerebral arteries of 14 adult patients undergoing cardiac operations using cardiopulmonary bypass and aortic clamping. Multi-dose cardioplegia (MDC) was used in 6 patients and single-dose cardioplegia (SDC) in the remaining 8. Manual count of microemboli during cross-clamp and during administration of cardioplegia was performed. Data were analyzed using STATA 13.0 statistical software (StataCorp, College Station, TX). Categorical variables were analyzed by Fisher’s exact test and continuous variables were analyzed by the independent sample T-test for unequal sample size. An alpha of < 0.05 was considered statistically significant.

Results: Baseline preoperative characteristics were similar between groups as shown in table 1. There were no differences in the ascending aortic atheroma grade (1.2 ± 0.4 MDC vs 1.6 ± 0.7 SDC, p=0.20), bypass times (141 ± 36 min MDC vs. 171 ± 33 min SDC, p=0.18), and cross-clamp times (118 ± 32 min MDC vs. 108 ± 45 min SDC, p=0.31). Use of multi-dose cardioplegia was associated with a seven-fold increase in the number of microemboli per minute of cross-clamp time (1.65 ± 1 vs 0.24 ± .18 emboli/min SDC, p=0.002). 

Conclusion: In this prospective pilot study, we found that the use of single-dose cardioplegia led to fewer cerebral microemboli when compared to the traditional multi-dose approach. This finding deserves further investigation to evaluate the benefits of single-dose delivery vs potential reduction in myocardial protection.

 

43.01 Understanding Unplanned Readmissions After Hiatal and Paraesophageal Hernia Repairs

Posted on January 25, 2017

R. Bhagat1, E. Juarez-Colunga2, N. O. Glebova1, W. G. Henderson2, D. Fullerton1, M. J. Weyant1, J. D. Mitchell1, R. McIntyre1, R. A. Meguid1  2University Of Colorado Denver,Department Of Biostatistics & Informatics,Aurora, CO, USA 1University Of Colorado Denver,Department Of Surgery,Aurora, CO, USA

Introduction: Hospital readmissions are viewed as a marker of inferior healthcare quality & penalized with decreased reimbursement. Characteristics of unplanned readmissions after hiatal & paraesophageal hernia repairs (HPHR) are not well understood. We sought to determine the association of complications to postoperative unplanned readmission to identify opportunities for intervention.

Methods: We analyzed the ACS NSQIP database (2012-14) to characterize 30-day postoperative related, unplanned readmissions after HPHR identified by CPT code. Timing of, reason for & association between postoperative complication & unplanned readmission was analyzed.

Results: Of 23,257 patients who underwent HPHR, 17,194 (74%) were female, mean age was 55.3 years & mean length of stay (LOS) was 2.4 days. 1,281 (6%) experienced >=1 complication; death occurred in 45 (0.2%) patients. 963 (4.1%) experienced a related, unplanned readmission within 30 days of surgery. Patients who were readmitted were older (mean age 56.4 vs 55.2 years, p=0.02), had a longer mean LOS (3.2 vs 2.3 days, p<0.001), had more complex operations (mean work relative value unit with standard deviation: 20.8 (10.3) vs 18.7 (11.0), p<0.001) & more emergency operations (3.3% vs 1.9%, p=0.001). Among patients who developed >=1 postoperative complications, 55% (706/1,281) had complications while an inpatient & 8% (57/706) readmitted, 41% (532/1,281) were identified after discharge & 54% (285/532) readmitted, & 0.2% (39/1,281) had complications both as an inpatient & after discharge & 74% (29/39) readmitted. Of patients who experienced an unplanned readmission, 39% (371/963) had a documented postoperative complication, with 77% (285/371) developing their complication after discharge. Complications at readmission were mainly gastrointestinal (GI) (42%; 390/937), infectious (13%; 124/937), pulmonary (10%; 98/937) & pain (10%; 97/937). 53% of related, unplanned readmissions occurred within 7 days of discharge, & 79% within 14 days (Figure 1).

Conclusion: Related, unplanned readmission within 30 days of surgery occurred in 4% of patients undergoing HPHR. Over half of patients who developed a complication after discharge were readmitted. Patients who experienced related, unplanned readmissions underwent more complex operations & were older than those not readmitted. The most common reason for readmission was GI complication. Over half of readmissions occurred within 1 week of discharge, & nearly 80% within 2 weeks. Follow-up within the first few days after discharge from surgery may help identify patients suffering post-discharge complications & who are at risk of unplanned readmission. This may facilitate outpatient intervention targeted at common complications to prevent unplanned readmission.

39.05 AAA Size is Associated with Long-term Survival After EVAR

Posted on January 25, 2017

S. Tsai1,2, H. Jeon-Slaughter3, H. Krishnamoorthi1, D. Timaran1,2, A. Wall2, S. Banerjee3,4, C. H. Timaran1,2, J. G. Modrall1,2  1University Of Texas Southwestern Medical Center,Vascular Surgery,Dallas, TX, USA 2Dallas Veterans Affairs Medical Center,Vascular Surgery,Dallas, TX, USA 3Dallas Veterans Affairs Medical Center,Cardiology,Dallas, TX, USA 4University Of Texas Southwestern Medical Center,Cardiology,Dallas, TX, USA

Introduction:  The long-term durability of EVAR has been demonstrated previously, but few studies have investigated risk factors for long-term survival after EVAR.  The purpose of this study was to identify factors associated with late mortality after elective EVAR.

Methods:  Retrospective data were collected from 288 consecutive patients who underwent elective EVAR at a single institution between January 2003 and December 2012.  The primary end-point was death within 10 years from EVAR.  Abdominal aortic aneurysm (AAA) size and age variables were dichotomized, and optimal cut-off points (AAA size ≥ 56mm and age ≥ 70) were determined using Receiver Operating Characteristics (ROC) curves.  A Cox proportional hazard model was used to conduct time to event analysis.

Results: The mean age of patients was 69.4±8.7 years, and 99% were male.  Mean follow-up was 49.3 ± 29.1 months.  In total, 133 patients (46%) died during follow-up.  Thirty day mortality was 1.3% (2/159) in the patients with AAA < 56mm and 2.3% (3/129) in patients with AAA ≥ 56mm (p=0.48).  All-cause mortality was not significantly affected by hypertension, hyperlipidemia, coronary artery disease, smoking status, or estimated GFR.  However, AAA size ≥ 56mm was associated with significantly increased 10-year mortality (Hazard ratio (HR) 1.63, 95% Confidence Interval (CI) 1.16-2.29, p=0.005).  In an adjusted Cox model (Figure) with covariates of age ≥70 and COPD, AAA size ≥ 56mm still increased mortality risk (HR 1.48, 95% CI 1.04-2.10, p=0.027). Both age ≥70 (HR 2.16, 95% CI 1.52-3.09, p<0.0001) and presence of COPD (HR 1.51, 95% CI 1.05-2.17, p=0.026) were also significantly associated with increased 10-year mortality rate.

 

Conclusion: Despite elective AAA repair, larger AAA size is associated with increased 10-year all-cause mortality after EVAR.

 

39.03 Risk Factors Associated With Peri-Operative Myocardial Infarction after Major Open Vascular Surgery

Posted on January 25, 2017

D. C. Sutzko1, A. T. Obi1, P. K. Henke1, N. H. Osborne1  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Objective: Amongst patients undergoing noncardiac surgery, major vascular surgery is associated with a high risk of perioperative MI.  Currently there are no evidence based guidelines to determine appropriate transfusion thresholds in the perioperative vascular surgery patient.  In a recent study on transfusion patterns and outcomes after noncardiac surgery, liberal transfusion protocols were associated with worse outcomes with the exception of patients that suffered from post-operative myocardial infarction (MI). With these results, we aimed to investigate specific risk factors for perioperative MI after major open vascular surgery to determine (1) which patients are at highest risk of MI, (2) the association of perioperative MI with intra and postoperative transfusion and (3) optimal strategies to prevent perioperative MI.

Methods: Patients undergoing major open vascular surgery (defined as open abdominal aortic aneurysm repair (oAAA repair), aorto-femoral bypass (AFB) and infrainguinal bypass (LEB)) were identified from the Michigan Surgical Quality Collaborative (MSQC) between 2008 and 2012. Rates of MI were described for each procedure. Preoperative, intraoperative and postoperative risk factors associated with MI were evaluated using univariate and multivariate statistics after adjusting for intraoperative factors including: anesthesia type, intraoperative blood loss, intraoperative transfusion and intraoperative vasopressor medications.

Results: 3,692 patients underwent major open vascular surgery, including 375 oAAA, 392 AFB, and 2,925 LEB procedures. The overall incidence of MI was 2.44% (N= 90), varying from 1.79% (N=7) for AFB, 2.36% (N=69) for LEB and 3.73% (N=14) for oAAA repair. Although pre-operative risk factors for MI included age, coronary artery disease, and preoperative hematocrit , after adjusting for intraoperative risk factors all preoperative risk factors were not significant. The only risk factors associated with MI after adjusting for intraoperative factors were the nadir hematocrit (OR=0.89, p<0.05) and postoperative transfusion (OR=2.69, p<0.05).

Conclusions: Vascular surgery is an independent risk factor for MI.  Among vascular surgery patients undergoing major open vascular surgery, no preoperative risk factors were independently associated with MI.  However, postoperative variables such as nadir hematocrit and postoperative transfusion were associated with MI.  Taken together, this data suggests that preoperative risk stratification based on co-morbidities is unlikely to successfully predict the most at risk patients.  However, minimizing excessive operative blood loss, avoiding physiologic stress and optimizing intra-operative resuscitation may mitigate risk of MI.

39.01 Uncontrolled Diabetes Increases Morbidity and Mortality after Carotid Endarterectomy

Posted on January 25, 2017

M. S. Parr1, V. Y. Dombrovskiy1, K. H. Nagarsheth1, R. Shafritz1, S. A. Rahimi1  1Rutgers-Robert Wood Johnson Medical School,Division Of Vascular Surgery,New Brunswick, NJ, USA

Introduction:
Single-institution studies demonstrated a negative effect of hyperglycemia on outcomes after carotid endarterectomy (CEA).  In this population-based study, we tested the hypothesis that postoperative morbidity and mortality after CEA in patients with uncontrolled diabetes mellitus (UCDM) might be significantly greater than in those with well-controlled diabetes (WCDM) and no diabetes (NDM).

Methods:
Using the ICD-9-CM diagnosis codes in the National/Nationwide Inpatient Sample 2006-2013 with revised weights in 2006-2011 for computing national estimates we selected patients with UCDM (250.x2 and 250.x3) and WCDM (250.x0 and 250.x1); all others were qualified as NDM patients. Rates of postoperative complications (stroke, transient cerebral ischemia and occlusion of cerebral arteries) as well as hospital mortality were compared between all these groups. Chi-square and multivariable logistic regression analysis with adjustment for patient demographics and comorbidities were used for statistics. Hospital length of stay and total hospital cost were compared with non-parametric Wilcoxon rank sum test.

Results:
A total of 614,190 patients undergoing CEA were estimated: 6,925 (1.1%) had uncontrolled diabetes, in 187,628 patients (30.6%) diabetes was well-controlled, and 419,637 (68.3%) did not have diagnosis of diabetes. Patients with UCDM compared to those with WCDM and NDM patients had higher rates of postoperative stroke (3.27%, 0.93% and 0.94%, respectively; P<0.0001), transient cerebral ischemia (1.73%, 0.74% and 0.78%; P<0.0001) and occlusion of cerebral arteries (5.31%, 1.21% and 1.14%; P<0.0001), and greater hospital mortality (1.43%, 0.25% and 0.27%; P<0.0001). This was confirmed in the multivariable analysis: uncontrolled diabetics compared to controlled counterparts were more likely to develop stroke (OR [odds ratio] =2.85; 95%CI [confidence interval] 2.47-3.27), transient cerebral ischemia (OR=2.10; 95%CI 1.74-2.53) and occlusion of cerebral arteries (OR=3.73; 95%CI 3.33-4.17), and also were more likely to die (OR=3.55; 95%CI 2.85-4.41). However, patients with WCDM compared to non-diabetics were less likely to have postoperative stroke (OR=0.94; 95%CI 0.88-0.99) and to die (OR=0.83; 95%CI 0.74-0.92) and had similar probabilities for transient cerebral ischemia and occlusion of cerebral arteries. Hospitalizations with UCDM had significantly longer hospital length of stay (5.8 days) and higher total hospital cost ($17,446) than those with WCDM (2.4 days and $10,342; P<0.0001), that, in turn, had longer length of stay and higher total cost than cases without diabetes (2.2 days and $9,760; P<0.005).

Conclusion:
Patients with uncontrolled diabetes have poorest outcomes following CEA. In contrast, patients with well-controlled diabetes had comparable and in some cases better outcomes than non-diabetics that confirms the need for strict pre- and post-operative diabetes control for those undergoing carotid endarterectomy.
 

34.10 Increasing Number and Age of Blood Increases Mortality in Massively Transfused Trauma Patients

Posted on January 25, 2017

R. Uhlich1, R. Patel1, J. Pittet1, P. Bosarge1, M. Marques1, H. Wang1, J. Kerby1  1UAB,Acute Care Surgery,Birmingham, AL, USA

Introduction:
Numerous studies have examined the association between blood age and mortality among trauma patients. This study was designed to account for the time-varying nature of exposure to stored blood and its effect on mortality.

Methods:
Patients receiving at least one unit of red blood cells between 2011 and 2014 were included. Blood bank data was queried for the age of blood and time of transfusion. Demographics, injury, and clinical characteristics were obtained from the trauma registry. The time at which a patient received at least one unit of blood stored > 7 days, > 14 days, or > 21 days was calculated. A Cox proportional hazards model adjusted for age, Injury Severity Score, and injury mechanism estimated hazard ratios (HRs) for the association between death in 24 hours and receiving at least one unit of stored blood. A separate model was created for each blood age category, and exposure to at least one unit of stored blood was entered as a time-varying covariate. Models were stratified by whether the patient received > 10 units of blood in 24 hours.

Results:
1,654 patients received at least one unit of PRBC (187 massively transfused). Increased hazard of 24-hour mortality was observed for those with exposure to at least one unit of blood > 7 days (HR 1.83, 95% CI 1.31-2.56), > 14 days (HR 1.49, 95% CI 1.05-2.10), or > 21 days (HR 1.75, 95% CI 1.17-2.62). The hazard increased when patients received at least 4 units of blood > 14 days (HR 3.54, 95% CI 2.20-5.71) or 21 days (HR 5.21, 95% CI 2.53-10.76). Patterns of association were observed among massively transfused patients.

Conclusion:
Exposure to increasing number and age of stored blood increases the hazard of 24-hour mortality for patients requiring large blood volume replacement. Clinical trials evaluating the effect of blood storage age on clinical outcomes in trauma are warranted.
 

34.09 Risk of Death in Elderly Blunt Trauma Patients: Complications Count

Posted on January 25, 2017

V. Gahlawat1, J. A. Vosswinkel1, A. J. Singer1, M. J. Shapiro1, J. E. McCormack1, E. Huang1, R. S. Jawa1  1Stony Brook University Medical Center,Stony Brook, NY, USA

Introduction:  A variety of factors are thought to influence outcomes following geriatric trauma. However, there is little detailed information regarding the effects of complications on outcomes following admissions for blunt trauma in the elderly.

Methods:  We performed a retrospective review of the trauma registry at a suburban regional trauma center from 2010 to 2015 for all elderly (>65 y) blunt trauma admissions with hospital length of stay (LOS) ≥ 3 days. Deaths in Emergency Department, burns and cardiac arrest were excluded. Patients were divided into three groups- No Complications [NC], minor complications only [MC], and major complications with or without minor complications [SC]. Major and Minor complications were defined as per TQIP. Univariate and multivariate analyses were performed.

Results: There were 2,469 admissions meeting inclusion criteria, NC (n=1,984), MC (n=211) and SC (n=274).  There was no significant difference amongst groups in terms of age (median years; NC- 81, MC- 82, SC- 81, p=0.60) and frequency of low fall as the mechanism of injury (NC- 74.7%, MC- 73.5%, SC- 72.3%, p=0.64). Pre-admission Do Not Resuscitate directive (DNR, NC- 6.6%, MC- 10.4%, SC- 9.9%, p=0.025) and Injury severity score (ISS, median [IQR]; NC- 9[5.5-13] , MC- 10[9-16], SC- 12[9-17], p<0.001) were lower in no complications group. With regards to outcomes, patients who suffered major complications after blunt trauma had increased intensive care unit (ICU) LOS, mechanical ventilation, hospital LOS, in-hospital mortality and fewer discharge to home (Table 1). In-hospital mortality increased with increasing number of major complications (0-2.6%, 1-12%, 2-29%, 3-20.0%, 4-50%). On multivariate stepwise forward logistic regression analysis, factors significantly associated with in-hospital mortality (Odds Ratios with 95%CI) were mechanical ventilation (9.56 [5.08-18.00]), pre-admission DNR (5.01 [2.64-9.49]), ICU stay (2.12 [1.06-4.23]), low fall mechanism of injury (2.07 [1.12-3.83]), major complications (1.56 [1.17-2.06]), ISS (1.08 [1.05-1.12]), and age (1.04 [1.01-1.07]).

Conclusion: Low fall was the most frequent mechanism of injury. There was a near linear relationship between the number of major complications and in-hospital mortality in elderly patients admitted with blunt trauma. The multivariate model had excellent discriminative characteristics for mortality, with an AUCROC of 0.911. The probability of death during hospitalization increased by a factor of 1.56 with each major complication (i.e. OR 6.24 with 4 complications). Once even a single major complication has occurred, great vigilance is warranted to prevent in-hospital mortality. Further study in a larger cohort is warranted.

34.08 Trauma-Induced Coagulopathy is associated with an Early, Discoordinated Inflammatory Response

Posted on January 25, 2017

R. A. Namas1, X. Zhu1, D. Liu1, O. Abdul-Malak1, J. Sperry1, Y. Vodovotz1, T. Billiar1  1University Of Pittsburgh,General Surgery,Pittsburgh, PA, USA

Introduction: Trauma-induced coagulopathy (TIC) is often associated with a broad systemic inflammatory response that can predispose patients to follow a complicated clinical course. Despite significant recent advancements associating post-traumatic inflammation with TIC, a better understanding of this complex interaction is needed. To characterize the systemic inflammatory response accompanying TIC, we analyzed an extensive time course of circulating inflammatory mediators coupled with data-driven modeling.

Methods: From a cohort of 472 blunt trauma survivors, 114 patients had TIC (defined by admission INR ≥ 1.3). After excluding patients with history of anticoagulant intake pre-trauma, 98 TIC patients (71 males [M] and 27 females [F], age: 39.7 ± 2, injury severity score [ISS]: 23.7 ± 1) were matched to 98 non-TIC patients (71/27 M/F, age: 39.8 ± 2, ISS: 23.4 ± 1) for age, gender ratio, and ISS using IBM SPSS®. Three samples within the first 24 h were obtained from all patients and then daily up to day 7 post-injury and assayed for twenty four inflammation biomarkers using Luminex™. Two-way analysis of variance was used to determine statistical significance (p<0.05) between the TIC and non-TIC sub-groups. Dynamic network analysis (DyNA) was used to infer dynamic connectivity and complexity among the inflammatory mediators.

Results: ICU length of stay (LOS), total LOS, and days on ventilation were statistically significantly prolonged in the TIC group when compared to non-TIC group. In addition, the TIC group had a greater requirement of operative intervention within the first 24 h post-admission. The TIC group had a higher degree of organ dysfunction from days 1 to 7 when compared to the non-TIC group. Importantly, circulating levels of IL-6, IL-10, MCP-1, MIG, IP-10, and IL-8 and were significantly elevated in the TIC group. DyNA suggested that the inflammatory response in the non-TIC group had a higher coordinated degree of interconnectivity while the response in TIC consisted of multiple sparse nodes with reduced interconnectivity within the initial 4 h post-injury.

Conclusion: These results suggest that post-traumatic coagulopathy, identified by elevated admission INR, is associated with a markedly differential inflammatory response when compared to patients that present without TIC despite similar injury patterns. Reduced dynamic network connectivity in the TIC patients suggests a discoordinated inflammatory response that might promote immune dysfunction and hence worse outcome.

 

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