34.01 Impact of Functional PET Imaging on the Surgical Treatment of Neuroblastoma

Posted on January 18, 2018

W. Hsu1, W. Hsu1  1National Taiwan University Hospital,Division Of Pediatric Surgery, Department Of Surgery,Taipei, ., Taiwan

Introduction:

Gross total resection (GTR) of neuroblastoma (NB) could be predicted by imaging-defined risk factors (IDRFs) on CT/MR images but might also be confounded by other biological features. This study aims to investigate the complementary role of positron emission tomography (PET) scans in predicting GTR of NB in addition to IDRFs.

Methods:

From 2007 to 2014, diagnostic PET scans with 18F-fluorodeoxyglucose (FDG) and 18F-fluoro-dihydroxyphenylalanine (FDOPA) were performed in 42 children with NB at National Taiwan University Hospital, Taipei, Taiwan. The extent of tumor resections was correlated with clinical features and imaging findings. 

Results:

Among 42 NB patients with diagnostic FDG and FDOPA PET images (median age, 2.0 [0.5–4.9] years; male:female, 28:14), 8 patients had their primary tumors responded completely to induction chemotherapy and were excluded from the analysis. For the rest 34 patients, 27 (79.4%) could achieve GTR of the primary tumor including 9 patients (26.5%) at the first operation and 18 patients (52.9%) at the best subsequent operation(s) , while the other 7 patients (20.6%) only had partial resection. Based on the primary tumors’ maximal standard uptake value (SUVmax) on PET scans, we found that the SUVmax ratio between FDG and FDOPA (G:D) was positively correlated with Hexokinase 2 (HK2; P = 0.002) gene expression but negatively with Dopa decarboxylase (DDC; P = 0.03) gene expression levels. Tumors with higher-than-median G:D ratio (G:D ≥ 1.4), indicating a “glycolytic” phenotype with less catecholaminergic differentiation, was also correlated with poor-risk genomic types (P < 0.001) and a lower probability of GTR (56% vs. 100%; P = 0.007). Using the G:D ratio to predict GTR also complemented the anatomical IDRF from CT/MRI (GTR rate, 46% vs. 100% among 20 patients with IDRF; P = 0.04). Yet, GTR or IDRF per se was not associated with survival outcome.

Conclusion:

NB tumors with higher FDG uptake and lower FDOPA uptake at diagnosis were associated with a less likelihood of GTR. The incorporation of functional PET imaging may help to develop a more tailored, risk-directed surgical strategy for NB patients.

 

34.02 Rate of Secondary Interventions After Open Versus Endovascular AAA Repair

Posted on January 18, 2018

H. Krishnamoorthi1,3, H. Jeon-Slaughter2,4, A. Wall1, S. Banerjee2,4, B. Ramanan1,3, C. Timaran1,3, J. G. Modrall1,3, S. Tsai1,3  1VA North Texas Health Care System,Vascular Surgery,Dallas, TX, USA 2VA North Texas Health Care System,Cardiology,Dallas, TX, USA 3University Of Texas Southwestern Medical Center,Vascular Surgery,Dallas, TX, USA 4University Of Texas Southwestern Medical Center,Cardiology,Dallas, TX, USA

Introduction:  While long-term durability and improved peri-operative outcome of endovascular AAA repair has been demonstrated, some studies have suggested an increased rate of secondary interventions compared with open AAA repair. More recent data suggest that rates between the two modalities may be similar. We investigated the rate of secondary intervention in patients undergoing elective EVAR or open AAA repair and the effect of AAA size in these two groups of patients.

Methods:  A retrospective, single-institution review was conducted between January 2003 and December 2012. Secondary intervention was defined as any intervention within 30 days of the procedure or an AAA repair-related procedure after 30 days, which included repair of endoleaks and incisional hernia repair. Cochran-Mantel-Haenszel statistics were conducted to examine associations between AAA size and need for secondary interventions over 10 years.

Results: A total of 342 patients underwent elective AAA repair. 274 patients underwent elective EVAR and 68 patients underwent open AAA repair.  The mean age of patients treated with EVAR was 69±9 years, while the mean age of patients treated with open AAA repair was 67±7 years. The mean follow-up period was 49 months post-EVAR (standard deviation 29 months) and 78 months post-open repair (standard deviation 46 months).  The rate of secondary intervention was significantly lower in the EVAR group compared with the open AAA repair group (14.9% vs 27.9%, p=0.004). The most common secondary intervention was repair of type II endoleak (n=14, 5.1%) after EVAR and incisional hernia repair (n=4, 5.9%) after open AAA repair. Of the 274 EVAR patients, 133 (48.5%) died during the study period, while 34 (50%) of the 68 open AAA repair patients died during the study period.  Need for secondary intervention was not associated with long-term mortality in either the EVAR or the open repair group (p=0.11 and p=0.87, respectively).  Furthermore, in both the open repair and EVAR groups, AAA size was not associated with rate of secondary intervention.

Conclusion: The rate of secondary intervention in patients treated with EVAR is significantly lower than in patients treated with open AAA repair.  However, secondary intervention is not associated with long-term survival in either group.
 

32.10 Routine pre-thyroidectomy laryngoscopy is not necessary in the era of intraoperative neuromonitoring

Posted on January 18, 2018

S. Goare1, E. Forrest1, J. Serpell1,2, S. Grodski1,2, J. C. Lee1,2  1The Alfred Hospital,Monash University Endocrine Surgery Unit,Melbourne, VICTORIA, Australia 2Monash University,Department Of Surgery,Melbourne, VICTORIA, Australia

Introduction:  Routine pre-operative vocal cord (VC) assessment with laryngoscopy in patients undergoing thyroid surgery allows clear documentation of baseline VC function, aides in surgical planning in patients with preoperative palsy, and facilitates the interpretation of intraoperative neuromonitoring (IONM) findings. This has been the practice in our institution for the last 20 years. In this study, we aimed to determine the rate of pre-operative vocal cord palsy (VCP) in our patient cohort;  to evaluate the associated risk factors for preoperative VCP; and therefore, build a case for a selective approach to pre-operative laryngoscopic VC assessment.

Methods:  :  This retrospective review study recruited patients from the Monash University Endocrine Surgery Unit database from 2000 to 2016. Patients who had a VC assessment by fiberoptic laryngoscopy prior to undergoing thyroid surgery were included. Case files were reviewed for potential indicators of VCP, including hoarseness and other symptoms, previous neck surgery, largest nodule dimension, and history of head and neck irradiation. 

Results: Of the 5 279 patients who had pre-operative laryngoscopy, 36 (0.68%) patients were found to have a VCP. Of these, 16 had a nodule > 3.5 cm, 15 had a hoarse voice, 12 had previous neck surgery, and 5 had a malignant cytology. More than one risk factor was present in 11 of these patients. Furthermore, the first 3 of these features would account for all 36 patients with pre-operative VCP. Pre-operative knowledge of malignancy was associated with palsy in 5 patients. However, all of these 5 patients also presented with either a hoarse voice or a nodule > 3 cm. Therefore, malignancy by itself was not an indicator of potential palsy. Approximately two-thirds of the 5 279 included patients had none of these 3 features and also did not have a VCP. Therefore, using these 3 pre-operative factors (hoarseness, previous surgery, nodule > 3.5 cm) as selection criteria, up to two-thirds of our patients could do without a pre-operative laryngoscopy and no palsy would have been missed. As this is a retrospective study, these data need to be interpreted with that in mind.

Conclusion: Using this large dataset, we have established that a VCP is extremely unlikely in the absence of previous neck surgery, hoarseness, or a large nodule. Therefore, in the era of intraoperative neuromonitoring, where the recurrent laryngeal nerve can be directly assessed, we support a selective approach to pre-operative laryngoscopy using the aforementioned criteria. 

 

32.08 Very Early vs. Early Readmissions in General and Vascular Surgery Patients

Posted on January 18, 2018

L. N. Clark1, M. C. Helm1, S. Singh1, J. C. Gould1  1Medical College Of Wisconsin,Milwaukee, WI, USA

Introduction:  Readmission rates are an important surgical quality metric.  Readmissions up to 30 days after discharge following a procedure are the most commonly examined metric.  We hypothesize that ‘very early’ readmissions (0-3 days after discharge) have a significantly different root cause than ‘early’ readmissions (4-30 days after discharge).

Methods:  The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) datasets from 2014-2015 were used to identify patients undergoing a general or vascular surgery procedure. Patients were excluded if they died during the index admission, were discharged greater than 30 days from the operation, or did not have readmission data entered. Patient demographics, medical comorbidities present at the time of surgery, and data regarding postoperative morbidity were analyzed. Complications were graded according to the Clavien-Dindo classification.  Binary logistic regression was used to compare age, functional status, comorbidities, discharge destination and complications to determine their relationship to any 30-day readmission as well as readmission within 3 days compared to 4-30 days following discharge.

Results: A total of 850,043 patients met inclusion criteria: 55.5% female, average age 55 years (range 18-89). Of these patients, 55,212 (6.5%) were readmitted within 30 days and 13,570 (1.6%) were readmitted within three days of discharge. These very early readmissions comprised 24.6% of all readmissions (Figure 1).  When evaluating all readmissions from 0-30 days regardless of timing, age ≥ 65 (Odds Ratio [OR] 1.5; 95% Confidence Interval [CI]; 1.5-1.6, p<0.0001), ≥3 comorbidities (OR 2.7; 95% CI; 2.7-2.8, p<0.0001), preoperative functional dependent status (OR 3.1; 95% CI; 2.8-3.3, p<0.0001), discharge to facility other than home (OR 2.8; 95% CI; 2.7-2.9, p<0.0001), any grade three or four complication prior to discharge (OR 2.4; 95% CI; 2.4-2.5, p<0.0001), and any grade three or four complication after discharge (OR 84.7; 95% CI; 81.3-88.1, p<0.0001) were all identified as risk factors.  The only factor found to be significantly associated with very early readmission compared to early readmission was any grade three or four complication prior to discharge (OR 1.3; 95% CI; 1.2-1.4, p<0.0001).

Conclusion: Readmissions within 3 days of surgery constitute a large portion of all 30-day readmissions. Grade 3 and 4 complications prior to initial discharge are significantly associated with an increased risk of readmission, especially within the first 3 days. Further research is needed determine if effective and targeted strategies can be developed to prevent very early readmission. 
 

32.04 Impact of Frailty on Failure to Rescue After Low Risk and High Risk Inpatient Surgery

Posted on January 18, 2018

R. Shah1, K. Attwood6, S. Arya2, D. E. Hall3, J. M. Johanning5, N. N. Massarweh4  1Henry Ford Health System,General Surgery,Detroid, MI, USA 2Emory University School Of Medicine,Division Of Vascular And Endovascular Therapy/ Department Of Surgery,Atlanta, GA, USA 3University Of Pittsburg,Center For Health Equity Research And Promotion, Veterans Affairs Pittsburgh Healthcare System,Pittsburgh, PA, USA 4Baylor College Of Medicine,VA HSR&D Center For Innovations In Quality, Effectiveness And Safety, Michael E DeBakey VA Medical Center,Houston, TX, USA 5University Of Nebraska College Of Medicine,Department Of Surgery,Omaha, NE, USA 6Roswell Park Cancer Institute,Surgical Oncology,Buffalo, NY, USA

Introduction:  Failure to rescue (FTR), or death after a potentially preventable complication, is a nationally endorsed, publically reported quality measure. However, little is known about the impact of frailty on FTR—in particular, after lower risk surgical procedures.

Methods:  Retrospective cohort study of 984,550 patients from the National Surgical Quality Improvement Program (2005-2012) who underwent inpatient general, vascular, thoracic, cardiac and orthopedic operations. Frailty was assessed using the clinically applicable Risk Analysis Index (RAI) and patients were stratified into five groups based on RAI score (<=10, 11-20, 21-30, 31-40 and >40). Procedures were categorized as low (≤1%) or high mortality risk (>1%). The association between RAI, the number of post-operative complications (0, 1, 2, 3+), and FTR was evaluated using hierarchical modeling. 

Results: Among the most frail (RAI >30) patients in the cohort, ~20% were aged 55 years or younger. Regardless of procedural risk, increasing RAI score was associated with both an increased occurrence of post-operative complications and the number of complications. For those who underwent low risk surgery, major complication rates were 3.2%, 8.6%, 13.5%, 23.8% and 36.4% for RAI scores of <=10, 11-20, 21-30, 31-40 and > 40, respectively and for patients undergoing high risk surgery, the corresponding rates of major complications were 13.5%, 23.7%, 31.1%, 42.5% and 54.4%, respectively. Stratifying by the number of complications, significant increases in FTR rates were observed across RAI categories after both low and high risk procedures (Figure 1; trend test, p<0.001 for all). Increasing RAI was associated with an increased risk of FTR that was most pronounced after low risk procedures. For instance, the odds ratios (ORs) for FTR after 1 major complication for patients undergoing a low risk procedure were 4.8 (3.7, 6.2), 8.1 (5.9, 11.2), 19.3(12.6, 29.6) and 48.8 (22.7, 104.9) for RAI scores of 11-20, 21-30, 31-40 and > 40, respectively and for patients undergoing a high risk procedure, the corresponding ORs were 2.6 (2.4, 2.8), 5.2 (4.8, 5.6), 9.3 (8.5, 10.3) and 19.5 (16.8, 22.6) respectively. 

Conclusion: Frailty has a dose-response relationship with complications and FTR that is similarly apparent after low and high risk inpatient surgical procedures.  Tools facilitating rapid assessment of frailty during preoperative assessment, may help provide patients with more accurate estimates of surgical risk and could improve patient engagement in peri-operative interventions that enhance physiologic reserve and can potentially mitigate aspects of procedural risk.

 

32.05 Bariatric Surgery Reduces the Incidence of Estrogen Receptor Positive Breast Cancer

Posted on January 18, 2018

T. Hassinger1, J. H. Mehaffey1, R. B. Hawkins1, B. D. Schirmer1, P. T. Hallowell1, A. T. Schroen1, S. L. Showalter1  1University Of Virginia,Department Of Surgery,Charlottesville, VA, USA

Introduction:  Bariatric surgery is an effective treatment for morbid obesity with long-lasting weight loss. Additionally, elevated body mass index (BMI) is known to be an important risk factor for the development of breast cancer, one of the most common cancer diagnoses among women in the United States. Therefore, we hypothesized that patients undergoing bariatric surgery would have a decreased incidence of estrogen receptor (ER) positive breast cancer when compared to a propensity-matched non-surgical cohort.

Methods:  The bariatric population for this study included all female patients that underwent bariatric surgery at a single institution between 1985 and 2015. Patients from all routine outpatient visits were identified from the clinical data repository (CDR) and matched 1:1 with bariatric patients using body mass index (BMI), relevant comorbidities, demographics, and insurance status. The primary outcome of interest was ER positive breast cancer. Chart review was performed on all patients with a breast cancer diagnosis. Univariate analyses were performed to compare the two groups.

Results: A total of 4,860 patients were included in this study, with 2,430 in both the bariatric surgery and non-surgery groups. Median follow-up time from date of surgery or date of initial morbid obesity diagnosis (non-surgery group) was 5.6 years. There was no difference in median age (42.0 [35.0-51.0] vs. 42.0 [31.0-53.0]; p=0.29) or medical comorbidities aside from gastroesophageal reflux disease (713 [29.3%] vs. 149 [6.1%]; p<0.0001). Seventeen (0.7%) patients in the bariatric surgery group were diagnosed with any breast cancer after surgery compared to 32 (1.3%) patients in the non-surgery group (p=0.03). The non-surgery group had more ER positive tumors (4 [36.4%] vs. 22 [71.0%]; p=0.04) as well as larger median tumor size (p=0.02). 

Conclusion: Morbidly obese female patients who underwent bariatric surgery were found to have fewer subsequent diagnoses of any breast cancer and ER positive breast cancer when compared to a propensity-matched cohort. These results suggest the possibility of an oncologic benefit to weight-loss surgery.

32.03 Operating Room Teams: Does Familiarity Make a Difference?

Posted on January 18, 2018

S. Fitzgibbons1,2, S. Kaplan3, X. Lei3, S. Safford5, S. Parker4  1MedStar Georgetown University Hospital,Surgery,Washington, DC, USA 2Georgetown Univeristy Medical Center,Washington, DC, USA 3George Mason University,Psychology,Fairfax, VA, USA 4Virginia Tech Carilion School Of Medicine And Research Institute,Human Factors,Roanoke, VA, USA 5Carillion Clinic,Pediatric Surgery,Lynchburg, VA, USA

Introduction: The composition of any given operating room team may vary procedure-to-procedure. Studies in healthcare have documented that greater familiarity between certain team member pairs or dyads (ex. surgeon and scrub) corresponds to improved effectiveness, with outcomes ranging from shorter cross clamp times during cardiopulmonary bypass to shorter operative times during mammoplasty. We sought to further our understanding of this effect beyond simple dyads by developing an OR team familiarity score reflective of the larger and more complex group, and determining the impact of the larger group familiarity on surgical processes and clinical outcomes.  

Methods: Data from a diverse, primarily urban healthcare system including 6 acute-care hospitals was extracted from a system-wide electronic medical record.  All knee arthroplasty cases performed between 2013 and 2016 were included in the data set.  Information regarding individual OR team participants and their roles in the surgery were collected, in addition to patient demographics (ASA class, age, gender, race, ethnicity), case information (surgical procedure, date and time of the operation)  and outcome variables (length of procedure, length of hospital stay).  Team familiarity was calculated using a previously published formula from Huckman, Staats, and Upton (2009).  A multilevel regression (i.e., random coefficient modeling) framework was applied to examine the impact of a team’s familiarity score on case length and post-op length of stay. In addition, specific familiarity scores for each possible dyad on the team was calculated and analyzed. Dyads were defined as pairs of core team members: surgeon, scrub, circulator, anesthesiologist.

Results:A total of 4546 knee arthroplasty cases were included in the data set with an average case length of 92.68 minutes and an average length of hospital stay of 3.22 days.  When controlling for patient age, gender, hospital, and ASA class, a team’s familiarity score during a case was significantly associated with a shorter case length, with 10 previous team member interactions predicting a decreased case length of approximately 1.1 minutes (p=.012).  Similarly, an increased team familiarity score predicted a decreased length of stay, with 10 previous team member interactions predicting a decrease in hospital length of stay of 0.1 days.  With respect to the impact of specific dyad familiarity, all dyads involving the circulator predicted a shorter length of hospital stay, while all three dyads between the surgeon, scrub and circulator predicted a shorter case length.

Conclusion:Overall team member familiarity in the operating room is associated with a small but significant decrease in the case length and hospital length of stay for patients undergoing total knee arthroplasty.

 

31.09 Adjuvant Chemotherapy after Neoadjuvant Chemoradiation in Esophageal Cancer

Posted on January 18, 2018

C. Takahashi1, R. Shridhar2, A. Patel3, J. Huston4, K. Meredith3  1Midwestern University,Glendale, AZ, USA 2University Of Central Florida,Orlando, FL, USA 3Florida State University,Tallahassee, FL, USA 4Sarasota Memorial Hospital,Sarasota, FL, USA

Introduction:  Patients with locally advanced esophageal cancer (EC) have poor long-term survival despite improvements in multi-modality care. Neoadjuvant chemoradiation (NCR) followed by surgical resection remains standard of care. However, the utilization of adjuvant therapy continues to be debated. Our study reviews the effectiveness of adjuvant therapy after neoadjuvant therapy in resected EC.

Methods:  Utilizing the National Cancer Database (NCDB) we identified patients with esophageal cancer who underwent NCR followed by esophagectomy and received adjuvant therapy compared to those who did not. Propensity score matched (PSM) analysis was performed. Baseline univariate comparisons of patient characteristics were made for continuous variables using both the Mann-Whitney U and Kruskal Wallis tests as appropriate. Pearson’s Chi-square test was used to compare categorical variables. Unadjusted survival analyses were performed using the Kaplan-Meier method comparing survival curves with the log-rank test. All statistical tests were two-sided and α (type I) error <0.05 was considered statistically significant.

Results: We identified 1,816 patients from the NCDB with EC, 1,664 (91.6%) with adenocarcinoma and 134 (7.4%) with squamous cell carcinoma. Both the adjuvant therapy group and the no adjuvant group had 908 patients with a median age of 60 years (26-83). There were 1,596 (87.9%) males and 220 (12.1%) females. Location of the tumor was 121 (6.7%) middle, 1,267 (7.0%) lower, and 371 (20.4%) at the gastroesophageal junction. Univariate analysis revealed age, R0 resection, T-stage, N-stage, grade, <10 lymph nodes removed and adjuvant therapy were predictors of survival. All patients who received adjuvant therapy revealed greater median and overall survival, 36.4 months and 34.5% versus 30.9 months and 33.2%, p=0.02. Node negative patients did not show a significance in survival with adjuvant therapy 57.2 and 55.4 months respectively, p=0.4. However node positive patients demonstrated improved median and overall survival with adjuvant therapy 31.1 months and 27% respectively compared to the no adjuvant therapy group 25.7 months and 24.3%, p=0.03. Multivariate analysis revealed node positive patients T-stage (p=0.002), R0 resection (p<0.001), and number of lymph nodes removed (p<0.001) were predictors of survival. Adjuvant therapy failed to be a predictor of survival (p=0.2). However, PSM revealed that patients who received adjuvant therapy exhibited an improved median survival over those who did not 36.4 months and 30.9 months, p=0.02.

Conclusion: Adjuvant therapy in all EC patients after neoadjuvant therapy does show improved median and overall survival. Similar to other studies, R0 resection and T-stage continue to influence survival. However, node negative EC patients were found to have no survival benefit with the addition of adjuvant therapy.

 

31.08 Online Information on Surgery for Pancreatic Cancer is Often Inadequate for Shared Decision-Making

Posted on January 18, 2018

C. Zhang1, A. Yang1, A. Halverson1  1Northwestern University,Chicago, IL, USA

Introduction:
Decision making regarding surgery for pancreatic cancer may be difficult for patients as surgery can improve survival but can also negatively impact quality of life. In order to more actively participate in decision making, patients often seek information on the Internet. The aim of this project was to assess the quality of publicly available online information regarding surgery for pancreatic cancer.

Methods:
This study was a cross-sectional survey of patient-centered websites that address surgery for pancreatic cancer. Two search engines (Google, Bing) were queried with the terms “pancreatic cancer treatment”, “pancreatic cancer surgery”, “Whipple procedure”, and “pancreaticoduodenectomy” to identify websites of interest. Each website was evaluated using the DISCERN instrument (www.discern.org.uk), a validated questionnaire developed to analyze written consumer health information on treatment choices. An additional questionnaire was used to evaluate website content specifically for pancreatic cancer surgical treatment. Two healthcare providers (surgeon, medical student) reviewed each website independently and inter-rater reliability (IRR) was calculated. In addition, one pancreatic cancer patient and one family member analyzed a randomly selected subgroup of study websites using the DISCERN instrument.

 

Results:

We identified 93 distinct websites; 45 met inclusion criteria. Website affiliations included: health care organizations (44%), non-profit organizations (22%), open-access general information (22%), and government/professional websites (11%). Using DISCERN, the two healthcare providers identified that only 24% of the websites had clear aims, 31% had identifiable references, and 36% noted the publication date (Figure). Overall, 4 websites (9%) were identified as excellent, and nine (20%) were of poor quality. In regard to pancreatic cancer surgery, 62% of websites discussed postoperative complications, 56% addressed quality-of-life (QOL) issues, and 53% acknowledged the surgery volume-outcome relationship. IRR was 0.75 for the 2 professional assessors on the overall rating. DISCERN assessment by patient/family evaluators demonstrated 83% agreement with the results by medical professionals. Major areas of disagreement included QOL and website bias.

Conclusion:

The quality of patient-centered online information on pancreatic cancer treatment is highly variable. Websites frequently lack updated information and references, and often do not provide adequate information for patients to make well-informed treatment decisions. However, patients and family members demonstrated the ability to learn strategies to critically evaluate online health information.

31.06 Neutrophil to Lymphocyte Ratio is a Preoperative Risk Factor in Intrahepatic Cholangiocarcinoma

Posted on January 18, 2018

S. Buettner2, B. Groot Koerkamp2, M. Weiss3, S. Alexandrescu4, H. P. Marques5, J. Lamelas5, L. Aldrighetti6, T. Gamblin7, S. K. Maithel8, C. Pulitano9, T. W. Bauer10, F. Shen11, G. A. Poultsides12, J. Marsh13, J. N. IJzermans2, T. M. Pawlik1  1Ohio State University,Columbus, OH, USA 2Erasmus MC University Medical Center,Dept. Of Surgery,Rotterdam, ZUID-HOLLAND, Netherlands 3Johns Hopkins University School Of Medicine,Baltimore, MD, USA 4Fundeni Clinical Institute,Bucharest, ROMANIA, Romania 5Curry Cabral Hospital,Lisbon, PORTUGAL, Portugal 6Ospedale San Raffaele,Milan, ITALY, Italy 7Medical College Of Wisconsin,Milwaukee, WI, USA 8Emory University School Of Medicine,Atlanta, GA, USA 9University Of Sydney,Sydney, NSW, Australia 10University Of Virginia,Charlottesville, VA, USA 11Eastern Hepatobiliary Surgery Hospital,Shanghai, CHINA, China 12Stanford University,Palo Alto, CA, USA 13University Of Pittsburg,Pittsburgh, PA, USA

Introduction: Alterations in the Neutrophil-to-Lymphocyte ratio (NLR) may be indicative of host immune response to cancer. We sought to determine whether preoperative NLR was associated with long-term outcomes among patients undergoing surgery for intrahepatic cholangiocarcinoma (ICC).

Methods: Patients who underwent resection for ICC between 1990-2015 were identified from 12 major HPB centers. NLR was calculated by dividing the absolute number of neutrophils by the absolute number of lymphocytes. The Kaplan-Meier method and Cox regression models were used to evaluate factors, including NLR, that potentially were associated with overall survival. Factors associated with survival based on the multivariable Cox model were utilized to create a point-based preoperative score to predict prognosis. 

Results: Among 1,000 patients who underwent resection for ICC, the majority of patients had a solitary tumor (n=810, 82.6%) and median tumor size was 6.0 cm (interquartile range [IQR]: 4.3-9.0); 168 (19.5%) patients had lymph node metastases on preoperative imaging. Preoperative jaundice was present in 98 (9.8%) patients, while 27 (2.7%) patients had extrahepatic disease. Median NLR was 2.68 (2.05-4.00).  Overall survival at 1-, 3-, and 5- years was 78.7%, 61.5%, and 39.1%, respectively.  NLR was associated with prognosis as patients with a NLR ≥3 had a median survival of 31.3 months (95%CI: 23.9-38.8) compared with 53.1 months (95%CI: 37.1-69.2) among patients with a lower NLR (p<0.001).  In addition, 1-, 3-, and 5-year survival was 73.5%, 46.4%, and 38.8% versus 84.6%, 61.1%, and 47.8% among patients with NLR ≥3 versus NLR < 3, respectively (p<0.001).  Using backwards selection based on the Akaike Information Criterion, a preoperative risk score was derived. Specifically, on multivariable analysis, number of lesions (Hazard Ratio [HR]: 1.17; p<0.001), tumor size (HR: 1.04; p<0.001), preoperative lymph node metastases (HR: 1.32; p=0.022), preoperative jaundice (HR: 1.65; p<0.001) and extrahepatic disease (HR: 2.39, p<0.001) were each predictive of survival. After controlling for these competing risk factors, NLR remained independently associated with long-term survival (HR: 1.04, 95%CI: 1.02-1.07; p=0.001).  The combination of these preoperative factors into a prognostic model had fair discrimination to predict post-operative survival (area under the curve, 0.65).

Conclusion: Elevated NLR was an independent predictor of worse long-term outcomes among patients with ICC undergoing resection. NLR may be an important factor associated with survival and can help estimate postoperative survival when used in a preoperative predictive model.

 

31.04 Clinical Fate of T0N1 Esophageal Cancer: Results from the National Cancer Database

Posted on January 18, 2018

C. Takahashi1, R. Shridhar2, A. Patel3, J. Huston4, K. Meredith3  1Midwestern University,Glendale, AZ, USA 2University Of Central Florida,Orlando, FL, USA 3Florida State University,Tallahassee, FL, USA 4Sarasota Memorial Hospital,Sarasota, FL, USA

Introduction:  The long-term survival for patients with locally advanced esophageal cancer (EC) remains poor despite improvements in multi-modality care. Neoadjuvant chemoradiation (NCR) followed by surgical resection remains pivotal in the management of patients with ECC.  However the outcomes of patients whose primary tumor exhibits a complete response with residual regional nodal disease (T0N1) remains unclear as well as the role for adjuvant therapy.

Methods:  Utilizing the National Cancer Database we identified patients with esophageal cancer who underwent NCR followed by esophagectomy who had subsequent pathology of T0N1.  Baseline univariate comparisons of patient characteristics were made for continuous variables using both the Mann-Whitney U and Kruskal Wallis tests as appropriate. Pearson’s Chi-square test was used to compare categorical variables. Unadjusted survival analyses were performed using the Kaplan-Meier method comparing survival curves with the log-rank test. All statistical tests were two-sided and α (type I) error <0.05 was considered statistically significant.

Results: We identified 7,116 patients diagnosed with EC (6,235 (87.6%) adenocarcinoma (AC), 881 (12.4%) squamous cell carcinoma (SCC) with a median age of 62 (21 – 88) years.  There were 6,031 (84.8%) males and 1,085 (15.2%) females. R0 resections were achieved in 6,668 (93.7%) patients and this correlated to improved survival, median survival 55.4 (RO) and 24.4 (R1) months respectively, p<0.001. The median nodes harvested were 13 (0-83) with a median positive LN’s of 1.4 (2.9%). Complete response (pCR) was achieved in 1,334 (18.7%), partial response (pPR) 2,812 (39.5 %) and non-response (pNR) 2,970 (41.7%).  There were 230 (3.2%) patients deemed as pathologic T0N1.  The median survival of patients with pCR was 61.7 months compared to 32.1 months in the T0N1 patients p<0.001. T0N1 patients did not demonstrate an improved survival over T1/2 patients who had a median survival of 30.5 months, p=0.77. However, T0N1 did reveal an improved survival over T3/4 patients who had a median survival of 24.6 months, p=0.02. Adjuvant chemotherapy in T0N1 did not provide a benefit in survival, median survival adjuvant versus no adjuvant 30.8 vs 32.1 months respectively, p=0.08. Multivariate analysis in T0N1 patients demonstrated only number of LN’s positive, histology SCC vs ACC, and margin as predictive of survival, HR 1.23 (1.10-1.36) p<0.001, HR 0.38 (0.22-0.67), p=0.001, HR 1.97 (1.7-2.27) p<0.001,respectively.

Conclusion: Patients with esophageal cancer who exhibit a pathologic T0N1 after NCR have oncologic fates similar to node positive patients.  Patients with pCR of the primary tumor and regional lymph nodes continue to demonstrate significant survival benefits over all remaining pathologic cohorts.

31.05 Total Neoadjuvant Therapy in Pancreatic Cancer

Posted on January 18, 2018

N. Goel1, A. Nadler1, W. H. Ward1, K. J. Ruth1, A. Karachristos1, J. P. Hoffman1, S. S. Reddy1  1Fox Chase Cancer Center,Surgical Oncology,Philadelphia, PA, USA

Introduction:

There is increasing interest in total neoadjuvant therapy (TNT) for pancreatic cancer. This entails systemic chemotherapy followed by chemoradiotherapy, and then definitive surgery as long as the disease remains localized. The perceived benefits are that all patients receive multimodality therapy, eradication of occult systemic disease, and the potential to downstage borderline resectable (BR) tumors for curative resection. This study evaluates whether TNT has an overall survival (OS) benefit compared to neoadjuvant chemoradiation therapy and upfront surgery. 

Methods:

This is a retrospective study of 182 pancreatic adenocarcinoma patients treated at our institution from 2000-2015 who underwent a pancreaticoduodenectomy (PD) or a total pancreatectomy. Patients undergoing distal pancreatectomy, those with macroscopic disease discovered at the time of surgery, and those with stage IV disease were excluded. 

Results:

The analytic cohort consisted of 66 patients in the TNT group, 29 in the neoadjuvant chemoradiation group, and 87 in the surgery first group. Median age at diagnosis was 67 in the TNT cohort, 72 in the neoadjuvant cohort, and 70 in the surgery first cohort. 46(69.7%) of the TNT patients were initially borderline resectable (BR) or unresectable and were clinically stage 2A or higher. 67(77%) of the upfront surgery patients were clearly resectable and were clinically stage 2A or lower. Ten(15.2%) of the TNT patients had a complete pathologic response. 55(83.3%) of the TNT patients had an R0 resection. On univariate analysis, treatment(p=0.0016), age(p=0.037), nodal status(p=0.01), and margin status(p=0.001) were statistically significant. On multivariate analysis, treatment(p=0.024), age(p=0.0014), and margin status(p<0.0001) remained significant. Surgery first had a statistically significant greater hazard ratio compared to the TNT group at 1.81. Median OS from date of diagnosis was 18 months in the upfront surgery group, 25 months in the neoadjuvant group, and 36.7 months in the TNT group (p=0.0019). The TNT group also had the greatest CA19-9 drop with 77% having at least a 50% response.

Conclusion:

Although limited data exist on the utility of TNT, our review, which is one of the largest to date, shows a statistically significant improvement in OS for the TNT group, despite more advanced disease. We achieved a median OS of 36.7 months and 5 year OS 31.5% with TNT in a patient population that was more advanced, including both BR and unresectable patients. TNT therefore offers favorable short- and long-term outcomes, as well as the benefit of optimally selecting patients for surgery based on fitness for TNT and tumor biology.

 

31.02 A Comparison of Colon versus Rectal Adenocarcinoma using Molecular Profiling

Posted on January 18, 2018

J. Purchla1, W. H. Ward1, F. Lambreton1, N. Nweze1, T. Li2, N. Goel1, S. Reddy1, E. Sigurdson1, J. M. Farma1  1Fox Chase Cancer Center,Department Of Surgical Oncology,Philadelphia, PA, USA 2Fox Chase Cancer Center,Philadelphia, PA, USA

Introduction: The role of molecular profiling (MP) in the evaluation and management of colorectal adenocarcinoma continues to grow. In conjunction with standard genotyping for disease-related mutations, MP provides a genetic blueprint of the analyzed colorectal tumors. Although similar histologically, the clinical behavior and treatment of colon and rectal cancers can be quite dissimilar. The purpose of this investigation is to compare the colon and rectal MPs.

Methods: A retrospective study was performed using MP data of colorectal patients of any stage who were treated at our tertiary cancer center between 2006 and 2017, and underwent a Targeted Cancer Panel and/or specific single gene tests. Those who did not undergo molecular profiling were excluded. Demographic, clinical, and pathological data were collected and analyzed. The Wilcoxon test and Chi-square test were used for statistical analysis.

Results: 355 colon cancers underwent MP, and 66.5% had a mutation affecting 42 different genes. 126 rectal cancers underwent MP and 79.4% has a mutation affecting 45 different genes (P=0.007). In the colon group, 53.2% were male, and in the rectal group, 63.5% were male (P=0.04). Additionally, in the colon group, 80.6% were white, and in the rectal group, 89.7% were white (P=0.02). Stage IV colon cancer patients comprised 45.0% of the cohort, and stage IV rectal cancer patients comprised 48.8% (P=0.6). KRAS mutation was seen in 43.4% of colon and 46.1% of rectal (P=0.65), BRAF mutation in 11.6% of colon and 5.0% of rectal (P=0.06), P53 mutation in 57.4% of colon and 62.6% of rectal (P=0.4), APC mutation in 47.4% of colon and 58.2% of rectal (P=0.08), SMAD4 mutation in 10.0% of colon and 13.7% of rectal (P=0.3), PIK3CA mutation in 17.0% of colon and 7.3% of rectal (P=0.02), and defective mismatch repair/microsatellite instability (dMMR/MSI) in 12.6% of colon and 1.6% of rectal (P=0.0004). No mutations were seen in 33.5% of colon and 20.6% of rectal tumors, 1 mutation was seen in 20.9% of colon and 23.8% in rectal, 2 mutations were seen in 20.9% of colon and 13.5% of rectal, and 24.8% of colon and 42.1% of rectal had more than 3 mutations (P=0.0005). In colon cancer patients with mutations: 41.5% were located in the right colon, 10.9% in the transverse colon, 10.0% in the left colon, 37.6% in the sigmoid/recto-sigmoid colon, and 7 patients were unreported.

Conclusions: In colon and rectal patients who underwent MP had mutations affecting more than 40 unique genes. Colon tumors had higher rates of BRAF and PIK3CA mutation, and dMMR/MSI in comparison to rectal cancers. Based on this descriptive analysis, further investigation with a larger sample size is needed to affirm these patterns and may affect future treatment decision making. 

31.03 Neoadjuvant Therapy Response in Esophageal Cancer Predicts Survival vs. Up-Front Esophagectomy

Posted on January 18, 2018

G. S. Chevrollier1, D. Giugliano1, F. Palazzo1, E. L. Rosato1, N. R. Evans1, A. C. Berger1  1Thomas Jefferson University,Department Of Surgery,Philadelphia, PA, USA

Introduction:
Despite advances in care, survival for patients with locally advanced esophageal cancer (EC) remains poor. It is known that patients who undergo neoadjuvant chemoradiation (nCRT) and have poor or no response (non-responders) have worse survival compared to those who respond. We sought to evaluate survival of patients who underwent nCRT compared to similarly-staged patients who underwent esophagectomy without nCRT (primary esophagectomy).

Methods:
Using our IRB-approved institutional esophagectomy database, we retrospectively identified all patients who underwent open or minimally invasive esophagectomy at our institution between January 1994 and June 2015. We separated patients into two groups: those who underwent nCRT (n=235) and those who underwent up-front esophagectomy with pathologic stage II or greater (primary esophagectomy, n=53). The neoadjuvant group was further separated into patients who were downstaged (responders, n=133) and those whose pathologic stage was the same or higher than their pre-nCRT clinical stage (non-responders, n=102). Overall and 5-year survival were compared between these three groups using Kaplan Meier survival curves and log-rank statistics, with significance set at p<0.05.

Results:
We identified 288 patients who met our inclusion criteria with an average age of 62 years. 53% of patients were male and 61% underwent open esophagectomy. The majority had adenocarcinoma (82%, n=236). Serious complication rates (grade 3 or higher according to the modified Clavien scale) were 28.4%, 26.3%, and 24.5% for non-responders, responders, and primary esophagectomy, respectively (p=NS).  The primary esophagectomy and non-responder groups had equal numbers of stage II (49% vs. 53%) and stage III (42% vs. 45%) cancers. Median survival was 36.2 months in the downstaged group (95% CI 27.2-42.6 months), 19.3 months in the non-responder group (95% CI 15-23.3 months), and 27.1 months in the primary esophagectomy group (95%CI 21.6-54.7 months) (p= 0.029). Five-year survival was 42% in the downstaged group, 25.8% in the non-responder group (HR 1.5), and 32.1% in the primary esophagectomy group (HR 1.2) (p=0.029).

Conclusions:
Patients with EC who fail to respond to nCRT have decreased survival compared to those who respond and those who undergo up-front esophagectomy. Neoadjuvant therapy in non-responders may delay definitive therapy in the form of esophagectomy, and may also expose patients to unnecessary morbidity and increased costs associated with nCRT. Further research is needed to identify potential non-responders with advanced resectable EC in order to provide more individually tailored treatment and avoid potentially harmful neoadjuvant therapy and delayed time to esophagectomy.

30.06 MELD Underestimates Morbidity and Mortality in Cirrhotic Patients for General Surgical Procedures.

Posted on January 18, 2018

M. Fleming1, F. Liu2,4, Y. Zhang2,3, K. Pei1  1Yale School Of Medicine,Department Of Surgery,New Haven, CT, USA 2Yale School Of Medicine,Section Of Surgical Outcomes And Epidemiology, Department Of Surgery,New Haven, CT, USA 3Yale School Of Public Health,Department Of Environmental Health Sciences,New Haven, CT, USA 4Beijing 302 Hospital,Beijing, BEIJING SHI, China

Introduction:
Ascites and the Model for End-Stage Liver Disease (MELD) score independently predict surgical morbidity and mortality. However, MELD, unlike other scoring systems for chronic liver disease such as the Child’s-Turcotte-Pugh, does not include the presence of ascites. Recently, MELD score has been shown to underestimate morbidity and mortality for cirrhotic patients undergoing colectomy for diverticulitis. We sought to ascertain whether this previously reported underprediction was generalizable to cirrhotic patients with ascites across a multitude of general surgery procedures.

Methods:
We performed an analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2005 through 2014 to calculate risk adjusted morbidity and mortality of cirrhotic patients with and without ascites undergoing the following common surgical procedures including both open and laparoscopic approaches: inguinal hernia repair, adhesiolysis for small bowel obstruction, cholecystectomy for acute cholecystitis, and ventral hernia repair. Stratification was performed by MELD score and presence of ascites. Patients with and without ascites were compared within each MELD stratum (low, moderate, and high) utilizing low MELD and no ascites as a reference group.

Results:
Overall there were 30,391 procedures included of which 19,311 (63.54%) were open and 11,080 (36.46%) were laparoscopic. Compared to the low MELD strata with no ascites, each group had increased risk for complications (all p < 0.0001) and within each MELD stratum the presence of ascites portends increased risk for complications (low MELD with ascites adjusted OR 3.22 CI 2.00-5.18, moderate MELD no ascites adjusted OR 1.72 CI 1.55-1.90, moderate MELD with ascites adjusted OR 3.70 CI 2.64-5.19, high MELD without ascites adjusted OR 2.93 CI 2.53-3.39, high MELD with ascites adjusted OR 6.38 CI 4.39-9.26). The same findings hold true when evaluating mortality (all p < 0.0001, low MELD with ascites adjusted OR 9.40 CI 3.53-25.01, moderate MELD without ascites adjusted OR 3.22 CI 2.36-4.40, moderate MELD with ascites adjusted OR 15.24 CI 8.17-28.45, high MELD without ascites adjusted OR 7.01 CI 4.90-10.05, high MELD with ascites adjusted OR 28.56 CI 15.43-52.88).  These trends hold true for all 4 general surgical procedures when adjusted morbidity and mortality were analyzed by procedure.

Conclusion:
Ascites increases the risk of perioperative morbidity and mortality across a myriad general surgery procedures in chronic liver disease patients when stratified by MELD score. These findings suggest that ascites plays a critical physiologic and predictive role for surgical patients that is not incorporated into MELD. Further studies should attempt to prospectively validate a novel clinical score inclusive of ascites that may predict outcomes with better accuracy.
 

29.10 Blunt Cerebrovascular Injury Incidence, Stroke-Rate, and Mortality with the Expanded Denver Criteria

Posted on January 18, 2018

A. Grigorian1, N. Kabutey1, S. Schubl1, M. Dolich1, V. Joe1, D. Elfenbein1, C. De Virgilio2, J. Nahmias1  1University Of California – Irvine,Division Of Trauma, Burns & Surgical Critical Care,Orange, CA, USA 2University Of California – Los Angeles,Harbor-UCLA Medicine Center, Department Of Surgery,Los Angeles, CA, USA

Introduction: Screening for blunt cerebrovascular injury (BCVI) (carotid artery injury [CAI] or vertebral artery injury [VAI]) requires computed tomographic angiography (CTA) of the neck. Conventional indications for screening may miss up to 20% of BCVI. Expanded indications for BCVI screening (expanded Denver criteria [eDC]) were created in 2012. The eDC includes additional signs, symptoms and risk factors to help capture that “missing” 20%. We hypothesized that the introduction of eDC would lead to an overall increase in the incidence of BCVI.  We also sought to identify risk factors for CAI and VAI, as well as whether an increased detection of BCVI would lead to a decrease in stroke rate and mortality.

Methods: The National Trauma Data Bank was queried for all blunt trauma admissions between 2007-2015. Two groups were stratified based on pre-eDC (2007-2011) or post-eDC era (2012-2015). The primary outcome was the incidence of BCVI. Secondary outcomes were stroke-rate and mortality. After a univariate logistic regression model identified significant covariates we performed a multiple logistic regression for analysis.

Results: Of the total 5,635,700 blunt trauma admissions there were 11,741 BCVIs (97.7% CAI, 2.9% VAI). The pre-eDC group was younger (median, 43.5 vs 47.1) with a higher injury severity score (mean, 10.8 vs 9.3). The post-eDC group had a higher prevalence of smokers (14.1% vs 6.1%), history of stroke (2.3% vs 1.9%) and hypertension (29.6% vs 21.3%) (all p<0.001). There were 5,085 BCVI in the pre-eDC group (0.20%), and 6,656 BCVI in the post-eDC group (0.23%) (p<0.001) translating to a 15% increase incidence of BCVI (OR 1.25, CI 1.20-1.30, p<0.001). The stroke-rate in the post-eDC was significantly higher (5.74% vs 13.49%) (OR 2.75, CI 2.40-3.15, p<0.001). There was no difference in mortality or number of patients with traumatic brain injury (p>0.05). The strongest predictors for BCVI were skull base fracture (OR 3.61, CI 3.46-3.77, p<0.001) and cervical spine fracture (OR 3.43, CI 3.29-3.57, p<0.001). The most significant independent traumatic risk factor for VAI was cervical spine fracture (OR 19.98, CI 15.85-25.19, p<0.001) while skull base fracture was the most significant for CAI (OR 3.62, CI 3.46-3.78, p<0.001). CAI was more likely to be associated with stroke than VAI in blunt trauma victims (OR 19.62, CI 18.25-21.10, p<0.001).

Conclusion: The incidence of BCVI following blunt trauma has significantly increased in the past few years.  This increase may be related to the adoption of expanded criteria for CTA of the neck in at risk patients.  Skull base fracture was the strongest traumatic risk factor for BCVI. CAI is more likely to be associated with stroke than VAI. Although detection may have increased, the stroke-rate doubled. Future research will be needed to investigate this further.

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

Posted on January 18, 2018

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

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

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

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

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

 

29.09 Isolated Parafalcine Subdural Hematoma: A Clinically Insignificant Finding

Posted on January 18, 2018

B. N. Cragun1, M. R. Noorbakhsh1, F. Hite Philp1, M. F. Ditillo1, E. R. Suydam1, A. D. Murdock1  1Allegheny General Hospital,Pittsburgh, PA, USA

Introduction:
Isolated parafalcine subdural hematoma (SDH) represents a common cause of trauma admission.  Although no distinction is made with regard to location or type of bleed in the guidelines for management of SDH, parafalcine SDH may represent a distinct clinical entity with differing clinical behavior.  We hypothesize that isolated parafalcine bleeds, as compared to other SDH, were unlikely to require neurosurgical intervention and do not benefit from critical care monitoring. 

Methods:
Trauma registry data was used to identify patients presenting to a single level I trauma center with isolated intracranial hemorrhage (ICH) from February 2016 to April 2017.  Isolated ICH was defined as abbreviated injury score (AIS) of ≥3 for head and <3 for any other body location, and we further identified patients with isolated SDH.  Data reviewed included: neurosurgical interventions, radiographic worsening of the bleed, mortality, level of care, GCS on admission and discharge, disposition, and demographics.

Results:
We identified 164 isolated SDH, of which 45 had isolated parafalcine ICH.  Antiplatelet or anticoagulant use was equally prevalent in both groups (49% of parafalcine bleeds vs 54% in other SDH).  Average age was 68 ± 21.  Parafalcine SDH had a similar rate of radiographic progression (8.9% vs 11.8%), but none had neurological deterioration and none required neurosurgical intervention.  Mortality was significantly lower in parafalcine SDH as compared to other SDH (0% vs 10.1%, p=0.04).  Mortality, length of stay (LOS), neurological deterioration, radiographic worsening, and need for neurosurgical intervention are compared between the two groups as summarized in Table 1.

Conclusion:
Our data showed no mortality, no clinical worsening, and no neurosurgical intervention in parafalcine SDH, suggesting that parafalcine bleeds represent a benign entity as compared to other SDH.  While several patients with parafalcine bleeds had radiographic progression, this did not translate to neurological deterioration or need for intervention.  This data suggests that admission to an ICU, as well as interval imaging, are unlikely to be helpful in the setting of isolated parafalcine SDH.  Collectively, these data begin to build evidence for our consideration of a change in practice in the management of parafalcine SDH, as they appear to be a distinct clinical entity from other types of SDH in our trauma population. 

29.07 Trauma Recidivism and Mortality Following Violent Injuries in Young Adults

Posted on January 18, 2018

A. M. Kao1, K. A. Schlosser1, M. R. Arnold1, P. D. Colavita1, R. F. Sing2, T. Prasad1, A. E. Lincourt1, B. R. Davis1, B. T. Heniford1  1Carolinas Medical Center,Gastrointestinal And Minimally Invasive Surgery,Charlotte, NC, USA 2Carolinas Medical Center,Trauma/Critical Care,Charlotte, NC, USA

Introduction: Trauma recidivism accounts for a significant number of emergency department and trauma center admissions. Injuries associated with recurrent violent trauma result in increased treatment costs and are a significant public health burden due to higher rates of morbidity and mortality in this patient cohort.

Methods: A prospectively maintained registry of patients presenting to a Level 1 Trauma Center was queried for patients ages 18 to 25 years who sustained a gunshot wound (GSW), stab wound, or blunt assault between 2009-2015. Demographics, injury data, and discharge disposition were reviewed. Patients presenting with violent injuries were compared using Chi square, Fisher’s exact tests and Kruskal-Wallis test. Primary outcomes included mortality and trauma recidivism, identified by patients who presented with at least two unrelated violent traumas during the study period. Re-hospitalization for complications resulting from the initial injury was excluded. Out-of-hospital mortality was identified using the Social Security Death Database.

Results:A total of 6,484 patients between 18-25 years presented to the Level 1 Trauma Center; 1,215 (18.7%) had sustained a blunt assault, GSW, or stab wound. Patients with violent injuries were 87.4% male, with mean age of 22.1±2.2 years; the distribution of injuries included 64.4% GSW, 21.1% stab, and 14.8% blunt assault. Compared to patients in the same age cohort who sustained non-violent injuries, patients with violent injuries had a greater risk of mortality (8.0% vs. 2.1%, p<0.0001).  Out-of-hospital mortality was 1.3% (vs 0.46% in non-violent, p<0.0005), with average time to death of 5.2±14.6 months from initial injury. The delayed mortality was significantly more likely in patients who initially presented after a GSW (89.7% vs 5.2% stab wound or 5.2% blunt assault, p<0.0001). Recidivism was 23.5% with mean time to second violent injury at 31.9±21.0 months; 15.0% had two unrelated trauma readmissions and 6.0% had 3 or more unrelated admissions. 90% of subsequent injuries occurred within 5 years, with 19% in the first 12 months. Initial injury in recidivists was GSW in 63.3%, compared to 22.3% with initial injury of stab wound and blunt assault 22.3% (p<0.001). 59.6% of patients who returned with an unrelated, second violent injury sustained a blunt assault, followed by GSW (26.6%) and stab wound (13.7%). There was no difference in age, length of stay, initial ED vitals, or injury severity score that correlated with trauma recidivism.

Conclusion:
In young trauma patients sustaining a violent injury, the burden of injury extends past discharge as patients have a significantly higher rate of mortality after discharge.  Nearly one-quarter of patients will represent due to violent trauma.  Improved medical, psychological, and social collaborative treatment of these high-risk patients is needed to interrupt the cycle of violent injury.

29.05 Alcohol Intoxication and Burn Injury Outcomes: A Propensity Score Analysis

Posted on January 18, 2018

L. T. Knowlin1,2, B. A. Cairns1, A. G. Charles1  1University Of North Carolina At Chapel Hill,Surgery,Chapel Hill, NORTH CAROLINA, USA 2Howard University Hospital,Surgery,Washington, DISTRICT OF COLUMBIA, USA

Introduction: Approximately half  of burn-injured patients have detectable blood alcohol levels at the time of hospital admission. Alcohol use has been hypothesized to exacerbate the immunosuppression process that occurs following burn injury leading to increase morbidity and mortality. We sought to examine the effects of alcohol intoxication on burn injury outcomes.

Methods: Patients ≥14 years old admitted to a large, tertiary care referral burn center between 2002 and 2012 were eligible for inclusion. The effect of alcohol intoxication on infection complications and in-hospital mortality was evaluated using standardized Cox proportional hazard regression. Models were standardized using inverse-probability of treatment weights to account for confounding by patient demographics and burn characteristics.

Results:A total of 1,719 patients were included in the study. Of these,19% (n = 329) had blood alcohol concentration (BAC) > 0 on admission and 13% (n =221) had a blood alcohol concentration above the legal limit (> 0.08). 31% (n=548) developed an infection complications such as pneumonia, wound infectin, urinary tract infection, or sepsis. There was no difference in the crude mortality rate for patients with any positive alcohol use (11% vs 8.6%, p> 0.05) and those with a BAC above the legal limit (12.6% vs 8.6%, p>0.05)  compared to sober patients. Intoxicated patients had a higher infection rate compared to sober patients (26% vs 15%, p<0.05).  A weighted Cox regression estimated increase hazard of progression to 30 day in-hospital mortality of 12% (HR = 1.12, 95% CI = 0.63-2.00) for positive alcohol use and 64% (HR = 1.64, 95% CI 0.84- 3.22) for BAC above legal limit compared to sober patients but was not significant.The adjusted 60-day cumulative risk for infection complications in alcohol intoxicated patients with inhalation injury was the highest at 35% compared to sober patients with inhalational injury, alcohol intoxicated without inhalational injury and sober without inhalational injury (35% vs. 29.1%, 27.2%, and 22.1%, respectively).(Figure 1)

Conclusion:Alcohol intoxication did not significantly increase risk of inpatient mortality compared to sober individuals following burn injury. However, alcohol intoxication had a significantly higher cumulative risk of infection complications. The immunosuppression response after burn injury is magnified in alcohol intoxicated individuals prompting the need for future therapeutic interventions to reduce poor outcomes among burn patients who drink alcohol.

 

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