72.10 Predictive Value of GEC for Thyroid Cancer after NIFTP Reclassification

Posted on January 18, 2018

A. R. Marcadis1, B. A. Shah2, D. A. Kerr2, O. Picado1, S. Liu1, J. I. Lew1  1University Of Miami,Division Of Endocrine Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA 2University Of Miami,Department Of Pathology,Miami, FL, USA

Introduction: Thyroid nodules with Atypia of Undetermined Significance/Follicular Lesion of Undermined Significance (AUS/FLUS, Bethesda III) on fine needle aspiration (FNA) pose a management dilemma for clinicians, and molecular assays have been developed in order to better predict thyroid malignancy or benignity. The Gene Expression Classifier (GEC) is one commonly used molecular test, with suspicious results corresponding to a 40% malignancy risk. Recently, encapsulated, non-invasive follicular variants of papillary thyroid carcinoma were reclassified as benign Non-Invasive Follicular Thyroid neoplasms with Papillary-like nuclear features (NIFTP). With this reclassification, such neoplasms previously considered malignant are now benign, which may alter the positive predictive value (PPV) of suspicious GEC results for malignancy. This study examines the impact of NIFTP reclassification on the PPV of GEC for thyroid malignancy.

Methods:  A retrospective, single-institution review of 75 surgical patients with AUS/FLUS thyroid cytology and suspicious GEC was conducted. For all patients, preoperative neck ultrasound and FNA reports were reviewed, and the lobe (right/left/isthmus), location (upper/middle/lower), and size of the suspicious thyroid nodule were correlated with final pathology. All encapsulated, non-invasive follicular variants of papillary carcinoma were re-evaluated by an endocrine pathologist and re-classified as NIFTP when appropriate. The PPV of GEC for malignancy in AUS/FLUS thyroid nodules was calculated both before and after NIFTP reclassification.   

Results: Of the 75 patients with AUS/FLUS thyroid nodules and suspicious GEC results, 61 (81%) were female, and 14 (19%) were male. 58 (77%) underwent total thyroidectomy, while 17 (23%) underwent thyroid lobectomy. On final pathology of the GEC suspicious nodule, 7 patients (9.3%) had encapsulated non-invasive follicular variants of papillary thyroid carcinoma which on pathology re-review were classified as NIFTP. The other 68 patients had final pathology which did not change after NIFTP reclassification; 25 of whom (33%) had malignancy (21 papillary thyroid cancer, 3 follicular thyroid cancer, 1 papillary microcarcinoma), and 43 (57%) of whom had benign pathology. Before NIFTP reclassification, the PPV for malignancy in AUS/FLUS nodules with suspicious GEC was 42% (32/75 malignant), whereas after NIFTP reclassification, the PPV was 33% (25/75 malignant). This decrease in PPV for malignancy after NIFTP reclassification was not statistically significant (p >0.05).

Conclusion: NIFTP reclassification as a benign thyroid neoplasm lowers, but does not cause a statistically significant change in the PPV of suspicious GEC results for malignancy in AUS/FLUS thyroid nodules. Surgeons and other clinicians should take this into consideration when evaluating AUS/FLUS thyroid nodules with suspicious GEC results. 

73.01 A 3 year Follow-up of Nonoperative Management in Ventral Hernia Patients With Comorbidities

Posted on January 18, 2018

K. Bernardi1, J. L. Holihan1, D. V. Cherla1, J. R. Flores1, L. S. Kao1, T. C. Ko1, M. K. Liang1  1University Of Texas Health Science Center At Houston,General Surgery,Houston, TX, USA

Introduction:
Individuals with comorbid conditions (e.g. obesity or smoking) are not only at increased risk to develop a ventral hernia but are at markedly increased risk for complications (including recurrence) following repair.  There is limited high-quality prospective data on the safety and efficacy of non-operative management of patients with ventral hernias.  Our objective was to determine the long term clinical and patient reported outcomes of non-operative management of patients with comorbidities also suffering from ventral hernias.
 

Methods:
This is the 3-year follow-up to a prospective observational single institution study of patient with comorbidities and ventral hernias.  Patients were contacted by phone to complete a standardized interview. Primary outcome was proportion of patients who underwent urgent or emergency surgery. Secondary outcomes were the change in quality of life (QoL) from their baseline interview and proportion of patients undergoing elective or emergent repair.  QoL was measured utilizing the modified activities assessment scale (AAS), a validated, hernia-specific QoL survey.  The minimal clinically important difference was considered a change of 7 points on a scale of 1-100 where 1=poor QOL and 100=perfect QOL.
 

Results:
Overall, 60 patients were followed to completion (Table below).  At the end of 3 years, 3 (5%) patients had died due to non-hernia related causes, 16 (26.7%) patients had at least one emergency room visit related to their hernia, 4 (6.7%) patients underwent urgent/emergent ventral hernia repair, and 15 (25%) patients underwent elective ventral hernia repair.  On average, non-operatively managed patients experienced no change in their QoL, while those who crossed over to operative management experienced a substantial improvement in their QoL.
 

Conclusion:
Non-operative management for patients with ventral hernias appears to be safe; however, there was a substantial crossover to operative intervention. For most patients who successfully completed non-operative management, their QoL did not change over 3 years.  On the other hand, patients who underwent ventral hernia repair had a major improvement in their QoL.

72.07 5-factor replacement index for the 11 factor modified frailty index in NSQIP

Posted on January 18, 2018

S. Subramaniam1, J. J. Aalberg1, R. P. Soriano2, C. M. Divino1  1Icahn School Of Medicine At Mount Sinai,Division Of General Surgery, Department Of Surgery,New York, NY, USA 2Icahn School Of Medicine At Mount Sinai,Department Of Geriatrics And Palliative Medicine,,New York, NY, USA

Introduction:  The modified frailty index (mFI-11) is a NSQIP based 11-factor index that has been proven to adequately reflect frailty and predict mortality and morbidity. These 11 factors, made of 16 variables, map to the original 70 item Canada Study of Health and Aging Frailty Index. In the past years, certain NSQIP variables have been removed from the database; as of 2015, only 5 out of the original 11 factors remain. The predictive power and usefulness of these five factors in an index (mFI-5) have not been proven in past literature. The goal of our study was to compare the mFI-5 to the mFI-11 in terms of value and predictive ability for mortality, post-operative infection and unplanned thirty-day readmission for future research and clinical use. 

Methods: The mFI-5 is made up of the following factors: functional status, diabetes, history of COPD, hypertension, and history of CHF and was calculated by dividing the number of  factors present for a patient by the number of available factors for which there were no missing data. Spearman’s Rho was calculated in order to compare mFI-5 and mFI-11 value. Predictive models, using both unadjusted and adjusted logistic regressions were created for each of the three chosen outcomes using 2012 NSQIP data, the last year all mFI-11 variables existed. Adjusted models were controlled for ASA classification, wound class, age, transfer status, surgical complexity represented by RVU, inpatient status, anesthesia type, and emergency type. Both adjusted and unadjusted models using mFI-5 were run on 2015 data to validate results. All above methods were conducted for the following nine surgical subspecialties including general surgery, cardiac surgery, neurosurgery, gynecology, orthopedics, otolaryngology, plastic surgery, thoracic surgery, urology, vascular surgery and then completed for all surgical subspecialties combined

Results: Correlation between the mFI-5 and mFI-11 were above 0.9 across all surgical specialties except for cardiac and vascular surgery. Adjusted and unadjusted models showed similar C-statistics for mFI-5 and 11 and strong predictive ability for mortality and post-operative complications. Predictive value for thirty day readmission was weak for both the mFI-11 and the mFI -5. 

Conclusion:The mFI-5 is an equally effective predictor as the mFI-11 in all subspecialties and is a strong predictor of mortality and post-operative complication. It has credibility for future use to study frailty within the NSQIP database. It also has potential in other databases and for clinical use.    

 

72.08 Laparoscopic Gastropexy in Elderly Patients with Large Paraesophageal Hernias

Posted on January 18, 2018

A. D. Newton1, D. A. Herbst1, K. R. Dumon1, D. T. Dempsey1  1Hospital Of The University Of Pennsylvania,Surgery,Philadelphia, PA, USA

Introduction: The optimal technique for paraesophageal hernia (PEH) repair has been debated. For the past several years, our surgical treatment algorithm for elderly patients with large symptomatic PEH has been formal laparoscopic repair if gastroesophageal reflux (GER) symptoms predominate, and laparoscopic anterior gastropexy alone if mechanical symptoms predominate. Our goal was to evaluate outcomes with this approach.

Methods: We retrospectively reviewed all first-time operations for large PEH (40% or more intrathoracic stomach) in patients ≥ age 65 performed by a single attending surgeon from 2011-2016. Primary outcome measures were perioperative morbidity and mortality, presence of herniated stomach or GER on upper gastrointestinal radiograph (UGI) 3 months postop, and subjective symptom improvement.

Results:  A total of 83 patients (mean age 76.9 years, 84% female) had a primary laparoscopic operation for large PEH (type 3, n=75; type 4, n=8). Thirty patients had formal repair (sac removal, posterior crural repair, partial fundoplication, gastropexy) and 53 had gastropexy alone. There were no open or esophageal lengthening operations and one 30-day reoperation. Median intrathoracic stomach percentage was 50% vs. 90% for formal repair vs. gastropexy. Mean operative time was 161.7 vs. 100.6 minutes (P<0.0001) for formal repair vs. gastropexy, and mean postoperative length of stay was no different (2.6 vs. 2.8 days). ASA was ≥ 3 for 53% vs. 70% (P=0.133) for formal repair vs. gastropexy. Overall 90-day morbidity was 15.7% (16.7% with formal repair vs. 15.1% with gastropexy, P=0.85). There was one post-discharge 30-day mortality. On UGI 3 months postop, one patient (3%) had > 10% of stomach above the diaphragm after formal repair compared to 59% after gastropexy (P<0.001), and 69% had demonstrable GER on UGI after gastropexy compared to 24% after formal repair (P<0.001). However, 71% were asymptomatic and 98% had improvement in preop symptoms after gastropexy; 76% were asymptomatic and 92% had improvement in preop symptoms after formal repair.

Conclusion: Laparoscopic gastropexy alone is a reasonable treatment for large PEH in elderly patients with predominately mechanical symptoms while formal repair gives good results when GER symptoms predominate. Esophageal lengthening is unnecessary in most patients. Postop UGI findings often do not correlate with clinical symptoms in this group.

72.05 Identifying Predictors of Prolonged Levothyroxine Dose Adjustment After Thyroidectomy

Posted on January 18, 2018

T. S. Atruktsang1, J. R. Imbus1, N. A. Zaborek1, D. F. Schneider1  1University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction:

Synthroid (levothyroxine) is one of the most prescribed drugs in the US. Despite its widespread use, and multiple dosing schemes, many patients struggle to achieve euthyroidism after thyroidectomy and suffer symptoms of hyper- or hypothyroidism. The purposes of this study are to describe time required for dose adjustment prior to achieving euthyroidism and to identify predictors of prolonged dose adjustment (PDA+) after thyroidectomy.

 

Methods:

This is a retrospective cohort study of patients from a single institution who achieved euthyroidism between 2007 and 2017 after undergoing total thyroidectomy or completion thyroidectomy for benign disease. Levothyroxine doses were calculated using our published BMI-based dosing algorithm; a single provider adjusted doses at 6 intervals. PDA+ was defined as needing at least 3 dose adjustments (top quartile) prior to achieving euthyroidism. We compared patient and disease characteristics of PDA+ patients to the remaining patients (PDA-) using Wilcoxon Rank Sum test or Chi-squared test where appropriate. Multivariate logistic regression was used to identify predictors of PDA+.

 

Results:

The 605 patients in this study achieved euthyroidism in a median of 116 days (range 14 – 863) and 1 dose adjustment (range 0 – 7). Only 222 (36.69%) patients were euthyroid without any dose adjustments. The 508 (83.97%) patients who were PDA- achieved euthyroidism in a median of 101 days (range 14 – 627) and 1 dose adjustment (range 0 – 2). The 97 (16.03 %) patients who were PDA+ achieved euthyroidism in a median of 271 days (range 52 – 863) and dose adjustments (range 3 – 7). PDA+ patients required more than twice the median number of days to achieve euthyroidism (271 vs. 101 days, p<0.001).

Compared to the PDA- group, the PDA+ group did not differ significantly in the proportion of patients with Graves’ disease or Hashimoto’s. However, PDA+ patients were more likely to have chronic renal insufficiency (5.2% vs. 1.6%, p=0.026). More than 3 times as many patients in the PDA+ group were taking iron (6.2% vs. 1.8%, p = 0.010). Similarly, nearly twice as many patients in the PDA+ group were taking multivitamin with minerals (22.7% vs. 11.6%, p = 0.003). When controlling for all other factors, iron supplementation (OR = 4.4, 95% C.I. = 1.43 – 13.55, p = 0.010) and multivitamin with mineral supplementation (OR = 2.4, 95% C.I. = 1.3 – 4.3, p = 0.004) were independently associated with PDA+. However, plain multivitamins were not associated with PDA+. Age, gender, preoperative thyroid disease, and co-morbidities did not independently predict PDA+. 

 

Conclusion:

After thyroidectomy at a high-volume center, achieving euthyroidism can take nearly four months. Iron and mineral supplementation are associated with PDA+. This information can be useful when counseling patients preoperatively and suggests that education about proper levothyroxine administration and interfering supplements may expedite achieving euthyroidism.

72.06 Stricter ioPTH Criterion for Successful Parathyroidectomy in Stage III CKD patients with pHPT

Posted on January 18, 2018

S. Liu1, A. Yusufali1, R. Teo1, M. Mao1, Z. F. Khan1, J. C. Farra1, J. I. Lew1  1University Of Miami Leonard M. Miller School Of Medicine,Division Of Endocrine Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA

Introduction:
The effect of altered parathormone (PTH) metabolism in renal insufficiency on intraoperative parathormone (ioPTH) monitoring during parathyroidectomy (PTX) for primary hyperparathyroidism (pHPT) remains unclear. A stricter >50% ioPTH drop with return to normal range criterion, rather than the classic >50% ioPTH drop criterion alone, may be needed to achieve optimal operative success in this patient population with renal disease. This study compares operative outcomes using classic and stricter >50% ioPTH drop criteria in patients with mild or moderate renal insufficiency undergoing PTX guided by ioPTH monitoring for pHPT.

Methods:
A retrospective review of prospectively collected data in 605 patients undergoing PTX guided by ioPTH monitoring for pHPT was performed. All patients had elevated calcium and PTH levels, with ≥6 months of follow up and a mean follow up of 45 months. Glomerular filtration rate (GFR) was estimated with the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. The National Kidney Disease Outcomes Quality Initiative (KDIGO) staging was used to define the stages of CKD based on estimated GFR (eGFR): Stage I with normal or high GFR (GFR>90 ml/min), Stage II Mild CKD (GFR= 60-89 ml/min), Stage III Moderate CKD (GFR = 45-59 ml/min). Patients with overt secondary hyperparathyroidism (CKD Stage IV and V) were excluded. Patients were further subdivided into patients with >50% ioPTH drop only criterion (classic) and patients with a >50% ioPTH drop to within normal range (<65 pg/mL) criterion (stricter). Operative outcomes including the rates of operative success, failure, recurrence, bilateral neck exploration (BNE) and multiglandular disease (MGD) were compared across the three CKD groups.

Results:
Of 605 patients, 38% (230/605) had normal renal function or stage I CKD, 44% (268/605) had Stage II CKD, and 18% (107/605) had Stage III CKD. In patients with Stage I and II CKD, there was no statistical differences in rates of operative success, failure, recurrence, BNE and MGD between patients with classic compared to those with the stricter criterion. However, in Stage III CKD patients, there was a significant difference in operative success rates between those patients who had >50% ioPTH drop alone and those who had >50% ioPTH drop and return to normal range, (92% vs. 100%, respectively, p<0.05). There was no difference in recurrence, BNE, or MGD rates in Stage III CKD patients between those who had classic >50% ioPTH drop compared to those with the stricter criterion. 

Conclusion:
PTX guided by ioPTH monitoring using the classic >50% ioPTH drop criterion is performed with the highest operative success in patients with normal renal function, Stage I, and Stage II CKD. However, in patients who have Stage III CKD, a stricter >50% ioPTH drop with return to normal range criterion may lead to improved rates of operative success, and should be used during PTX in this patient population with renal disease. 
 

72.04 Adrenal Incidentaloma Follow-up is Influenced by Patient, Radiological and Medical Provider Factors

Posted on January 18, 2018

D. I. Maher1, E. Williams1, S. Grodski1,2, J. W. Serpell1,2, J. C. Lee1,2  1Alfred Hospital,Monash University Endocrine Surgery Unit,Melbourne, VIC, Australia 2Monash University,Department Of Surgery,Melbourne, VIC, Australia

Introduction: The majority of adrenal incidentalomas (AI) are benign, although some are large, functional or malignant, and may require surgery. Therefore, all require follow-up. This case-control study aims to determine the pattern of AI follow-up in a level 1 trauma centre in Melbourne Australia, focussing on the factors that influence whether follow-up is facilitated.

Methods: Patients with CT-detected AIs between January 2010 and September 2015 at The Alfred Hospital were included. Case files were identified using a key word search of electronic CT reports. Patients were excluded if the primary purpose of the CT was to investigate adrenal disease, or if the patient had a history of known adrenal mass. Cases were assessed by two authors and reviewed for demographics, managing unit, CT indication and findings, and follow-up arrangements. To consistently determine if “follow-up” occurred, a strict definition of the term was applied. Statistical analysis using t-test, Chi-squared test and logistic regression was performed using Stata SE v14, with a p-value of < 0.05 set as significant.

Results: A total of 38 848 chest and abdominal CTs were performed in the study period, yielding 804 patients with AIs who met inclusion criteria (mean age 65, 58 % male). The mean size of AI was 23 mm. Univariate analysis demonstrated that follow-up was more likely to occur in younger patients (mean age 62 vs 66, p < 0.001); in larger lesions (mean size 26 mm vs 21 mm, p < 0.001); if the CT suggested follow-up (p < 0.001); or if the CT report suggested a diagnosis (p < 0.001). Follow-up arrangements were most likely to be made by the trauma unit (39 %, p = 0.01).

A multivariable analysis supported the significance of these findings and indicated that the CT report and managing unit strongly influence follow-up rates. When a diagnosis was suggested by the CT report, follow-up was more likely to be facilitated (odds ratio 0.63, 95 % CI 0.45 – 0.88; p < 0.01). Additionally, more cases in the follow-up group had a follow-up recommendation in the CT report (2.88, 1.95 – 4.26; p < 0.01). A large difference in the frequency of follow-up was noted between the Trauma Unit compared to other units (1.77, 1.09 – 2.89; p < 0.02). This variance is possibly due to the introduction of a dedicated adrenal lesion protocol.

Follow-up arrangements were made for 245 cases (30 %). In 36 % of these cases (N = 88) follow-up occurred at The Alfred Hospital. Seven cases (8 %) required surgical intervention. Histopathology confirmed four adrenal cortical tumours, two metastatic melanomas and one phaeochromocytoma. 

Conclusions: This study highlights that AI follow-up is often overlooked, and that approaches need to be developed to ensure that all cases receive the review they require. This study demonstrates that follow-up is influenced by patient, radiological and medical provider factors. An adrenal lesion follow-up protocol may improve follow-up rates, but requires further research.

71.10 Survival after the Introduction of the Lung Allocation Score In Simultaneous Lung-Liver Recipients

Posted on January 18, 2018

K. Freischlag2, M. S. Mulvihill1, P. M. Schroder1, B. Ezekian1, S. Knechtle1  1Duke University Medical Center,Surgery,Durham, NC, USA 2Duke University Medical Center,School Of Medicine,Durham, NC, USA

Introduction:
The optimal management of patients with combined lung and liver failure is uncertain. Simultaneous lung and liver transplantation (LLT) confers survival benefit over remaining on the waitlist for transplantation. In 2005, the lung allocation score (LAS) was introduced and significantly reduced waitlist and overall mortality in single organ lung transplants. The current system for simultaneous LLT generally matches a recipient with a donor based on his or her LAS. Oftentimes this results in a relatively low MELD score at transplantation compared to liver alone. However, the current impact of LAS on LLT is unknown. To ascertain whether the current lung allocation system has improved survivability in this cohort, we studied LLT before and after the introduction of LAS.

Methods:
The OPTN/UNOS STAR file was queried for adult recipients of simultaneous LLT. Demographic characteristics were subsequently generated and examined. Kaplan-Meier analysis with the log-rank test compared survival between groups. A hazard ratio was generated based on the presence of LAS alone.

Results:
A total of 64 recipients of LAS were identified as suitable for analysis. Of those, 10 underwent transplant prior to the introduction of LAS. Comparatively, those without a LAS score had a higher mean FEV1 (48.22 vs 29.56, p=0.012), higher mean creatinine at transplant (1.22 vs 0.73, p=0.001), higher percentage diagnosed with primary pulmonary hypertension (40% vs 0%, p=0.004), and an earlier mean transplant year (1999.4 vs 2011.17, p<0.001). Survival was significantly lower in the LLT cohort before the introduction of LAS compared to the cohort after LAS (Figure 1- 1-year: 50.0% vs 83.3%, 5-year: 40.0% vs 67.5%, 10-year: 20.0% vs 55.6%, p=0.0073).  Presence of LAS was a predictor of decreased mortality (OR 0.051, 95%CI 0.006-0.436, p=0.007). 

Conclusion:
LLT is a rare procedure and most national analyses have included patients before and after the introduction of the LAS. Our study shows that survival in combined lung-liver transplantation after the introduction of the lung allocation score was significantly increased and presence of LAS was a predictor of decreased mortality.  While many factors contributed to the changes in mortality, the cohorts before and after the introduction of LAS are significantly different and should be treated as such when conducting future studies in simultaneous thoracic and abdominal organ allocation.
 

71.08 Kidney Paired Donation Programs Don't Become Concentrated with Highly Sensitized Candidates Over Time

Posted on January 18, 2018

C. Holscher1, K. Jackson1, A. Thomas1, C. Purcell2, M. Ronin2, A. Massie1, J. Garonzik Wang1, D. Segev1  1Johns Hopkins University,Baltimore, MD, USA 2National Kidney Registry,New York, NY, USA

Introduction: In order to utilize a willing but incompatible living donor, transplant candidates must either proceed with incompatible living donor kidney transplantation or attempt to find a more compatible match using kidney paired donation (KPD). For the latter, the benefit of a “better” match must be balanced with the morbidity and mortality associated with increased dialysis time while searching for a match. A common criticism of KPD registries is that the "easy-to-match" candidates match and leave the registry pool quickly, and thereby create a registry pool concentrated with difficult to match patients, making future KPD matches challenging. We hypothesized that, given alternative treatments such as deceased donor kidney transplant priority and desensitization, this concern would no longer be the case.

Methods: We studied 1894 registrants to the National Kidney Registry (NKR), the largest KPD registry in the United States (US), between 2011 and 2015. Candidates were considered a part of the KPD registry pool for the year they registered, and remained in the pool after registration until they matched into a KPD transplant or were removed from the registry for other reasons such as death, receipt of a deceased donor kidney transplant, or incompatible living donor transplant. The prevalent composition of the NKR pool was compared across years, comparing by age, gender, race/ethnicity, body mass index (BMI), ABO blood type, and panel reactive antibody (PRA) categories. Comparisons were made with chi-square, ANOVA, and t-tests, as appropriate.  

Results: Candidates were median age 50 (IQR: 38-60) years, 48% female, 66% white, and had a median BMI of 27 (23-31). Overall, 59% of candidates had blood type O, 24% had blood type A, 15% had blood type B, and 2% had blood type AB. The mean PRA was 53 with 29% having a PRA of 0, 29% having a PRA of 1-79, 18% having a PRA 80-97, and 24% having a PRA 98 or higher. Notably, there were no statistically significant differences by year in age, gender, race, BMI, blood type, or PRA. Further, there were no statistically significant changes by year in the composition of the pool by PRA category (Figure).  

Conclusion: In the largest KPD registry in the US, there is no evidence that KPD registrants have become more difficult to match over time. This should encourage continued enrollment of incompatible donor/recipient pairs in KPD registries to facilitate compatible transplantation.

71.07 Early Hypertension, Diabetes, and Proteinuria After Kidney Donation: A National Cohort Analysis

Posted on January 18, 2018

C. Holscher1, S. Bae1, M. Henderson1, S. DiBrito1, C. Haugen1, A. Muzaale1, A. Massie1, J. Garonzik Wang1, D. Segev1  1Johns Hopkins University,Baltimore, MD, USA

Introduction:  Living kidney donors (LKDs) are at greater risk of end stage renal disease (ESRD) than the general population. While late post-donation ESRD is more likely due to hypertension (HTN) or diabetes (DM), early post-donation ESRD is often secondary to glomerulonephritis and is associated with proteinuria. Better understanding of the prevalence of and risk factors for early post-donation proteinuria, HTN, and DM will improve LKD follow-up care.

Methods:  Using SRTR data, we identified 41260 LKDs who underwent donor nephrectomy from 2008-2014 with follow-up data included through 2017. Given the high loss to follow-up (59% missing proteinuria, 33% missing HTN, and 31% missing DM), sensitivity analyses were done using inverse probability weighting (IPW) and multiple imputation by chained equations (MICE). Multiple logistic regression models were used to compare risk factors for proteinuria, HTN, and DM.

Results: Among LKDs, 1.55%1.70%1.86% had HTN, 0.06%0.09%0.13% had DM, and 5.11%5.47%5.84% had proteinuria at two years post-donation. Sensitivity analyses revealed similar estimates of HTN and DM, but slightly higher estimates of proteinuria [6.09%6.44%6.84% (IPW) and 6.35%6.72%7.23% (MICE)]. HTN was more likely in older (for each 10 years, aOR: 1.341.491.66), more obese (for each 5 BMI units, aOR: 1.171.341.53), and hypertensive (for each 10 mmHg, aOR: 1.351.451.56) LKDs. HTN was less likely in LKDs who had donated more recently (by year, aOR: 0.900.941.00), were female (aOR: 0.630.780.97), Hispanic/Latino (

Reference: white, aOR: 0.430.640.94), and not related to the recipient (aOR: 0.580.730.93). DM was more likely in LKDs who were Hispanic/Latino (aOR: 1.393.8510.64) and had higher BMIs (aOR: 1.131.933.28). Proteinuria was more likely in LKDs who had higher BMIs (aOR: 1.121.231.36) and in African American LKDs (aOR: 1.481.852.32) and Hispanic/Latino LKDs (aOR: 1.211.511.88) relative to white LKDs. Proteinuria was less likely in LKDs who were older (aOR: 0.770.830.90), female (aOR: 0.640.760.89), and were not related to their recipient (aOR: 0.700.830.99, Table). 

Conclusion: The low early post-nephrectomy prevalence of HTN, DM, and proteinuria in LKDs is reassuring and suggests risk of ESRD is limited to a small proportion of LKDs. Improved understanding of which LKDs are at risk for these conditions might improve pre-donation risk stratification and counseling as well as post-donation prevention of ESRD. 

71.05 Arterial, but Not Venous, Reconstruction Increases Morbidity and Mortality in Pancreaticoduodenectomy

Posted on January 18, 2018

S. L. Zettervall1, J. Holzmacher1, T. Ju1, G. Werba1, B. Huysman1, P. Lin1, A. Sidawy1, K. Vaziri1  1George Washington University School Of Medicine And Health Sciences,Surgery,Washington, DC, USA

Introduction:  Vascular reconstruction during pancreaticoduodenectomy is increasingly utilized to improve pancreatic cancer resectability. However, very few multi-institutional studies have evaluated the morbidity and mortality of arterial and venous resection with reconstruction during this procedure.

Methods:  A retrospective analysis of prospectively collected data was performed utilizing the targeted pancreas module of the National Surgical Quality Improvement Program (NSQIP) for patients undergoing pancreaticoduodenectomy from 2012-2014. Demographics, comorbidities, and 30-day outcomes were compared among patients who underwent venous or arterial reconstruction and no vascular reconstruction. Multivariate analysis was utilized to adjust for differences in demographic and operative characteristics.

Results: 3002 patients were included in NSQIP in the time period studied: 384 with venous reconstruction, 52 with arterial reconstruction, and 2566 without. Patients who underwent both venous and arterial reconstruction were excluded (N=81). Compared to patients without reconstruction, those with venous reconstruction had more congestive heart failure (0.2% vs. 1.8%, P <.01), and those with arterial reconstruction had higher rates of pulmonary disease (11.5 vs. 4.5%, P =0.02). Pre-operative chemotherapy was more common in both venous (34% vs 12%, P < .01), and arterial reconstruction (21% vs 12%, P < .04). On multivariate analysis, there was also no increase in morbidity or mortality following venous reconstruction, compared to those without reconstruction. In contrast, using multivariate analysis, arterial reconstruction was associated with increased 30-day mortality with an Odds Ratio (OR): 6.7, 95%; Confidence Interval (CI): 1.8-25. Also morbidity was increased as represented with return to the operating room (OR: 4.5, 95%; CI: 1.5-15), pancreatic fistula (OR: 4.4, 95%; CI: 1.7-11), and reintubation (OR: 3.9, 95%; CI: 1.1-14).

Conclusion: These findings suggest that venous reconstruction, may be considered to improve survival in patients previously thought of as unresectable due to venous involvement. Careful consideration should be made prior to arterial reconstruction given the significant increase in perioperative complications and death within 30-day from operative procedure.

 

71.04 Significance of repeat hepatectomy for intrahepatic recurrence of HCC within Milan criteria

Posted on January 18, 2018

T. Gocho1, Y. Saito1, M. Tsunematsu1, R. Maruguchi1, R. Iwase1, J. Yasuda1, F. Suzuki1, S. Onda1, T. Hata1, S. Wakiyama1, Y. Ishida1, K. Yanaga1  1Jikei University School Of Medicine,Department Of Surgery,Minato-ku, TOKYO, Japan

Introduction: Standard treatment strategy for intrahepatic recurrence (IHR) of hepatocellular carcinoma (HCC) within Milan criteria (MC) after primary hepatic resection is different between Western countries and Japan. In Western countries, salvage liver transplantation (ST) is reported to have good results, while repeat hepatectomy in Japan is usually a treatment of choice for patients with good hepatic reserves in Japan. The aim of this study is to evaluate the prognostic impact of IHR of HCC within MC and to identify factors related to IHR within MC.

Methods: Between April 2003 and December 2015, 218 patients were treated with primary resection for HCC at Jikei University Hospital. Of those, 118 patients who developed IHR were retrospectively reviewed, and the significance of the following clinicopathological factors were assessed: patient factors (age, sex, viral status, background liver), primary and recurrent tumor factors (size, number, macroscopic portal vein invasion), treatment modality and 5-year overall survival after recurrence (5-y OS).

Results: Median age was 68 years (29 – 90) and 107 patients (91%) were male. Sixty-eight patients (58%) developed IHR within MC, and 37 patients (54%) were treated with repeat hepatectomy. With the median follow-up period of 64.6 months, IHR within MC showed significantly better 5-y OS (74%) as compared with IHR beyond MC (22%) (p < 0.001?. 5-y OS of the patients with IHR within MC treated with repeat hepatectomy was 85%, which was better than reported 5-y OS of ST. By univariate analysis, the patients with IHR within MC had higher rate of HBV+?p = 0.034?, tumor size more than 5 cm ?p < 0.001? and macroscopic PV invasion ?p = 0.041?. By multivariate analysis, independent prognostic factors consisted of tumor size more than 5 cm ?p = 0.041?, macroscopic PV invasion (p = 0.027? and repeat hepatectomy ?p < 0.001?.

Conclusion: IHR within MC after primary liver resection in selected patients for HCC could be treated with repeat hepatectomy with good outcome as compared with ST.

71.03 So Many Pancreatic Cystic Neoplasms, So Little Known About Their Natural History

Posted on January 18, 2018

F. F. Yang1, M. M. Dua2, P. J. Worth2, G. A. Poultsides3, J. A. Norton3, W. G. Park4, B. C. Visser2  1Stanford University,School Of Medicine,Palo Alto, CA, USA 2Stanford University,Hepatobiliary & Pancreatic Surgery,Palo Alto, CA, USA 3Stanford University,Surgical Oncology,Palo Alto, CA, USA 4Stanford University,Gastroenterology & Hepatology,Palo Alto, CA, USA

Introduction: Pancreatic cystic neoplasms (PCNs) are a frequent incidental finding on imaging performed for indications unrelated to the pancreas. Guidelines for management of PCNs are largely based on surgical series; important aspects of their natural history are still unknown. The purpose of this study was to characterize which PCNs can be safely observed.

Methods: A retrospective study of patients who either underwent immediate resection of a PCN (within 6 weeks of presentation) or observation with at least two imaging studies between 2004-2014 was performed. Descriptive statistics and multiple logistic regression analyses were performed to determine predictors of premalignancy and malignancy.

Results:  Of the 1151 patients in this study, 66 (5.7%) underwent immediate surgery while 1085 patients had surveillance with a median follow-up of 15.5 months, mean of 24.7 (SD 25.6). Of the observed patients, 183 (16.9%) demonstrated radiographic progression, while the majority (83.1%) did not progress. Eighty-four (7.6%) of the observed patients eventually underwent surgery for concerning features with a median of 8.0 months until resection, mean of 18.1 (SD 26.1). The risk of malignancy among patients undergoing immediate surgery was 65%. The risk of developing malignancy during the first 12 months of surveillance was 5.3%, while the risk for malignancy decreases with surveillance time (TABLE).

Multiple logistic regression demonstrated that amongst all patients, jaundice (OR=36.3, CI 95%=5.96-221, p<0.0001), initial cyst size>3.0cm (OR=5.14, CI 95%=1.13-23.5, p=0.035), solid component (OR=2.96, CI 95%=1.04-8.42, p=0.042), and main pancreatic duct dilation (MPD)>5mm (OR=4.18, CI 95%=1.18-14.9, p=0.27) were independent predictors of premalignancy or malignancy. Among observed patients, jaundice (OR=13.9, CI 95%=1.48-130.3, p=0.021), unintentional weight loss (OR=8.03, CI 95%=1.59-40.5, p=0.012), radiographic progression (OR=3.42, CI 95%=1.28-7.91, p=0.004), and MPD>5mm (OR=4.99, CI 95%=1.24-20.0, p=0.023) were independent predictors of premalignancy or malignancy.

Conclusion: Relatively few pancreatic cystic lesions progress to malignancy during surveillance, especially beyond a time frame of one year. However, the risk of transformation does persist after 5 years of follow-up. This understanding of the natural history, predictors of malignancy, and especially the timeframe of transformation of PCN to either carcinoma-in-situ or invasive adenocarcinoma is important for counseling of patients undergoing surveillance.

71.02 Raid Growth Speed of Cyst was a Predictive Factor for Malignant Intraductal Mucinous Papillary Neoplasms

Posted on January 18, 2018

K. Akahoshi1, N. Chiyonobu1, H. Ono1, Y. Mitsunori1, T. Ogura1, K. Ogawa1, D. Ban1, A. Kudo1, M. Tanabe1  1Tokyo Medical And Dental University,Hepato-Biliary-Pancreatic Surgery,Bunkyo-ku, Tokyo, Japan

Introduction:
Intraductal mucinous papillary neoplasms (IPMN) are cystic tumors of the pancreas with the ability to progress to invasive cancer, and being discovered with increasing frequency. Currently, the timing of surgical treatment is determined based on the international consensus guideline. However, pre-operative risk stratification for malignant IPMN is sill difficult. Novel predictors for malignant potential of IPMN are expected to be identified.

Methods:
This is a retrospective, single-center study of IPMN patients who underwent surgical resection between 2005 and 2015, and 81 patients were enrolled. Clinical and pathological data were collected and analyzed. The differences between benign IPMN and malignant IPMN were compared. Malignant IPMN was defined as presence of high-grade dysplasia or invasive cancer based on pathological diagnosis of resected specimen.

Results:
Of the 81 patients, 46 showed benign (low to intermediate dysplasia) and 35 showed malignant IPMN. Malignant IPMN were present in 28% of patients with branch duct type (10/36), 55% with combined duct type (17/31) and 57% with main duct type (8/14). Fifty-nine percent (24/41) of patients with high-risk stigmata and 27% (10/37) with worrisome features exhibited malignant IPMN. High-risk stigmata significantly correlated with malignant potential (p=0.006). Next, cyst growth speed of branch duct type and combined type patients with at least 2 contrast-enhanced imaging studies was measured. Average cyst growth speed of benign IPMN and malignant IPMN patients was 0.979±1.796mm/year and 6.933±2.958mm/year, respectively (p<0.001).

Conclusion:
Rapid cyst growth speed was a predictive factor for malignant IPMN as well as high-risk stigmata. Evaluation of cyst growth speed would contribute to optimize treatment strategy of IPMN patients.
 

7.19 Finding the Surgical “Sweet Spot” in Colorectal Cancer: Timing Affects Survival.

Posted on January 18, 2018

R. J. Kucejko1, T. Holleran1, D. E. Stein1, J. L. Poggio1  1Drexel University College Of Medicine,Surgery,Philadelphia, PA, USA

Introduction:  Surgical resection is the mainstay of definitive treatment for colon and rectal cancer.  Prior studies have shown that earlier surgery for other malignancies can improve long-term survival.  Research has shown that emergent treatment for colorectal cancer leads to lower long-term survival, but the effect of timing for elective surgery has not been well studied.  Quality metrics have been established for the administration of chemotherapy in colorectal surgery, but none exist for the timing of surgery.  This study aims to determine the optimal timing of elective surgical resection of colon and rectal cancer.

Methods:  A retrospective review was performed on the National Cancer Database (NCDB) on patients between 2004 and 2013 with a primary site corresponding to colon or rectum.  Patients were included if the entry was for their first and only malignancy, and if definitive surgical treatment was performed prior to other modalities.  Patients were excluded if the number of days to diagnosis was unknown, or diagnosis was made on autopsy.  Patients were separated into 15-day strata and post-operative outcomes were assessed by chi-squared and Mann-Whitney U tests.  Overall survival was evaluated by Cox regression.

Results: 595,174 patients were analyzed, with 78.7% having colon cancer and 21.3% having rectal cancer.  62.4% of all patients were operated on between 0 to 15 days after definitive diagnosis, with 30.2% having an operation the same day as diagnosis.  Cox regression analysis controlling for age, stage, and Charlson comorbidity score showed the lowest overall survival rate in patients operated on within the first 15 days of diagnosis.  When days 0 through 15 were analyzed individually, a significantly lower survival was noted between days 2 through 6.  The highest survival was seen in patients operated on between 16 and 90 days after definitive diagnosis.

Conclusion: The timing of surgery in colon and rectal cancer significantly affects overall survival.  Patients operated on the same day of diagnosis may represent those in need of emergent surgery, yet those patients did not have the lowest overall survival when controlling for disease stage, age, and comorbidities.  The high percentage of patients receiving definitive operations within the first 15 days suggest patients may be receiving definitive operations too soon.  They would likely benefit from pre-operative optimization of medical comorbidities, nutrition, and social support, as no benefit is seen from rushing to surgery.  There is a need for further analysis of pre-operative variables to determine why the lowest survival exists between days 2 to 6 after definitive diagnosis. 

 

7.15 Trends and Outcomes for Minimally Invasive Surgery for Inflammatory Bowel Disease

Posted on January 18, 2018

C. H. Davis1, T. Gaglani2, H. R. Bailey1,2, M. V. Cusick1,2  1Methodist DeBakey Heart And Vascular Center,Department Of Surgery,Houston, TX, USA 2University Of Texas Health Science Center At Houston,Department Of Surgery,Houston, TX, USA

Introduction:
The relapsing and remitting nature of Inflammatory Bowel Disease (IBD) predisposes patients to the development of fibrotic strictures, which must often be managed surgically. Laparoscopy provides the potential for enhanced perioperative care. Previous studies comparing morbidity and trends of open versus laparoscopic resection in IBD have been constrained by length of study and sample size. The aim of this study was to assess the trends of laparoscopic utilization over time and to compare operative outcomes with between open vs. laparoscopic technique.

Methods:
Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, patients with primary diagnosis of IBD undergoing surgical resection from 2005-2015 were identified using a combination of ICD-9 and CPT codes. Utilization as well as morbidity and mortality rates were then compared between open and laparoscopic resections.

Results:
A total of 29,266 resections were performed on IBD patients; 4,856 (16.6%) performed laparoscopically. The mean age in the open and laparoscopic groups was 43.8 and 38.9 years, respectively. The mean BMI in the open and laparoscopic groups was 25.7 and 25.2 kg/m2. The use of laparoscopy increased over time from 5.9% in 2005 to 23.2% in 2015. Comparing laparoscopic versus open, postoperative complication rates favored laparoscopy in each of the 16 categories. (Table 1) The most common complications in both laparoscopic and open methods were organ space infection (5.4% vs. 6.9%), superficial surgical site infection (4.6% vs. 7.1%), and urinary tract infection (1.3% vs. 3.4%). Length of stay was also markedly reduced in the laparoscopic group (6.4 vs. 9.3 days).

Conclusion:
These data indicate that the number of laparoscopic resections for IBD have been increasing over time. Favorable complication rates, operating time and hospital stay suggest that laparoscopy may be a safer option and should be preferred for fibrotic bowel resection. There are various limitations of this study that stem from the use of the NSQIP database. Skill or training level of surgeons and outcome data past 30 postoperative days are not captured. Furthermore, there was limited information about the clinical complexity of each case as the database did not contain inflammatory markers such as C-reactive protein or sedimentation rates. Future analyses should be conducted about the relative efficacy of robotic surgery as well as single incision laparoscopic surgery.
 

7.14 Perineural Invasion is a Significant Prognostic Factor in Non-Metastatic Colon Cancer.

Posted on January 18, 2018

L. G. Leijssen1,2, A. M. Dinaux1,2, H. Kunitake1,2, L. G. Bordeianou1,2, D. L. Berger1,2  1Massachusetts General Hospital,General And Gastrointestinal Surgery,Boston, MA, USA 2Harvard School Of Medicine,Brookline, MA, USA

Introduction:  ?Perineural invasion (PNI) is associated with adverse oncological outcomes in colorectal cancer. However, it’s often underreported and not considered in the TNM staging system. The aim of this study is to clarify the role of PNI in patients with non-metastatic colon cancer.?

Methods:  Patients with stage I-III colon cancer who underwent elective surgery at our tertiary center between 2004-2014 were extracted from a prospectively maintained database (n=1090). Long-term outcomes were compared, and differences were determined by multivariable Cox regression models adjusted for stage and potential confounders. ?

Results: PNI was identified in 168 (15.4%) patients and associated with left-sided tumors, greater tumor size, and advanced disease. Histopathological features including extramural vascular invasion, large and small vessel involvement, and poor differentiation were correlated with PNI. Furthermore, recurrence rates were significantly higher in patients with PNI presence (P<0.001). This was mainly explained by a higher rate of distant recurrence (8.7% vs. 30.4%, P<0.001), with liver (14.9%), peritoneum (8.9%), and lung (8.3%) as the main sites of metastasis. The estimate 5-year overall (OS) and disease-free survival (DFS) were both worse in the PNI positive group (OS: 79.7% vs. 55.1%; DFS: 87.9% vs. 60.8%, both P<0.001). Patients with stage-II disease and PNI presence had significantly worse OS than stage-III patients with no PNI (P<0.001). However, adjuvant therapy reversed this adverse outcome to comparable OS (P0.205). Multivariate analysis demonstrated PNI as an independent predictor for both overall (HR 1.77, 95% CI: 1.31-2.40, P<0.001) and disease-free survival (HR 1.72, 95% CI: 1.20-2.54, P0.004).?

Conclusion: Our study supports the benefits of adjuvant therapy in stage-II colon cancer with PNI positivity. PNI presence is an independent and poor prognostic factor in non-metastatic colon cancer and should be considered as a factor in disease stratification.?

 

7.13 Pre-operative Predictors of Prolonged Length-of-Stay with Enhanced Recovery After Surgery (ERAS)

Posted on January 18, 2018

T. S. Wahl1, J. D. Owen1, L. E. Goss1, J. S. Richman1, M. S. Morris1, G. D. Kennedy1, J. A. Cannon1, D. I. Chu1  1University Of Alabama At Birmingham,Department Of Surgery,Birmingham, AL, USA

Introduction: ERAS decreases post-operative length-of-stay (pLOS) and cost following colorectal surgery. It remains unclear, however, which patients will fail ERAS based on pre-operative assessments. We hypothesized that patient-level factors, such as social determinants of health (SDOH), would predict prolonged post-operative length-of-stay.

Methods: All adult patients undergoing colorectal surgery with ERAS from 2015 at a single-institution were identified. ERAS failure was defined as an observed pLOS greater-than-the-expected pLOS calculated using the ACS-NSQIP Risk Calculator. Patients were stratified by ERAS success or failure. Pre-operative patient-level characteristics including SDOH were compared. Backwards step-wise logistic regression identified independent predictors of ERAS failure.

Results: Of 210 patients, 39 (18.6%) patients were ERAS failures. No differences in SDOH or ERAS compliance rates were observed between groups. Compared to non-ERAS failures, ERAS failure patients experienced a median pLOS 12 days (IQR 8-14) compared to 3 days (IQR 3-4) (p<0.001). ERAS failure was associated with active smoking, white race, and emergency surgery. On adjusted analysis, pre-operative smoking status (OR 2.4 95%CI 1.1-5.6, p=0.03) and emergency surgery (OR 5.0 95%CI 1.9-13.5, p<0.01) were independently associated with ERAS failure. On adjusted analysis of elective surgery patients, the presence of pre-operative opioid prescriptions was independently associated with ERAS failure (OR 4.8 95%CI 1.7-13.7, p=0.03).

Conclusion: Pre-operative patient characteristics associated with ERAS failure are smoking status, emergency surgery, and having outpatient opioid prescriptions. These factors represent potential targets for future interventions to prevent ERAS failure.
 

7.12 Risk Factors Associated with Readmission after Ileal Pouch-Anal Anastomosis: An ACS-NSQIP Analysis

Posted on January 18, 2018

N. P. McKenna1,4, E. B. Habermann3,4, A. E. Glasgow4, K. L. Mathis2, A. L. Lightner2  1Mayo Clinic,Department Of Surgery,Rochester, MN, USA 2Mayo Clinic,Division Of Colon And Rectal Surgery,Rochester, MN, USA 3Mayo Clinic,Department Of Health Science Research,Rochester, MN, USA 4Mayo Clinic,Robert D. And Patricia E. Kern Center For The Science Of Health Care Delivery,Rochester, MN, USA

Introduction: While the increased risk for readmission after ileal pouch-anal anastomosis (IPAA) relative to other colorectal surgery operations is known, reasons and risk factors for readmission remain poorly understood. The purpose of this study was to identify preventable reasons for readmission and to delineate risk factors for readmission in the perioperative period.

Methods: Patients with a diagnosis of chronic ulcerative colitis (CUC) undergoing either total proctocolectomy with IPAA (two-stage) or proctectomy with IPAA (three-stage) were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2012 to 2015.  Reasons for unplanned readmission within 30 days of procedure were reviewed and categorized as infectious, dehydration/electrolyte abnormalities, small bowel obstruction/ileus, venous thromboembolism, ostomy related, pouch related, pain, bleeding, and other/missing. The primary outcome rate measured was readmission within 30 days of discharge as calculated by person-years method. Cox Proportional Hazard models determined independent risk factors for readmission overall and for specific categories.  

Results: 3473 patients met inclusion criteria with an overall readmission rate of 33% per 30 person days. Identified reasons for readmission included infectious complications (32%), dehydration/electrolyte abnormalities (23%), small bowel obstruction/ileus (15%) and venous thromboembolism (VTE) (5%). Multivariable analysis found race/ethnicity of Hispanic white and black/African American (both versus non-Hispanic white, HR: 1.5, p=0.02 and HR: 1.4, p=0.02, respectively) to be independently associated with thirty-day readmission. When looking at specific reasons for readmission, age 57+ (versus age 18-32, HR: 2.3, p<0.01) and hypertension requiring medication (HR: 1.5, p=0.04) were associated with readmission for dehydration/electrolyte abnormalities; two stage IPAA was associated with readmission for VTE (HR 6.5, p=0.01), while obesity (HR 1.5, p<0.01), operative time 330+ minutes (versus <189 minutes, HR: 2.2, p<0.01), and Hispanic white race/ethnicity (versus non-Hispanic white, HR: 2.0, p<0.01) were associated with readmission for infectious complications.

Conclusions: One-third of patients were readmitted after IPAA, with infectious complications and dehydration making up the majority of reasons for readmission. Targets for quality improvement include potentially preventable reasons for readmission such as dehydration and VTE. The development of pathways to prevent dehydration after discharge in high-risk patients and consideration of extended VTE prophylaxis after two-stage IPAA could help reduce the high readmission rate after IPAA. 

7.07 Primary Tumor Sidedness Differentially Affects Overall Survival for Stage I-IV Colon Adenocarcinoma

Posted on January 18, 2018

J. Watson1, M. Turner1, Z. Sun1, D. Becerra1, J. Migaly1, C. Mantyh1, D. Blazer1  1Duke University Hospital,Department Of General Surgery,Durham, NC, USA

Introduction: Recent studies have observed differences in overall survival and response to chemotherapy in left compared to right-sided colon cancer. This suggests biologic differences within tumor laterality. We evaluated the impact of left compared to right-sided primary tumors on overall survival for patients with stage I-III and stage IV colon cancer in both operative and non-operative cohorts, utilizing a large national cancer database.

Methods: The 2006-2013 National Cancer Data Base was queried for patients with single primary, stage I-IV colon adenocarcinoma. Patients were grouped by stage and tumor location based on embryologic boundaries. Left side was defined as splenic flexure to the sigmoid colon, and right side was defined as cecum to transverse colon. Patients with appendiceal, overlapping, or unspecified tumor locations were excluded. Overall survival was compared using Cox Proportional Hazard modeling while adjusting for demographic, clinical, and tumor characteristics. The analysis was conducted separately for patients who had operative and non-operative management (stage IV) of the primary tumor.

Results: For stage I-II tumors, 114,839 patients underwent resection, 62% for right and 38% for left-sided tumors. After adjustment for patient and tumor characteristics, patients with right-sided tumors had superior survival compared to those with left-sided tumors (HR for left-sided tumors, right-sided reference [HR]: 1.13, p<0.001). For Stage III tumors, 71,024 patients underwent resection (59% right-sided, 41% left-sided tumors). Of 60,788 patients with stage IV tumors, 41,371 (68%) patients underwent resection (57% right-sided, 43% left-sided). For the 19,417 patients with stage IV cancer who did not undergo surgery, 56% were right-sided tumors, and 44% were left-sided tumors. After adjustment for patient and tumor characteristics, left-sided tumors had superior survival compared to right-sided tumors in Stage III tumors, Resected Stage IV tumors, and Unresected  Stage IV Tumors with respective Hazard Ratios of Stage III 0.90, p<0.001, Stage IV Resected HR 0.71, p<0.001, and Stage IV Unresected HR 0.77, p<0.001.

Conclusion: Primary tumor laterality affects overall survival across stages for colon adenocarcinoma. In this analysis, patients with right-sided tumors have superior survival for stage I-II disease. However, left-sided tumors have superior survival in advanced disease, stage III-IV. These results from a large, national cancer database reinforce and extend previous subgroup analyses of large cooperative group trials.  These findings provide investigators better prognostication tools and provide a possible avenue to better understand the molecular mechnisms in patients with colon adenocarcinoma.

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