64.03 National Trends and Predictors of Adequate Nodal Sampling for Resectable Gallbladder Adenocarcinoma

Posted on January 18, 2018

A. J. Lee1, Y. Chiang1, C. Conrad1, Y. Chun-Segraves1, J. Lee1, T. Aloia1, J. Vauthey1, C. Tzeng1  1University Of Texas MD Anderson Cancer Center,Surgical Oncology,Houston, TX, USA

Introduction: For gallbladder cancer (GBC), the new American Joint Committee on Cancer 8th edition (AJCC8) staging system classifies lymph node (LN) stage by the number of metastatic LN, rather than their anatomic location as in AJCC6 and AJCC7.  Additionally, AJCC8 now recommends resection of ≥6 LNs for adequate nodal staging.  In the context of this new staging system and recommendation for GBC surgery, we evaluated current national trends in LN staging and sought to identify factors associated with any and/or adequate LN staging according to this new guideline.

Methods: Utilizing the National Cancer Data Base (NCDB), we identified all gallbladder adenocarcinoma patients treated with surgical resection with complete tumor staging information between 2004-2014.  We excluded patients with T1a and lower pathologic T-stage, as nodal staging is not indicated in these patients.  Nodal staging and nodal positivity rates were compared over the study period.  Univariate and multivariate logistic regression modeling were performed to identify factors associated with any and/or adequate nodal staging.

Results: We identified 11,525 patients with T-stage ≥T1b, for whom lymphadenectomy is recommended.  Only 49.6% (n=5,719) of patients had any LN removed for staging.  On multivariate analysis, treatment at academic centers (OR=2.33, p<0.001), more recent year of diagnosis (OR=2.29, p<0.001), clinical node-positive status (OR=3.46, p<0.001), pathologic T2 stage (OR=1.25, p<0.001), and radical surgical resection (OR=4.85, p<0.001) were associated with higher likelihood of having any nodal staging.  Age ≥80 (OR=0.57, p <0.001), and higher co-morbidity index (OR=0.70, p<0.001) were associated with lower likelihood of having any nodal staging.  However, of the 5,719 patients who underwent any nodal staging, only 21.8% (n=1,244) met the AJCC8 recommendation of adequate LN staging.  On multivariate analysis, female sex (OR=1.18, p=0.02), treatment at academic centers (OR=1.52, p<0.001), radical surgical resection (OR=2.53, p<0.001), and pathologic T4 stage (OR=2.14, p<0.001) were associated with having ≥6 LN resected concomitantly with their oncologic operation.  Patients over 80 years old (OR=0.60, p<0.001) and in South region (OR=0.79, p=0.002) were less likely to have adequate LN sampling according to the new recommendation.

Conclusion: National trends in the overall GBC LN staging rate of 49.6% do not live up to the new AJCC8 recommendations.  Furthermore, the finding that only 21.8% of patients met the 6 LN threshold highlights the gap between the new AJCC8 recommendations and reality.  We have identified demographic and clinicopathologic factors associated with any and/or adequate LN staging, which can be incorporated into future targeted quality improvement initiatives.

63.09 Outcomes in VATS Lobectomies: Challenging Preconceived Notions

Posted on January 18, 2018

D. J. Gross1, P. L. Rosen1, V. Roudnitsky4, M. Muthusamy3, G. Sugiyama2, P. J. Chung3  2Hofstra Northwell School Of Medicine,Department Of Surgery,Hempstead, NEW YORK, USA 3Coney Island Hospital,Department Of Surgery,Brooklyn, NY, USA 4Kings County Hospital Center,Department Of Surgery, Division Of Acute Care Surgery And Trauma,Brooklyn, NY, USA 1SUNY Downstate,Department Of Surgery,Brooklyn, NY, USA

Introduction:   The number of thoracic resections performed for lung cancer is expected to rise due to increased screening in high risk populations. However majority of thoracic surgical procedures in the US are performed by general surgeons (GS). Currently Video Assisted Thoracoscopic Surgery (VATS) has become the preferred approach to lung resection when feasible. Our goal is to examine short term outcomes of VATS lobectomy for malignancy performed by either GS or CT surgeons using the America College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) database.

Methods:  Using ACS NSQIP 2010-2015 we identified patients that had an ICD 9 diagnosis of lung cancer (162) that underwent VATS lobectomy (CPT 32663). We included only adults (≥18 years) and elective cases and excluded cases that had preoperative sepsis, contaminated/dirty wound class, and missing data. Risk variables of interest included demographic, comorbidity, and perioperative variables. Outcomes of interest included 30-day postoperative mortality, 30-day postoperative morbidity, and length of stay (LOS). Univariate analysis comparing cases performed by GS vs CT was performed. We then performed propensity score analysis using a 3:1 ratio of CT:GS cases with categorical outcome variables assessed using conditional logistic regression.

Results: A total of 4,308 cases met criteria; 649 (15.1%) by GS and 3,659 (84.9%) by CT. Mean age in the GS group was 68.6 vs 67.8 years in the CT group (p=0.034). There was a greater proportion of African American patients in the GS compared to CT group (8.0% vs 3.4%, p<0.0001), but higher rates of dyspnea with moderate exertion in the CT compared to GS group (19.8% vs 12.9%, p<0.0001). Operative time was shorter in the GS group vs CT group (179 vs 196 minutes, p <0.0001).  After propensity score matching the two groups were found to be well balanced on all risk variables. LOS was longer in the GS vs matching CT group (mean 6.2 vs 5.3 days, p=0.0001). Conditional logistic regression showed that GS treated patients had no greater risk of 30-day mortality (p=0.806), but had greater risk of postoperative sepsis (OR 2.20, 95% CI [1.01, 4.79], p=0.047).

Conclusion: In this large observational study using a prospectively collected clinical database, we found that while general surgeons had longer LOS, compared to cardiothoracic trained surgeons there were no differences in short-term mortality and morbidity with the exception of increased risk of postoperative sepsis. Further prospective studies are warranted to investigate oncologic and long-term outcomes.

63.10 Acid Suppression to Prevent Gastrointestinal Bleeding in Patients with Ventricular Assist Devices

Posted on January 18, 2018

A. W. Hickman1, N. W. Lonardo1, M. C. Mone1, A. P. Presson1, C. Zhang1, R. G. Barton1, S. H. McKellar1, C. H. Selzman1  1University Of Utah,Salt Lake City, UT, USA

Introduction:  The high incidence of gastrointestinal bleeding (GIB) in patients with ventricular assist devices (VAD) is well known, but there is limited evidence to support the use of proton pump inhibitors (PPI) or histamine receptor antagonists (H2RA) for preventing GIB in patients who require treatment for their cardiac disease with VAD implantation.

Methods: The institutional Surgical and Cardiovascular ICU and VAD databases within an academic cardiac mechanical support and transplant center were queried for patients who underwent VAD implantation between 2010 and 2014. The devices included HeartWare, HeartMate II, Jarvik 2000, or SynCardia TAH devices and could be used for left, right or both-sided failure. An observational cohort study was conducted on the final population to identify which prophylactic acid suppressing drug regimen was associated with the fewest number of GIB events within 30-days after VAD implantation: PPI or H2RA, or no acid suppressing therapy. Secondary outcomes included an evaluation of the timing, etiology, and location of all GIB events. Univariate and multivariate regression was performed using clinically important covariates. A combined variable for pre-existing GIB risk was created based on history of GIB and previous use of acid suppressive medication. Based on the number of GIB events, the acid suppressing treatment and three other covariates were used in the final model.

Results: There were a total of 138 patients included for analysis, 19 (13.8%) of which had a GIB event within the 30-day period. Both H2RA and PPI use were associated with a reduction in GIB events when compared to no acid suppressive therapy. In the logistic regression analysis controlling for ICU admission APACHE II score, preoperative hematocrit, and pre-existing GIB risk, the PPI cohort had a statistically significant reduction in GIB [OR 0.18 (0.04-0.79) p=0.026] (see table).

Conclusion: This review of patients with newly implanted VAD revealed that the use of acid suppressing therapy during the postoperative ICU period resulted in fewer GIB events. When controlling for severity of illness and known risks for bleeding, those patients treated with a PPI had a statistically lower risk for GIB. Cardiothoracic surgeons and ICU clinicians should consider this treatment option in order to reduce complications for this high-risk subset of patients.

 

63.04 Incidence, Costs and Length of Stay for Heparin Induced Thrombocytopenia in Cardiac Surgery Patients

Posted on January 18, 2018

E. Aguayo1, K. L. Bailey1, Y. Seo1, A. Mantha2, V. Dobaria1, Y. Sanaiha1, P. Benharash1  1University Of California At Los Angeles,Department Of Surgery/ Division Of Cardiac Surgery,Los Angeles, CA, USA 2University Of California – Irvine,School Of Medicine,Orange, CA, USA

Introduction:
Heparin is routinely used in many cardiovascular procedures to prevent thrombosis. An antibody mediated process, heparin-induced thrombocytopenia (HIT) occurs in a small subset of patients exposed to heparin. While hemorrhage is thought to be rare in HIT, the incidence of stroke, pulmonary embolism, and deep vein thrombosis dramatically increase. While some have suggested a recent increase in the incidence of HIT, data on the impact of HIT on costs and length of stay (LOS) after cardiac surgery is generally lacking. The present study aimed to assess national trends in the incidence and resource utilization associated with HIT in cardiac surgical patients. 

Methods:
A retrospective cohort study was performed identifying adult cardiac surgery patients (≥ 18 years) with a diagnosis of HIT were identified using the 2009-2014 National Inpatient Sample (NIS) Database and International Statistical Classification of Diseases and Related Health Problems (ICD9) codes. In hospital mortality and GDP-adjusted cost were evaluated using hierarchical linear models adjusting for socioeconomic, demographic and comorbidity measured by Elixhauser Index.

Results:
Of the 3,985,878 adult cardiac surgery patients, 16,610 (0.42%) had HIT as a primary diagnosis with no trend over the study period. Compared to those without the diagnosis, HIT patients were on average older (67.1 vs 65.1, p<0.001), insured by Medicare (62% vs 52%, p<0.001), and had a higher Elixhauser comborbidity index (4.48 vs. 3.75, p<0.001). HIT was associated with significantly longer index LOS (19.1 vs 10.6 days, p<0.001) and higher hospitalization costs (91,977 vs $52,090, p<0.001). After adjustment for baseline differences, HIT was independently associated with increased risk of death (OR 2.72, 95% CI: 2.41-3.06), stroke (OR 2.12, 95% CI: 1.72-2.62), deep venous thrombosis (OR: 8.63, 95% CI: 7.60-9.80), and pulmonary embolism (OR: 5.43, 95% CI: 4.55-6.48).

Conclusions:

Based on this national analysis of adult cardiac surgical patients, HIT disproportionately affected those with government sponsored health insurance. The presence of HIT was associated with a significantly longer LOS, higher costs and comorbidities. The incidence of serious complications such as stroke, DVT, and PE more than doubled in HIT patients. These findings have significant implications in the era of value-based healthcare delivery. In addition to reducing unnecessary exposure to heparin, proper diagnosis and treatment is essential for favorable outcomes in these patients.

 

63.05 Immune Cell Alterations after Cardiac Surgery Associated with Increased Risk of Complications and Mortality

Posted on January 18, 2018

D. J. Picone1, N. R. Sodha1, T. C. Geraci1, J. T. Machan1, F. W. Sellke1, W. G. Cioffi1, S. F. Monaghan1  1Brown University School Of Medicine,Surgery,Providence, RI, USA

Introduction: Systemic inflammatory response syndrome (SIRS) frequently occurs following cardiac surgery, a controlled traumatic event. Typically, emphasis is placed on the white blood cell count; however, immune cell responses following trauma have been associated with poor outcomes.  We hypothesize that lymphocyte loss and lack of recovery after cardiac surgery will predict poor outcomes.

Methods: This is a retrospective review of all adult post-cardiac surgery patients from a single institution from Oct 2008 to Oct 2015. Patients were included if they had more than two complete blood counts (CBC) drawn in the first 7 days post operatively. Demographic data, complications, hospital and ICU length of stays, operative data, and mortality were obtained from the Society of Thoracic Surgery (STS) database. Laboratory data was obtained from the medical record.  Leukocyte, neutrophil, and lymphocyte counts were retained. Patients were grouped based on the pattern of response of elevation/depression and normalization versus failure of normalization for each component (leukocyte, neutrophil, lymphocyte). Kaplan-Meier curves and odds ratios were used to analyze association with 30 day mortality, development of pneumonia, renal failure, post-operative sepsis, and all complications. 

Results: 2401 patients were included in the leukocyte group and 1795 patients in both the neutrophil and lymphocyte groups. Patients who developed increased leukocytosis that remained elevated within 7 days had an increased risk of mortality (8.7%), compared to both those who normalize (2.9%, p <0.0001) and those who did not develop a leukocytosis (1.8%, p <0.0001). There was no difference in mortality for the neutrophil or lymphocyte groups.  Patients who did not develop post-operative lymphopenia had decreased risk compared both to those with persistent lymphopenia and those with normalization of lymphopenia, as indicated respectively in the following: pneumonia (OR 0.42 (CI 0.25-0.69), 0.49 (CI 0.24-0.98)); renal failure (OR 0.21 (CI 0.12-0.39), 0.36 (CI 0.15-0.8)); sepsis (OR 0.21 (CI 0.06-0.64), 0.11 (CI 0.03-0.36)); all complications (OR 0.42 (CI 0.30-0.61), 0.37 (CI 0.23-0.58)). Leukocytosis that failed to normalize was associated with increased risk of pneumonia (OR 2.5 (CI 1.2-3.4)) and all complications (OR 3.46 (CI 2.5-4.8)). There was no associated complication risk with neutrophilia.

Conclusion: Failure to normalize leukocytosis after cardiac surgery is associated with higher risk of mortality. Development of lymphopenia in the post-operative period is associated with increased risk of post operative complications. Use of these routinely ordered labs may help identify patients at risk for complications and who should not be “fast tracked” for discharge. Future work will compare the predictive nature of these laboratory tests versus standard predictors from the STS database.

 

63.03 The Additive Effect of Comorbidity and Complications on Readmission after Pulmonary Lobectomy

Posted on January 18, 2018

R. A. Jean1,2, A. S. Chiu1, J. D. Blasberg3, D. J. Boffa3, F. C. Detterbeck3, A. W. Kim4  1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA 2Yale University School Of Medicine,National Clinician Scholars Program,New Haven, CT, USA 3Yale University School Of Medicine,Section Of Thoracic Surgery, Department Of Surgery,New Haven, CT, USA 4Keck School Of Medicine Of USC,Division Of Thoracic Surgery, Department Of Surgery,Los Angeles, CA, USA

Introduction: Hospital readmission after cardiothoracic surgery has a significant effect on healthcare delivery, particularly in the era of value-based reimbursement. Studies have shown that readmission after major surgery is significantly associated with preoperative comorbidity burden and the development of postoperative complications. We sought to investigate the additive impact of comorbidity and postoperative complications on the risk of readmission after thoracic lobectomy, and compare which of these factors were driving this phenomenon. 

Methods:  The Healthcare Cost and Utilization Project’s Nationwide Readmission Database (NRD) between 2010 and 2014 was used as the dataset for this study. The NRD was queried for discharges for pulmonary lobectomy with a primary diagnosis of lung cancer. Patients surviving to discharge were followed for rates of 90-day readmision. Readmission rates were calculated for low-risk patients who had no comorbidity and no postoperative complications.  Next, rates were compared iteratively by the presence of Elixhauser comorbidity and postoperative complications. Adjusted linear regression, accounting for patient age, sex, insurance status, and income, was used to calculate the mean change in readmission rate by the number of comorbidities and postoperative complications.

Results: A total of 106,262 pulmonary lobectomies were identified over the study period, of whom 20,112 (18.9%) were readmitted within 90 days of discharge. Of this total cohort, the mean age was 67.7 ± 0.11 years, with a mean of 2.5 Elixhauser comorbidities and an mean incidence of 0.8 postoperative complications per patient. Of the 5812 (5.5%) patients with no comorbidities or postoperative complications, 680 (11.7%) were readmitted. At the other extreme, of the 6121 (5.8%) of patients with 3+ comorbidities and 3+ complications, 1877 (30.7%) of patients were readmitted. After adjusting for age, sex, and insurance status, each additional comorbidity and any postoperative complication were associated with a 2.3% (95% CI 2.0% – 2.6%) and 2.7% (95% CI 2.3% – 3.2%) increased probability of readmission, respectively.

Conclusion: Among patients with the lowest risk profile, there was an 11.7% 90-day readmission rate. Adjusting for other factors, each additional comorbidity increased this rate by approximately 2.3%, while each postoperative complication increased this rate by 2.7%. These results demonstrate that even among optimized patients without postoperative complications, there remains notable risk of rehospitalization, indicating that careful patient selection and the avoidance of complications may not completely reduce readmission risk after pulmonary lobectomy.

 

63.02 Risk Factors for and Outcomes of Conversion to Thoracotomy during Robotic-Assisted Lobectomy

Posted on January 18, 2018

S. Hernandez2, F. Velez-Cubian2, R. Gerard2, C. Moodie1, J. Garrett1, J. Fontaine1,2, E. Toloza1,2  1Moffitt Cancer Center,Thoracic Oncology,Tampa, FL, USA 2University Of South Florida Health Morsani College Of Medicine,Tampa, FL, USA

Introduction:   We aimed to identify risk factors and outcomes for conversion to thoracotomy from robotic-assisted video-assisted thoracoscopic (R-VATS) pulmonary lobectomy.

Methods:   We retrospectively analyzed all patients (pts) who underwent R-VATS lobectomy for primary lung cancer by one surgeon between September 2010 and August 2016.  Patients were grouped to “conversion” versus “non-conversion” to open lobectomy.  Patients’ demographics, co-morbidities, pulmonary function tests (PFTs), perioperative outcomes, hospital length of stay (LOS), tumor histology, and pathologic stage were compared between groups.  Chi-square, analysis of variance, Student’s t-test, or Kruskal-Wallis test was used, with p≤0.05 as significant.

Results:  Twenty pts (5.3%) required conversion to open lobectomy from a total of 380 R-VATS lobectomy pts.  “Conversion” pts were similar in age, BMI, smoking history, co-morbidities, and PFTs to “non-conversion” pts.  More “conversion” pts received neoadjuvant therapy than “non-conversion” pts (25.0% vs. 3.6%; p<0.001).  Estimated blood loss (EBL) was higher in “conversion” pts (500 mL [interquartile range (IQR)=675] vs 150 mL [IQR=150]; p<0.001), and median operative time was longer for “conversion” pts (298 min [IQR=157] vs 171 min [IQR=71]; p<0.001), compared to “non-conversion” pts.  Tumor laterality and having an extended resection or re-do surgery did not significantly differ between groups.  Bleeding from a pulmonary vessel occurred in 50% of “conversion” pts versus 0.3% of “non-conversion” pts (p<0.001).  Tumor size, histology, grade of differentiation, and lymphovascular invasion were not significant factors for conversion.  Patients with pN2 disease had higher risk for conversion (45.0% vs 16.4%; p<0.001).  Pulmonary complications were similar between groups, including prolonged air leak (15.0% vs 21.9%; p=0.46), pneumonia (5.0% vs 6.4%; p=0.80), and respiratory failure (0% vs 1.9%; p=0.53), as was in-hospital mortality (5.0% vs 1.1%; p=0.14).  However, “conversion” pts were at higher risk for cardiopulmonary arrest (5% vs 0.6%; p=0.029), cerebrovascular accident (5% vs 0%; p<0.001), and multi-organ failure (10% vs 0.6%; p<0.001).  Median chest tube duration (5.0 days [IQR=3.8]) for “conversion” pts was longer compared to “non-conversion” pts (4.0 days [IQR=4.0]; p=0.022).  Median hospital LOS was also longer for “conversion” pts (6.0 days [IQR=5.5] vs 4.0 days [IQR=4.0]; p=0.026). 

Conclusions:  Pulmonary lobectomy via R-VATS approach is associated with low conversion rate to thoracotomy.  However, pts with neoadjuvant therapy or clinical N2 disease should be counseled about higher risk of conversion to thoracotomy.  Further, preoperative cardiovascular risk assessment and postoperative monitoring for cardiovascular events are important.

62.09 Readmission for Falls Among Elderly Trauma Patients and the Impact of Anticoagulation Therapy

Posted on January 18, 2018

A. S. Chiu1, R. A. Jean1, M. Flemming1, B. Resio1, K. Y. Pei1  1Yale University School Of Medicine,Surgery,New Haven, CT, USA

Introduction:
Traumatic falls are the leading source of injury and trauma related hospital admission for adults over 65 in the United States. A strong predictor of future falls is a history of previous falls, making patients hospitalized for a fall a high-risk population. It is unknown exactly how frequently this group is hospitalized for a repeat fall. Additionally, there remains debate whether to resume anticoagulation in elderly patients who fall due to fears of bleeding complications with repeat falls. We evaluated the rates of readmission after a fall and frequency of bleeding complications.

Methods:

The National Readmission Database is a nationally representative, all-payer database that tracks patient readmissions. All patients over 65 and admitted in the first 6 months of 2013 and 2014 for a traumatic fall were included for analysis. Those who died during their index hospitalization were excluded.

Primary outcome measured was 6-month readmission rate for a subsequent traumatic fall. Secondary outcomes included the frequency of death and bleeding complications (intracranial hemorrhage, solid organ bleed, and hemothorax) during readmission. Further analysis was conducted stratifying by anticoagulation use.

Results:

In the first 6 months of 2013 and 2014, there were 342,731 admissions for a fall. The cohort had a mean age of 80.2 and 9.3% were on anticoagulation. The rate of 6-month readmission for a repeat fall was 4.7%. Of those who were readmitted for a fall, 3.9% died during the subsequent admission and 12.6% had a bleeding complication. The mortality rate among those with a bleeding complication was 8.5%. The most common bleeding complication on readmission was intracranial bleed (90.8%), followed by hemothorax (5.8%) and solid organ bleed (3.5%).

The rate of readmissions for falls among patients on anticoagulation (4.4%) was not significantly different from those not on anticoagulation (4.7%, p=0.0933). The percent of readmitted patients with bleeding complications was also not statistically different (12.2% with anticoagulation vs. 12.6% without anticoagulation, p=0.7629). However, the mortality rate was higher among those on anticoagulation (6.0% vs. 3.7% without anticoagulation, p=0.0211). Specifically, among patients readmitted with a bleeding complication, those on anticoagulation had a significantly higher mortality rate (24.8% vs. 7.0% without anticoagulation, p<0.0001).

Conclusion:

Among patients hospitalized for a fall, nearly 5% will be re-hospitalized for a subsequent fall within 6 months. Patients on anticoagulation do not have increased rates of bleeding complications when hospitalized for repeat falls; however, when they do have a bleed, they have far higher mortality rates than those not on anticoagulation. Given the high rate of repeat falls and the potential to fatally exacerbate injuries when on anticoagulation, caution should be exercised when restarting anticoagulation among elderly patients hospitalized for a fall.

6.17 National Practice Trends for the Management of Lung Cancer: A Dartmouth Atlas Study

Posted on January 18, 2018

I. C. Bostock1, F. Sheikh1, T. M. Millington1, D. J. Finley1, J. D. Philips1  1Dartmouth Hitchcock Medical Center,Thoracic Surgery,Lebanon, NH, USA

Introduction:
Anatomic resection is the standard of care for early-stage lung cancer. Video-assisted thoracoscopic surgery (VATS) has been established as a safe and effective alternative to an open approach. The aims of this study were to: 1) Characterize open versus VATS surgical practice trends for the management of lung cancer in the United States, and 2) Describe if particular regions of the country utilize minimally invasive surgery more frequently.

Methods:
Using the Dartmouth Atlas Rate Generator, the population of Medicare beneficiaries from the ages of 65 to 99 years with full Part A and B coverage and no HMO coverage for the years of 2006 and 2014 was selected. The diagnosis of lung cancer (ICD-9 codes: 162.0 162.2 162.3 162.4 162.5 162.8 162.9) with subsequent selection of CPT codes to describe thoracoscopic (32601, 32607, 32655, 32663, 32666, 32667, 32668, 32669, 32670, 32671) and open lung resections (32096, 32097, 32141, 32505, 32506, 32507, 32608, 32440, 32442, 32445, 32480, 32482, 32484, 32486, 32488) were queried. Comparison of data between 2006 and 2014 with descriptive statistics and a univariate analysis were performed using student’s t-test and chi-square, as appropriate. A p-value <0.05 was considered statistically significant. Heat maps were generated based on the distribution of cases by geographic region.

Results:
A total of 24,368,333 and 23,921,059 patients for the years of 2006 and 2014, were analyzed. A diagnosis of lung cancer was made in 167,418 patients (0.7%) and 167,506 patients (0.7%) in 2006 and 2014 (p=0.7), respectively. A surgical intervention was performed in 17,249 patients (10.3%) during 2006 and 18,603 patients (11.1%) in 2014 (p=0.01). A VATS approach was performed in 2,512 patients (15%) during 2006 and 9,578 patients (54%) during 2014 (p=0.01). In 2006, California, New York, and New Jersey performed the most VATS procedures, in comparison to 2014, when New York, Florida, and California performed the most VATS procedures. 

Conclusion:
The incidence of lung cancer in the United States was unchanged from the period of 2006 to 2014. A change in surgical practice patterns was evident, with a significant increase in the use of VATS techniques in more than 50% of cases after this eight-year period. This indicates that VATS has become the preferred technique in the population studied.  
 

6.15 Risk Factors Contributing to Cardiac Events Following Thoracic Endovascular Aneurysm Repair (TEVAR)

Posted on January 18, 2018

D. Acheampong1, P. Paul1, P. Boateng1, I. Leitman1  1Mount Sinai School Of Medicine,New York, NY, USA

Introduction:  Cardiac events (CE) following TEVAR have been associated with morbidity and mortality. A large risk-adjusted database was used to understand contributing factors. 

Methods:  A retrospective analysis was performed for completed procedures done from 2010-2015 using the American College of Surgeons -National Surgical Quality Improvement Program (ACS-NSQIP) participant user file. Adult patients (≥18 years) who underwent TEVAR were identified and 30-day outcomes were examined. Initial univariate analysis was conducted on all pre-operative risk factors. Univariate and multivariate analyses were performed to assess risk factors for CE following TEVAR. A P-value of < 0.05 was considered statistically significant.

Results: The study identified 130 out of 2403 (5.4%) patients who underwent TEVAR that developed cardiac events as defined by ACS-NSQIP. Pre-operative leukocytosis, ASA score ³3 and functional dependence were associated with CE post-TEVAR. Underlying major risk factors for CE included emergency operation (53.43% vs 18.58%, p<0.01), ventilator dependence (15.38% vs 0.17%, p<0.01), currently on dialysis (11.53% vs 3.77%, p<0.01), SIRS (19.23% vs 6.30%, p<0.01), sepsis (3.84% vs 0.87%, p<0.01) and septic shock (2.3% vs 0.01%, p<0.01). Patients with postoperative renal failure (3.84% vs 0.99%, p<0.01), unplanned return to operating room (21.53% vs 9.37%, p<0.01) and operation time >180mins (37.7% vs 26.8%, p<0.01) also had increased associated post-operative cardiac events.  CE greatly increased mortality (60.8% vs 2.2%).

Conclusion: CE following TEVAR is associated with significant mortality. Patients with identified risk factors should carefully observed following intervention.  

 

 

6.16 SURGICAL STAGING SUPERIOR TO PET SCAN FOR ASSESSMENT OF DISEASE RESPONSE FOR MEDIASTINAL LYMPHOMA

Posted on January 18, 2018

L. Kane1, H. Savas1, M. DeCamp1, A. Bharat1  1Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA

Introduction:

Mediastinal lymphoma affects young individuals, typically in the second through fourth decades of life, and constitutes over 7% of all lymphomas. The primary treatment modality remains systemic chemotherapy with or without radiation. Response to therapy is determined using PET scan. Unfortunately, in over 25% of patients, PET remains positive and it is unclear whether persistent PET avidity in the mediastinum represents residual disease or inflammatory changes resulting from therapy. Percutaneous image guided biopsy has typically resulted in poor accuracy due to the heterogeneity of the residual mass as well as the difficult nature of needle access. We hypothesized that minimally invasive thoracoscopic techniques would enable better sampling of the PET avid mediastinal lesion, allowing accurate assessment of residual disease following first-line treatment of mediastinal lymphomas.

Methods:
This is a retrospective analysis of a prospectively maintained database. Between January 2009 and December 2015, all patients (n=77) who underwent initial surgical incisional biopsy for diagnosis were included. The surgical biopsies were performed using minimally invasive techniques (video-thoracoscopy or robotic surgery) and required the surgeon to keep performing the biopsy until frozen section was positive or at least until the mass on the ipsilateral hemi-mediastinum was resected. Statistical analysis was performed by a biostatistician using SPSS software. 

Results:
Of the study cohort, 34 patients underwent surgical restaging for PET avid residual mass while 43 either had a complete response with no PET activity or were lost to follow up. The cohort of 34 patients included 76% Caucasians, 50% females, and had a median age of 28 years. The types of lymphoma were predominantly Hodgkins (32%) and Diffuse Large B cell Lymphoma (38%). In these 34 patients with residual PET activity, surgical biopsy revealed presence of lymphoma in 53% of patients. Patients detected to have persistent lymphoma revealed no significant difference in tumor volume reduction compared to those with no residual disease (51% versus 39%) and no significant difference in reduction in PET SUV (68% versus 60%). In all biopsies, significant adhesions between lung and mediastinum were noted, and the median length of the surgical procedure was 75 minutes. However, there were no surgical complications. The length of stay for all patients was less than 24 hours. All patients detected to have residual lymphoma underwent second-line therapy guided by the pathological analysis. 

Conclusion:
While the current standard for patients with mediastinal lymphoma presenting with residual PET activity after completion of first line therapy is surveillance alone, our data suggests that a large number of these patients have residual lymphoma which can be safely diagnosed using minimally invasive surgery. Detection of residual lymphoma has significant implications in further treatment of these patients. 

6.06 Correlation of Anastomotic Leak and Neoadjuvant Chemoradiotherapy in Esophageal Cancer

Posted on January 18, 2018

D. Lee1, C. Takahashi2, R. Shridhar3, J. Huston4, K. Meredith1  1Florida State University College Of Medicine,Gastrointestinal Oncology,Sarasota, FL, USA 2Midwestern University,Phoenix, AZ, USA 3University Of Central Florida,Orlando, FL, USA 4Sarasota Memorial Health Care System,Sarasota, FLORIDA, USA

Introduction:  Anastomotic leaks (AL) causes significant morbidity after esophagectomy. Most patients receive neoadjuvant chemoradiation (NCR) prior to esophagectomy which has been associated with increase perioperative complications and mortality. We report on a comparison of AL rates in upfront surgical (US) and NCR patients. 

Methods:  A prospectively managed esophagectomy database was queried for US and NCR patients treated between 1996-2015. Predictors of AL rate were identified using multivariate (MVA) analysis and propensity score matching (PSM). 

Results: We identified 820 patients (US – 288; NCR – 532). Overall AL rate was 5.4%.  Decreased AL rate was observed in NCR patients on MVA (8% vs 4.1%; p = 0.04) but no difference was seen after PSM (7.7% vs 4.2%; p=0.14). MVA of factors associated with decreased AL in US patients included distal esophageal tumors and body mass index (BMI) >25. Age, gender, year of surgery, histology, anastomotic location, and diabetes were not prognostic.  Before PSM, MVA of NCR patients of factors associated with decreased AL revealed that only thoracic anastomosis was prognostic. However, this was not observed after PSM.  MVA of factors associated with decreased AL in all patients revealed thoracic anastomosis, NCR, and BMI 25-30. After PSM, only distal esophageal tumors and thoracic anastomosis were prognostic for decreased AL. 

Conclusion: There is no difference in the AL rate between US and NCR patients.  Decreased AL rate was observed in patients with distal esophageal tumors and thoracic anastomosis.

 

6.07 Perioperative Outcomes Following Esophagectomy With Gastric vs. Non-Gastric Reconstruction?

Posted on January 18, 2018

M. Varasteh Kia2, J. K. Canner1, R. J. Battafarano1, S. C. Yang1, E. L. Bush1, M. V. Brock1, E. R. Haut1,3, S. R. Broderick1  1Johns Hopkins University School Of Medicine,Baltimore, MD, USA 2Johns Hopkins Bloomberg School Of Public Health,Epidemiology And Biostatistics,Baltimore, MD, USA 3Johns Hopkins Bloomberg School Of Public Health,Health Policy And Management,Baltimore, MD, USA

Introduction

To restore gastrointestinal continuity following esophagectomy, tubularized stomach is the preferred conduit.  In scenarios where the stomach cannot be used non-gastric conduits such as jejunal or colonic interpositions are employed. There are inconsistencies between previous studies examining outcomes associated with the use of non-gastric conduits. Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, we examined perioperative outcomes in patients reconstructed with gastric and non-gastric conduits to better characterize the relative risks of morbidity and mortality associated with these procedures. 

 

Methods

2006 – 2015 ACS-NSQIP esophagectomy cases were separated into gastric and non-gastric conduits based on CPT codes. Emergent and non-cancer resections were excluded. We examined perioperative differences between the two groups using chi-square and nonparametric Wilcoxon rank sum tests. Unadjusted and adjusted risk ratios of postoperative complications were estimated using Poisson regression with robust error variance.

 

Results

After exclusions, there were 6,321 and 210 patients in the gastric and non-gastric groups, respectively.  In unadjusted comparisons, significant differences were identified in 30-day mortality rate (3.32% vs 10.48%, p < 0.001), prolonged hospitalizations (5.30% vs 10.26%; p = 0.02), median length of stay (10% vs 13%; p < 0.001), reoperation rate (14.27% vs 30.43%, p < 0.001) and operative time (342 vs 384 minutes; p < 0.001) between the gastric and non-gastric groups.  No significant differences were identified in the occurrence of superficial, deep or organ/space surgical site infection, pneumonia, or readmission. After adjusting for age, gender, ethnicity, history of diabetes, smoking status, history of COPD, weight loss >10% in prior 6 months and BMI, there remained significant differences between groups in 30-day mortality (RR 0.33 [0.22-0.50]) for gastric vs non-gastric conduit), prolonged hospitalization (RR 0.51 [0.30-0.90]), and reoperation (RR 0.46 [0.35-0.61]), respectively (Table 1). 

 

Conclusion

The use of non-gastric conduit interposition following esophagectomy for carcinoma is associated with higher chance of mortality. However, the underlying reasons for this difference could not be identified using ACS-NSQIP data. Limitations of this study include its retrospective nature and the inherent limitations of the ACS-NSQIP dataset.  This analysis may help to inform shared decision making when considering alternate conduits for reconstruction for esophageal cancer patients in whom the gastric conduit is not feasible.

6.08 Innominate versus Axillary Artery Cannulation for Hemiarch Repair

Posted on January 18, 2018

M. Eldeiry1, M. Aftab1, K. Yamanaka1, M. S. Mosca1, C. Ghincea1, J. C. Cleveland1, D. Fullerton1, T. B. Reece1  1University Of Colorado Denver,Cardiothoracic Surgery,Aurora, CO, USA

Introduction:

Innominate artery cannulation has gained some popularity over the last decade as an alternative to axillary artery cannulation for providing antegrade cerebral perfusion (ACP) during repair of the ascending aorta and arch. Innominate artery cannulation provides several advantages including avoidance of an additional incision and use of a larger caliber artery to provide ACP. We hypothesize that these advantages make innominate artery cannulation superior to axillary artery cannulation as it can decrease operative times and potentially decrease blood loss.

Methods:

This was a single center retrospective analysis of 177 patients who underwent hemiarch replacement between 2009 and 2016. All patients qualified including emergent cases. Groups were separated by mode of cannulation: axillary vs innominate. Outcomes evaluated included cardiopulmonary bypass (CPB) time, cross-clamp (XC) time, circulatory arrest (CA) time, post-operative transfusions, intensive care unit length of stay, development of any neurological complications, end organ failure, and mortality. Sub-group analysis was performed for elective and emergent cases.

Results:

Axillary and innominate artery cannulation accounted for 42.4% (n=75) and 57.6% (n=102) of cases, respectively. There was no difference in patient characteristics except for a higher incidence of lung disease in the axillary group (21% vs. 9%, p=0.029). More emergent cases were performed in the axillary group (60% vs. 18%, p<0.001).

Operative times are summarized in Figure 1. Innominate cases had shorter CPB and CA times. In the elective subgroup, CA times were shorter for the innominate cases. However, the emergent subgroup displayed no difference.

Less transfusions were given in the innominate group including RBC (2[0,14] vs. 0[0,8], p<0.001), PLT (2[0,7] vs. 2[0,4], p=0.030) and FFP (6[0,20] vs. 3[0,11], p<0.001). A similar trend was observed for RBC and FFP in the elective subgroup. No difference was observed in the emergent subgroup.

There was no statistical difference in remaining outcomes between cases of axillary and innominate cannulation in the combined, elective, and emergent groups.

Conclusions:

Alternate cannulation strategies for open arch anastomoses are evolving with a trend towards utilizing the innominate artery. These data suggest that innominate cannulation is at least equivalent to, and may be superior to, axillary cannulation. The innominate artery provides a larger conduit vessel for perfusion and this decrease in resistance to flow, allowing for faster cooling and rewarming, maybe why CPB times were lower in this group. Innominate cannulation is a safe and potentially advantageous technique for hemiarch repair.

6.05 Long Term Survival and Echocardiographic Findings After Left Ventricular Aneurysmectomy

Posted on January 18, 2018

A. A. Assi1, S. F. Bolling1, H. J. Patel1, M. Deeb1, M. A. Romano1, J. W. Haft1, R. L. Prager1, F. D. Pagani1, P. C. Tang1  1University Of Michigan,Department Of Cardiac Surgery,Ann Arbor, MI, USA

Introduction:
This study investigates the long term outcomes and predictors of mortality for left ventricular (LV) aneurysmectomy.

Methods:
From 1992 to 2017, there were 109 patients who underwent a LV aneurysmectomy procedure. Long term survival was determined from hospital records and the National Death Index. Preoperative demographics, clinical characteristics and features, operative technique and follow up echocardiography findings were analyzed using Cox regression and log-rank to determine variables influencing survival.

Results:
Median age was 63 (IQR=19) years, with 25 (22.9%) females. There were 101 (93%) true and 8 (7%) pseudo-aneurysms. Location of the aneurysm was antero-apical in 92 (84%) and posterior in 17 (16%).  Average preoperative left ventricular diastolic dimension (LVIDD) was 6.7+2.7cm.  Operative technique included primary closure without a patch in 58 (53%) and closure with patch in 51 (47%) patients.  Concomitant surgeries included mitral valve (MV) repair (n=40, 37%), MV replacement (n=5, 5%), tricuspid valve (TV) repair (n=4, 4%), aortic valve (AV) replacement (n=3, 3%), coronary bypass grafting (n=76, 70%; 1.6+1.3 grafts) and VSD closure (n=5, 5%). Redo-sternotomies were performed in 12 (11%) patients. Median echocardiography follow up was 2.9 yrs (IQR=9.0), and was obtained in 59 (54%) patients. LVEF improved from 28+13% to 33+16% (P=0.011).  There was a higher incidence of moderate to severe right ventricular (RV) function at follow-up (12% preoperatively versus 38% at follow-up; P=0.021) and higher incidence in severe TV regurgitation in patents who did not undergo repair (8.9% versus 22.2% respectively; P=0.004). Median echo follow up of MV repair was 3.6 (IQR=9.5) yrs. MV repair led to sustained improvements in MR (P=0.001) where only 2 (5%) experienced recurrent moderate-severe MR. For patients who did not undergo a MV procedure, there was no difference in preop and follow up MR severity (P=0.586). Median patient follow up was 7.1 yrs (IQR=8.5). Overall 5, 10, and 15 year survival were 71.9%, 48.1% and 26.2% respectively (Fig. 1). A multivariable analysis identified concomitant TV repair (P=0.001), increasing preoperative TV regurgitation (P=0.037), and concomitant AV replacement (P=0.086) as independent predictors of mortality.

Conclusion:
Long term survival following LV aneurysmectomy is adversely influenced by RV function.  While sustained improvement in LVEF and decreased MR following MV repair can be expected, RV function continues to decline accompanied by worsening tricuspid regurgitation. Close surveillance and aggressive medical management of RV failure is warranted in this patient population.
 

6.03 Impact of Depression on Readmission Outcomes after Coronary Artery Bypass Graft Surgery

Posted on January 18, 2018

E. A. Aguayo1, Y. Juo1, Y. Seo1, K. L. Bailey1, V. Dobaria1, Y. Sanaiha1, P. Benharash1  1University Of California – Los Angeles,Department Of Surgery/ Division Of Cardiac Surgery,Los Angeles, CA, USA

Introduction:
Postoperative depression affects between 10-40% of patients after cardiac operations and is associated with significantly worse cardiovascular outcomes. Indeed, depression screening has been recommended in the care of patients undergoing cardiac operations. While its exact causes are unknown, the incidence and impact of new onset depression beyond acute follow up remain ill defined. The present study aimed to evaluate the incidence, risk factors, and prognostic implication of depression during 90-day readmission after coronary artery bypass surgery (CABG). 

Methods:
A retrospective cohort study was performed identifying patients with no prior depression who received CABG using the 2010-2014 National Readmissions Database (NRD). Adult CABG patients who were readmitted within 90 days of discharge were categorized based on the presence of new-onset depression. Association between development of postoperative depression and mortality/complications during rehospitalization was examined using logistic regression models, adjusting for comorbid conditions. In-hospital mortality and GDP-adjusted costs were evaluated using hierarchical linear models and comorbidity via the Elixhauser Index. 

Results:
A total of 423,455 patients without prior diagnosis of depression were identified as undergoing CABG during the study period. Nationally, 18.9% of patients were readmitted within 90 days of index discharge, of which 5.6% developed new-onset depression. Within the readmitted cohort, risk factors for new-onset depression included female gender (OR=1.45, 95% CI: 1.33-1.57, p<0.01), experiencing a surgery-related complication (OR=1.18, 95% CI: 1.03-1.34, p=0.01), prolonged stay during index stay (OR=1.23, 95% CI: 1.12-1.35, p<0.01) and being discharged to locations other than home (OR=1.61, 95% CI: 1.48-1.76, p<0.01). Postoperative depression was independently associated with elevated odds of systemic complication during readmission (OR=1.17, 95% CI: 1.09-1.27, p<0.01), prolonged hospital stay (OR=1.61, 95% CI: 1.42-1.82, p<0.01), discharge to disposition other than home (OR=1.51, 95% CI: 1.35-1.69, p<0.01) and higher hospitalization costs (coefficient $906.1, 95% CI: 130.9-1681.3, p=0.02). The overall mortality during readmission was 2.6% while new-onset depression was associated with lower odds of death after adjusting for baseline differences (OR=0.56, 95% CI: 0.42-0.74, p<0.01).

Conclusions:
New-onset of depression following discharge CABG was associated with significantly worse outcomes during rehospitalization. The results of this national study supports institution of psychiatric evaluation and measures to reduce the development of depression following cardiac operations. Programs to incorporate early detection and timely management of depression may reduce systemic complications during readmission and enhance quality of care and postoperative recovery.

6.01 National Volume-Outcome Relationships for Extracorporeal Membrane Oxygenation

Posted on January 18, 2018

K. L. Bailey1, Y. Sanaiha1, E. Aguayo1, Y. Seo1, V. Dobaria1, R. J. Shemin1, P. Benharash1  1David Geffen School Of Medicine, University Of California At Los Angeles,Division Of Cardiac Surgery,Los Angeles, CA, USA

Introduction:
With calls for value-based healthcare delivery, high-risk procedures are increasingly being performed at more experienced centers. Recent studies produced conflicting associations of hospital volume and outcomes for critically-ill patients on extracorporeal membrane oxygenation (ECMO), with some suggesting higher mortality at high-volume centers. We aimed to describe the relationship of institutional volume and mortality in ECMO patients and assess causes of discrepant outcomes. 

Methods:
Adult patients receiving ECMO from 2008-2014 were identified from the National Inpatient Sample (NIS). Volume was calculated as tertiles of total institutional discharges for each year independently. Statistical analyses included multivariable logistic regression and propensity matching to adjust for patient demographics and comorbidities as measured by the Elixhauser Index. 

Results:
Of the estimated 18,684 ECMO patients, 14%, 28% and 58% were admitted to low-, medium-, and high-volume centers, respectively. Large centers had the greatest relative fraction of respiratory failure cases (45%), while medium and small centers commonly treated postcardiotomy syndrome (44% and 56%, respectively). Mortality at low-volume hospitals (43.7%) was lower compared to the rate at medium (50.3%, P=0.03) and high-volume (55.6%, P=0.002). On multivariate regression, high-volume, respiratory failure, and cardiogenic shock were predictors of mortality. Length of stay was shorter at low-volume hospitals than at medium- (14.8 vs 21.1 days, P<0.001) and high-volume (14.8 vs 25.2 days, P<0.001). Similarly, cost was lower at small centers ($142,803) compared to medium ($166,458, P<0.001) and large ($176,397, P<0.001). In sub-group analysis of high-volume institutions, 4,183 (39%) patients were transferred to the reporting hospital and 6,676 (62%) patients were initial admissions. The majority of transferred patients received ECMO for respiratory failure (56%). After propensity matching, the transferred cohort had higher mortality (58.5% vs 53.7%, P=0.045) and greater cost ($190,300 vs $168,970, P=0.009) compared to patients admitted directly to the index hospital.  

Conclusion:
Our findings in this contemporary ECMO experience depict an association between high-volume institutions and greater mortality in the overall sample and in patients transferred to larger centers. Whether this phenomenon represents selection bias or transfer from another facility deserves further investigation and will aid with the identification of surrogate markers for quality of high-risk interventions. Improved selection criteria and the prediction of futile care are essential for the future growth of ECMO technology. 

54.19 A New Paradigm for the Acute Care Surgeon: The Active Cancer Patient Population

Posted on January 18, 2018

C. R. Horwood1, S. Byrd1, E. Schneider1, K. Woodling1, J. Wisler1, A. P. Rushing1  1Ohio State University,General Surgery,Columbus, OH, USA

Introduction:
With advances in cancer treatment, patients with active cancer are living longer and developing common conditions that fall outside the realm of oncologic treatment. There is little data describing the clinical decision-making and subsequent outcomes that occur in patients with cancer that present with an emergency general surgical diagnosis. The purpose of this study is to evaluate factors that determine operative management (OM) versus non-operative (NOM) management and subsequent outcomes of colonic emergencies within a cancer population.

Methods:
A single institution registry at a comprehensive cancer center was queried to identify patients with an active cancer diagnosis that had a surgical consult placed for one of three acute colonic surgical diagnoses between 2011 and 2016. The diagnoses included colitis (with or without peritonitis), bleeding diverticulosis, and diverticulitis. Records were retrospectively reviewed for patient demographics, baseline clinical characteristics, OM vs NOM interventions, and outcomes. Primary outcomes examined include hospital length of stay (LOS), 30-day mortality, disposition at discharge, and post-operative complications.

Results:
A total of 87 patients were evaluated of which 38 (43.7%) underwent OM vs 49 (56.3%) who underwent NOM. Differences in initial lab values included median white blood cell count (WBC) and median serum lactate. Median WBC was 8.1 in the OM group vs 4.6 in the NOM group, (p<0.001), and median serum lactate was 2.32 in the OM group vs 0.95 in the NOM group, (p<0.001). Thirteen patients had peritonitis at the time of surgical consult in the OM group vs zero in the NOM group, (p<0.001). With regard to post-operative outcomes, there was no difference in hospital LOS, but there was a difference in 30-day mortality and discharge to home between the groups. Median LOS in the OM group was 13.5 days vs 9 days in the NOM group (difference of 4.5 days, p=0.16). However, 30-day mortality was 32% in the OM group vs 6% in the NOM group (p=0.003) and discharge to home occurred in 35% of patients in the OM group compared to 80% in the NOM group (p<0.001). Within the OM group, 70% of patients had at least one post-operative complication.

Conclusion:
Not surprisingly, patients with higher WBCs, lactic acidosis, and peritonitis were more likely to undergo surgical intervention. Operative management was offered to sicker patients, and as a result, this group had a higher 30-day mortality and were less likely to be discharged home. While more work is needed to evaluate risk stratification for post-operative morbidity, particularly as it compares to non-cancer patients undergoing similar surgical procedures, these preliminary outcomes should be discussed with the active cancer patient prior to pursuing surgical intervention.
 

54.15 Surgeon-Placed Endoscopic Stent As Rescue Therapy For Failed Esophageal Repair After Trauma

Posted on January 18, 2018

K. Chow1, H. N. Mashbari1, M. Hemdi1, E. Smith-Singares1  1University Of Illinois At Chicago,Division Of Surgical Critical Care,Chicago, IL, USA

Introduction:
Esophageal trauma represents an uncommon but potentially catastrophic injury with a reported overall mortality of up to 20%. The management of iatrogenic and spontaneous perforations have been previously described with well-established guidelines which have been mirrored in the trauma setting. Esophageal leaks are the most feared complication after primary surgical management and present a challenge to salvage. There has been increasing reports in the literature supporting the use of removable covered metal stents to heal esophageal perforations and leaks in the non-trauma setting. We present the largest case series of four patients presenting with external trauma induced esophageal injuries, with failure of initial primary surgical repair with subsequent development of a leak successfully managed with esophageal stenting.

Methods:
A retrospective review of four patients who underwent endoscopically placed indwelling covered metal stents after leakage of primary esophageal repair was performed. Demographic information, hospital stay, additional interventions, complications, imaging studies, ISS scores, and outcomes were collected.

Results:
Our cohort consisted of 4 patients with penetrating injuries to the chest and neck with esophageal injuries (3 thoracic and 1 cervical esophageal injuries) managed with esophageal stenting after leaks were diagnosed following primary repair. Leaks were diagnosed on average post-operative day 9 with stents placed within 3 days after diagnosis. There was complete resolution of their esophageal fistulas with all patients resuming oral intake (averaging 72 days after stent placement). Three patients (75%) required further endoscopic interventions to adjust the stent due to migration or for dilations due to strictures. Mortality was 0%, all patients survived to be discharged from the hospital with average ICU length of stay of 30 days.

Conclusion:
The use of esophageal stenting has progressed over the last few years, with successful management of both post-operative upper gastrointestinal leaks as well as benign, spontaneous, or iatrogenic esophageal perforations. While the mainstay of traumatic esophageal injuries remains surgical exploration, debridement, and repair with perivisceral drainage; our case series illustrates that the use of esophageal stents is an attractive adjunct that can be effective in the management of post-operative leaks after attempted repair of external penetrating traumatic injuries to the esophagus.
 

54.14 ROTEM Guided Transfusion Reduces Incidence of Pelvic Packing in Patients who Sustain Pelvic Injury.

Posted on January 18, 2018

B. Zahoor1, S. Kent1, J. Piercey1, M. Randell1, K. Tetsworth1, D. Wall1  1Royal Brisbane & Women’s Hospital,Trauma,Brisbane, QLD, Australia

Introduction: ROTEM guided transfusion in the management of acutely injured patients has contributed significantly in their care especially when compared to earlier transfusion goals of standard ratio. Of particular interest, patients who sustain pelvic injury and require transfusion constitute a special and fragile population have the potential to benefit from ROTEM guided management. We introduced the use of ROTEM in our trauma service to guide our transfusion protocol and wanted to quantify any differences observed in the management of these critically ill patients.

Methods: We completed a retrospective review, at our Level 1 Trauma center, from 2011-2016. We selected for adult patients who sustained both a pelvic injury and required transfusion. We further classified this cohort according to whether transfusion goals were directed by ROTEM or Standard Ratio. Our primary outcome of interest was the need for pelvic packing, which is the primary surgical intervention of choice at our institution who present with severe pelvic injury and do not improve with conservative management.

Results: Our review yielded 46 patients who sustained both a pelvic injury and required transfusion. Our study population mean demographics were described as follows: mean age of 43 y.o, admission BP 99/63 mmHg, admission HR 124 bpm, admission SI 1.22, admission GCS 8 and admission ISS 31.2. Twenty-nine patients were managed with Standard Ratio (1:1:1) transfusion goals in reference; of these, 17 (59%) underwent pelvic packing in the management of their pelvic injury. Seventeen patients were managed with ROTEM guided transfusion; 7 (41%) of these patients underwent pelvic packing in the management of their pelvic injury. Of note, all patients survived at 30 days post admission.

Conclusion: At our institution, the introduction of ROTEM guided transfusion in patients who sustained pelvic injury was associated with a decrease in need for pelvic packing. This is in comparison to patients who were transfused using

traditional goals of standard ratio. Further study is warranted to look at additional variables in patient management to fully elaborate the benefit of using ROTEM guided transfusion in pelvic injury patients who from our limited experience seem to benefit from a reduced surgical intervention rate and risk.

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