61.16 Blockade of the TCA Cycle in Type 2 Diabetes and the Metabolic Syndrome

Posted on January 31, 2019

W. Pories1, T. E. Jones1, J. Houmard1, C. J. Tanner1, D. Zeng1, K. Zou3, P. M. Coen2, B. H. Goodpaster4, W. E. Kraus2, J. Yang1, G. L. Dohm1, W. Pories1  1East Carolina University,Brody School Of Medicine,Greenville, NC, USA 2Duke,Metabolism,Durham, NC, USA 3Boston University,Biochemistry,Boston, MA, USA 4Sanford Bunham Prebys Medical Discovery Institute,Orlando, FL, USA

Introduction:
Blood lactate, an indicator of metabolic failure in critical care, indicates dependence on the anaerobic partitioning of glucose, reflected by increased lactate production. In this study, we explored basal lactate levels in normal individuals and preoperative patients with the metabolic syndrome, before and after correction of glucose metabolism, with surgery and with exercise.

Methods: Fasting lactate levels and insulin sensitivity were determined during IVGTT in non-obese subjects and patients with metabolic disease prior to Roux-en-Y gastric bypass as well as 1 week, 1-3 months, 7-9 months and more than 12 months following RYGB.  Subjects with the metabolic syndrome were also studied at baseline and after 9 months of exercise.

Results: Subjects with the metabolic syndrome have higher lactate (1.67 +/- 0.11 mM) than non-obese controls (1.06 +/- 0.05 mM, P< .001) and respond to a glucose/insulin challenge with higher lactates.  Lactate concentrations, including basal levels, were significantly reduced a week after RYGB and remained at levels like non-obese for more than a year.  The greatest improvement in fasting lactate occurred in those who were most metabolically impaired (highest lactate). Fasting lactate was also reduced by exercise in metabolically impaired subjects (by 0.21 mM, p = 0.028) (Figure 1).

Conclusion: Elevated blood lactate levels reflect metabolic impairment, correctible in the severely obese with the gastric bypass and/or exercise.  These data suggest that the metabolic syndrome is caused by a signal, perhaps from the foregut, which limits entry of pyruvate into the TCA cycle.

 

61.11 Lack of Lymphocyte Recovery After Esophagectomy Predicts Mortality and Recurrence

Posted on January 31, 2019

B. M. Hall1, T. Geraci1, J. Machan1, S. Milman1, W. Cioffi1, T. Ng1, S. Monaghan1  1Warren Alpert Medical School of Brown University,Department Of Surgery,Providence, RI, USA

Introduction:
Esophagectomy performed for esophageal cancer is a relatively high morbidity and mortality operation.  The immediate morbidities have been shown to have major impacts on patient’s long term survival.  Prior research at our institution has found decreased lymphocyte counts to be an independent predictor of mortality in some populations.  We hypothesized the lymphocyte count postoperatively would predict outcomes in esophagectomy patients as well.

Methods:
A retrospective review was performed of all esophagectomies for adenocarcinoma performed over 13 years at our center by a single surgeon.  The routinely obtained postoperative lymphocyte counts were analyzed for their trend, separating patients into three groups: never low, low with by recovery, and low without recovery.  Resolution of lymphopenia was assessed at postoperative day four.  Outcomes between these groups were then compared, with the primary end points being all cause mortality and recurrence analyzed with Kaplan Meier curves.

Results:
In total, 207 patients were included in the review with a minimum one year follow up.  Our 5 year mortality and recurrence rates were 49% and 44% respectively.  Recurrence was significantly higher in patients in patients with persistent lymphopenia [41% (64/158)] compared to those who did recover [13% (5/39)] (p = 0.0019) and those whose counts never dropped [10% (1/10)] (p = 0.0024).  For mortality, the persistent lymphopenia group was significantly higher [54% (85/158)] as compared to the two other groups combined [33% (16/49)] (p = 0.0225).  There was no significant difference in immediate complications including leak rate and infections, nor hospital length of stay.  There were more patients with persistent lymphopenia who had a higher clinical stage (36 vs 13% p = 0.0051) and received neoadjuvant chemotherapy (86% vs 28% p < 0.0001).  However, neither of these preoperative factors were predictive of mortality.

Conclusion:
There is a significant increase in the mortality and cancer recurrence rates in those patients whose lymphocyte count drops without recovery following their esophagectomy.  These data imply differences in immune responses to the stress of surgery that that can be measured and are indicative of overall outcomes.  As a portion of already routine postoperative labs, consideration of lymphocyte trends would an early indicator of potential poor outcomes in these patients.  
 

61.10 Treatments Modalities for Esophageal Adenocarcinoma in the US: Trends and Survival Outcomes

Posted on January 31, 2019

M. Di Corpo1, F. Schlottmann1, P. D. Strassle2, C. Gaber2, M. G. Patti1,2  1University Of North Carolina At Chapel Hill,Department Of Surgery,Chapel Hill, NC, USA 2University Of North Carolina At Chapel Hill,Department Of Medicine,Chapel Hill, NC, USA

Introduction:  The rise in incidence of esophageal adenocarcinoma in the United States over the last decade has been well documented; however, data on trends in use of different therapies and their impact on long-term survival are lacking. We aimed to: a) assess the national trends in the use of different treatment modalities; and b) compare survival outcomes among the different treatment strategies. 

Methods:  A retrospective, population-based analysis was performed using the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) Program registry for the period 2004-2014. Adult patients (>18 years old) diagnosed with esophageal adenocarcinoma were eligible for inclusion. Treatments of interest included chemoradiation, esophagectomy, and chemoradiation plus esophagectomy. The yearly incidence of each treatment strategy was calculated using Poisson regression. A weighted Cox regression model was used to assess the overall effect of each treatment on mortality. Inverse-probability of treatment weights were used to account for potential confounding by year of diagnosis, sex, age, race/ethnicity, tumor grade, and derived AJCC TNM value. 

Results: A total of 10,755 patients were included. The median follow-up time was 15 months (interquartile range 7 – 33). During the study period, the percentage of esophagectomy alone significantly decreased from 14.6% to 4.8% (p<0.0001), the percentage of chemoradiation alone significantly decreased from 25.45% to 28.5% (p=0.08), and the percentage of chemoradiation plus esophagectomy significantly increased from 13.7% to 19.8% (p<0.0001). The 60-month survival rate was 13.0% for chemoradiation only, 33.0% for esophagectomy only, and 36.3% for chemoradiation plus esophagectomy (figure). After accounting for patient and cancer characteristics, both esophagectomy (hazard ratio [HR] 0.62, 95% CI 0.55, 0.70, p<0.0001) and chemoradiation plus esophagectomy (HR 0.45, 95% CI 0.41, 0.48, p<0.0001) had significantly lower rates of mortality compared to chemoradiation only.

Conclusion: The use of esophagectomy alone has decreased, and both the use of chemoradiation plus esophagectomy and chemoradiation alone have increased for patients with esophageal adenocarcinoma. Considering the better survival outcomes achieved with surgical resection, the use of chemoradiation alone should be discouraged in surgically fit patients.    

 

61.08 Defective Homologous Recombination in Platinum-based Chemotherapy for Gastric Cancer

Posted on January 31, 2019

T. Katada1, H. Ichikawa1, Y. Hirose1, M. Nagahashi1, Y. Shimada1, T. Hanyu1, T. Ishikawa1, Y. Kano1, Y. Muneoka1, J. Sakata1, T. Kobayashi1, H. Kameyama1, T. Wakai1  1Niigata University Graduate School of Medical and Dental Sciences,Division Of Digestive And General Surgery,Niigata, NIIGATA, Japan

Introduction: Defective homologous recombination (HR) due to genetic alteration of HR genes contributes to a high response of platinum therapy in ovarian and breast cancers. The aim of this study is to clarify the clinical significance of defective HR in platinum-based chemotherapy for gastric cancer (GC).

Methods: A total of 26 patients (19 men and 7 women, with a median age of 66 years) who underwent platinum-based chemotherapy for unresectable metastatic GC were enrolled. Metastatic sites after gastrectomy were lymph node in 10 (38%), liver in 8 (31%), peritoneum in 8 (31%), others in 2 (8%) patients. Genetic alterations of HR genes (BRCA1, BRCA2, RAD50, RAD51C, RAD51D, BLM, PALB2 and FANCD2) in the primary tumor were assessed by cancer gene-panel. We evaluated the association between defective HR and treatment response (RECIST ver. 1.1), progression free survival (PFS) and overall survival (OS).

Results: BRCA1, BRCA2, RAD50, BLM, and FANCD2 mutations were shown in 3 (12%), 2 (8%), 2 (8%), 1 (4%) and 1 patient (4%), respectively. Overall, 6 patients (23%) had genetic alterations of HR genes (defective HR group). Objective response rate (complete or partial response) was 60% in the defective HR group and 27% in the proficient HR group (P = 0.29). Disease control rate (complete or partial response or stable disease) was 100% in the defective HR group and 47% in the proficient HR group (P = 0.06). PFS was significantly longer in the defective HR group than in the proficient HR group (median 6 months vs. 3 months; P = 0.035). OS was also significantly longer in the defective HR group than in the proficient HR group (median 18 months vs. 8 months; P = 0.025).

Conclusions: Genetic alteration of HR genes was significantly associated with a high response of platinum-based chemotherapy and favorable patient outcome in unresectable metastatic GC. Clinical utility of the assessment of defective HR in GC is worth considering further large-scale validation studies.

61.01 Short- and Long-term Respiratory Functions After Esophagectomy for Esophageal Cancer

Posted on January 31, 2019

H. Ichikawa1, T. Otani1, T. Hanyu1, T. Ishikawa1, K. Usui1, M. Nemoto1, T. Sakai1, Y. Kano1, Y. Muneoka1, Y. Shimada1, M. Nagahashi1, J. Sakata1, T. Kobayashi1, H. Kameyama1, T. Wakai1  1Niigata University Graduate School of Medical and Dental Sciences,Division Of Digestive And General Surgery,Niigata, NIIGATA, Japan

Introduction: The impact of surgical procedures on respiratory functions after esophagectomy for esophageal cancer is not fully investigated. The aim of this study is to clarify the difference in short- and long-term respiratory functions after esophagectomy between the surgical procedures.

Methods: A total of 48 patients who underwent curative esophagectomy for thoracic esophageal cancer from 2003 to 2012 were enrolled in this single-institutional prospective study. We evaluated volume capacity (VC) and forced expiratory volume 1.0 (FEV1.0) at six points as follows: before esophagectomy (baseline), 3, 6, 12, 24 and 60 months after esophagectomy. We compared the change ratio to baseline values between the three surgical procedures: open esophagectomy (OE, N = 19), minimally invasive esophagectomy (MIE, N = 16), and transhiatal esophagectomy (THE, N = 13). The baseline respiratory functions before esophagectomy were not significantly different between the three groups.

Results: The decline of VC in THE group (median change ratio: 0.91) were significantly less than that in OE (0.75) and MIE group (0.80) 3 months after esophagectomy (P < 0.01). VC in MIE and THE group recovered at 0.94 and 0.98 of the median change ratios; however, VC in OE group remained at 0.85 and lower than that in MIE and THE group 12 months after esophagectomy (P = 0.016). The median change ratios of VC in OE (0.83), MIE (0.84) and THE groups (0.88) were not significantly different 60 months after esophagectomy (P = 0.176). FEV1.0 in OE (0.78) and MIE (0.81) group significantly more declined than that of THE group (0.97) after 3 months (P < 0.01). FEV1.0 in OE and MIE group recovered at 0.89 and 0.89; however, they were significantly lower than that in THE group (0.99) 12 months after esophagectomy (P = 0.015). Although FEV1.0 in THE group kept the baseline value after esophagectomy, the median change ratios of FEV1.0 in OE (0.84), MIE (0.86) and THE groups (0.94) were not significantly different 60 months after esophagectomy (P = 0.46).

Conclusion: THE contributes to maintaining short-term respiratory function after esophagectomy for esophageal cancer. MIE is advantageous in the early recovery of VC as compared with TTE. The differences in respiratory functions after esophagectomy between the surgical procedures are not observed after a long-term follow-up.
 

55.19 A Systematic Review of Malrotation Presenting Between 1 and 19 Years of Age

Posted on January 31, 2019

K. T. Gemayel1, G. Romero-Velez2, S. Burjonrappa1  1University Of South Florida College Of Medicine,Department Of Pediatric Surgery,Tampa, FL, USA 2The Children’s Hospital at Montefiore,Department Of Pediatric Surgery,Bronx, NY, USA

Introduction:
Midgut malrotation is a congenital anomaly of intestinal rotation and fixation where in an incomplete rotation or a complete failure of rotation of the primitive intestinal loops around the superior mesenteric artery axis occur during the fetal period. We have personally evaluated two adolescent cases of malrotation, and it is the intent of this review to further investigate the intraoperative presentation and clinical symptoms of adolescent malrotaion in addition to our findings. Adolescent and adult age malrotation are difficult to diagnose clinically and the focus of this case series and systematic review is malrotation after the age of 1 year and inclusive of the adolescent population.

Methods:
To further evaluate intraoperative findings and clinical symptoms associated with adolescent malrotation, systematic analysis was done using Cochrane, Medline and Pubmed databases. Database search was guided using keywords “malrotation”, “volvulus”, “Ladd’s procedure”, “pediatrics”, and “adolescent”. Inclusion criteria were selected based on case series in the English language, with patients in-between 1-19 years of life, with clear cut description of intraoperative findings with perioperative evaluation. Exclusion criteria was non-English literature, age under 1 year and older than 19 years without a clear cut description of findings. Operative findings were categorized based on Stringer’s classification of malrotation, with type II and III essentially representing pre-axial and post-axial malrotation.

Results:
Systematic review yielded 75 cases in which were distributed by Stringer's classification into norotation (n= 14), duodendal malrotation (n= 37), duodenal and cecal malrotation (n= 24). Intraoperative findings were analyzed for presence of volvulus, narrow mesenteric base and presence of Ladd Bands with varying clinical symptoms (as shown in figure).

Conclusion:
In conclusion, in the case of intermittent intestinal obstruction in young adults, physicians should keep in mind that early and accurate diagnosis of malrotation with an appropriate surgical treatment may save patients from unexpected complications. Due to the presence of atypical symptoms, the diagnosis of malrotation requires a high index of suspicion, appropriate diagnostic studies, and aggressive definitive surgical treatment.
 

55.06 Simulated Street Crossing Intervention is Associated with Lower Rate of Pedestrian Injury in Children

Posted on January 31, 2019

C. M. McLaughlin1, W. Barry1,2, E. Barin1, M. Mert3, C. Lowery4, J. Upperman1,2, H. Arbogast4, A. M. Jensen1,2  1Children’s Hospital Los Angeles,Pediatric Surgery,Los Angeles, CA, USA 2University Of Southern California,Department Of Surgery,Los Angeles, CA, USA 3Southern California Clinical and Translational Science Institute,Los Angeles, CALIFORNIA, USA 4Children’s Hospital Los Angeles,Injury Prevention,Los Angeles, CA, USA

Introduction:  Unintentional injury is the leading cause of death in children. Elementary school children are at high risk for street crossing-related injuries. We hypothesized that an interactive pedestrian safety educational intervention is associated with lower incidence of pedestrian-related injuries in elementary school-aged children.

Methods:  An interactive pedestrian safety educational intervention was implemented at target Los Angeles County elementary schools beginning in 2009. The intervention was designed to be administered over one day and included formal didactic education followed by simulated street crossings using a life-size set (Figure). A retrospective cohort study was conducted of 10 schools from 2012-2017. A statewide traffic records database was queried for reported pedestrian-related injuries in elementary school-aged (4-11 y) children at intervention school districts. Pedestrian-related injury incidence was compared one year before and after the intervention. A standardized rate ratio was calculated by comparing injury incidence at intervention school districts to the entire city of Los Angeles. A negative binomial model was used and p<0.05 was considered statistically significant.

Results: The total number of injuries reported in elementary school-aged children in intervention school districts was n=6 before and n=2 after the intervention, resulting in a significantly lower incidence rate (1.22 vs 0.40 per 10,000 children/year; p<0.001). The standardized rate ratio still reflected a significantly lower incidence of pedestrian-related injury after the intervention (rate ratio 0.28; 95% CI 0.11-0.73).

Conclusion:
Interactive street safety education at Los Angeles elementary schools was associated with a lower incidence of pediatric pedestrian-related injury. The observed difference was still significant after adjusting for injury incidence in the entire city of Los Angeles. These data suggest formal pedestrian safety education should be included into injury prevention efforts in similar urban communities.
 

55.05 H is just a Number? Using the Hirsch Index to Describe Academic Productivity Amongst Pediatric Surgeons

Posted on January 31, 2019

K. N. Lucey1, K. T. Anderson1, M. A. Bartz-Kurycki1, M. C. Henry1  1University of Arizona Medical Center,General Surgery,Tucson, AZ, USA

Introduction: The Hirsch Index (h-index) is a measure of academic output based on the number of published works and the subsequent citations of work. It is frequently used as a factor in academic promotions. The utility of the h-index in pediatric surgery has not been established.

Methods: Faculty members of pediatric surgery fellowship programs as listed by the American Pediatric Surgical Association (APSA) were identified. Faculty rank and gender as noted on department and institutional websites were captured. Faculty of programs that did not provide a clinical appointment were noted to be instructors. Published articles, citations with and without self-citations, book citations, and h-index with and without self-citations or book citations were collected through Scopus. Publication years were defined by 2018 minus the year publications were noted by Scopus. Student’s t-test and linear regression were used for analysis.

Results: From 58 pediatric surgery fellowship programs, 456 faculty were identified who had a record in Scopus, and whose demographics were available from their institutional websites. The cohort for analysis included 42 (9.2%) department chairs, 84 (18.4%) professors, 145 (31.8%) assistant professors, 120 (26.3%) associate professors, 63 (13.8%) instructors and 2 (0.4%) professor emeritus. Most faculty were male (n=331, 72.6%). During an average of 20.5±9.6 publication years, the mean h-index was 16.8±.12.6 with a range from 1 to 111. H-index did not change significantly with the removal of self-citation (16.4±12.2, p=0.65) nor with the removal of book citations (15.8±11.5, p=0.20). H-index increased with publication years and faculty rank but the trajectory of the index differed by gender (figure). Adjusting for publication years and faculty rank, female faculty had a lower overall h-index (Male faculty mean h-index: 18.7±13.6 vs Female faculty 11.9±7.8, p<0.01).

Conclusions: According to the Hirsh index, male faculty out produce female faculty, even after accounting for length of publishing time and faculty rank in pediatric surgery. Further research is needed to evaluate causes of the discrepancy in academic productivity.

55.04 Natural History of Gastrojejunostomy Tubes in Children

Posted on January 31, 2019

R. E. Wilson1, P. K. Rao1, A. J. Cunningham1, S. Krishnaswami1, E. N. Dewey1, M. C. Boulos1, N. A. Hamilton1  1Oregon Health And Science University,Pediatric Surgery,Portland, OR, USA

Introduction:
Gastrojejunostomy (GJ) tubes are frequently used to provide enteral nutrition in patients who do not tolerate gastric feeds. GJ tubes are reported to have a high rate of minor complications, most commonly thought to be migration into stomach, requiring unplanned urgent interventions. However, there is currently insufficient literature on the lifespan of GJ tubes, reasons for failure, and recommendations for optimal techniques and timing of replacement. We aimed to evaluate the natural history of GJ tubes in pediatric patients to guide clinical management.       

Methods:
We reviewed all pediatric patients who underwent GJ tube placement or exchange at our institution from January 2012 to July 2018. Demographic data was collected, as was time and indication for replacement or removal of GJ tubes. End points for the study include permanent removal of GJ tube or mortality. Current feeding status of each patient was also recorded.

Results:

Seventy-nine patients underwent 205 GJ tube procedures. Four had prior fundoplication. The tubes lasted a median of 98 days (interquartile range = 54-166) and patients had a median of 2 GJ tubes. The most common indication for tube change was a structural/mechanical problem with the tube, occurring 56 times (43.1%). These included broken balloons (27, 20.8%), loose connector rings (17, 13.1%) and tube plugging (9, 6.9%). Other indications for tube replacement included dislodgement of tube from tract (45, 34.6%), migration of tube into stomach or esophagus (11, 8.5%), routine change (9, 6.9%), or other (9, 6.9%). Thirty-four percent of tubes replaced were able to be performed without general anesthesia or sedation (Table 1).

 

Twelve patients (15.2%) died from their primary disease during the study period. Thirty-two patients (40.5%) ultimately tolerated gastric feeds. Nine (11.4%) of these patients required subsequent fundoplication. The remaining 23 patients (29.1%) progressed to gastric feeds without subsequent fundoplication. Conversion to gastric feeding without subsequent fundoplication occurred at a median time of 212 days.

Conclusion:
Gastrojejunostomy tubes offer a safe and effective feeding option in patients who do not tolerate gastric feeds.  Most tubes fail due to intrinsic structural/mechanical issues and not secondary to migration into the stomach. No additional operative therapy is needed in 44% of patients, as many ultimately tolerate gastric feeds or suffer early mortality from their primary disease. Finally, exchange of GJ tubes without anesthesia is a viable option in many cases and can increase feasibility of long-term GJ use.

55.03 Pediatric Breast Abscess: National Epidemiology and Management at Children’s Hospitals

Posted on January 31, 2019

J. A. Sobrino1, J. A. Sujka1, L. A. Benedict1, J. D. Fraser1, T. B. Lautz2, T. A. Oyetunji1  1Children’s Mercy Hospital – University Of Missouri Kansas City,Department Of Surgery,Kansas City, MO, USA 2Ann & Robert H. Lurie Children’s Hospital of Chicago,Department Of Surgery,Chicago, IL, USA

Introduction:
Pediatric breast abscesses are rare. Data is lacking on their epidemiology and management. Adult literature has demonstrated that aspiration and antibiotics are a safe and effective first line treatment with incision and drainage (I&D) reserved for complicated collections or failure of aspiration. I&D is of particular concern in the pediatric population given the unique concern of injury to the pre-pubertal breast bud leading to a cosmetic defect. The purpose of our study was to evaluate the current national management of pediatric breast abscesses.

Methods:
A retrospective review was conducted utilizing the Pediatric Health Information System (PHIS) database including patients less than 18 years old with appropriate ICD 9 and 10 diagnostic codes for breast abscesses and corresponding procedure codes for I&D or aspiration. Patients with length of stay greater than 5 days were excluded. Details were collected on demographics, imaging, procedures, comorbidities, length of stay, and 30-day re-admissions. Medians are reported with interquartile ranges.

Results:
A total of 3,381 patients were included. Only female patients were analyzed, and this included 2,796 patients (83%). Median age at presentation was 13 years (7, 15). Seventeen percent (481) occurred in patients less than a year old. Toddler and early childhood ages accounted for 4% of patients each before increasing in middle childhood (9%) and early adolescence (60%). The racial composition was 46% white and 36% black.
Fifty-seven percent of patients had no imaging performed and 43% (1,199) underwent an ultrasound. Four hundred and eighty patients (17%) underwent I&D, 192 (7%) underwent aspiration, and 60 (2%) patients were treated with interventional radiology guided drainage. I&D rates varied from 16% to 28% by age group and 0 to 50% by hospital. There were no differences in rates of aspiration (p = 0.536) or I&D (p = 0.056) between age groups.
Mean length of stay was 1.3 days. Length of stay was longest in infants (1.8 days, p = < 0.005). The length of stay was shorter for I&D compared to aspiration (1.6 vs 1.9 days, p = 0.002). The overall 30 day readmission rate was 17% (482). There was no difference in readmission rate between those treated with I&D compared to aspiration (16% vs 14%, p = 0.64).

Conclusion:
Despite concerns for damage to a developing breast bud, rates of I&D are high throughout the nation. Overall the management of pediatric breast abscesses is variable and needs standardization with long term follow up of the two most common methods of drainage. Further study is needed.
 

55.02 Recurrence of Central Venous Catheter Infections after Treatment in Pediatric Surgical Patients

Posted on January 31, 2019

B. D. Hosfield1, A. K. Bagwell2, R. J. Vandewalle1, A. P. Ladd1  1Indiana University School Of Medicine,Pediatric Surgery,Indianapolis, IN, USA 2Indiana University School Of Medicine,Indianapolis, IN, USA

Introduction:   Children requiring long-term central venous access are at risk for catheter associated blood stream infections (CLABSI).  Treatment of CLABSI requires either removal of the catheter or antimicrobial treatment to sterilize the catheter and bloodstream, which is again at risk for CLABSI development.  The purpose of this study is to identify factors that predispose the development of a second CLABSI.  

Methods:   A single-center institutional database was queried from 1/1/2010 to 12/31/2016 for patients aged 0-18 years old with a tunneled central venous catheter (tCVC) and diagnosis of CLABSI.  The studied cohort were patients who developed a second CLABSI from the same tCVC.  Patients undergoing treatment for malignances or solid organ/hematologic transplants were excluded.  Factors associated with the treatment of the index CLABSI and the recurrence were analyzed.  

Results:  Thirty-one patients treated for CLABSI met study criteria of developing a second CLABSI.  The median age for original tCVC placement was 15 months (IQR 4.5-33 months).  Twenty-six patients in the cohort (83.9%) had short bowel syndrome (SBS).  Three additional patients with SBS were identified who could not treat their CLABSI with antibiotics (clearance rate of 89.7%).  The median time from tCVC placement to first CLABSI was 67 days (IQR 32.5-125.5 days).  Multivariate analysis revealed a significantly shorter length of time from tCVC placement to first CLABSI for patients with SBS versus other indications (59 vs. 161 days, respectively; p=0.012) when controlling for age, gender, and culture data.  The median time between initial and recurrent CLABSI in the study group was 49 days (IQR 24.5-91 days).  There was no difference in median days from first CLABSI to second CLABSI for patients with SBS versus other diagnosis (48.5 vs. 53 days, respectively; p=0.747).  Patients with isolates of Staphylococcus Aureus at the first CLABSI had a significantly longer length of time from first to second CLABSI when compared to those with other bacteria isolates on initial CLABSI cultures (104 vs. 43 days; p=0.001).

Conclusion:  Initial CLABSI appears to occur earlier in pediatric patients with SBS compared to other indications for tCVC placement.  Additionally, CLABSI due to isolated Staphylococcal Aureus infections confer a longer time before CLABSI recurrence among those lines salvaged with intravenous antibiotics.

 

55.01 Risk Factors for Venous Thromboembolism in Pediatric Patients with Inflammatory Bowel Disease

Posted on January 31, 2019

K. A. McKie1, R. J. McLoughlin2, M. P. Hirsh2, P. P. Nazarey2, M. Cleary2, J. T. Aidlen2  1University Of Massachusetts Medical School,Worcester, MA, USA 2University Of Massachusetts Medical School,Surgery,Worcester, MA, USA

Introduction:
Patients with inflammatory bowel disease (IBD) have been shown to have twice the risk of developing venous thromboembolism (VTE) when compared to those without IBD. While the overall risk of VTE in the pediatric population is lower, the literature demonstrates that pediatric patients with IBD are also at increased risk of VTE. The factors augmenting the risk of VTE in pediatric IBD patients, including those undergoing major surgery have not been previously determined.

Methods:
Patients (<21 years old) were identified with an ICD-9 diagnosis of IBD (555.X or 556.X) or Crohn’s Disease (CD) (555.X) in the Kids’ Inpatient Database (KID) for the years 2006-2012. Procedure and ICD-9 diagnosis codes were scrutinized. VTE was defined by ICD-9 codes. National estimates were obtained using case weighting. Multivariable logistic regression was performed adjusting for age, race, gender, major surgical procedure, hypercoagulable states or diseases, and obesity. All p-values <0.05.

Results:
A total of 44,554 patients with IBD were identified and 28,132 patients with CD. Of the IBD patients, 456 (1.01%) developed VTE during their hospital admission, while 205 (0.72%) CD patients developed VTE. The oldest patients, those having an increased length of stay, a major surgical procedure or a coagulation disorder had the highest rate of VTE with both IBD and CD.  After performing adjusted logistic regression, undergoing a major operating room (OR) procedure was associated with a 2.04 and 2.35 times greater odds of developing VTE for IBD and CD patients, respectively. A coagulation disorder was associated with increasing the odds of a VTE by 8.95 and 8.90 times in IBD and CD, respectively.

Conclusion:
Pediatric patients with IBD are known to be at increased risk of VTE. Our study demonstrates that undergoing a major surgical procedure increases the risk for VTE in those with a diagnosis of CD or IBD. The pediatric IBD population with known hypercoagulable diagnoses are additionally at risk for VTE.  Given these findings, VTE prophylaxis for pediatric patients with IBD should be considered in both the perioperative setting and for those with concurrent hypercoaguable diagnoses.
 

51.09 Mortality of Non-trauma Emergency Laparotomy in an Acute Care Surgery Center.

Posted on January 31, 2019

A. D. Shahait1, A. D. Hollenbeck1, D. Kristl1, H. Dolman1, J. D. Tyburski1, G. Mostafa1  1Wayne State University,General Surgery,Detroit, MI, USA

Introduction:  Emergency laparotomy (ER) is a common operation that deals with a wide range of pathologies. Preoperative optimization is often lacking due to the urgent nature of the disease process. Multiple studies have shown a mortality rate of 14% in ER compared to 1.5-9.8% in elective operations. In this study, we review the outcome of ER at our academic acute care surgery center.

Methods:  A retrospective analysis of all adult patients who underwent non-trauma ER, between January 2008 to December 2013 was conducted. Data included; demographics, clinical features, preoperative laboratory, comorbidities, time to surgery, ICU admission, and 30 & 90 days mortality.     

Results: A total of 234 patients [123 male (52.6%), 111 female (47.4%)] were included. ER was performed within 4 hours (immediate) of presentation in (93) 39.7% ,within 4-12 hours (early) in (53) 25.4%, and within 12-24 hours (late) in (63) 30.1% of patients. Overall mortality was (16) 6.8%, and (15) 6.4% at 30 and 90 days, respectively. Both 30-day and 90-day mortality were significantly higher with chronic obstructive pulmonary disease (p=0.014), blood transfusion (p <0.001), ICU admission (p<0.001), Ventilator days > 4 (p=0.013), hyperlipidemia (p=0.014), heart rate > 90 beat/minute (p=0.003), temperature >38 C or <35 C (p=0.013) and Systolic blood pressure < 90 mmHg (p<0.001). The timing of surgery, gender, age >75 years, ethnicity, cardiovascular diseases, smoking, and body mass index had no impact on mortality.

Conclusion:  ER can be performed with lower mortality than previously reported. Specific predictors of mortality are identified that could improve optimization and be used for risk assessment.

51.08 Evolution of a Scale Based Pay Plan for an Academic General Surgery Division

Posted on January 31, 2019

E. W. Nelson1, M. C. Mone1, C. Ward1, S. R. Finlayson1  1University Of Utah,General Surgery/Surgery,Salt Lake City, UT, USA

Introduction: In response to internal and external pressures to be sustainable, equitable, and transparent, faculty pay models in academic surgery have been evolving.  This review examines the transition from a purely incentive based model to a scale based pay plan and the effects on clinical productivity as measured by relative value units (RVUs) as well as possible impact on recruitment, attrition, compensation, and sustainability.

Methods:  Over a three year transition period (7/2015-6/2018) an academic division of general surgery converted from a purely incentive based pay model to a scale based model.   Beginning on July 1, 2015, faculty salaries of 18 academic general surgeons were renegotiated and fixed at or near the average of the previous four fiscal years, July 2011 – June 2014.  Two full time VA faculty and three faculty with administrative positions were not included.  Over the next 18 months, a graduated scale based on rank and years in rank was developed using 50th % AAMC salary guidelines with refinements for subspecialties based on national standards including AMGA, SVC, and MGMA.  When the scale was implemented on Jan 1, 2017, all faculty salaries above scale were frozen at that level and salaries below scale were adjusted half way to scale with eventual adjustment to full scale pending financial sustainability for the entire group. For comparison, incentive based years included fiscal years 2011 to 2015 and pay scale years were fiscal years 2016-2018. When calculating RVU averages per year, years worked by surgeons included partial years based on date of hire and separation.

Results: On January 1, 2017, when compared to the salary scale, twelve faculty (6 males and 6 females) had previous salaries that were below scale and had annualized adjustments half way to scale.  Overall, adjustments averaged $15,345 with a maximum of $60,000.  Additional salary adjustments for males averaged $11,403 and $19,087 for females.  Between fiscal year 2011 and fiscal year 2018 the division grew by 160%, from 10 (8 males and 2 females) to 26 (16 males and 10 females).  New faculty salaries were determined on scale based on previous academic rank and years in rank.  Over the same period, 5/30 faculty left the division only one of whom had been placed on the salary scale; two recruited to other academic programs, two into private practice, and one transferred to another division. Based on the growth in faculty size, total divisional RVU’s grew from 65,063 in 2011 to 164,096 in 2018.  However, when comparing incentive based years to pay scale years, per faculty average RVU’s/year decreased by 5.5% (7347 vs 6943).

Conclusion: Transition from an incentive based salary plan to a scale based model has had only modest effect on surgeon yearly RVU productivity and faculty attrition.  While the transition to full scale of all faculty awaits financial sustainability, exceptional diverse growth through recruitment has been maintained.

 

51.07 Psoas Muscle Area Predicts Acute Respiratory Distress Syndrome in Acute Pancreatitis

Posted on January 31, 2019

P. Kandagatla1, A. Hodari Gupta1, D. Abbass1, C. Fisher1, B. Knisely2, R. Cho2, N. Schmoekel1, J. Stassinopoulos1  1Henry Ford Health System/Wayne State University,Department Of Surgery,Detroit, MI, USA 2Henry Ford Health System/Wayne State University,Department Of Radiology,Detroit, MI, USA

Introduction:

            Acute Respiratory Distress Syndrome (ARDS) is a serious complication of acute pancreatitis. However, limited literature exists pertaining to patient characteristics that can help predict the development of ARDS among patients with acute pancreatitis. Sarcopenia, based on psoas muscle area on imaging, has been predictive of outcomes after surgery. We hypothesized that sarcopenia would correlate with the development of ARDS in patients admitted for acute pancreatitis.

Methods:

            We performed a retrospective study of patients that were admitted to the ICU for acute pancreatitis at our institution. Patients that did not have a CT of their abdomen were excluded from the study. Patient characteristics including demographics, medical history, BMI, labs at admission, and functional status were collected. An average psoas muscle area for each patient was calculated at the level of L3 and standardized to their height. Sarcopenia was determined by gender-based cutoffs of the psoas areas. We then performed both univariate and multivariate analysis to determine significant covariates in the development of ARDS.

Results:

            We included 218 patients in the study. Of these patients, 32 (14.7%) developed ARDS. In univariate analysis, there was no significant difference in the proportion of patients with ARDS that were sarcopenic (50.0% vs 35.7%, p = 0.12). The mean age was significantly higher in those that developed ARDS (58.0 vs 47.3, p<0.01). There was no difference in gender (59.4% male vs 55.9%, p = 0.72), mean BMI (30.1 vs 29.1, p = 0.52), mean albumin (2.71 vs 2.85, p = 0.48), and mean serum creatinine (2.01 vs 1.52, p = 0.14). Patients with ARDS had a higher proportion of biliary etiology (38.7% vs 14.9%, p < 0.01, history of coronary artery disease (21.9% vs 11.4%, p = 0.01) and COPD (25.0% vs 10.3%, p = 0.02). Patients that developed ARDS also had a lower proportion of functionally independent patients (54.2% vs 80.9%, p<0.01). In multivariate analysis, the only significant predictors for ARDS were the presence of sarcopenia (OR = 5.15, 95% CI: 1.23-21.49) and a history of COPD (OR = 6.60, 95% CI: 1.46-29.96).

Conclusion:

            In our single institute retrospective study, we have found a significant relationship between the presence of sarcopenia based on psoas muscle area and the development of ARDS. Further research on utilizing this simple measurement to risk-stratify patients with acute pancreatitis is warranted.

51.05 Local vs. Other Forms of Anethesia for Open Inguinal Hernia Repair: A Meta-Analysis of RCTs

Posted on January 31, 2019

M. B. Argo1, J. G. Favela1, S. Huerta1  1University Of Texas Southwestern Medical Center,General Surgery,Dallas, TX, USA

Introduction: There continues to be variation in the choice of anesthetic technique for open inguinal hernia repair (OIHR) worldwide, which seems to be guided by patient’s satisfaction and surgeon’s preference. The factors determining the use of local anesthetic (LA) compared to spinal (SA) and general (GA) anesthesia remains equivocal as previous data has compared either SA or GA [all others (AO)] to LA. We hypothesize that outcomes and operative room times are superior with LA compared to AO for the repair of OIHR. The present study is an analysis of all randomized controlled trials (RCTs) in patients undergoing OIHR comparing LA to AO.

Methods:  PubMed, MEDLINE, Ovid syntax from 1949 to Jan 2018 , the Cochrane Library, Google, ang Google Scholar were reviewed by two independent reviewers following PRISMA guidelines. We identified 73 potential manuscripts, following exclusion of papers that were not OIHR, did not include anesthesia type, and non-randomized trials, 16 RCT’s were available for inclusion. The parameters evaluated were short-term complications (urinary retention, wound infections, and hematomas), patient satisfaction, length of hospital stay (LOS), total surgical time, total operating room time, and postoperative pain. Review Manager 5.3 was used to test for overall effect between the included studies. 

Results: The use of local anesthesia was favored in the majority of analyses. Overall complication rate favored LA (p=0.12), but only urinary retention was significantly decreased in LA (p=0.002). Both wound infection (p=0.12) and hematoma (p= 0.67) favored OA. Patient satisfaction favored the use of LA (p=0.10). Total surgical time was increased in LA versus OA (p = 0.86; 95% CI [-7.2,8.6]), but the overall operating room time was significantly decreased when LA was used (p<0.001; 95% CI [-18.4,-7.1]). Seven of the ten studies that recorded LOS reported a significant decrease when LA was used.  

Conclusion: This meta-analysis demonstrates that LA is a well-tolerated anesthetic approach for OIHR.  OR times and urinary retentions are significantly improved with LA vs.AO.  LA improves the economic burden by decreasing operating room time and decreasing overall intraoperative and early postoperative costs, which is significant for a procedure performed so frequently.   

 

51.03 Comparison of Robotic Versus Laparoscopic and Open Repair for Inguinal Hernias

Posted on January 31, 2019

D. T. Lammers1, J. P. Kuckelman1, J. Bingham1  1Madigan Army Medical Center,Department Of General Surgery,Tacoma, WA, USA

Introduction:
Inguinal hernia repair is one of the most common surgical procedures performed worldwide. The development of the robotic assisted inguinal hernia repair theoretically allows for optical and technical advantages over laparoscopic surgery with improved post-operative pain and recovery over open methods. These theories are yet to be clearly described with a paucity of data comparing robotic inguinal hernia repairs to other commonly performed methods. We characterize our experience with robotic assisted inguinal hernia repair compared to open and laparoscopic approaches.

Methods:
Retrospective review using a prospectively collected data base of all inguinal hernia repairs over 7 years at a single institution. Data was grouped to compare between robotic, laparoscopic and open cases. Comparisons were made for all perioperative data, including patient demographics, intra and post-operative outcomes. Statistical significance was set at a p value of 0.05 comparing mean using ANOVA and Chi-square analysis.

Results:
A total of 277 matched cases met inclusion criteria and were compared. There were no statistical differences in age, gender, or preoperative comorbidities between groups. BMI was significantly higher in the robotic group when compared to laparoscopic and open inguinal hernia repairs at 31 vs 26 and 27, respectively (p=0.001). Operative times were found to be significantly longer with robotic cases at an average of 146 minutes vs 75 minutes in the open group and 86 minutes with laparoscopic cases (p=<0.001). Greater than 30 day follow up was accomplished in 95% of patients. Readmission within 30 days occurred more frequently with the open group (2.4%) when compared to both laparoscopic (1.2%) and robotic (0%) groups (p=0.03). There were no differences seen between groups with regards to post-operative complications including surgical site infections, return to the operating room, length of stay, thromboembolic events, and death (Figure 1).

Conclusion:
Robotic inguinal hernia repair was preferentially performed in larger patients with significantly better or equivalent outcomes when compared to laparoscopic or open inguinal hernia repairs, although associated with longer operative times. Robotic repairs are a viable and safe option for inguinal hernias.
 

51.02 Analysis of the Pediatric Appendicitis Score as a Clinical Adjunct

Posted on January 31, 2019

J. Stevens4, N. Vaughan3, L. Burkhalter2, G. Wools2, A. Alder1,2  1University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA 2Children’s Medical Center,Department Of Pediatric Surgery,Dallas, Tx, USA 3Baylor Scott and White Medical Center,Department Of Surgery,Dallas, TEXAS, USA 4University Of Texas Southwestern Medical Center,Medical School,Dallas, TX, USA

Introduction:  Acute appendicitis is the most common cause for urgent surgical intervention in children. Accurate and timely diagnosis of pediatric appendicitis is thought to minimize complications. The pediatric appendicitis score (PAS) was developed by Samuel in 2002 and has been refined to help guide decision-making for diagnosing appendicitis with a goal to limit unnecessary imaging or procedures and to lower hospital costs. PAS is the core of a practice guideline that was implemented at our institution in September 2012 with intent to minimize unnecessary imaging and lower negative appendectomy rates. The purpose of this study was to evaluate the integration of the PAS into our appendicitis pathway to determine appropriateness of utilization.

Methods:  This is a retrospective review of all patients at an urban, referral children’s hospital whose evaluation for appendicitis included a PAS from July 2017 to December 2017. Data analyzed included imaging rates, appendectomy rates and pathology reports.

Results: 1741 patients were evaluated with 503 undergoing appendectomy. 423(24.3%) patients had a complete PAS with the remaining missing portions of the PAS, most commonly lab results. 1501(92%) patients had an ultrasound and 339(20.8%) had a CT with 66(4%) having imaging done before the PAS was filled out. 109 patients had conclusive imaging from an outside hospital and were excluded from these results. Overall compliance with the PAS protocol was 11.3% with 96.6% of patients with a completed PAS >7 having imaging. 

Conclusion: The PAS has not become a valuable tool as part of our appendicitis pathway to reduce over-imaging of children and lower negative appendectomy rates. Compliance with the guideline (PAS >7) would have resulted in a reduction of ultrasound and CT utilization of 243(16.2%) and 78(23%), respectively. In contrast, compliance would have doubled the negative appendectomy rate from 4 to 8%. Often, imaging is ordered prior to completion of the PAS. The default approach to any patient with possible appendicitis appears to be an ultrasound first and possibly a CT if it is still inconclusive. The PAS has not proven to be an important component of an acute appendicitis practice guideline at a busy tertiary children’s facility with a high volume of patients with appendicitis. A practice guideline that reflects our current practice potentially would save time, money and prevent patients from unnecessary radiation exposure from CT scans.

 

51.01 The Feasibility of Extracorporeal Membrane Oxygenation (ECMO) in Burn and Inhalation Injury Patients

Posted on January 31, 2019

T. D. Reid1, Y. Mikhaylov-Schrank1, C. Gaber1, P. D. Strassle1, R. Maine1, S. M. Higginson1, A. G. Charles1, C. Beckman1, B. A. Cairns1, L. Raff1  1University Of North Carolina At Chapel Hill,Chapel Hill, NC, USA

Introduction:
Burn inhalation patients are at risk for Acute Respiratory Distress Syndrome (ARDS) given pulmonary damage, systemic cytokine release, and large volume fluid resuscitation. As many as 86% of mechanically ventilated burn patients suffer from ARDS. Extracorporeal Membrane Oxygenation (ECMO) is a useful adjunct in patients with severe ARDS after failure of maximal ventilatory therapy. However, few studies have looked at the utility of ECMO following burn inhalation injury. We hypothesized that the use of ECMO in burn and inhalation injury patients is both safe and effective.

Methods:
This is a retrospective review of prospectively collected ECMO program data at the University of North Carolina. Patients included in the study were All adult and pediatric patients with burns and/or inhalation injury with ARDS that underwent Veno-venous (VV) or Veno-arterial (VA) ECMO cannulation between November 2008 and October 2017. Baseline characteristic information was collected. Primary outcomes included mortality on ECMO and 30-day mortality. Secondary outcomes included critical care and ECMO related complications. Frequencies and percentages were presented for categorical data and medians and interquartile ranges were presented for continuous data.

Results:
Of the 21 patients in this study, 16 (76%) were male. Six (29%) patients had burns only, 3 (14%) had inhalation injury only, and 12 (57%) had both burns and inhalation injury. Median percent burn was 28% of total body surface area. Patients had a median age of 48 years (IQR 26-55) with a range of 2 to 72 years. Median hours on ECMO was 116 hours and 90% percent of cannulations were VV. Substance abuse was common in this population at 33%. Eight (38%) patients required hemodialysis, which was performed via the ECMO circuit, and 12 (57%) patients were placed on a lasix infusion. Tracheostomy was performed in 18 (86%) patients. One (5%) patient died while on ECMO from cardiac causes. Total 30 day mortality was 19% (n=4) and 90-day mortality was 24% (n=5). These additional deaths were sepsis-related. Eight (38%) patients had ECMO-related complication; 3 (14%) had minor bleeding, 3 (14%) had bleeding requiring transfusion of more than 2 units, 1 (5%) had a deep venous thrombosis at the cannula site, 1(5%) had a malpositioned cannula, and 1(5%) had an arrhythmia. Only two of the patients who died had a complication related to ECMO. Both patients had bleeding requiring transfusion, however both patients died of sepsis unrelated to the bleeding. 

Conclusion:
In this study, 30-day survival was 81%, and 90-day survival was 76%. While 38% of patients had complications, the majority were minor and did not lead to morbidity or mortality. These numbers are comparable to the current literature on ECMO unrelated to burns, that demonstrate a survival of approximately 60-75%. ECMO in burn and inhalation injury patients appears to be safe and effective. Larger trials are needed to examine the use of ECMO in this population.
 

48.16 Single Center Outcome with a Percutaneous Right Ventricular Device in Right Ventricular Failure

Posted on January 31, 2019

B. Badu1, M. T. Cain1, Z. R. Laste2, L. Durham1, L. Joyce1, D. Ishizawar3, M. Saltzberg3, N. Gaglianello3, A. Mohammed3, D. L. Joyce1  1Medical College Of Wisconsin,Cardiothoracic Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,Radiology,Milwaukee, WI, USA 3Medical College Of Wisconsin,Cardiology/Medicine,Milwaukee, WI, USA

Introduction:

Severe right ventricular (RV) failure requiring right ventricular assist device (RVAD) implantation is encountered following severe acute pulmonary hypertension secondary to acute respiratory distress syndrome or pulmonary embolism, and left ventricular assist device (LVAD) implantation.  Mortality at 1-year reach 30% and 40%, respectively1. Percutaneous RVAD technology is emerging, but understudied2.

Methods:

Patient charts were retrospectively reviewed for demographic and perioperative cardiac hemodynamic data, etiology of RV failure, and comorbid conditions in all patients receiving percutaneous RVAD support at our academic institution between April 2017 and August 2018. The primary outcomes we assessed were in-hospital mortality, duration of RVAD support, ICU length of stay, and device related complications such as bleeding, stroke, and the need for surgical revision.

Results:

Percutaneous RVAD was used in 23 patients (16 men, 70%); median age, 58 [19 to 66] years). Indications for implantation included RV failure post LVAD implantation (n=11, 48%), acute respiratory distress syndrome (n=5, 22%), myocardial infarction (n=5, 22%), post cardiac transplant (n=1, 4%), and viral cardiomyopathy (n=1, 4%).  Median duration of support was 14 (3 to 23) days and 18 (78%) patients were successfully weaned or underwent cardiac transplantation. Overall in-hospital mortality was 34.8%. In-hospital mortality among patients with RV failure after permanent LVAD was 0 % with 1 late death at 150 days.  Mortality among patients with primary pulmonary etiology was 40%. There was no mortality with RV failure post-transplant or after viral cardiomyopathy. Severe postoperative bleeding requiring reoperation was noted in 3 (13%) patients. Superior vena cava obstruction occurred in 2 (8%) patients and device migration in 1 (4%) patient. No device-related infection or pulmonary emboli were noted.

Conclusion:

Percutaneous RVAD support appears to be a versatile and effective tool in treating patients with severe RV failure, with particular benefit after LVAD implantation. These findings support the need for additional investigation into the benefits of this device.

 

References:

1. Kirklin JK, Naftel DC, Pagani FD, Kormos RL, Stevenson LW, Blume, et al. Seventh INTERMACS annual report: 15,000 patients and counting. J Heart Lung Transplant. 2015;34;1495-504.

2. Ravichandran AK, Baran DA, Stelling K, Cowger JA, Salerno CT. Outcomes with the Tandem Protek Duo dual-lumen percutaneous right ventricular assist device. ASAIO J. 2018;64:570-2.

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