45.04 Perioperative Sepsis Predicts Deep Venous Thrombosis In Colorectal Surgery Patients: A NSQIP Review

Posted on December 22, 2014

Q. Hatch1, D. Nelson1, J. Maykel3, E. Johnson1, B. Champagne2, N. Hyman4, S. Steele1  1Madigan Army Medical Center,Surgery,Tacoma, WA, USA 2Case Western Reserve University School Of Medicine,Cleveland, OH, USA 3University Of Massachusetts Medical School,Worcester, MA, USA 4University Of Chicago,Chicago, IL, USA

Introduction: Little data exists regarding the impact of perioperative sepsis on deep venous thrombosis (DVT) rates in colorectal surgery patients. We sought to quantify the current rate of 30-day DVT in colorectal surgery patients, and hypothesized perioperative sepsis increased the DVT rate in this patient population.

Methods: CPT codes were used to identify patients who underwent major colon or rectal surgery as reported to the National Surgical Quality Improvement Program (NSQIP) in 2010. Patients were stratified by the presence or absence of DVT in the perioperative period, and cohorts were compared in terms of demographics, comorbidities, and the presence of sepsis. Sepsis was defined by specially-trained NSQIP data collectors using Systemic Inflammatory Response Syndrome criteria with an identified infectious source.

Results: Of the 26,554 patients who underwent a major colorectal operation, 462 (1.7%) developed a deep venous thrombosis. Older patients (66 years vs. 61 years), open (77% vs. 23%) or emergency (31% vs. 15%) surgery, chronic steroid use (11% vs. 7%), and perioperative systemic sepsis (39% vs. 13%) were more likely to develop a DVT (P<0.01).  Current smokers and patients undergoing major rectal surgery were less likely to develop DVT (P≤0.02). On multivariate logistic regression analysis (controlling for ASA score, age, major rectal surgery, open surgery, length of hospital stay, smoking, and emergency surgery), systemic sepsis was independently associated with higher rates of DVT (OR=2.6, 95% CI 2.0-3.3, P<0.001).

Conclusion: Perioperative sepsis is a significant risk factor for post-operative deep venous thrombosis in the colorectal surgery population. Increased vigilance for DVT is warranted in patients who experience infectious complications after colorectal surgery.

 

45.05 Radiation Exposure Trends in Children with Appendicitis: Is Image Gently working?

Posted on December 22, 2014

M. M. McGuire1,2, T. A. Oyetunji3, H. T. Jackson1,4, W. Pastor1, D. I. Bulas1,4, F. G. Qureshi1,4  1Children’s National Medical Center,Surgery,Washington, DC, USA 2All Children’s Hospital,Surgery,St. Petersburg, FL, USA 3Howard University College Of Medicine,Washington, DC, USA 4George Washington University School Of Medicine And Health Sciences,Washington, DC, USA

Introduction:  The Alliance for Radiation Safety in Pediatric Imaging was formed in 2006 with a goal to promote radiation protection for children undergoing imaging.  In 2007 the alliance started the Image Gently campaign which promoted lower dosages and practice changes.  We studied the impact of the campaign on imaging trends in children with appendicitis.

Methods:  The Pediatric Health Information System (PHIS) database was queried for all cases of appendicitis from 2004-2013.  Imaging type used and severity of appendicitis was collected.

Results: 104,006 cases of appendicitis were identified with 41% perforated. There was an increase in total imaging over time for all cases (59.46% in 2004 to 65.53% in 2013). Computed tomography scan (CT) use reduced from 37.97% in 2004 to 25.47% in 2013 for all patients. Concomitantly ultrasound (US) use increased for all cases from 26.88% in 2004 to 52.2% in 2013.  Total imaging in perforated appendicitis trended downward (82.43% in 2004 to 65. 20% in 2013). CT scan use also decreased in perforated appendicitis from 49.60% in 2004 to 19.34% in 2013 while US increased from 38.93% in 2004 to 52.15% in 2013. There was increased CT use in all groups from 2004 to 2007 before plateauing and dropping especially in perforated appendicitis. 

Conclusion: Total Imaging has increased in children with appendicitis, with an increasing use of US and reduced use of CT.  CT scan use first increased and then decreased after 2007.  The reduction in CT use and increase in US use may be related to the Image Gently campaign.

45.06 Value of Routine Post-Op Upper GI Esophagogram After Uncomplicated Nissen Fundoplication

Posted on December 22, 2014

A. Bhama1, V. Wu1, B. Nardy1, H. Chong1  1University Of Iowa Hospitals And Clinics,General Surgery,Iowa City, IA, USA

Introduction: Laparoscopic Nissen fundoplication (LNF) is commonly performed for medically refractory gastroesophageal reflux disease and in conjunction with symptomatic hiatal hernia repairs. Though associated with a low incidence of postoperative complications, it may be still be a common practice to obtain postoperative upper gastrointestinal contrast studies (UGI) in the immediate postoperative setting. Extensive literature search did not reveal any literature regarding the use of routine UGI following LNF. The aim of this study is to evaluate the postoperative utility of UGI following uncomplicated LNF in leak assessment.

Methods: A single institution, retrospective review was performed of adult patients who underwent LNF from 2006 to 2012. Indications for LNF were refractory GERD or hiatal hernia repair. 171 patients were identified. Those undergoing reoperative surgery or Collis gastroplasty with LNF were excluded. Ten were excluded for reoperative surgery, and 19 were excluded for undergoing Collis gastroplasty. The final study comprised of 142 patients. UGI and postoperative outcomes were assessed from this group of patients. All UGI were obtained between postoperative days one through three and interpreted by staff radiologists. The cost of study was obtained from the radiology billing department.

Results: Of the 142 patients reviewed, the mean age of patients undergoing surgery was 56.9 years, with a female predominance 72%.  Indication for operation was refractory GERD in 58% (n=83) of patients, paraesophageal hernia repair in 42 %(n=59) of patients. UGI studies were obtained in 94% (n=134) of patients. Of the 134 UGI studies, no leaks were identified; however, one was a false negative study, and the patient required emergent reoperation for gastric perforation found on CT. There was no clinical suspicion for leaks in those who did not undergo UGI. Negative predictive value of UGI for leak was found to be 99.3%. Sensitivity, specificity and PPV are unable to be calculated given that no tests were positive for leak. Cost of each UGI and CT scan with interpretation was $816 and $4020 respectively.

Conclusion: This study suggests that there is little utility of UGI in the early postoperative period following uncomplicated LNF for refractory GERD and paraesophageal hernia repairs. If clinical suspicion of leak arises, a CT scan with oral contrast should be obtained in lieu of an UGI study.

 

45.07 Predictors of Operative Failure in Parathyroidectomy for Primary Hyperparathyroidism

Posted on December 22, 2014

D. C. Cron1, S. Kapeles1, S. Kwon1, P. Kirk1, E. Andraska1, B. McNeish1, D. T. Hughes1  1University Of Michigan,Surgery,Ann Arbor, MI, USA

Introduction:  Cure rates for hyperparathyroidism with parathyroidectomy are typically 95%; however, studies analyzing risk factors for operative failure and persistent hyperparathyroidism are limited. This study sought to identify predictors of operative failure in parathyroidectomy for primary hyperparathyroidism.

Methods:  This is a retrospective review of 2084 adult patients with primary hyperparathyroidism who underwent initial parathyroidectomy at a single center from 1999-2012.  Parathyroidectomy included both directed-approach (59%) and bilateral explorations (41%). The following data were collected: age, sex, perioperative lab values, imaging results, thyroid pathology, intraoperative data including parathyroid hormone (IOPTH) levels, and number of excised glands. Biochemical cure was defined as both an IOPTH decrease of ≥50% from the baseline and a level in the normal range (<75pg/ml). Operative failure (persistent disease) was defined by two or more postop serum calcium measurements ≥10.2mg/dL or a single calcium ≥11.0mg/dL when no other data available. Univariate logistic regression and backwards-stepwise multivariate logistic regression were used to identify significant predictors of operative failure. 

Results: Operative failure was identified in 65 patients (3%), with 35% having reoperative parathyroidectomy as a result. Significant predictors of failure on univariate analysis included: failure to meet IOPTH criteria, lower excised gland weight (< median of 600mg), multiple glands excised, bilateral exploration, lower preop PTH, higher preop calcium, and higher final IOPTH. A correct pre-op sestamibi was protective (Fig. A). Preop ultrasound localization was not associated with operative success. Predictors retained in the multivariate model included: IOPTH criteria met (OR=0.2, CI 0.1-0.3, P<0.01), low gland weight (OR=4.2, CI 2.0-9.0, P<0.01), high preop calcium (OR=1.9, CI 1.3-2.8), and low preop PTH (OR=0.99 CI 0.99-1.0, P=0.03). The C-statistic for this model was 0.80 (Fig. B). 

Conclusion: Operative failure of parathyroidectomy for primary hyperparathyroidism is rare; however, failure to meet IOPTH criteria, low preoperative PTH levels, high preoperative calcium levels, and low gland weight are risk factors for persistent disease.

 

45.08 Substernal Goiter: When is a Sternotomy Required?

Posted on December 22, 2014

L. Nankee1, H. Chen1, D. Schneider1, R. Sippel1, D. M. Elfenbein1  1University Of Wisconsin,Madison, WI, USA

Introduction: Sternotomy for substernal goiters (SSG) is associated with greater morbidity than a cervical approach.  Accordingly, predicting which patients will require a sternotomy is imperative for pre-operative planning.  In this study, we analyzed the pre-operative and post-operative characteristics of patients with SSG compared to those with large goiters contained entirely within the neck, or a cervical goiter (CG). We sought to identify predictors for sternotomy as a surgical approach for the removal of SSG. 

Methods: A retrospective review of the Endocrine Surgery Database was performed.  Patients were included if they had large (>100g) thyroids or any mention of a substernal component during their pre-operative workup.  Between 1995 and 2013, 220 patients met these criteria.  Comparisons were made between patients who had a SSG and patients who had a CG.  Further comparisons were made between those with a SSG who required sternotomy to excise their thyroid and those who underwent cervical incision only.

Results: Of the 220 patients, 127 (58%) patients had SSG, of whom 7 (5.5%) required sternotomy.  On bivariate analysis, there were no differences in gender, BMI, preoperative symptomatology, postoperative complications or length of stay for patients who had SSG vs CG.  Patients with SSG were older (62 + 15 vs 51 + 17 years, p<0.001), more likely to undergo preoperative CT scanning (69% vs. 31%, p<0.001), and less likely to have preoperative hyperthyroidism (10% vs. 29%, p<0.001).  Patients who underwent a sternotomy showed no difference in terms of gender, age, BMI, preoperative hyperthyroidism, or postoperative complications compared to those with SSG who underwent cervical incision thyroidectomy.  All patients who underwent sternotomy underwent preoperative CT scanning and were more likely to have preoperative symptoms of chest pressure and voice complaints.  Furthermore, all patients who underwent sternotomy had extension of the thyroid gland below the aortic arch.  Sternotomy took an average of 2 hours longer than a cervical incision, was associated with significantly more blood loss (600 + 408 vs. 190 + 118, p=0.04), and a longer length of stay (3.1 + 0.9 vs. 1.8 + 1.6 days, p=0.03) than cervical thyroidectomy. 

Conclusion: Sternotomy for SSG is rare.  All patients necessitating sternotomy had extension below the aortic arch on preoperative CT scanning, and were more likely to present complaining of chest pressure and voice issues.  

 

45.09 Potential Targets to Improve in Disparities in Thyroid Surgery Outcomes

Posted on December 22, 2014

L. E. Kuo1, H. Wachtel1, G. C. Karakousis1, D. L. Fraker1, R. R. Kelz1  1Hospital Of The University Of Pennsylvania,Department Of Surgery,Philadelphia, PA, USA

Introduction:  In an effort to improve surgical outcomes and minimize disparities, a great deal of attention has been focused on referral to high volume surgeons. While this is one potential solution, it is not feasible for all patients. Moreover, within high volume practices, thyroidectomy outcomes have been shown to be inferior amongst non-whites. We sought to examine differences in time to surgical consultation and presentation for treatment of benign thyroid conditions in an attempt to identify alternative targets for improving surgical care.

Methods:  We used our prospective endocrine surgery registry from 2002-2012 to identiry patients who underwent thyroidectomy for benign disease. Patients were classified as white or non-white. Patient demographics (race, age, gender, median income), disease history (diagnosis, time until surgical referral, symptoms at surgical consultation), surgical characteristics (mass, pathology) were examined. The primary outcome variable was time to surgical referral. Specimen characteristics were secondary outcome variables. Univariate analyses were performed using the Wilcoxon ranksum and chi square tests, as appropriate. A multivariable linear regression was performed to examine the influence of median income of race on time to surgical referral with adjustment for potential confounders.

Results: 1144 patients were studied. 81.7% were white and 18.3% were non-white. There was no difference in patient age or gender between the groups. Non-white patients had a lower median income than white patients ($46,622, interquartile range(IQR) $30,912:72,762 vs. $75,784, IQR $58,518:90,788, p<0.001). Non-white patients were more likely to report compressive symptoms than whites (53.6% vs. 32.2%, p<0.001), as well as dysphagia (19.6% vs. 13.2%, p=0.017). Non-white patients had a longer median time to surgical referral (0yrs, IQR 0:5) than whites (0yrs, IQR 0:3, p<0.017), and this difference remained after adjusting for confounders. Non-white patients also had a greater median thyroid mass (23.3gm, IQR 12.0:56.4 vs. 59.6gm, IQR 28.8:40.8, p<0.001). Amongst patients with goiter as the indication for surgery, non-white patients had significantly larger glands than white patients: 105.9gm, IQR 50.0:186.5 vs. 70.9gm, IQR 34.3:129.6, p<0.001.

Conclusion: Non-white patients had a longer time to surgical referral, were more likely to report symptoms of compression at the time of surgical referral, and had larger thyroids at the time of resection than white patients. This is the first time a racial disparity has been reported in presentation to surgical care for benign thyroid disease. Disparities in access to surgical care for benign disease are difficult to quantify due to limitations in the availability of clinical information in claims registries and datasets. Further studies are indicated to examine the benefits of referring patients for surgery while their condition is mild enough to be successfully treated by a surgeon. 

 

45.10 Outcomes Using Double-Stapled Technique for Esophagoenteric Anastomosis in Gastric Cancer

Posted on December 22, 2014

A. Falor1, A. Choi1, S. Merchant1, M. Lew2, B. Lee1, I. B. Paz1, R. Nelson3, J. Kim1  1City Of Hope National Medical Center,Division Of Surgical Oncology,Duarte, CA, USA 2City Of Hope National Medical Center,Department Of Anesthesia,Duarte, CA, USA 3City Of Hope National Medical Center,Department Of Biostatistics,Duarte, CA, USA

Introduction: Several surgical techniques to perform esophagoenteric anastomosis for total/proximal gastrectomy have been described including the double-stapled technique (DST), which involves a circular stapled anastomosis across the stapled end of the esophagus. Since prior reports on DST for gastric cancer are limited, our objective was to examine rates of anastomotic leak and stricture with DST for esophagoenteric anastomosis in patients with gastric cancer.

Methods: A single institution review was performed for patients who underwent total/proximal gastrectomy with DST between 2006 and 2014. All DST were performed using the OrVil™ and an end-to-end anastomosis (EEA) stapler. Patient and treatment-related variables were tabulated. Anastomotic leaks were defined as perianastomotic extravasation of oral contrast on radiographic imaging or anastomotic disruption on endoscopy. Stricture was defined as symptomatic anastomotic narrowing requiring dilation.

Results: Of 55 patients who underwent DST between 2006 and 2014, total gastrectomy was performed in 44/55 (80%), proximal gastrectomy in 6/55 (11%) and completion gastrectomy in 5/55 (9%). Eleven patients (20%) had multi-visceral resection at the time of gastrectomy. Fifty patients (91%) had adenocarcinoma on final pathology, and 22 patients (40%) received neoadjuvant chemotherapy. Six patients (10.9%) had undergone radiation therapy prior to completion gastrectomy for recurrent disease. Operative approach was open (n=26/55; 47.2%), laparoscopic (n=26/55; 47.2%), and robotic (n=3/55; 5.4%). The leak rate was 5/55 (9%) occurring at a median of 14 days (5-20 days). The stricture rate was 12/55 (21.8%) occurring at a median of 86 days (40-405 days). Leak and stricture rates improved with increased experience. During the 2012-2014 period, the rates of anastomotic leak and stricture were 0/19 (0%) and 3/19 (15.7%), respectively. The overall complication rate was 21/55 (38.1%) of which 60% were classified as Clavien-Dindo grade III-V complications. On multivariate analysis, none of the aforementioned variables correlated with risk for leak or stricture.

Conclusion: In the largest Western series of DST esophagoenteric anastomoses for gastric cancer, our experience demonstrates that DST is a safe and effective technique with low rates of anastomotic leak and stricture.

 

46.01 Both Systemic Inflammation and Visceral Obesity Are Associated with Colorectal Cancer Recurrence

Posted on December 22, 2014

C. T. Aquina1, A. S. Rickles1, C. P. Probst1, B. J. Hensley1, A. A. Swanger1, K. Noyes1, J. R. Monson1, F. Fleming1  1University Of Rochester,Surgical Health Outcomes & Research Enterprise (S.H.O.R.E.),Rochester, NY, USA

Introduction:  Much recent attention has been directed towards the detrimental effects of a pro-inflammatory state on tumorigenesis and oncologic outcomes. Our research group has previously shown a relationship between elevated metabolically active visceral fat volume and recurrence-free survival in colorectal cancer. Other studies have demonstrated a similar link to colorectal cancer outcomes with laboratory inflammation markers such as the neutrophil-to-lymphocyte ratio. We sought to investigate whether pre-operative inflammatory indices are associated with long-term colorectal cancer outcomes and whether this relationship is mediated by visceral obesity.

Methods:  A single-center retrospective chart review was performed for patients undergoing surgical resection for colorectal cancer between 2000 and 2009. Pre-operative CT scans were used to calculate visceral fat volume (VFV) based upon a previously validated method. Pre-operative laboratory values within 90 days of the date of surgery were used to calculate the neutrophil-to-lymphocyte ratio (NLR). A pre-operative NLR>3 was used as a cut-off to define high NLR according to previous literature. Visceral obesity was defined as VFV>1620cm3 based upon the results of a receiver operating characteristic curve. Five-year recurrence-free survival was defined as locoregional or distant recurrence within 5 years of surgery. Chi-square, Student’s T-test, Kaplan-Meier, and Cox proportional-hazards analysis were used to compare pre-operative and surgical characteristics with recurrence-free survival.  

Results:  Overall, 141 patients met inclusion criteria with 75 patients having a high NLR (53.2%) and 48 patients having visceral obesity (34%). Patients with a high NLR had significantly higher levels of VFV (mean=1741cm3 vs. 1399cm3, p=0.04). On Kaplan-Meier analysis, both high NLR (p=0.03) and visceral obesity (p=0.005) were independently associated with reduced 5-year recurrence-free survival for stage II colorectal cancer but not stages I or III. Using separate Cox proportional-hazards models due to the association between high NLR and visceral obesity, both high NLR (HR=4.04, p=0.04) and visceral obesity (HR=4.05, p=0.03) were associated with a more than 4-fold risk of cancer recurrence within 5 years for stage II colorectal cancer.

Conclusion:  Both pre-operative systemic inflammation, as captured by an elevated pre-operative neutrophil-to-lymphocyte ratio, and visceral obesity are associated with worse recurrence-free survival for stage II colorectal cancer. Additional study is warranted at exploring the association between these two factors and developing strategies at improving outcomes for this high-risk population.

 

46.02 Minimally invasive distal pancreatectomy for cancer: Short-term oncologic outcomes in 1733 patients

Posted on December 22, 2014

M. Abdelgadir Adam1, K. Choudhury3, M. Dinan2, S. Reed2, R. Scheri1, D. Blazer1, S. Roman1, J. Sosa1,2  1Duke University Medical Center,Surgery,Durham, NC, USA 2Duke Clinical Research Institute,Durham, NC, USA 3Duke University Medical Center,Biostatistics,Durham, NC, USA

Introduction: Emerging data from high-volume institutions suggest that minimally invasive distal pancreatectomy (MIDP) provides favorable perioperative outcomes and adequate oncologic resection.  However, it is unclear if these outcomes are generalizable at a population level. This study examines patterns of use and short-term outcomes from MIDP vs. open distal pancreatectomy for pancreatic cancer.  

Methods: Adult patients undergoing distal pancreatectomy were identified from the National Cancer Database, 2010-2011. Descriptive statistics were used to characterize patterns of laparoscopic and/or robotic MIDP use. Multivariable modeling was applied to determine factors associated with use of MIDP and compare short-term outcomes from MIDP vs. open surgery, while adjusting for patient, clinical, and tumor characteristics.

Results: A total of 1,733 patients underwent distal pancreatectomy for cancer: 535 had MIDP and 1,198 had open surgery. Use of MIDP increased 43% between 2010 to 2011, from 220 to 315 cases. Across both study years, the conversion rate from MIDP to open distal pancreatectomy was 23%. MIDP cases were performed at 215 hospitals, with the overwhelming majority of hospitals (97%) performing <10 cases overall. The majority of MIDP cases (67%) were performed at academic institutions. Patients were more likely to undergo MIDP if they were older [odds ratio (OR) 1.02 (95% confidence interval (CI) 1.01-1.04), p<0.01], privately insured [OR 1.41 (CI 1.04-1.92), p=0.03], diagnosed in 2011 (vs. 2010) [OR 1.48 (CI 1.17-1.86), p<0.01], or had a diagnosis of a neuroendocrine malignancy (vs. adenocarcinoma) [OR 1.82 (CI 1.37-2.40), p<0.01]. After adjustment, compared to the open group, those who underwent MIDP were more likely to have negative surgical margins [OR 1.66 (CI 1.12-2.46), p=0.01] and a shorter length of stay [relative risk (RR) 0.82 (0.76-0.89), p<0.01]; the number of lymph nodes removed [RR 0.94 (0.85-1.04), p=0.24], rates of 30-day readmission [OR 1.15 (0.72-1.83), p=0.57] and 30-day mortality [OR 0.34 (0.06-1.80), p=0.20] were similar between groups.     

Conclusion: Use of MIDP for cancer is increasing, with most centers performing a low volume of these procedures. Use of MIDP for body and tail malignancies of the pancreas appears to have short-term outcomes that are similar to those of open procedures with the benefit of a shorter length of hospital stay. Larger studies with longer follow-up should be undertaken to examine clinical outcomes.

 

46.03 Menopausal Status Does Not Predict Recurrence Score Using Oncotype DX Assay

Posted on December 22, 2014

D. N. Carr3, N. Vera3, J. Mullinax1, D. Korz1, W. Sun1, M. Lee1, S. Hoover1, W. Fulp2, G. Acs4, C. Laronga1  1Moffitt Cancer Center And Research Institute,Breast Program,Tampa, FL, USA 2Moffitt Cancer Center And Research Institute,Biostatistics,Tampa, FL, USA 3University Of South Florida College Of Medicine,Tampa, FL, USA 4Women’s Pathology Consultants, Ruffolo Hooper & Associates,Tampa, FL, USA

Introduction:  Adjuvant treatment planning for early stage, estrogen receptor (ER) positive invasive breast cancer has been historically based on menopausal status. The Recurrence Score (RS) from the 21-gene breast cancer assay (ODX) is predictive of distant recurrence in this population, but is rarely applied to younger, premenopausal patients (pts). To evaluate the validity of this historical bias, we sought to evaluate the relationship between menopausal status and the recurrence score derived from the Oncotype DX assay.

Methods:  An IRB-approved retrospective review was conducted of invasive breast cancer pts with known RS. Eligibility for performance of the ODX was based on NCCN guidelines or physician discretion. Data collected included demographics, clinical-pathologic variables, surgery type, adjuvant treatment and outcomes. Menopausal status was documented at time of ODX. Perimenopausal women were classified with premenopausal for statistical analyses. Comparisons on RS were made by menopausal status (premenopausal vs. postmenopausal) using general linear regression model and the exact Wilcoxon Rank Sum Test. 

Results: 607 pts with invasive breast cancer and a RS were identified. Menopausal status was available for 600 pts (166 premenopausal, 434 postmenopausal) comprising our study population. Median age for the entire population was 58yrs (range: 27-84); 47yrs for premenopausal and 62yrs for postmenopausal. Median invasive tumor size was 1.5 cm for both cohorts. No significant differences were seen between cohorts for overall survival, metastatic disease rate, histologic grade, lymphovascular invasion (LVI), nodal status, stage, adjuvant chemotherapy, or endocrine therapy use. Mastectomy rate was higher in the premenopausal group (53.8%), compared to postmenopausal (41.9%) (p=0.0001), and thus receipt of breast irradiation was lower in premenopausal women. Despite the higher mastectomy rate in premenopausal women, a higher local-regional recurrence rate (3% vs. 0.7%; p=0.0384) was observed. Degree of ER expression was lower in premenopausal women (95%) than postmenopausal (100%) (p<0.0001). Median RS was the same (16) for both premenopausal (range: 0-62) and postmenopausal (range: 0-63) women. Tumor size, nodal status, and stage did not affect RS. Menopausal status as a categorical variable was not predictive of RS (p value = 0.7731). Factors predicting higher RS included higher mitotic rates (p<0.0001), higher nuclear grade (p<0.0001), decreased tubule formation (p=0.0001), presence of LVI (p=0.002), high grade (p<0.0001), and lower expression levels of ER/PR (p<0.0001).  

Conclusion: Menopausal status has limited predictive power for distant breast cancer recurrence. We have shown that RS across the spectrum of menopausal status is well distributed in this cohort of women. Therefore, menopausal status alone should not preclude recommendations for performance of ODX in ER-positive, early stage breast cancer.
 

46.04 Tumor Associated Macrophage Expression of Folate Receptor β in Lung Cancer: Prognostic Significance

Posted on December 22, 2014

A. Bain1, A. Vachani6, P. Low7, S. Singhal4, C. Deshpande5  6Perelman School Of Medicine At The University Of Pennsylvania,Department Of Medicine,Philadelphia, PA, USA 1Perelman School Of Medicine At The University Of Pennsylvania,Philadelphia, PA, USA 4Perelman School Of Medicine At The University Of Pennsylvania,Department Of Surgery,Philadelphia, PA, USA 5Perelman School Of Medicine At The University Of Pennsylvania,Department Of Pathology,Philadelphia, PA, USA 7Purdue University,Department Of Chemistry,West Lafayette, IN, USA

Introduction:  This study was undertaken in order to better elucidate the relationship between Folate Receptor Beta (FRβ) positive macrophages and cancer prognosis. Tumor associated macrophages (TAMs) play a key role in promoting inflammation and regulating the immune response to malignancies.  FRβ is a useful target because its expression is limited to activated macrophages in a subset of disease conditions, including neoplasms.  While previous work has suggested a relationship between FRβ+ macrophages and cancer prognosis, to our knowledge no such studies exist for lung adenocarcinoma.

Methods: 69 patients underwent resection for primary lung adenocarcinoma from 2003-2006.  Under IRB approved protocol, a tissue microarray (TMA) was constructed using formalin-fixed, paraffin-embedded specimens from patient tumors.  A TMA section was stained using FRβ-specific monoclonal antibody m909 in antibody diluent (1:100).  Cytoplasmic staining was measured for FRβ+ macrophage frequency and staining intensity. Samples were scored as 0, no staining; 1+, weak; 2+, moderate; and 3+, strong.  Average scores for patients with ≥2 scored TMA tumor cores (n=50) were included in the analysis.  An unweighted product score was derived from the frequency and intensity scores to yield a total score of 0-9.  Clinical measures including tumor staging and survival status were followed for a minimum of 4 years.  The relationship between FRβ expression and survival time was tested using a student's t-test, and differences of tumor staging and survival times were compared by one-way ANOVA.  Statistical analyses were done with Stata 13 (StataCorp., College Station, TX).

Results: 37 patient TMA cores had FRβ product scores ≥4, and 29 patients had product scores ≥6.  The difference in mean survival time for patients with product scores ≥6 (1750.8 days) and patients with product scores <6 (1417.0 days) was 333.8 days (p-value = 0.0493).  Among deceased patients, mean survival time for the ≥6 group (1121.1 days) was greater than for the <6 group (901.5 days).  The difference in mean survival time between patients with Stage I/II disease and Stage III disease was 257.0 days (p-value = 0.1588).  The relationship between tumor stage and FRβ expression was not statistically significant (Fisher’s exact, p-value = 0.180).

Conclusion: Previous clinical studies have suggested that FRβ expression is limited to M2 macrophages and is associated with poor outcomes.  However, our results indicate that FRβ expression may be associated with longer survival times in patients with lung adenocarcinoma.  FRβ expression was also a better prognostic indicator of survival time than tumor stage alone.

46.05 Accuracy of Surgeons In Predicting the Dose of Levothyroxine After Total Thyroidectomy

Posted on December 22, 2014

H. M. Yong1, T. W. Yen1, K. Doffek1, D. B. Evans1, T. S. Wang1  1Medical College Of Wisconsin,Department Of Surgery / Division Of Surgical Oncology,Milwaukee, WI, USA

Introduction:  Following total thyroidectomy, levothyroxine (LT4) is often prescribed at discharge by the surgical team, with follow-up thyroid function tests (TFTs) and dose adjustments primarily managed by the endocrinologist or primary care physician (PCP). The aim of this study was to investigate the accuracy of the surgical team in determining the initial LT4 dose.

Methods:  A retrospective chart review of a prospectively collected, thyroid database was performed of 420 patients with benign thyroid disease who underwent a completion or total thyroidectomy between 1/2009-10/2014 and were prescribed an initial LT4 dose by the surgeon. Data collected included age, gender, body mass index (BMI: kg/m2), pre- and postoperative final pathology, initial surgeon-prescribed LT4 dose, TFTs, subsequent modifications to LT4 dose by the primary care physician/endocrinologist, and the time to achieve biochemical (TSH 0.45 – 4.5 uIU/mL) euthyroidism. All patients had follow-up with an endocrinologist or PCP within 8 weeks of surgery; data on LT4 doses were collected for six months postoperatively.

Results: The final cohort consisted of 289 patients. Median age was 53 years (range, 18-86) and 248 (86%) were female. Median BMI was 31.1 (range, 16.1-63.7). The median LT4 dose initially prescribed was 137 mcg (1.65mcg/kg; range –75-200); 119 (41%) patients achieved normal serum TSH values at initial follow-up and required no dose adjustments. Of the remaining 170 patients, 52 (31%) had elevated TSH levels at initial follow-up, requiring a median adjustment of 25 mcg (range, 11-50). Of the 118 patients with suppressed TSH levels at initial follow-up, the median adjustment was 21.5 mcg (range, 3-60). At 6 months, 59 (34%) of the 170 patients who required an initial dose adjustment had follow-up data; 57 (97%) were euthyroid, achieved at a median of 4.6 months (range, 2–6) and a median of 2 provider visits (range, 2-5).  

For the overall cohort, there was no difference in the proportion of patients who required dose adjustment by BMI or race. However, there was a significant difference in the proportion of patients requiring dose adjustment by age; older patients were more likely to be on too high a dose of LT4 at initial follow-up (p=0.0117; Table).

Conclusion: The initial dose of LT4 prescribed by the surgical team after total thyroidectomy was accurate in less than 50% of patients, with more patients being prescribed a higher dose of LT4 than ultimately required, particularly in the elderly. This underscores the importance of follow-up with thyroid function testing within the initial postoperative period and suggests that preoperative discussion with their referring provider for initial LT4 doses may be appropriate.
 

46.06 Preoperative Anemia Predicts Poor Outcomes for Non-Metastatic RCC Patients with Venous Thrombus

Posted on December 22, 2014

K. E. Zorn1, W. P. Christensen1, V. Margulis3, T. M. Bauman1, C. G. Wood2, E. J. Abel1  1University Of Wisconsin,Urology,Madison, WI, USA 2University Of Texas MD Anderson Cancer Center,Urology,Houston, TX, USA 3University Of Texas Southwestern Medical Center,Urology,Dallas, TX, USA

Introduction: In approximately 10% of renal cell carcinoma (RCC) patients, tumor extends beyond the kidney into the venous system, increasing the risk of postoperative recurrence.  Anemia is known to predict worse survival in patients with metastatic RCC, but the prognostic ability of preoperative anemia has not been studied in non-metastatic high risk RCC patients. The purpose of this study was to evaluate whether patients with preoperative anemia had worse postoperative cancer outcomes using a multi-institutional contemporary series of non-metastatic RCC patients with venous involvement.

Methods: A comprehensive review of clinical and pathological risk factors was performed for consecutive RCC patients with thrombus treated between 2000 and 2012 at three separate institutions. Univariate and multivariate Cox proportional hazards analysis was used to evaluate association of anemia or other common risk factors for cancer specific survival (CSS) and recurrence free survival (RFS).

Results:  A total of 470 non-metastatic patients were treated surgically for RCC with venous thrombus invasion from 2000-2012 at participating centers. Thrombus extended into the renal vein in 259 (55.1%) patients, into the IVC <2cm in 65 (13.8%) patients, into the IVC >2cm but below hepatic veins in 81 (17.2%) patients, and within the IVC above the hepatic veins in 65 (13.8%) patients.

Median follow-up was 28.4 months (IQR 12.2-54.9) and 188 (40.0%) patients developed recurrent disease within the follow-up period. Of patients that developed recurrent disease, initial site of recurrent disease was solitary for 128 (68.1%) patients while 60 (31.9%) patients presented initially with multiple sites of metastatic disease.  Preoperative hemoglobin was independently predictive of recurrence with a hazard ratio of 1.727 (95% CI: 1.251-2.385, p=0.0009). Other independent predictors of recurrence included BMI ≤20, perinephric fat invasion by tumor, non-clear cell histology and tumor width.

Median CSS was 136.6 (IQR 43.8-NR) months and 112 (23.8%) patients died of RCC within the follow-up period. BMI, systemic symptoms, IVC thrombus level above the hepatic veins, and estimated blood loss were associated with CSS on univariate analysis. On multivariate analysis, only preoperative hemoglobin less than lower limit of normal (HR 2.051, p=0.02) and tumor width per cm (HR 1.078, p=0.02) were independently predictive of CSS.

Conclusion: In non-metastatic RCC patients with venous invasion, preoperative anemia and tumor diameter were independent predictors of recurrence and cancer mortality.

46.07 Right vs. Left Colectomy Outcomes in Colon Cancer Patients

Posted on December 22, 2014

H. Aziz1, M. R. Torres1, V. Nfonsam1  1University Of Arizona,Tucson, AZ, USA

Introduction:

Optimization of surgical outcomes after colectomy continues to be actively studied, but most studies group right-sided and left-sided colectomies together. The aim of our study was determine whether the complication rate differs between right-sided and left-sided colectomies for cancer.

Methods:

We identified patients who underwent laparoscopic colectomy for colon cancer in the 2005-2010 American College of Surgeons National Surgical Quality Improvement Program database and stratified cases by right and left side. The two groups were matched using propensity score matching for demographics, previous abdominal surgery, pre-operative chemotherapy and radiotherapy, and pre-operative laboratory data. Outcome measures were: 30-day mortality and morbidity.

Results:

We identified 2,512 patients who underwent elective laparoscopic colectomy for right-sided or left-sided colon cancer in the database. The two groups were similar in demographics, and pre-operative characteristics. There was no difference in overall morbidity (15% vs 15.7%; p-0.8) or 30 day mortality (1.5% vs 1.5%; p-0.9) between the two groups. Sub-analysis revealed higher surgical site infection rates (9% vs 6%; p-0.04), higher incidence of ureteral injury(0.6% vs 0.49%; p-0.04), higher conversion rate to open colectomy (51% vs. 30%; p-0.01) and a longer hospital length of stay (10.5+/-4 vs. 7.1+/-1.3 days; p-0.02) in patients undergoing laparoscopic left colectomy.

Conclusion:

Our study highlights the difference in complications between right-sided and left-sided colectomies for cancer. Further research on outcomes after colectomy should incorporate right vs left side colon resection as a potential preoperative risk factor.

46.08 Impact of laterality on perioperative morbidity and mortality following major hepatic resection.

Posted on December 22, 2014

S. C. Pawar1, A. Robinson1, R. S. Chamberlain1  1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA

Introduction: Anatomic variations and technical nuances involved in performing a left sided hepatic resection versus a right-sided hepatic resection make the procedures distinctly different. This study examined the relationship between laterality and perioperative outcomes in hepatic hemi-resection and aimed to determine whether specific complications are associated with the types of hepatic resection, and if so whether unique complication profiles exist for left and/or right hemiresections.

Methods: American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was used to identify patients who underwent elective open hepatectomies between 2002 and 2012. Demographics, 60 perioperative risk factors, and 32 postoperative complications were analysed using Multivariate analyses. 

Results: Among 5,355 patients, 2,614 underwent right hepatic resection, 1,439 left hepatic resection, and 1,302 extended hepatic resection. The median age was 60 years; with a male to female ratio of 1:1 and 65 % of patients had an ASA score of 3 to 4. Among patients undergoing open elective hepatectomies 44 % had disseminated cancer and 22 % had received chemotherapy prior to surgery. The most prevalent co-morbidity was hypertension (46%).The three groups were similar with regards to preoperative comorbidities.Overall 30-day mortality rate was 3.3% (173/5,243) and morbidity was 50.5%. The 30 day mortality rate was significantly higher among trisegmentectomy and right hepatectomy patients relative to left hepatectomies (4.8% and 3.6 % Vs 1.5%).  Patients with right sided hepatic resections had a higher rate of morbidity in terms of number of cases with 5 or more complications (4.6% vs. 2%; p < 0.001), and overall morbidity (51% vs. 41%, p < 0.001). Though superficial site infection (SSI) rates were similar for both procedures (5% vs. 4.6 %, p < 0.04), right hepatic resections had a higher rate of organ/space SSI (7.3% vs. 6%, p < 0.001). Left sided hepatic resection had lower rates of blood transfusions (28.6% vs. 36%, p < 0.0001); lower respiratory complications (3.5% vs 5%, p < 0.001), lower renal complications (0.8% vs. 1.6%, p < 0.001) and a shorter hospital stay (6 vs 7, p < 0.05).

 

Conclusion: Analysis of the NSQIP perioperative outcomes data confirms that extended hepatectomies (trisegmentectomy) are associated with the highest risk for mortality and morbidity.  Right hepatic lobectomy is associated with a significantly higher incidence of post-operative complications than left hepatic lobectomy, most notably with regards to intraoperative/postoperative blood transfusions, biliary leaks, cardiac complications, sepsis and 30 day operative mortality.

 

 

 

46.09 Aggressive Papillary Thyroid Microcarcinoma: Population based study from SEER database (1989-2011).

Posted on December 22, 2014

S. C. Pawar1, R. S. Chamberlain1  1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA

Introduction: Papillary thyroid microcarcinoma (PTMC) usually follows an indolent course and is considered a low risk tumor.  However recent studies have identified several cases of PTMC with locoregional recurrences in the neck and with distant metastases.  It is imperative that the clinicians have a better understanding of PTMC and specifically characteristics of PTMC with aggressive behavior.

Methods: The Surveillance, Epidemiology, and End Results (SEER) program was queried for patients diagnosed with PTMC between 1989 and 2011. Age, gender, tumor size, lesion type, extent of disease, stage, surgery, and mortality were analyzed for papillary thyroid micro carcinomas (≤ 1cm) and compared to papillary tumors of size (> 1 cm).  Clinical and pathological characteristics of patients with PTMC were compared to PTMC patients who died of cancer specific death using multivariate analyses. 

Results:Among 53,429 patients diagnosed with Papillary thyroid carcinoma, 36,093(67%) were diagnosed with PTC tumors of size (> 1 cm) and 17,336 (32%) were PTMC (≤ 1 cm). The median age of the entire cohort was 48 yr (PTMC (49 yr) and PTC (48 yr)), however patients with PTMC with aggressive behavior were significantly old (64 yr). Females dominated the study cohort for both PTC (> 1 cm) and PTMC (≤ 1 cm) (73% vs 81% respectively). PTMCs were more likely to present as multifocal tumors compared to PTC (> 1 cm) (14% Vs 8% respectively). 82% of PTMCs had localized disease at the time of diagnosis, 17% had regional spread, and 1% had distant metastasis. Multivariate analysis identified extrathyroidal invasion, multifocality, male gender, Asian race, and tumors with regional and distant metastasis at diagnosis as significant independent predictors of mortality in PTMC patients.  Patients with PTMC who died were more male (Odds ratio [OR], 4.34; p < 0.0001), of Asian ethnicity (OR, 1.35; p < 0.005), and elderly (OR, 9.77; p < 0.001). 

Conclusion:Although most PTMCs are considered low risk, up to 17% of patients with PTMC exhibit aggressive behavior in regards to extrathyroidal invasion, multifocality, regional spread, distant metastasis at diagnosis, and may benefit from a more radical therapeutic approach. PTMCs with aggressive behavior are more common among male gender, elderly age group, and Asian ethnicity.

 

 

46.10 Adjuvant Chemotherapy Attenuated the Impacts of Perineural Invasion in Stage III Colorectal Cancer

Posted on December 22, 2014

T. Suzuki1, K. Suwa1, K. Hanyu1, Y. Mitsuyama1, K. Eto1, M. Ogawa1, T. Okamoto1, T. Fujita1, M. Ikegami2, K. Yanaga1  1The Jikei University School Of Medicine,Department Of Surgery,Tokyo, , Japan 2The Jikei University School Of Medicine,Department Of Pathology,Tokyo, , Japan

Introduction: Perineural invasion (PNI) is associated with decreased survival in several malignancies, but no robust evidence has been documented in colorectal cancer (CRC). The aim of the present study was to evaluate the association of PNI and outcomes of patients after colorectal resection for CRC, focusing on the impact of adjuvant chemotherapy on survival rates of patients with PNI.

Methods: We retrospectively reviewed 224 consecutive patients who underwent surgery for Stage I to IV CRC between January 1999 and December 2004. The presence or absence of PNI of the tumor was determined by experienced pathologists in our institution. Overall and disease-free survival rates were estimated using the Kaplan-Meier method, and intergroup differences in survival curves were tested with the log-rank test. To evaluate the correlation between PNI and survival, PNI was entered into a Cox proportional hazards model as an independent variable.

Results: PNI was detected in 63 of the 224 patients (28%) and positively correlated with lymphatic invasion (P = 0.003), venous invasion (P = 0.006), lymph node involvement (P = 0.002), size of tumor (P = 0.019), postoperative chemotherapy (P = 0.023), and incidence of metastasis or recurrence (P < 0.0001). The 5-year disease-free survival rate was 1.6-fold in patients with PNI-negative tumors as compared to PNI-positive tumors (66% vs 44%, respectively; P < 0.001). The 5-year overall survival rate was 71% for PNI-negative tumors, which was significantly higher than 40% for PNI-positive tumors (P < 0.001). A multiple regression analysis revealed that PNI was a strong prognostic factor for overall survival. In a subset analysis of patients with stage III CRC, adverse effects of PNI on survival were attenuated by adjuvant chemotherapy, but adjuvant chemotherapy did not completely reverse the effects of PNI.

Conclusion:PNI was associated with poor prognostic markers such as lymphatic invasion and lymph node involvement, and predicted worse survival in patients with stage III CRC. Adverse effects of PNI on survival were attenuated by adjuvant chemotherapy. Intensive chemotherapy and strict surveillance seem be warranted in patients with CRC of stage III with PNI.

 

45.01 The Impact of Age and Frailty on Surgical Outcomes After Ileal Pouch-Anal Anastomosis

Posted on December 22, 2014

J. N. Cohan1,3, P. Bacchetti2, M. G. Varma1, E. Finlayson1,3  1University Of California – San Francisco,Department Of Surgery,San Francisco, CA, USA 2University Of California – San Francisco,Department Of Epidemiology And Biostatistics,San Francisco, CA, USA 3University Of California – San Francisco,Institute For Health Policy Studies,San Francisco, CA, USA

Introduction:  Historically, older patients with ulcerative colitis were not considered candidates for ileal pouch-anal anastomosis (IPAA).  However, evidence from several single-center studies suggests that IPAA can be performed in selected older patients with surgical outcomes similar to those in younger patients.  In order to evaluate whether this finding is generalizable, we used a national database including patient data from 374 US hospitals to examine outcomes after IPAA.   

Methods:  Using the American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP) database, we identified all patients with ulcerative colitis who underwent total proctocolectomy or completion proctectomy with IPAA from 2005-2012.  We examined the associations of age and frailty trait count with length of stay and major surgical complication count using multivariate linear and negative binomial regression.  In both models, we adjusted for important procedure and patient characteristics (see table footnote).  The frailty trait count includes frailty traits present in the NSQIP database that are frequently used in frailty indices: diabetes, hypertension, congestive heart failure, functional status, and ≥10% body weight loss over six months prior to surgery.

Results:  IPAA was performed in 2493 patients with ulcerative colitis.  Thirty-day mortality was 0.002% (N=7).  Patients older than age 50 were more likely to have diabetes (20.4% vs 2.6%), hypertension (32.9% vs 8.0%), blood transfusion (6.8% vs 3.6%), ≥1 frailty trait (39.7% vs 14.2%), and American Society of Anesthesiologists class 3-4 (35.4% vs 17.6%) than younger patients (all p≤0.001).  The majority of patients had no serious postoperative complications (age <50: 79.5%, age 50-59: 80.4%, age ≥60: 79.1%).  After adjusting for important procedure and patient characteristics, age ≥60 was associated with a minor (15%) increase in number of complications (p=0.40) and with a 0.8 day increase in length of stay (p=0.036).  The average adjusted length of stay was 7.4 days in patients age <50, 7.7 days in patients age 50-59, and 8.2 days in patients age ≥ 60.  Frailty trait count ≥1 was associated with small increases that did not reach statistical significance (Table).  

Conclusion:  Among patients with ulcerative colitis undergoing IPAA in the NSQIP database, advanced age and frailty were associated with only slightly increased postoperative complications, but the effect of age ≥60 on length of stay was close to a full day.  These findings suggest that IPAA may be a safe surgical option for older patients with ulcerative colitis.  Future work should evaluate functional outcomes in older patients across a spectrum of hospitals.

45.02 Post-Operative Troponin Testing and Cardiac Interventions among Patients with Coronary Stents

Posted on December 22, 2014

C. N. Holcomb1, L. A. Graham2, T. M. Maddox4, K. M. Itani3, M. T. Hawn1,2  1University Of Alabama At Birmingham,Department Of Gastrointestinal Surgery,Birmingham, AL, USA 2Birmingham VA Medical Center,The Center For Surgical, Medical Acute Care Research And Transitions (C-SMART,Birmingham, AL, USA 3Boston University And Harvard Medical School,Department Of Surgery,Boston, MA, USA 4University Of Colorado School Of Medicine,Cardiology,Denver, COLORADO, USA

Introduction: Patients with coronary stents undergoing non-cardiac surgery are at an increased risk of adverse cardiac events.  Knowledge of this risk may increase the number of troponin tests and influence interventions performed in the early post-operative period. 
 

Methods: The VA Patient Treatment File was used to identify coronary stents implanted in the VA system from October 1, 1999 through September 30, 2010. Patients undergoing non-cardiac surgery within 24 months of coronary stent were identified using VA Surgical Quality Improvement Program data. Each stented patient was matched to two non-stented patients undergoing non-cardiac surgery. Matching variables included age, race, surgical specialty, fiscal year of the operation, work RVU, and components of the revised cardiac risk index.  Cardiac troponin (cTroponin) levels drawn in the first 72 hours following surgery were assessed and a cTroponin >0.04ng/ml was considered a positive test.  The outcomes of interest were MI, cardiac catheterization, and death.  Bivariate frequencies were compared using chi-square test. 

Results: Over the 11 year study period, 5,855 stented patients and 11,371 non-stented patients with similar cardiac risk underwent an inpatient surgery.  Within the first 72 hours of surgery, patients with coronary stents had higher rates of cTroponin testing (25.5% vs 18.7%, p<0.001) with more positive tests (56.4% vs. 52.9%, p=0.04) compared to non-stented patients.  Among those tested, stented patients experienced higher rates of MI (9.8% vs 6.3%, p<0.001).  Myocardial infarctions were diagnosed at lower maximum cTroponin values in stented patients versus non-stented patients (Figure).   Following a diagnosis of MI, patients with stents were more likely to undergo cardiac catheterization (31.2% vs 19.9%, p<0.01) with no difference in cardiac mortality (17.2% vs 20.9%, p=0.34) between the two cohorts. 

Conclusions: Post-operative cTroponin testing among patients with coronary stents was associated with higher observed MI rates and cardiac catheterizations at lower maximum troponin levels but no observed difference in mortality following MI compared to non-stented patients.  Further studies should be done to determine factors predicting improved outcomes with cardiac interventions following surgery. 

 

 

 

 

45.03 Independent Predictors of Postoperative Ileus Development

Posted on December 22, 2014

M. Murphy4, S. Tevis4, G. Kennedy4  4University Of Wisconsin,School of Medicine And Public Health, Department Of Surgery,Madison, WI, USA

Introduction:  Postoperative ileus has a significant impact on patient wellbeing, and with a 15% incidence in colectomy patients, costs US hospitals more than 750 million dollars a year. While some causative mechanisms have been identified, little is known about what places patients at risk for ileus. We sought to characterize preoperative and intraoperative predictors of ileus in colectomy patients.

Methods:  Patients who underwent elective surgery between 2011-2012 were identified from the colectomy-specific ACS-NSQIP database. We performed descriptive statistics and evaluated demographics, comorbidities, health indicators, preoperative treatments, and operative characteristics as independent risk factors for ileus using multivariate analyses.  All analyses were performed with SPSS version 22.  A p-value < 0.05 was considered significant for the purposes of this study.

Results: We included 9734 patients in this analysis. Of the patients in this study, 1364 (14%) were found to have a postoperative ileus.  Patients who developed an ileus were more likely to develop any postoperative complication (26.4% v 9.9%, p < 0.001). In addition, patients who suffer post-operative ileus are significantly more likely to be readmitted (20% vs 13%, p < 0.001) and more likely to require reoperation (37% vs 13%, p < 0.001) compared with patients without ileus. Independent risk factors for ileus included demographic and preoperative factors including older patient age (OR 1.95, 95% CI 1.58-2.42), male gender (OR 1.41, 95% CI 1.24-1.60), obesity (OR 1.32, 95% CI 1.12-1.56), preoperative chemotherapy (OR 1.53, 95% CI 1.21-1.94), preoperative ascites (OR 1.86, 95% CI 1.07-3.22), preoperative sepsis (OR 1.74, 95% CI 1.32-2.29), and smoking (OR 1.20, 95% CI 1.02-1.41).  Intraoperative and perioperative factors included lack of oral antibiotics (OR 1.29, 95% CI 1.10-1.50), lack of mechanical bowel preparation (OR 1.15, 95% CI 1.01-1.32), open approach (OR 2.04, 95% CI 1.77-2.36), and long operation times (OR 1.63, 95% CI 1.36-1.96).

Conclusion: We identified a number of modifiable risk factors for development of ileus including smoking, weight loss, preoperative oral antibiotics, mechanical bowel preparation, and surgical approach.  Preoperative modification of risk factors for ileus may not only improve patients’ quality of life, but may also influence outcomes such as postoperative complications, readmission, and reoperation.

 

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