31.02 Prevalence and Impact of Admission Hyperfibrinolysis in Severely Injured Pediatric Trauma Pateints

Posted on December 22, 2014

I. N. Liras1, B. A. Cotton1, J. C. Cardenas1, M. T. Harting1  1University Of Texas Health Science Center At Houston,Houston, TX, USA

Introduction:  Hyperfibrinolysis (HF) on admission is associated with increased mortality in adult trauma patients. Several studies have demonstrated that 9% of severely injured adults present to the emergency department (ED) with HF. The purpose of the current study was to (1) define HF in pediatric patients and a relevant cut-point for therapeutic intervention (if any), (2) identify the prevalence of HF in severely injured pediatric patients, and (3) determine if HF on admission is as lethal a phenomenon as it is in adults. 

Methods:  Following IRB approval, we identified all pediatric trauma admissions (≤17 years old) that met highest-level trauma activation criteria between 01/2010 and 12/2013. Fibrinolysis rates were determined using LY-30 by rapid thrombelastography (rTEG),which represents the percent reduction of the maximal clot amplitude (fibrinolysis) 30 minutes after such amplitude is achieved. HF was defined a priori as initial LY-30 inflection point that translated to a doubling of mortality. Two previous studies in adults demonstrated an inflection point of ≥3%; where mortality doubled from 9 to 20%. We began by identifying a relevant inflection point to define HF and its prevalence, followed by univariate analysis to compare HF and non-HF patients. Finally, a purposeful logistic regression model was developed to evaluate predcitors of mortality in severely injured pediatric patients. 

Results: 819 patients met study criteria. LY-30 values were plotted against mortality. A distinct inflection point was noted at ≥3%, where mortality doubled from 6 to 14%. Of note, mortality continued to increase as the amount of lysis increased, with a 100% mortality demonstrated at an LY-30 ≥30% (compared to 77% in adults).  Using LY-30 ≥3%, patients were stratified into HF (n=197) and non-HF (n=622), with prevalence on admission of 24%. With the exception of HF patients being younger (median 11 vs. 15 years; p<0.001), there were no differences in demographics, scene vitals or injury severity scores between the groups.  On arrival to the ED, HF patients had a lower systolic blood pressure (median 118 vs. 124 mmHg) and lower hemoglobin (median 12.2 vs. 12.7 g/dL); both p<0.001). Controlling for age, arrival vital signs, admission hemoglobin and injury severity (ISS), logistic regression identified admission LY30 ≥3% (OR 6.2, 95% CI 2.47-16.27) as an independent predictor of mortality.

Conclusion: Similar to adults, admission HF appears to reach a critical threshold at LY30 ≥3% in pediatric patients. Admission HF in pediatric patients occurs more frequently than in adults (24 vs. 9%) but is similarly associated with a doubling in mortality (6 to 14%). Admission LY-30 ≥3% carries a 6-fold increased likelihood of mortality in severely injured pediatric patients. HF on admission may serve to rapidly identify those injured children and adolescents likely to benefit from hemostatic resuscitation efforts and to guide anti-fibrinolytic therapy.&nbsp

31.03 Predicting Progressive Hemorrhagic Injury from Isolated Traumatic Brain Injury and Coagulation

Posted on December 22, 2014

L. E. Folkerson1, D. Sloan1, B. A. Cotton1, J. B. Holcomb1, J. S. Tomasek1, C. E. Wade1  1University Of Texas Health Science Center At Houston,Houston, TX, USA

Introduction:  Traumatic brain injury (TBI) and acute coagulopathy of trauma have been the focus of much research as the combination leads to major disability and death. Progressive hemorrhagic injury (PHI) is associated with increased operative interventions and poor outcomes. Identifying which subset of patients will experience PHI based on initial head CT and laboratory coagulation data has proven difficult. We hypothesize that a subtype of TBI and coagulation status would be predictors of PHI. 

Methods:  This was a retrospective analysis from a single institution of adult patients who presented with the highest level of trauma activation between October 2010- May 2013, (n=1645). Patients (n=617) were identified who underwent at least 2 head CT scans within 24 hours of presentation. Patients with polytrauma (AIS ≥ 3 in all areas other than the head) and those on pre-hospital anticoagulants were excluded, leaving 279 patients in the study group with isolated TBI. Rapid thrombelastography (rTEG) was obtained on Emergency Department (ED) arrival and coagulopathy was defined as an ACT ≥128, MA ≤55, LY-30 ≥3.0 or platelet count ≤150 x 103/µL. Subtypes of TBI were categorized into the following groups: subdural hemorrhage (SDH), subarachnoid hemorrhage (SAH), intraparenchymal contusion/hemorrhage (IPC/H), epidural hematoma (EDH) and combined (CD). PHI was defined as an increase in size of the intracranial hemorrhage from initial head CT as determined by a radiologist. Operative intervention and patient outcomes were recorded. Multivariable logistic regression was used to assess the effect of subtype and coagulation status on PHI. Data are reported as median (IQR).

Results: Of the 279 patients evaluated, 157 patients (56%) had PHI on repeat head CT and 122 (44%) were stable. There was no significant difference in admission GCS, systolic blood pressure or base deficit between groups; all p>0.3. Patients with PHI were older, 44 (27-58) vs 35 (25-52); had a greater incidence of platelet count ≤150 x 103/µL (13% vs 7%); greater incidence of IPC/H (34% vs 11%); a higher ISS, 21 (16-26) vs 17 (14-25); less hospital free days, 14 (0-23) vs 24 (14-27); higher mortality, (17% vs 4%); and higher likelihood of operative intervention (45% vs 34%, OR 1.8, 95% CI 1.0-3.0); all p <0.001. There were no differences in TEG parameters between groups or the incidence of coagulopathy (PHI 51% vs stable 42%; OR 0.6, 95% CI 0.33-0.92). When controlling for age, GCS, and coagulopathy, patients with an IPC/H were more likely to experience PHI than patients with other subtypes of TBI (OR 4.3 p <0.0001, 95% CI 2.2-8.4).

Conclusion: This retrospective analysis demonstrates that patients with IPC/H on initial head CT are more likely to experience PHI. TEG parameters and coagulopathy were not as strong predictors as IPC/H and age for PHI. Therefore, the presence of IPC/H in older patients should raise concern about the probability of PHI. 
 

31.05 Utilizing Group-Based Trajectory Modeling to Understand Patterns of Hemorrhage and Resuscitation

Posted on December 22, 2014

S. A. Savage1, J. J. Sumislawski1, W. P. Dutton1, B. L. Zarzaur2  1University Of Tennessee Health Science Center Memphis,Memphis, TN, USA 2Indiana University-Purdue University Indianapolis,Indianapolis, IN, USA

Introduction:  Retrospective studies of traumatic hemorrhage have embraced the concept of massive transfusion, in which all patients reaching a set volume (commonly ten units over 24 hours) are included.  Patterns of hemorrhage vary, however, and massive transfusion definitions do little to describe these differences or their related outcomes.  The purpose of this study is to describe subpopulations of hemorrhage in a cohort of injured patients from an urban Level One trauma center.  We hypothesize that distinct group trajectories may be identified.

Methods:  Patients requiring at least one unit of packed red blood cells (PRBC) in the first 24 hours of admission, and not suffering isolated head injury, were identified from June 2012 to May 2013.  Time of blood transfusion, in minutes, was collected for each PRBC transfused in all patients.  These times were then aggregated into 30-minute blocks over the first day.  Group-based trajectory modeling was performed using Proc Traj (SAS, v. 9.3), with best model-fit determined using Bayesian Information Criterion (BIC) values.

Results: 318 patients met inclusion criteria for this study.  72% were male, the mean age was 39.5 years (SD 18), 39% suffered penetrating trauma, mean ISS was 17 (SD 11), mean 24 hour transfusion volume was 7 units PRBC (min 1u – max 50u) and overall mortality was 14%.  Transfusion patterns for patients receiving > 10 units PRBC/24 hours (n=71) are shown in Figure 1.  12% of massive transfusion patients (group 1) actually received intermittent PRBC transfusions throughout the first day.  All 318 patients were modeled to demonstrate 4 distinct trajectories for transfusion in figure 2.  20% of patients received negligible PRBC volumes over 24 hours (MIN- group1).  34% of patients received low but steady volumes of PRBC (LSV-group 2).  29% of patients received a moderate volume of PRBC only early in the hospital course (Early Bleeding (EB) – group 3).  Patients in group 4 represent the massively bleeding subpopulation and comprise 17% of patients (MB).  MB patients received large volumes of PRBC over the first seven hours and intermittently after that. 

Conclusion: Traditional definitions of massive transfusion encompass both rapidly hemorrhaging patients, as well as those who are transfused gradually for other indications.  These definitions are too broad.  In this study, group-based trajectory modeling was used to demonstrate subpopulations of hemorrhage that are more clinically relevant.  Understanding the trajectories of hemorrhage in injured subpopulations will allow more efficient allocation of clinical resources and concentrate research efforts on truly hemorrhaging subgroups.

 

31.06 High ratio FFP and platelet transfusion in nontrauma massive transfusion: too much of a good thing?

Posted on December 22, 2014

E. W. Etchill1, L. M. McDaniel1, S. P. Myers1, J. S. Raval2, A. B. Peitzman1, J. L. Sperry1, M. D. Neal1  1University Of Pittsburgh School Of Medicine,Department Of Surgery,Pittsburgh, PENNSYLVANIA, USA 2University Of North Carolina School Of Medicine,Division Of Transfusion Medicine,Chapel Hill, NORTH CAROLINA, USA

Introduction: Current resuscitation strategies in trauma focus on the delivery of fixed ratios of fresh frozen plasma (FFP) and platelets (PLT) along with packed red blood cells (PRBC) as part of massive transfusion protocols. Unfortunately, there is a paucity of evidence regarding the outcomes of massive transfusion protocols in the non-trauma setting where patients may exhibit a different coagulopathic profile. We hypothesized that the use of increased plasma and platelet to red blood cell ratios ( > 1:2) results in no significant difference in morbidity or mortality compared to lower plasma and platelet to red blood cell ratios ( ≤ 1:2). 

Methods: This was a 2-year retrospective single institutional analysis of massively transfused non-trauma patients. Pediatric and obstetric patients, patients on anticoagulants, and patients who died within 24 hours of transfusion were excluded. Ratios of fresh frozen plasma-packed red blood cell (PRBC) were calculated and divided in to a high ratio (FFP:PRBC >1:2) and a low-ratio (FFP:PRBC ≤1:2) group. Platelet ratios were calculated in the same manner. The primary outcomes of interest were 48-hour and 30-day mortality among patients receiving greater than 10 units of PRBC in a 24 hour period. Secondary outcomes included length of stay, ICU days, and ventilator free days. Logistical regression was utilized and a Cox regression survival analysis was performed after controlling for major co-morbidities, ASA and APACHE II scores.  
 

Results: Among 292 massively transfused non-trauma patients, cardiovascular surgery, GI bleeds, and intraoperative complications were the most common indications for massive transfusion. 48-hour mortality, post-transfusion hospital length of stay, ICU length of stay, and ventilator-free days were not significantly different between the high and low ratio FFP:PRBC groups. Interestingly, giving higher ratios of FFP (>1:2 FFP:PRBC) was significantly associated with decreased 30-day survival (66.6% vs. 82.2 %, p =0.0056).

30-day mortality, post-transfusion hospital length of stay, ICU length of stay, and ventilator-free days did not significantly differ between the high and low ratio PLT:PRBC groups. Using multivariate logistic regression analysis, neither FFP:PRBC nor PLT:PRBC ratios were predictors of 48-hour or 30-day mortality. 

Conclusion: Our study suggests that higher ratios of FFP and PLT to PRBC, which have been shown to provide a survival benefit in trauma populations, may be of limited benefit in the non-trauma, massively transfused population. Furthermore, a higher ratio of FFP may actually be associated with an increased mortality. Further prospective investigation into the appropriateness of balanced resuscitation in non-trauma populations is warranted. 

31.08 Old Blood and Complications in the Massively Transfused Trauma Patient: A Cautionary Tale

Posted on December 22, 2014

A. Lubitz1, K. Hollenbach2, E. Chan1, E. Dauer1, L. Sjoholm1, A. Pathak1, T. Santora1, A. Goldberg1, J. Rappold1  1Temple University School Of Medicine,Department Of Surgery,Philadelpha, PA, USA 2University Of California – San Diego,Skaggs School Of Pharmacy And Pharmeceutical Sciences,San Diego, CA, USA

Introduction:  The age of stored packed red blood cells (pRBC) and it's relationship to the development of complications in trauma patients requiring massive transfusions (≥ 10 units pRBC/24 hour) remain poorly understood. Laboratory studies have revealed evidence of the accumulation of storage lesions and decreased oxygen carrying capacity in pRBCs stored for greater than 14 days. The clinical significance of these findings on the development of both infectious and non-infectious complications remains unknown.

Methods: A retrospective cohort study of all massive transfusion (MTP) patients at an urban level 1 trauma center between 2008 and 2012 was conducted.   Data were abstracted from the trauma registry and corroborated with medical and blood bank records; included were standard demographic information, mechanism of injury, injury severity score (ISS), the amount and age of pRBCs transfused and patient outcomes.  Data were analyzed using STATA 13.1. Variables were created to examine the age of blood received in the MTP resuscitation by week and by < 14 days. Initial comparisons were made using t-tests and chi-square statistics, as appropriate.  Logistic regression was used to determine the odds of complication associated with percent of blood < 14 days of age.  Subsequent analyses were conducted independently for both infectious and non-infectious complications.

Results: There were a total of 133 MTP patients during the study period: 70 with at least one complication and 63 with no complications.  The mean age of patients with complications was slightly younger than those without complications (30.3±10.8 vs. 32.1±14.1).  Patients with complications had lower injury severity scores (ISS) than patients without complications (24.1±13.4 vs. 27.9±19.1).  Patients with complications were 3.3 times more likely to have 50% or more blood transfused that was  ≥ 14 days of age than patients with no complications (95% CI = 1.4, 8.3).  When the analysis was restricted to infectious complications, the effect of aged blood was greater (OR = 5.7; 95% CI = 1.7, 24.4). Neither age nor ISS changed these associations.

Conclusions: These data indicate that aged blood was associated with a significant increased risk of complications.  Further studies are warranted to determine what factors in blood ≥ 14 days of age may exist that puts massively transfused trauma patients at risk for the development of complications, particularly infections.

31.09 Mopeds: Not the Lesser Evil

Posted on December 22, 2014

M. Stawikowska1, B. L. Brewer1, B. L. Zarzaur1, J. Coleman1, D. V. Feliciano1, G. S. Rozycki1  1Indiana University School Of Medicine,Surgery,Indianapolis, IN, USA

Introduction:  Compared to motorcycles (MC), use of scooters and mopeds (MP) is largely unregulated as MP are perceived as safer than MC.  The objective of this retrospective study was to compare the demographics, injury patterns and injury severity of MP and MC crash victims.  The hypothesis was that the two groups will have similar injury patterns and severity of injuries.

Methods: This retrospective, observational study was performed by reviewing the trauma registry at an urban level 1 trauma center.  All patients admitted after a motorcycle crash (MCC) or moped crash (MPC) from 2010 – 2014 were included in the study.  Patient demographics, insurance and injury related factors were compared.

Results: 1194 patients met inclusion criteria (1031 MCC, 163 MPC).  Age and gender were similar between the two groups.  MP drivers were more likely to be non-white (p=0.001) than MC drivers, and were significantly less likely to wear a helmet (p<0.001) or to be insured (p<0.0001).  MP drivers were also more likely to be under the influence of alcohol (p<0.001) or drugs (p<0.001).  MP drivers were significantly more likely to sustain traumatic brain injury (p=0.002) than MC drivers, while patients in MCC were more likely to sustain spinal cord injuries (p=0.004).  Mean ISS and percent of patients with long bone fractures were similar between the two groups.

Conclusion: Despite being less regulated, victims of MPC are at least as likely, if not more likely, to suffer serious injury compared to victims of MCC.  Also, MP riders are more likely to ride helmetless and with drug or alcohol impairment.  While the use of MP may be perceived as safer than MC, stricter regulations governing this type of road vehicle should be pursued to prevent serious injury.

 

32.02 Clinicopathologic Features and Time Interval Analysis of Contralateral Breast Cancers

Posted on December 22, 2014

E. L. Liederbach1, R. Piro1, R. Watkin1, K. Hughes1, C. Wang2, C. Pesce1, D. J. Winchester1, K. Yao1  1Northshore University Health System,Surgery,Evanston, IL, USA 2Northshore University Health System,Center For Biomedical Research Informatics,Evanston, IL, USA

Introduction: Multiple studies have shown that contralateral prophylactic mastectomy improves survival, but follow-up for most of these studies are five years or less and provide little data on tumor characteristics of the contralateral breast cancer (CBC). We hypothesized that most CBCs develop after five years and that these CBCs have favorable tumor characteristics.

Methods: This is a single institution retrospective review of 323 patients who were diagnosed with CBCs from 1990 to 2014. CBCs were diagnosed at least one year after the primary cancer diagnosis. BRCA mutation carriers were not excluded. Utilizing chi-square tests and one-way ANOVA tests, we examined the time interval and pathological features between the primary and contralateral cancer.

Results: The average time interval between the primary and CBC was 7.15 years (median: 6.2, range: 1.01-23.0), with 60.4% of patients having a time interval of >5 years. Older patients ≥70 yo developed a CBC sooner than patients <70 yo (5.0 and 7.6 years respectively, p<.001). A majority of stage III patients (69.2%) developed a CBC within 5 years compared to 51.9% of stage 0, 39.3% of stage I, and 36.6% of stage II patients (p=.039). On average, patients with ILC developed their CBC in 9.2 years compared to 7.1 years for IDC patients, 6.6 years for mixed histology patients, and 5.9 years for DCIS patients (p=.016).  Factors that had no influence on the time interval between CBCs were race, body mass index, menopausal status, use of hormone replacement therapy, family history of breast/ovarian cancer, estrogen receptor (ER) status, BRCA status, tumor grade, and presence of lymphatic vascular invasion. In comparison to the first primary breast cancer, a higher proportion of CBCs were stage I (51.0% vs. 36.2%), T1 tumors (72.1% vs. 59.1%), node negative (67.5% vs. 62.2%), and ER(+) tumors (68.7% vs. 51.7%).  Of the 252 patients with available tumor size information for both breast cancers, 54 (21.4%) patients developed a CBC that was >1cm larger than their original primary, and only 25 (9.9%) patients developed a CBC that was >2cm larger than their original primary. There were 201 (62.2%) patients with node negative disease for their first breast cancer, and only 28 (13.9%) of these patients developed a node positive CBC. Of the 300 patients with stage information, 85 (28.3%) patients had a higher stage CBC compared to their first primary. Of the 67 patients with an ER(-) primary, 44 (62.7%) developed an ER(+) CBC. 

Conclusion: A majority of CBCs develop >5 years after the diagnosis of the first primary breast cancer. CBCs have more favorable tumor characteristics than the primary tumor because they tend to be smaller, less aggressive, and lower in stage compared to the primary breast cancer. Patient age, stage, and tumor histology significantly influence the time interval from primary to CBCs. It is unlikely that CBC would affect survival at five years of follow-up given this data.
 

32.03 Increasing Incidence of Duodenal Neuroendocrine Tumors: Incidental Discovery of Indolent Disease?

Posted on December 22, 2014

S. Dennis1, S. D. Kachare1, N. Vohra1, E. E. Zervos1, T. L. Fitzgerald1  1East Carolina University Brody School Of Medicine,Greenville, NC, USA

Introduction: An exponential increase in gastroenteropancreatic neuroendocrine tumors (GEP-NT), including pancreatic, gastric, colorectal and small bowel primaries has been clearly documented. Studies often combine duodenal neuroendocrine tumors (D-NET) with other small bowel GEP-NTs, as such the natural history and clinical ramifications of this diagnosis are poorly understood. We sought to better define the epidemiology of this malignancy.

Methods: Patients diagnosed with duodenal “carcinoid” tumors from 1983-2010 were identified in the SEER tumor registry. Information within the registry was used to classify patients as Stage I, II, III or IV utilizing the East Carolina University modified AJCC stage for D-NET.

Results:A total of 1,258 patients were identified.  The mean age was 64 years. The majority of patients were male and white, 55.6% and 68.8% respectively. Most patients presented with Stage I disease (66.2%), while 10.3% presented with Stage II, 12.6% with Stage III and 11.0% with Stage IV disease. Patients who met inclusion criteria were divided in to two cohorts: group one, those diagnosed from 1983 to 2005 and group two, those diagnosed from 2005-2010. Over the study period there was a clear increase in the incidence rate of D-NET, rising from 0.27 per 100,000 in 1983 to 1.1 per 100,000 in 2010 (Figure). The p-value for this trend was < 0.001. The 5-year disease-specific survival was significantly improved for Group two as compared to Group one, 89.3 vs. 85.2%, p=0.05. However, the disease-specific survival by stage remained similar.  The survival difference between the two groups is likely due to stage migration. When comparing Group two to Group one, patients in the former group were more likely to present with stage I disease (69.9 vs. 57.5 %, p <0.01) and less likely to present stage III (11.8 vs. 14.4%, p 0. 039) and IV disease (19.8 vs. 7.3%, p <0.001).

Conclusion:Prognosis for D-NET, in contrast to other small bowel NET, is excellent.  As with all GEP-NET, the prevalence of D-NETs has steadily increased over the last three decades. This has been coincident with a migration to earlier disease stage and improved disease-specific survival.  These data suggest an increase in the incidental discovery of indolent D-NETs.   

 

30.01 Profile of hepatocellular carcinoma in surgical area: about 100 cases.

Posted on December 22, 2014

P. S. Diop1, I. Ka1, M. Faye1, J. M. Ndoye1, B. Fall1 1Department of General Surgery , General Hospital of Grand Yoff , Dakar, Senegal

The aim of our study was to determine the characteristics of hepatocellular carcinoma (HCC) in surgery and consider therapeutic strategies

PATIENTS AND METHODS:
This was a retrospective analysis of 100 records of patients referred for treatment of HCC from January 2006 to March 2013 .

Results:
The study population involved 72 men and 28 women, mean age 58,49ans with extremes of 18 and 78. The underlying cirrhosis was present in 93 % of cases; due to hepatitis B ( 91 % ) and hepatitis C ( 2 % ) . The topography was as follows 66 % left , and right 23 % 11 % of bilateral tumors . The evaluation criteria resectability showed: a mean tumor size of 12 ± 4.7 cm , 87% of score CHILD A, 13% of score CHILD B and 12% of venous invasion . The mean follow-up for the whole population was 10.2 ± 9mois .

Surgical resection was effective in 31% of patients. Rates without recurrence in1 and 2 years survival rates were 30.43% and 21.73 % for patients resected .

Conclusion:Hepatic resection is possible in our context in selected patients with acceptable immediate results. The major obstacles to improving disease-free survival are delayed consultation and inaccessibility of adjuvant therapies for HCC.
 

30.02 Occult Metastases in Node-negative Breast Cancer: A SEER-based Analysis

Posted on December 22, 2014

C. W. Kimbrough1, K. M. McMasters1, A. R. Quillo1, N. Ajkay1  1University Of Louisville,Hiram C. Polk, Jr. Department Of Surgery,Louisville, KY, USA

Introduction: Although multiple retrospective studies suggest that occult metastases are a significant prognostic factor in breast cancer, the results of two prospective randomized trials have questioned the role of immunohistochemistry (IHC) in detecting occult disease for patients initially found to be node-negative. In this study, we sought to evaluate factors associated with overall survival in node-negative breast cancer patients staged by immunohistochemistry using the Surveillance, Epidemiology, and End Results (SEER) database.

Methods: The SEER database was queried for all patients between 2004 and 2011 with invasive lobular or ductal carcinoma and no evidence of distant metastases. Only patients with regional lymph nodes coded as negative on hematoxylin and eosin (H&E) stains that underwent additional studies using IHC were included for analysis. Patients were stratified by nodal involvement and overall survival was compared using Kaplan-Meier analysis with a log-rank test. Multivariate analysis controlling for patient and tumor characteristics was performed using a Cox-proportional hazards regression model.

Results: Overall, 93,070 patients were identified. Of these, 11,377 patients (12.2%) had occult metastases; 4657 with isolated tumor cells (N0(i+)) and 6720 with micrometastases (N1mi). On Kaplan-Meier analysis, occult metastases were associated with a small but significant decrease in overall survival (p<0.001). The 5-year survival approached 92.2% in patients without occult disease, while 5-year survival for occult metastases was 89.6%. Once further stratified by N-stage, there was no difference in overall survival observed between N0(i-) and N0(i+) patients (p<0.449), although N1mi patients demonstrated worse survival compared to both N0(i-) and N0(i+) groups (p<0.001). On multivariate analysis, micrometastasis remained an independent predictor for decreased survival compared to IHC-negative patients (HR 1.40, 95% CI 1.28–1.53), while isolated tumor cells were not a significant predictor (HR 1.05, 95% CI 0.92-1.20). Other negative prognostic factors included male sex, age at diagnosis, African-American ethnicity, increasing tumor grade, increasing T-stage, and negative hormone receptor status.

Conclusions: Patients with occult metastases found via IHC demonstrated a significant, but relatively small 2.6% overall survival difference at 5-years compared to patients with no evidence of nodal disease. Most of this survival difference is attributable to micrometastases, as isolated tumor cells have no prognostic significance in this study.  Discontinuing the classification of isolated tumors cells as a separate subgroup of N0 disease warrants further consideration.

30.03 The Impact of Malignant Pleural Mesothelioma Histologic Subtype on Outcomes in the SEER Database

Posted on December 22, 2014

C. J. Yang1, P. Speicher1, B. Gulack1, R. R. Meyerhoff1, M. Hartwig1, T. D’Amico1, D. Harpole1, M. Berry1,2  2Stanford,Cardiothoracic Surgery,Palo Alto, CA, USA 1Duke University Medical Center,Department Of Surgery,Durham, NC, USA

Introduction: Histologic subtype for malignant pleural mesothelioma (MPM) is known to be an important determinant of both treatment and survival.  This study was conducted to specifically quantify the impact of MPM histology on the use of surgery and survival in a population-based analysis.

 

Methods: Overall survival (OS) of patients with stage I-III epithelioid, sarcomatoid (including spindled and desmoplastic mesothelioma and fibrous mesothelioma not otherwise specified), and biphasic MPM in the Surveillance, Epidemiology, and End Results database from 2004 to 2010 was evaluated using multivariable Cox proportional hazard models.

 

Results: Of 1,199 patients who met inclusion criteria, the histologic subtype was epithelioid in 823 patients (69%), biphasic in 149 patients (12%), and sarcomatoid in 227 patients (19%).  Median survival was 14 months in the epithelioid group, 10 months in the biphasic group and 4 months in the sarcomatoid group (p<0.0001) (figure).  Cancer-directed surgery was utilized more often in epithelioid (37%, n=303) and biphasic patients (44%, n=65) compared to sarcomatoid patients (26%, n=58) (p=0.004).  Among patients who underwent surgery, median survival was 19 months in the epithelioid group, 12 months in the biphasic group and 4 months in the sarcomatoid group (p<0.0001).  In multivariable analysis, surgery was associated with improved survival in the epithelioid group (hazard ratio [HR] 0.70; p<0.001) but not in the biphasic (HR 0.68; p=0.10) or sarcomatoid (HR 0.82; p=0.27) groups. 

 

Conclusions: Cancer-directed surgery is associated with improved survival for MPM patients with epithelioid histology, but patients with sarcomatoid and biphasic histologies have poor prognoses that may not be improved by operative treatment.  The specific histology of patients with MPM should be identified prior to treatment whenever possible, so that patients with non-epithelioid histologies and particularly sarcomatoid MPM are not exposed to the risks of surgery without any likely benefit.

 

 

30.04 Trends in Radiation Therapy for Elderly Women with Early Stage Breast Cancer: A Report from the NCDB

Posted on December 22, 2014

O. Kantor1, E. Leiderbach2, C. Wang3, D. J. Winchester2, C. E. Pesce2, K. Yao2  1University Of Chicago,Department Of Surgery,Chicago, IL, USA 2NorthShore University Health System,Department Of Surgery,Evanston, IL, USA 3Northshore University Health Systems,Center For Biomedical Research Informatics,Evanstol, IL, USA

Introduction:
Several randomized controlled trials in 2004 have examined the efficacy of radiation in elderly women with early stage breast cancer without demonstrating a survival benefit to radiation. Omission of radiation for this cohort has been incorporated into National Comprehensive Cancer Network guidelines for patients meeting criteria. We examined trends in radiation utilization for elderly patients since publication of these trials.

Methods:
Using the National Cancer Data Base (NCDB), radiation therapy utilization was determined for patients with early stage, estrogen receptor positive (ER+), clinically node negative invasive cancer treated with breast conserving surgery and hormone therapy from 2004 to 2011. Chi square tests and logistic regression models were used for analysis.

Results:
Adjuvant radiation therapy after breast conserving surgery decreased from 83.8% to 76.0% among those ≥70yo with ER+ tumors ≤2cm. For patients who did not receive hormonal therapy, radiation utilization significantly decreased from 60.7% to 52.4% over the study period.  Among those patients who did not undergo radiation therapy, the rate of hormone therapy significantly increased from 36.9% to 52.7%. There is variation in the use of radiation according to patient and tumor factors; 95.3% of 60-69 year olds, 81.6% of 70-79 year olds, and only 59.1% of 80-90 year olds received radiation therapy in 2011. 83.2% of grade 3 tumors received radiation in 2011, compared to 73.3% of grade 1 tumors. Patients without lymph node staging were much less likely to receive radiation therapy compared to those that did (45.7% versus 77.8%).

The rate of external beam radiation has significantly decreased from 69.9% to 46.2%, while alternate forms of radiation have increased twofold from 14.2% to 29.8% (Figure 1). Brachytherapy has increased from 5% in 2004 to 11.7% in 2011. Independent predictors of receiving alternate forms of radiation include being treated at a community cancer center (OR 1.43, CI: 1.32-1.54), living >50 miles from the hospital (OR 1.50, CI:1.28-1.76), and living in the Mid-Atlantic (OR 2.42, CI: 2.16-2.71) or South Atlantic (OR 2.14, CI: 1.91-2.39) regions. Caucasian women, those with private insurance, grade 1 tumors, T1a tumors, and PR positive tumors were also more likely to receive alternate forms of radiation.

Conclusion:
Time trends in the NCDB reflect a gradual acceptance of evidence from randomized clinical trials supporting the omission of radiation therapy for women 70 and older with ER+ early stage breast cancer.  However, the majority still receive radiation, influenced by tumor size and grade, and many are receiving alternate forms of radiation, particularly brachytherapy.
 

30.05 Clinical Significance of Obesity −related Factors in Perioperative Management of Esophageal Cancer

Posted on December 22, 2014

Y. Kikuchi1, H. Takeuchi1, H. Kawakubo1, K. Fukuda1, R. Nakamura2, T. Takahashi2, N. Wada1, Y. Saikawa1, T. Omori1, Y. Kitagawa1  1Keio University School Of Medicine,Department Of Surgery,Shinjuku, TOKYO, Japan 2Keio University School Of Medicine,Tumor Center,Shinjuku, TOKYO, Japan

Introduction: Recently, the proportion of overweight esophageal cancer patients has been increasing according to a change of dietary habits and progress in endoscopic diagnosis. In this study, we clarified the relations between obesity and postoperative complications after esophagectomy in patients with esophageal cancer.

 

 

Methods: Between January 2008 and March 2014, a total of 215 patients with esophageal cancer who underwent an esophagectomy was included. We qualified the body mass index (BMI), visceral fat area (VFA) and subcutaneous fat area (SFA) on cross-sectional computed tomography scans obtained at the umbilicus level with CYNAPSE VINCENT™. Patients were divided to two groups according to their BMI group (<25 or ≧25kg/m ²) , VFA group (<100 or ≧100cm ²), which are defined by Japan Society for the Study of Obesity and SFA group (<100 or ≧100cm ²).

 

Results:A total of 215 patients were divided to two groups according to their BMI,  VFA, and SFA: normal BMI (n=178) and high BMI (n=37), normal VFA (n=138) or high VFA (n=77), and normal SFA (n=134) and high BMI (n=81) , respectively. Operative time was significantly longer in high BMI than normal BMI (561 vs 526 minutes, P=0.043) and longer in high SFA than normal SFA (552 vs 520 minutes, P=0.002), but operative blood loss was similar in each groups. Maximum level of postoperative CRP was significantly higher in high BMI than normal BMI (17.1 vs 13.7mg/dL , P＜0.001) , higher in high VFA than normal VFA (16.1 vs 13.2mg/dL, P＜0.001), and higher in high SFA than normal SFA (15.5 vs 13.5, P=0.004). PaO2/FiO2 ratio of postoperative day1 was significant lower in high BMI than normal BMI (326 vs 384, P＜0.001) , lower in high VFA than normal VFA (341 vs 393, P＜0.001), and lower in high SFA than normal SFA(342 vs 394, P＜0.001). The incidence of anastomotic leakage was significant higher in high SFA than normal SFA (28% vs 10%, P=0.001), higher in high BMI than normal BMI (27% vs 15%, P=0.087), and higher in high VFA than normal VFA (23% vs 14%, P=0.076). Surgical site infection was significant higher in high SFA than normal SFA (38% vs 19%, P=0.003). Complications rates were similar in each groups.

 

Conclusion:Obesity was relation to operative time, maximum level of postoperative CRP, PaO2/FiO2 ratio of postoperative day1. High BMI and VFA were not associated with an increased incidence of complications after esophagectomy; however, anastomotic leakage and surgical site infection occurred more frequently in obese patients. Therefore, we should pay careful attention to obese patients with esophageal cancer for management after esophagectomy. Moreover, it is useful to examine SFA in obese patients with esophageal cancer.

 

28.07 A Prospective Study to Determine the Best Predictors of Symptomatic Hypocalcemia After Thyroidectomy

Posted on December 22, 2014

B. C. James1, M. White1, S. Nagar1, C. Nocon2, E. Kaplan1, P. Angelos1, R. H. Grogan1  1University Of Chicago,Division Of Endocrine Surgery/Department Of Surgery/Pritzker School Of Medicine,Chicago, IL, USA 2University Of Chicago,Division Of Otolaryngology/Department Of Surgery/Pritzker School Of Medicine,Chicago, IL, USA

Introduction:

One of the major morbidities associated with thyroidectomy is hypocalcemia.  With the increasing push towards outpatient surgery, we sought to determine whether a single serum calcium or PTH level drawn after total thyroidectomy combined with clinical factors could predict the development of symptomatic hypocalcemia.

Methods:
This single institution, prospective cohort study evaluated 197 patients undergoing total thyroidectomy with and without central lymph node dissection (LNDx) over a 17-month period.  Serum calcium and parathyroid hormone (PTH) levels were measured one hour after surgery and again on postoperative day 1 (POD1).  Serum levels were grouped into PTH ≤ 10pg/dL or >10 and calcium levels ≤ 8mg/dL or >8.  Using Student’s t-test with significance defined as p<0.05 and linear regression testing, univariate and multivariate analyses were performed to determine which serum levels and clinical factors best predicted symptomatic hypocalcemia.

Results:
197 patients underwent total thyroidectomy, 103 (52%) for malignancy and 94 (48%) for benign disease.  Of these, 29 (15%) patients underwent LNDx and 29 (15%) patients underwent parathyroid autotransplantation.  Thirty-four (17%) patients had a 1-hour postoperative PTH of 10 or less while 31 (16%) patients had a POD1 PTH of 10 or less.  Sixteen (8%) patients had a 1-hour postoperative calcium of 8 or less while 83 (42%) patients had a POD1 calcium of 8 or less.  In total, 9 (4.5%) patients developed symptomatic hypocalcemia. When we evaluated for clinical factors, five of these nine patients had undergone LNDx and 4 required autotransplantation. Four of these 9 symptomatic patients had a POD1 PTH of 10 or less and also had a 1-hour postoperative PTH of 10 or less.  Thus, a PTH of 10 or less 1-hour postoperatively or on POD1 was 44% sensitive (CI 13.97-78.60) in predicting symptomatic hypocalcemia.  Linear regression analysis demonstrated a strong correlation (r=0.826) between 1-hour postoperative and POD1 PTH levels.  Comparing 1-hour postoperative calcium and POD1 calcium, neither value correlated with the development of symptomatic hypocalcemia (p>0.21).  On multivariate analysis, parathyroid autotransplantation did not increase the sensitivity of 1-hour postoperative PTH. However, when combining a 1-hour postoperative PTH level of ≤ 10 with LNDx, the sensitivity increased to 67% with a specificity of 74%.

Conclusion:

We found that the 1-hour postoperative PTH was equivalent to the POD1 PTH in predicting the development of hypocalcemic symptoms.  Considering the advantages of having an equally predictive PTH level 1-hour postoperatively, we believe the 1-hour postoperative PTH level is the best test to use.  When combining this value with patients who underwent LNDx, few patients who develop hypocalcemic symptoms are missed.  We therefore recommend all patients with a PTH ≤ 10 or undergoing LNDx be placed on calcium supplementation before discharge.

 

28.08 Intraoperative Parathyroid Hormone Level Spikes: Do They Predict Single Gland Disease?

Posted on December 22, 2014

A. A. Carr1, T. W. Yen1, D. B. Evans1, T. S. Wang1  1Medical College Of Wisconsin,Division Of Surgical Oncology,Milwaukee, WI, USA

Introduction:
During parathyroidectomy for primary hyperparathyroidism (pHPT), increases (“spikes”) in intraoperative parathyroid hormone (IOPTH) levels from the preoperative [baseline] PTH may occur due to manipulation of abnormal parathyroid gland(s) prior to resection. These IOPTH spikes may lead to longer operative times and/or more extensive neck exploration. The aim of this study was to determine if the extent of IOPTH increase may predict the presence of single gland disease (SGD).

Methods:
This is a retrospective review of a prospective parathyroid database of patients undergoing parathyroidectomy for sporadic pHPT from 1999 to 2013. Demographic and clinical data were collected from all patients who had an increase in IOPTH level from baseline drawn prior to induction of anesthesia to the time of first gland excision (T0) and the extent of the IOPTH spike was calculated. Patients were divided into 3 groups: Group 1 had no IOPTH spike at T0, Group 2 patients had a T0 spike of 1-3 times above the baseline PTH, and Group 3 had a T0 spike >3 times above the baseline PTH.

Results:
Of the 911 patients in the cohort, there were 645 (71%) patients in Group 1, 234 (26%) in Group 2, and 32 (3%) in Group 3. A single parathyroid adenoma was resected in 87%, 78% and 100% of patients in Groups 1, 2 and 3, respectively (Table). An IOPTH spike of >3 times above the baseline had a specificity and positive predictive value of 100% for predicting SGD. The median gland weight in Group 3 (920mg) was significantly larger than those in Groups 1 and 2 (440 and 460mg, respectively). At a median follow-up of 22 months (interquartile range 11-37 months) for the entire cohort, there was no difference in rates of persistent or recurrent disease between the three groups.

Conclusion:
IOPTH spikes occur in over 25% of patients undergoing parathyroidectomy for sporadic pHPT. Patients with IOPTH spikes >3 times above the BL PTH are more likely to have larger, single adenomas, whereas patients with IOPTH spikes of 1-3 times above the baseline more often have multi-gland disease. This suggests that in patients with significant elevation in IOPTH levels between the baseline and excision of a large parathyroid adenoma, no further surgical exploration is required prior to conclusion of the procedure.
 

28.09 Does Levothyroxine Administration Impact Parathyroid Localization?

Posted on December 22, 2014

R. R. Ayers1, K. Tobin2, D. Elfenbein1, C. J. Balentine1, R. S. Sippel1, H. Chen1, D. F. Schneider1  1University Of Wisconsin,Endocrine Surgery,Madison, WI, USA 2University Of Oregon,Eugene, OR, USA

Introduction: Proper localization is crucial in performing minimally invasive parathyroidectomy for primary hyperparathyroidism (PHPT).  Ultrasonography (US) and Tc-99m sestamibi (MIBI) scintigraphy are common methods used for localization.  As the appearance and activity of the thyroid gland may impact parathyroid localization, the purpose of this study was to determine how exogenous use of the thyroid hormone, levothyroxine (LT), affects parathyroid localization.

Methods: Adult patients with PHPT who underwent parathyroidectomy from 2001 to 2014 were retrospectively identified from a prospectively collected database.  Patients undergoing initial operation without concurrent thyroid surgery or familial hyperparathyroidism were included.  Levothyroxine (+LT) and non-levothyroxine (-LT) patients were matched 1:3 based on age, gender, presence of goiter, and pre-operative parathyroid hormone (PTH) levels. Further subgroup analysis was performed on patients previously treated with radioactive iodine (RAI) and patients undergoing single adenoma (SA) resection.

Results: Of the 1,737 patients that met inclusion criteria, 286 were on LT at the time of their localization scan and were matched to 858 –LT patients.  There was no difference in gender, age, pre-operative labs, or co-morbidities between the +LT and -LT patients. Use of LT not did significantly impact the percentage of correct MIBI localization scans when compared to -LT patients (p = 0.83). 31 of the 286 +LT patients were post-RAI treatment and this did not impact localization by MIBI either (p = 0.55).  Interestingly, use of LT significantly hindered parathyroid localization by US in comparison to the –LT group (48.4 vs 62.2%, p < 0.01) regardless of the reason for LT supplementation (post-RAI: 22.2 vs 67.4 %, p = 0.02).  Additionally, for the 73% of patients having SA resection, the percentage of correct US localization was significantly less for +LT when compared to –LT patients (56.7 vs 71.8%, p < 0.01) while MIBI localization accuracy was not significantly different (p=0.31). When examining only patients where a single upper gland was removed, the +LT group was less likely to have a correct US compared to the –LT group (50% vs. 72.8%, p<0.01).  There was no difference in percentage of correct US for patients who only had a single lower gland removed (p = 0.51).

Conclusion: Exogenous levothyroxine is associated with impaired parathyroid localization with US but not MIBI.  This effect could be due to the thyroid’s echotexture in patients with hypothyroidism limiting the ability to detect more posteriorly located upper glands with US.
 

28.10 Low Parathyroid Hormone Levels after Total Thyroidectomy: Incidence and Time to Resolution

Posted on December 22, 2014

K. M. Ritter1, D. Elfenbein1, D. F. Schneider1, H. Chen1, R. S. Sippel1  1University Of Wisconsin,Division Of General Surgery, Department Of Surgery,Madison, WI, USA

Introduction: Parathyroid hormone (PTH) levels are often measured after thyroid surgery and can be used to detect patients at risk for postoperative hypoparathyroidism. The goals of this study were to elucidate the time course of parathyroid gland function recovery and to determine the incidence of permanent hypoparathyroidism.

Methods: Patients who underwent a total or completion thyroidectomy from 1/2006 to 12/2013 were identified from a retrospective review of a prospectively collected institutional database. Low PTH was defined as a PTH measurement <10 pg/mL immediately after surgery. Patients were followed for 1 year. Recovery of parathyroid gland function was defined as PTH ≥10 pg/mL and no need for therapeutic calcium or activated vitamin D (calcitriol) supplementation to prevent hypocalcemic symptoms. Patients were considered to be permanently hypoparathyroid if they had not recovered within 1 year. Multivariate logistic regression modeling was performed to identify independent risk factors for a low postoperative PTH and for permanent hypoparathyroidism.

Results: Of 1054 total thyroidectomy patients, 189 (18%) had postoperative PTH <10 pg/mL. Of those 189 patients, 132 (70%) showed resolution within 2 months of surgery, a third (n=49) of which had resolved within 1-2 weeks of surgery. Of the 57 patients with hypoparathyroidism at 2 months, 49% resolved by 6 months after surgery and an additional 16% resolved by 1 year. At 1 year, 20 patients were considered to have permanent hypoparathyroidism due to the need for ongoing supplementation. Surprisingly, 50% of those patients had recovery of PTH levels to ≥10 pg/mL yet still required supplementation to avoid symptoms. The permanently hypoparathyroid group represents 11% of patients with initial postoperative PTH <10 pg/mL and 2% of the entire cohort. On multivariate analysis, independent risk factors for low postoperative PTH included parathyroid autotransplantation (OR = 2.6; 95% CI, 1.8-3.8) and the presence of parathyroid tissue on final pathology report (OR = 2.2; 95% CI, 1.5-3.3). The only independent risk factor for permanent hypoparathyroidism was parathyroid tissue on pathology report (OR = 3.6, 95% CI, 1.1-11.5). Interestingly, age, gender, neck dissection, thyroiditis, and malignancy were not independently associated with low postoperative PTH or permanent hypoparathyroidism.

Conclusion: Low PTH is a common occurrence after thyroid surgery, but the vast majority of patients showed parathyroid gland function recovery within 2 months of surgery. Notably, 5% of patients with low postoperative PTH resolved 6-12 months after surgery, suggesting that 12 months may be the most appropriate time point for defining hypoparathyroidism as permanent.

 

29.01 Treatment strategy for hepatocellular carcinoma with portal vein tumor thrombosis

Posted on December 22, 2014

T. Ochiai1, T. Sato1, Y. Ohata1, H. Ueda1, A. Oba1, K. Akahoshi1, K. Nakao1, T. Furuyama1, E. Katsuta1, H. Ito1, S. Matsumura1, A. Aihara1, D. Ban1, T. Irie1, A. Kudo1, S. Tanaka1, M. Tanabe1  1Tokyo Medical And Dental University,Hepato-Biliary-Pancreatic Surgery,Bunkyo-ku, Tokyo, Japan

Introduction: Hepatocellular carcinoma (HCC) is the most common type of primary liver tumor and is the fifth most common malignancy worldwide. The prognosis of patients with HCC accompanied by portal vein tumor thrombus (PVTT) is generally poor, therefore, the role of surgical resection for HCC with PVTT is controversial. This study aimed to evaluate the efficacy of initial surgery for HCC with PVTT and secondary treatments; hepatectomy, radiofrequency ablation (RFA), transcatheter arterial chemoembolization (TACE), chemotherapy, radiation, for recurrence after curative resection.

Methods: From April 2000 to December 2013, initial hepatic resection for 617 patients with HCC was performed at our hospital. Among these patients, a retrospective study was carried out on 79 patients (12.8%) with PVTT.

Results:The 1, 3- and 5-year overall survival rates were 65%, 41% and 38% in 66 patients who underwent curative resection and 18%, 0% and 0% in 13 patients who underwent non-curative surgery, respectively. Forty six patients with PVTT located in the segmental or sectoral portal vein showed significantly better survival than 20 with PVTT extended to right and/or left portal veins, the main portal vein or the superior mesenteric vein (Fig. 1). After initial curative resection, tumor recurrences were observed in 46 patients; 11 patients met Milan Criteria and 35 patients exceeded the criteria at first diagnosis of recurrence. Among 46 patients, 43 patients were treated by heaptectomy in 3 patients, RFA in 6, TACE in 16, or chemotherapy in 18. The overall survival was significantly better in hepatectomy and RFA than in TACE, chemotherapy and radiation.

Conclusion:Liver resection is justified in selected patients with PVTT located in the segmental or sectoral branches of the portal vein. Liver resection and RFA are suitable treatments for recurrence, however, 53% (35 of 66) of patients who underwent initial curative hepatectomy showed HCC recurrence that exceeded Milan criteria in this study. Effective adjuvant treatments need to be developed to counteract the high incidence of recurrence.

 

29.02 Mortality Following Pancreatoduodenectomy: The Influence of Fistula Risk

Posted on December 22, 2014

M. T. McMillan1, M. H. Sprys1, J. A. Drebin1, M. K. Lee1, R. E. Roses1, D. L. Fraker1, .. The Pancreatic Fistula Study Group1, C. M. Vollmer1  1University Of Pennsylvania Perelman School Of Medicine,Surgery,Philadelphia, PA, USA

Introduction:  Postoperative pancreatic fistula (POPF) is the most common and morbid complication following pancreatoduodenectomy (PD). The previously validated Fistula Risk Score (FRS) considers the presence of endogenous (gland texture, duct size, pathology) and operative (blood loss) risk factors to predict the occurrence of clinically relevant fistula (CR-POPF; ISGPF Grade B/C). These CR-POPF risk factors may also influence mortality; however, this has not been proven.

Methods:  This multinational study of 4,307 PDs involved 55 pancreatic surgical specialists at 15 high-volume institutions. Patients were stratified for 90-day mortality risk using the FRS (0-10 points) and assigned to one of four risk zones: negligible (0 points), low (1-2), moderate (3-6), or high (7-10). A Cox regression identified predictors for mortality while adjusting for FRS risk, as well as surgeon, institutional, and operative factors.   

Results: The overall mortality rate was 2.1% (N=89), with institutional rates ranging from 1.0 -8.6%. Individual surgeon rates—for those who contributed ≥ 25 cases—ranged from 0 – 11.1%. Clinically relevant fistulas accounted for 36% of the overall mortalities and their presence strongly correlated with higher rates of mortality (6.6 vs. 1.5%; P<0.001). Nearly 70% of deaths occurred in the setting of soft pancreatic parenchyma and intraoperative blood loss > 700 mL was associated with a greater than two-fold increase in mortality risk. The mean Fistula Risk Score was significantly greater in patients who suffered mortality (4.6 vs. 3.7; P<0.001). In fact, patients with high CR-POPF risk (FRS 7-10) had over a fivefold increase in mortality risk compared to patients at negligible risk (P=0.010; Figure). There was no significant difference in mean FRS between fistulous and non-fistulous mortalities (4.6 vs. 4.6; p=0.899); however, the median POD of mortality was two times greater in cases of mortality due to a CR-POPF (28 [IQR: 40] vs. 14 [IQR: 26] days; P=0.010). While surgeon years of experience and career PD volume did not significantly influence overall mortality, institutional PD volume > 75 cases per year correlated with reduced rates (1.9 vs. 4.9%; P=0.006).

Conclusion: Procedure-specific risk influences mortality after pancreatoduodenectomy. Improvements in pancreatic fistula outcomes will likely lead to improved survival following PD. 

 

29.03 Minimally Invasive Esophagectomy has Lower Severity of Complications than Open/Hybrid Esophagectomy

Posted on December 22, 2014

A. Chaudhary1, M. J. Pucci1, A. C. Berger1, E. L. Rosato1, N. R. Evans1, K. Chojnacki1, F. Palazzo1  1Thomas Jefferson University,Philadelphia, PA, USA

Introduction:  Minimally Invasive Esophagectomy (MIE) is increasingly utilized for the treatment of esophageal and gastroesophageal junction (GEJ) malignancies; however, perioperative morbidity remains significant. We sought to compare the severity of complications between patients undergoing MIE and Open/Hybrid Esophagectomy (OHE).

Methods:  Our single institution IRB-approved prospectively maintained database was retrospectively queried and a contemporary series of patients who underwent MIE (2008-2013) was compared to a cohort undergoing OHE – Mckeown approach (39), Ivor Lewis approach (16), Hybrid (13) (2000-2013). Hybrid esophagectomy was defined as having one component of the surgery performed minimally invasively—either thoracoscopic or laparoscopic. Perioperative complications were graded using the Clavien-Dindo classification.  Statistical analysis was performed using two-tailed t-test and Fisher exact test to assess the impact of operative approach (MIE vs. OHE) on operative blood loss (EBL), length of stay (LOS), rates of respiratory failure, anastomotic leaks, arrhythmias, and complication grades 3-5.

Results: MIE (n = 104) and OHE (n = 68) cohorts were similar with respect to age (p=0.288) and gender (p=0.322). The MIE cohort tended to have higher BMI (p=0.125), earlier stage disease (p=0.025), and was less likely to receive neoadjuvant CRT (p=0.001). The MIE cohort had significantly lower EBL (171 vs. 454 mL, p<0.001), decreased LOS (11 vs. 22 days, p<0.001), and lower grade 3 (1.9% vs. 10.3%, p=0.029) and grade 4 (13.5% vs. 27.9%, p=0.028) complications. No differences were noted in the rates of respiratory failure (21.2% vs. 36.2%, p=0.110), anastomotic leaks (20.2% vs. 14.7%, p=0.421), or arrhythmias (21.2% vs. 13.2%, p=0.308).

Conclusion: These data support the use of MIE over OHE for the surgical treatment of esophageal and GEJ malignancies. These findings need to be confirmed in future prospective studies.

 

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