75.18 Streptococcal Pharyngitis and Appendicitis in Children

Posted on December 22, 2014

J. W. Nielsen1, V. Pepper1, B. D. Kenney1  1Nationwide Children’s Hospital,Pediatric Surgery,Columbus, OH, USA

Introduction: Appendicitis is a common surgical disease in children.  Several other pathologies can mimic appendicitis in children including mesenteric adenitis which has been associated with pharyngitis.  We sought to further understand the link between appendicitis-like symptoms and another common childhood disease, streptococcal (strep) pharyngitis.

Methods: All patients undergoing ultrasound imaging for appendicitis in our emergency department during 2013 were reviewed (n=1572).  A total of 207 patients were identified who underwent both ultrasound for appendicitis and testing for strep pharyngitis (rapid strep test with reflex PCR test if negative).  Demographic and outcomes data between rule out appendicitis patients who underwent strep testing and those who did not were compared.  Chi- square and Fisher's exact tests were performed on categorical variables and T-tests were used for continuous variables with p<0.05 being considered significant.

Results:  Strep testing was more common in younger patients (mean age=8.26 years vs. 10.26 years p<0.001) and evenly matched by gender (104 male, 103 female). Of the 207 patients tested for strep pharyngitis only 8 patients had appendicitis and only 35  (16.9%) patients tested positive for strep pharyngitis.  There were no patients identified who tested positive for both strep pharyngitis and had appendicitis.  Five negative appendectomies were performed in the strep pharyngitis tested group for a negative appendectomy rate of (5/13) 38.5%, compared to 7.7% (23/296) (p=0.003) in the non-test group. Two of the patients with negative appendectomies in the strep testing group had positive strep tests and the remaining 3 were negative.  The appendicitis rate among the strep testing group was lower at 3.8% (8/207) compared to 20% (273/1365) in the non-tested group (p<0.001).

Conclusions: Patients undergoing testing for strep pharyngitis were more likely to be young.  Strep testing was also associated with much lower rates of appendicitis and higher negative appendectomy rates.  No patients undergoing strep testing were positive for both appendicitis and strep pharyngitis.  In cases where patients have sufficient symptoms to warrant testing for strep pharyngitis a diagnosis of appendicitis is less likely. The low rates of positive strep tests and appendicitis suggest that patients with abdominal pain and symptoms of pharyngitis most likely have a viral illness that in most cases does not warrant additional testing.  Prudence must be exercised to correctly diagnose pathology and to avoid unnecessary testing.

73.19 Geographical Location and Lack of Seasonality Determines Incidence of Acute Appendicitis

Posted on December 22, 2014

D. F. Nino1,3, J. S. Barajas-Gamboa4, S. W. Bickler2, J. A. Nino3  1Johns Hopkins University School Of Medicine,Pediatric Surgery / Surgery,Baltimore, MD, USA 2University Of California – San Diego,Pediatric Surgery / Surgery,San Diego, CA, USA 3Universidad Nacional De Colombia,Pediatric Surgery / Surgery,Bogota, CUNDINAMARCA, Colombia 4Universidad Autonoma De Bucaramanga,Surgery,Bucaramanga, SANTANDER, Colombia

Introduction:  Incidence of acute appendicitis (AA) varies by geographical region, season, race, sex and age. We have determined the incidence of AA and perforation rate at a referral teaching hospital located in Colombia. We hypothesize that due to geographical location and lack of distinct seasons there is no variability in the incidence of AA throughout the year.

Methods:  Under IRB approval, a retrospective review of a prospectively maintained database of all surgical cases was carried out. The number of appendectomies was determined for a 5-year period and analyzed per month. Multivariate analyses included age, sex and perforation rate. A two-way ANOVA, p<0.05 was considered significant. Multivariate linear regressions were used to determine correlation between independent variables, incidence and perforation rate. 

Results: Between 01/2008 and 12/2012 we identified 3921 cases of AA, 60.8% male and average age 9-years-old (range 2–16). The number of cases per month for the five years analyzed averaged 65 (range 40–83 cases/month). The incidence of AA remained constant throughout the different months (p = 0.1178) and did not vary per year analyzed (p = 0.6805). Multivariate regression analysis demonstrated no effects of age and sex in the total incidence. Perforation rate averaged 34.3% (23.5 – 45%) without variation per-month or per-year. 

Conclusion: Our study indicates that the geographical location of our country and subsequent lack of seasonality have an impact on the incidence of AA. Contrary to current literature we found no seasonal variation. More studies are warranted to determine the cause or lack thereof of variation in the incidence of AA.

 

71.16 Predictors of Mastectomy Skin Necrosis in Autologous Breast Reconstruction

Posted on December 22, 2014

C. R. Vargas1, M. Paul1, P. G. Koolen1, K. E. Anderson1, B. T. Lee1  1Beth Israel Deaconess Medical Center,Surgery / Plastic And Reconstructive Surgery,Boston, MA, USA

Introduction:
Mastectomy skin flap necrosis represents a significant clinical morbidity following autologous breast reconstruction.  In addition to aesthetic deformity, necrosis of the native mastectomy skin may require debridement, additional reconstruction, and prolonged wound care, and can delay planned oncologic treatment.  This study aims to evaluate seven potential patient and procedural factors in order to identify predictors of mastectomy skin necrosis.

Methods:
A retrospective review was performed of all immediate autologous breast reconstruction procedures performed at a single academic center between January 2004 and December 2013.  Patient records were queried for age, mastectomy weight, pre-operative radiation therapy, pre-operative chemotherapy, diabetes, active smoking, previous breast surgery, and post-operative mastectomy skin flap necrosis.  Mastectomy weight was divided into quartiles for improved clinical interpretability. 

Results:
There were 698 immediate autologous microsurgical flaps performed by three surgeons at our institution during the study period; mean patient age was 49.3±8.3 years and average mastectomy weight was 769.3±413 grams.  The incidence of mastectomy skin flap necrosis was 13%.  Univariate analysis revealed a significantly higher incidence of mastectomy skin necrosis in patients with diabetes (p = 0.017) as well as those with higher mastectomy weight (p = 0.001).  No significant association was found for age, pre-operative radiation, pre-operative chemotherapy, active smoking, or previous breast surgery.  Multivariate analysis, adjusted for clustering related to bilateral reconstruction, demonstrated a statistically significant association between mastectomy skin necrosis and increasing mastectomy weight (OR 1.54, p < 0.001).  The association between diabetes and mastectomy skin necrosis was not significant after covariate adjustment.

Conclusion:
Increasing mastectomy weight is significantly associated with post-operative mastectomy skin necrosis following autologous reconstruction.  This factor should be considered during patient counseling, procedure selection, and operative planning.  Interestingly, patient age, pre-operative chemotherapy, radiation, active smoking, and previous breast surgery did not predict a significantly higher risk of mastectomy skin necrosis.

71.18 Synovial White Cell Count For Diagnosis Of Septic Arthritis. Are Current Tests Appropriate?

Posted on December 22, 2014

K. Perera1, M. Armstrong1  1Eastern Health,Melbourne, VICTORIA, Australia

Introduction:

Septic arthritis is an emergency, potentially causing irreversible joint destruction and

disability. Synovial WCC and polymorphonuclear cell percentage is the best predictor of

septic arthritis likelihood. Yet, synovial WCC and differential are not routinely assessed.

We aim to investigate the incidence of this and develop correct synovial fluid analysis

practices.

Methods:

A retrospective analysis of native joints having had arthrocentesis for suspicion of septic

arthritis at Box Hill Hospital (BHH) between September 2011 and September 2013

inclusive. Recruitment was from the Eastern Health Decision Support Service (DSS), who

maintains a database compiled from all systems within Eastern Health; of which BHH is a

member.

The study was limited to large joints; this includes hip, knee and shoulder. All prosthetic

joints were excluded from the patient population.

All patient histories were examined for suspicion of septic arthritis and subsequent

arthrocentesis. Pathology records were accessed to determine incidence of cell count and

differential.

Results:

One hundred and thirty-six cases of joint aspirations were identified within the time frame,

of which sixty-seven fit our criteria for evaluation. All but two cases were delivered using

the DSS, which was limited to data compiled only until June 2013. The two remaining

cases were identified with a manual search of the radiology and pathology databases from

June to September 2013.

22 of the 67 joint aspirates studied did not have a cell count carried out. Four of these 22

cases had a diagnosis of septic arthritis. In five aspirates, there was a failure to confirm a

definite diagnosis and were thus conservatively treated as a septic joint. The remaining

acute joints in which no cell count was done were gout (7 cases), pseudogout (5 cases) and

rheumatoid arthritis (1 case).

Cell counts were not routinely detected for a variety of reasons. Eleven aspirates were

deemed too viscous, and in eight cases the sample had clotted prior to pathologist

assessment. Two cases had insufficient volume, and one sample was too bloodstained to

calculate a cell count and differential; likely due to traumatic aspiration.

Conclusion:

33% of acute monoarthritis’ evaluated over the study period failed to have a synovial fluid

WCC and differential. This may be due to inadequate samples, or lack of appropriate

collection tube. Better education is required for appropriate collection and test requesting

wherein a diagnosis of septic arthritis is in question.

70.19 Sarcopenia as a Predictor of Outcomes of Palliative Surgery

Posted on December 22, 2014

A. M. Blakely1, S. Brown2, D. J. Grand2, T. J. Miner1  2Brown University School Of Medicine,Department of Radiology,Providence, RI, USA 1Brown University School Of Medicine,Department Of Surgery,Providence, RI, USA

Introduction:

Sarcopenia, defined as the degenerative loss of muscle quality with age, has been shown to be associated with worse outcomes following resection of various cancer types. Sarcopenia is usually assessed by evaluating psoas muscle density and/or cross-sectional area at the level of the third or fourth lumbar vertebra. To date, sarcopenia has not been evaluated as a predictor of outcomes following palliative surgery.

 

Methods:

Retrospective analysis of a prospective database of all palliative surgery patients receiving an operation from January 2004 to December 2012 was performed. Those patients with a pre-operative abdominopelvic computed tomography (CT) and follow-up of at least 6 months were selected for analysis. CT scans were evaluated by a resident and attending radiologist for mean total psoas muscle cross-sectional area and density. Time from CT to operation, primary tumor type, and post-operative complications were recorded.

 

Results:

From January 2004 to December 2012, 57 patients were identified as having undergone a palliative procedure with prior abdominopelvic CT scan available for evaluation.  Of 57 patients, 27 (47.4%) were male, with median age of 63 years. Median time from CT scan to operation was 10 days. Regarding primary tumor type, 15 (26.3%) were pancreas, 9 (15.8%) colon, 7 (12.3%) stomach, 4 (7.0%) lung, 3 (5.3%) ovary, 3 (5.3%) cholangiocarcinoma, and 16 (28.1%) other. Thirty-day post-operative morbidity was 31.6% and mortality was 5.3%. Mean total psoas area was 1622.8 mm2 (range 785.3 to 3641.3 mm2, standard deviation (SD) 586.6), and the mean psoas density was 49.8 Hounsfield units (HU) (range 27.1 to 69.8 HU, SD 9.9). Increasing age was associated with decreased total psoas area (p=0.0027) and decreased psoas density (p=0.0005). However, neither total psoas area nor density were associated with the development of complications (p=0.88 and p=0.48, respectively).

 

Conclusions:

Sarcopenia, assessed by either psoas muscle area or density, was not associated with complications following palliative surgery. Patient selection for palliative surgery continues to be challenging. Sarcopenia may retain some value in the pre-operative assessment of advanced cancer patients as a component of a frailty index.

70.01 Ventriculoperitoneal shunt in patients with CNS neoplasms: An analysis of 59 cases

Posted on December 22, 2014

F. Nigim1, J. Critchlow1, E. Kasper1  1Beth Israel Deaconess Medical Center,Department Of Surgery,Brookline, MA, USA

Introduction:
About 1-5% of patients with cerebral metastasis suffer from hydrocephalus, and so do about 40% of patients with primary brain tumors. These patients often carry a poor prognosis. The aim of the present study is to reassess the validity of VPS placement with the assistance of the general surgeon in the abdominal part in oncological patients.

Methods:
 A total of 59 patients underwent first time VPS placement at BIDMC between 2004 and 2012; 40 had hydrocephalus from brain metastasis and 19 from primary tumors. Analyzed independent variables included demographics, BMI, PMH, clinical presentation, indication for surgery, Karnofsky performance status (KPS) score, and surgical technique; dependent variables were post-operative symptoms and occurrence, cause, and time of shunt failures. Outcomes were analyzed via T-test and Kaplan-Meier estimates for shunt survival.

Results:
Mean age was 57.2 years; and mean operative time was 50.4 minutes. Symptomatic palliation was achieved in 93%; patients with severe symptoms (e.g. debilitating headaches and nausea and vomiting) did benefit significantly from VPS placement. Mean follow-up time was 6.3 months, complications occurred in only 6.7% (n=4) patients during follow up; with 2 wound infections treated with antibiotics, and 2 shunt obstructions requiring revision. Initial KPS and 3-month KPS were 65 ± 16.4 and 75 ± 16.0, respectively. We started with 59 patients, 16 (27.1%) patients were alive at 6-month and 10 (16.9%) patients were alive at 1-year, in all survived patients the shunt was functioning. 

Conclusion:
VPS remains a valid option for cancer patients with low KPS and improves the quality of life in those patients, even in the setting of previous infection, hemorrhage, or leptomeningeal disease since shunt patency outlasts the overall survival of nearly all patients. 
 

7.12 Irradiated Rectal Cancer: Is There a Role for Preoperative Interventions?

Posted on December 22, 2014

D. M. Hayden1, C. Holmes1, A. Lasinski1, S. Nassoiy1, M. Chiodo2, K. Wolin1, T. Saclarides1  1Loyola University Medical Center,Department of General Surgery,Maywood, Illinois, USA 2Loyola University Medical Center,Stritch School Of Medicine,Maywood, Illinois, USA

Introduction:  The treatment course of locally advanced rectal cancer is long, tedious and wrought with morbidity.  This disease burden is underappreciated; however there may be amenable factors to improve peri- and postoperative outcomes. 

Methods:  Retrospective review of patients with stage II and III rectal cancer treated with neoadjuvant chemoradiation followed by radical resection at a single tertiary care center 2006-2013.

Results: 57 patients were included; mean age was 60.4 (36-82); 57.9% were male.  Mean BMI was 29.0 (19.0-43.4); 40.4% were obese and 15.8% had BMI>35.  Co-morbidities were common: 40.4% had hypertension, 24.6% diabetes, 8.8% CAD and 5.3% had COPD. 12.3% were current smokers and 49.1% previously smoked.  37 (64.9%) patients had LAR and 35.1% had APR. Only 7.0% had laparoscopic resection. Mean operative time 355.2 (120-630) minutes.  Mean blood loss was 452 ml (50.0-3000); 14.0% required transfusion and 28.1% ICU admission. Mean length of stay was 11.0 (4.0-62.0) days.  45.6% had complications, most commonly fever, ileus and abscess.  36.8% of patients required readmission.  Obese patients had longer LOS that trended toward significance (13.6 vs.9.2, p=0.078); however, complications were not more common. Those with BMI>35 had higher risk of pneumonia, DVT and sepsis (p=0.02-0.05).  Current and previous smokers were more likely to be readmitted (p=0.043).  4 of the 6 patients discharged to rehab/skilled nursing had BMI>30. 

Conclusion: The treatment of irradiated rectal cancer involves morbid operations, complications and readmissions. Our patients are obese with multiple comorbidities that contribute to poorer outcomes. However, lifestyle interventions like exercise and smoking cessation at diagnosis may help to decrease this burden. 

 

7.13 CA19-9 Levels Can Predict Findings at Diagnostic Laparoscopy in Pancreatic Cancer:A Prospective Study

Posted on December 22, 2014

S. Gopinath1, U. Ballehaninna1, R. S. Chamberlain1,2,3  1Saint Barnabas Medical Center,Department Of Surgery,Livingston, NJ, USA 2Rutgers University, New Jersey Medical School,Department Of Surgery,Newark, NJ, USA 3Saint George’s University,Department Of Surgery,Grenada, Grenada, Grenada

Introduction: Serum CA 19-9 levels assessment is a cornerstone of pancreatic cancer management as it plays an important role in the diagnosis, prognosis, response to treatment and staging.  To date very few studies have assessed whether preoperative serum CA 19-9 levels can reliably predict laparoscopic findings, in terms of both resectability and the identification of  pancreatic cancer metastases in pancreatic cancer patients deemed resectable on traditional imaging studies. 

Methods: Clinico-pathologic characteristics including serum CA 19-9 levels were prospectively collected in 58 patients with pancreatic cancer deemed resectable by preoperative work up.  Intraoperative data collection included findings at laparoscopy (peritoneal and liver metastasis) and/or operative exploration (resectable or unresectable). Wilcoxon-Rank- Sum test was used to determine whether preoperative serum CA 19-9 levels correlated with findings at laparoscopy, assess tumor resectability and staging.

Results:Fifty-eight patients with pancreatic cancer underwent diagnostic laparoscopy followed by surgical exploration with curative intent. Mean age was 67.5 years (range, 43-88 years).  Preoperative serum CA 19-9 levels in these patients ranged from 2-3344 u/ml. Peritoneal or liver metastasis was identified by laparoscopy in 23 patients (40%) whereas 35 patients (60%) underwent curative pancreatic resection. Mean serum CA 19-9 levels for resectable tumors were 927.5 u/ml (range; 9-6137) compared to 2362.9 u/ml (range 2-26871) in unresectable tumors. A mean serum CA 19-9 level of 2362.9 u/ml was statistically significant in predicting inoperable pancreatic tumor at the time of laparoscopy.  A linear correlation of serum CA 19-9 levels with pancreatic cancer stage was also observed (Figure)

Conclusion:Preoperative serum CA 19-9 levels have excellent correlation with diagnostic laparoscopy findings in regards to determining pancreatic cancer resectability. Given the wide range of serum CA-19-9 levels observed in this small study, large scale studies are necessary to more precisely define more narrow  serum CA-1-9-9 levels that can be used clinically to accurately predict pancreatic cancer stage and to differentiate resectable from unresectable pancreatic cancer.

 

7.14 Safety and efficacy of intraoperative radiotherapy in treating locally advanced pancreatic cancer

Posted on December 22, 2014

X. Che1, Y. Chen1, J. Zhang1, C. Wang1  1Cancer Hospital Chinese Academy Of Medical Sciences,Department Of Abdominal Surgical Oncology,Beijing, BEIJING, China

Introduction: Several studies have shown that intraoperative radiotherapy provides a marginal increase in the survival rate for patients with resectable pancreatic cancer. For locally advanced unresectable pancreatic cancer patients, however, the result was scarce and inconsistent. The aim of present study is to assess the safety and efficacy of intraoperative radiotherapy in unresectable pancreatic cancer.

Methods: From January 2008 to October 2013, 176 cases of locally advanced pancreatic cancer were treated with intraoperative radiotherapy and postoperative concurrent chemoradiotherapy and chemotherapy including 61 T3 cases and 115 T4 cases; maximum diameter of tumor: 3-9cm with an average of 5.1 ± 1.5cm; diameter of  applicator for IORT: 4-10cm with an average of 5.9 ± 1.0cm; irradiation intensity:6-15Mev with an average of 11.6 ± 1.1Mev; irradiation dose:1000-2000cGry with an average of 1400 ± 245cGry.

Results:Intraoperative blood loss of intraoperative radiotherapy was 50.5ml in average, postoperative pancreatic fistula was 4%, delayed gastric emptying was 9.9%, and the differences were not statistically significant compared with surgery alone. There was no level 3 or more hematologic toxicity. 49 patients were treated with intraoperative radiotherapy plus postoperative concurrent chemoradiotherapy and chemotherapy: median survival time was 14.7 months and survival rate for 1 year was 65%; rate of pain relief was 72%. As for conventional chemoradiotherapy without intraoperative radiotherapy, median survival time was 11.1 months, survival rate for 1 year was 23% and rate of pain relief was 41%. 

Conclusion:In conclusion, intraoperative radiotherapy may be delivered safely and effectively in combination with chemoradiotherapy for patients with locally advanced unresectable pancreatic cancer.

 

7.15 Preoperative Platelet to Lymphocyte Ratio is a Prognostic Factor for Pancreatic Cancer.

Posted on December 22, 2014

Y. Shirai1, H. Shiba1, T. Horiuchi1, R. Iwase1, K. Haruki1, K. Abe1, Y. Fujiwara1, K. Furukawa1, S. Onda1, D. Hata1, T. Sakamoto1, Y. Futagawa1, Y. Toyama1, Y. Ishida1, K. Yanaga1  1The Jikei University School Of Medicine,Department Of Surgery,Tokyo, TOKYO, Japan

Introduction

Pancreatic cancer is one of the most common digestive cancers, and only 10-20% are operable disease. There are several prognostic indices such as tumor size, nodal involvement, resection margin status, and tumor differentiation. However, preoperative estimation of oncological prognosis remains to be established. In several reports, preoperative platelet to lymphocyte ratio (PLR) and neutrophil to lymphocyte ratio (NLR) are significant prognostic indicators in digestive malignancies. The objective of this study was to evaluate whether preoperative PLR or NLR is a significant prognostic index in resected pancreatic invasive ductal adenocarcinoma.

Methods

A total of 131 patients who underwent pancreatic resection for pancreatic invasive ductal adenocarcinoma were available from prospective maintained database. The patients were divide into two groups as PLR <150 or ≥150, and as NLR <5 or NLR ≥5, respectively. Survival data were analyzed using the Log-rank test for univariate analysis and Cox proportional hazards for multivariate analysis. P value <0.05 was judged as significant.

Results

The preoperative PLR was a significant prognostic index by Kaplan-Meier and Log rank tests. The median Overall Survival in patients with PLR <150 was 38.6 months, which was significantly better than 17.6 months for PLR ≥150 (p=0.001). The PLR retained its significance on multivariate analysis (HR, 1.688; 95 % CI, 1.045–2.726; p = 0.032) along with tumor size (p=0.035), resection margin status (p=0.048), and tumor differentiation (p=0.002).

Conclusion

The preoperative PLR is a significant independent prognostic index in resected pancreatic invasive ductal adenocarcinoma.

 

7.16 Should I Stay or Should I Go Now: Factors Influencing High Length of Stay After Pancreatectomy

Posted on December 22, 2014

M. Radomski1, A. Zureikat1, S. M. Novak1, J. Steve1, J. Marsh1, K. K. Lee1, A. Tsung1, D. Bartlett1, H. J. Zeh1, M. E. Hogg1  1University Of Pittsburgh,Pittsburgh, PA, USA

Introduction: In this healthcare climate, much scrutiny is being paid to cost, readmission, and length of stay (LOS).  Complex pancreatic surgeries have been associated with prolonged postoperative courses.  Many studies have looked at overall data and low outliers for pancreaticoduodenectomy.  However, little exists on high outliers and factors that contribute to prolonged stays.  We sought to evaluate the contribution of social, preoperative, operative, and postoperative patient related factors to extended LOS in major pancreatic resections.

Methods: A retrospective review of a single institution’s pancreaticoduodenectomies (PD) and distal pancreatectomies (DP) was performed from 6/2009 to 3/2014 for all pathologies and technical approaches. Interquartile ranges (IQR) were calculated and the highest quartile was evaluated and compared to the lower three quartiles.

Results:A total of 350 PD (42% open) and 127 DP (21% open) patients were analyzed with a 3rd IQR of >14 and >8 days respectively. Social factors including race, distance, insurance status, and marital status were not significant for PD; however, divorce was associated with longer LOS in DP (p<0.0001).  Pre-operative characteristics of higher age (p=0.0003), age adjusted Charlson Comorbidity Index (p=0.002), body mass index (p=0.01), and American Society of Anesthesia assessment (ASA, p=0.005) were associated with increased LOS in PD; whereas, only higher ASA (p=0.0188) was associated in DP.  Albumin, Ca19-9, previous abdominal surgery, and neoadjuvant therapy were not significant for PD or DP.  Increased operative time (p=0.009), blood loss (EBL, p=0.03), and transfusion (p=0.03) all were associated with longer LOS in PD; however, only EBL (p=0.03) was associated with longer LOS in DP.  A trend toward more LOS outliers was seen in the open PD group (p=0.06) compared with robotic, but not in the DP group (p=0.63). For the PD group, pancreatic fistula (p<0.0001), delayed gastric emptying (p<0.0001), and pseudoaneurysm (p<0.0001) were associated with extended hospitalizations.  No specific post-operative complications led to increased LOS in the DP group but the high LOS group was more likely to have had any complication (p=0.007) compared to the rest of the cohort.  High LOS outliers were more likely to go to skilled nursing facilities, acute care facilities, and rehab than home in both PD (p=<0.0001) and DP (p=0.005) groups.  The high LOS group had more readmission in the PD group (p=0.005) but not in the DP group (p=0.64).

Conclusion:More patient pre-, intra-, and post-operative factors lead to high LOS outliers seen in the PD group than the DP group; but the DP group also had a social factor associated with increased LOS.  Pre- and Intraoperative factors are hard to change, but further subgroup analysis in the PD group looking at management of specific complications and physician related factors may help identify better or sooner management to decrease LOS for these factors.

7.17 The Bipedicled, Conjoined Deep Inferior Epigastric Perforator (DIEP) Flap: a Concept in Evolution

Posted on December 22, 2014

P. G. Koolen1, B. T. Lee1, H. Erhard3, D. Greenspun2  1Beth Israel Dearoness Medical Center,Division Of Plastic Surgery,Boston, MA, USA 2Greenwich Hospital,Division Of Plastic Surgery,Greenwich, CT, USA 3Albert Einstein College Of Medicine,Division Of Plastic Surgery,Bronx, NY, USA

Introduction:

Autologous tissue transfer remains a mainstay for reconstruction of the breast. The deep inferior epigastric perforator artery (DIEP) flap has become a primary option at many institutions, yielding satisfactory aesthetic results. This type of reconstruction remains a challenge in thin patients with scant abdominal tissue or in previously irradiated breasts. Previous studies have described the use of stacked DIEP flaps, divided at the midline. We report on a modification with the use of a bipedicled, conjoined DIEP flap in thin patients; this avoids division of preexisting midline vasculature. 

Methods:

Patients undergoing a bipedicled, conjoined DIEP flap procedure for unilateral breast reconstruction over the course of two years were included in this study. Pre-operative imaging was obtained using MRA or CTA to support surgical planning of the primary and secondary vascular pedicles. Utilization of the entire abdomen was required for volume and the vascular networks were isolated on both sides. The primary flap was anastomosed to the internal mammary vessels and inset medially, whereas the secondary flap was folded towards the lateral side and a vascular anastomosis was performed from the secondary pedicle to side branches of the primary pedicle (Figure 1). Surgical technique was standardized for consistency.

Results:

We report on our experience with 27 patients undergoing bipedicled, conjoined, stacked DIEP flaps for unilateral (n=25) or bilateral (n=2) breast reconstruction. Important advantages included good volume, projection, ability to sculpt the flap, and creation of a teardrop shaped breast mound. In patients with previous radiation, the additional skin supplied by using both sides of the abdomen allowed for extensive replacement of damaged mastectomy skin. The secondary flap has blood supply across the midline as well as the second vascular pedicle and had “supercharged” perfusion, unlike in stacked flaps where the midline tissue is divided.
 

Conclusion:

Bipedicled, conjoined DIEP flap procedures are a reliable modification in patients requiring the entire abdominal tissue volume to create a unilateral breast. In using both vascular pedicles and preserving the midline blood supply, this allows for maximal perfusion of both flaps. This modification can be used in thin patients with limited abdominal tissue and does not require contralateral reduction procedures or use of alternative flaps.  
 

7.18 The Impact of Tumescent Technique on Outcomes of Autologous Breast Reconstruction

Posted on December 22, 2014

C. R. Vargas1, P. G. Koolen1, J. A. Ricci1, B. T. Lee1  1Beth Israel Deaconess Medical Center,Surgery / Plastic And Reconstructive Surgery,Boston, MA, USA

Introduction:
Use of the tumescent dissection technique during mastectomy has been reported to facilitate development of a hydrodissection plane, to shorten operating time, to reduce operative blood loss, and to provide additional local anesthesia.  Despite these advantages, the impact of this technique on post-operative outcomes remains unclear.  Several prior studies have suggested that tumescent dissection has a negative impact on post-operative complications following immediate implant placement, however, the effect on autologous reconstruction has not been clearly established.

Methods:
A retrospective review was conducted, using a prospectively maintained database, of all immediate autologous breast reconstruction procedures performed at a single academic center between January 2004 and December 2013.  Electronic patient records were queried for age, BMI, diabetes, active smoking, pre-reconstruction radiation therapy, mastectomy weight, and tumescent technique during mastectomy.  Mastectomy weight was divided into quartiles for improved clinical interpretation.  All post-operative occurrences of breast hematoma, seroma, and mastectomy skin necrosis were also collected.

Results:
A total of 698 immediate autologous post-mastectomy breast reconstruction flaps were performed during the study period; mean patient age was 49.3±8.3 years and average mastectomy weight was 769.3±413 grams.  49.2% of the mastectomies were performed using the tumescent dissection technique.  Univariate analysis revealed no significant difference in the incidence of breast hematoma (p=0.779), seroma (p=0.180), or mastectomy skin necrosis (p=0.688) in patients who underwent tumescent dissection during mastectomy.  Multivariate analysis, adjusted for clustering related to bilateral reconstruction, also demonstrated no significant association between the use of tumescent technique and post-operative breast hematoma (p=0.978), seroma (p=0.340), or mastectomy skin necrosis (p=0.759) after covariate adjustment.

Conclusion:
Use of the tumescent dissection technique during mastectomy is not significantly associated with adverse outcomes following autologous breast reconstruction.  Despite concern for its impact on implant reconstruction, our findings suggest that the tumescent method can be used safely in conjunction with autologous procedures.

7.19 From Free Flaps to Freestyle Locoregional Perforator Subunit Flaps- a Paradigm Shift over 230 Cases.

Posted on December 22, 2014

M. W. Findlay1,2,3,4, S. Sinha2, A. Rotman2, J. Ting2, S. Fairbank1, T. Wu2, F. Behan2  1Stanford University,Division Of Plastic And Reconstructive Surgery,Palo Alto, CA, USA 2The Peter MacCallum Cancer Centre,Divison Of Surgical Oncology,East Melbourne, VIC, Australia 3The University Of Melbourne,Department Of Surgery Royal Melbourne Hospital,Parkville, VIC, Australia 4Monash University,Combined Plastic And Reconstructive Surgery Unit,Clayton, VIC, Australia

Introduction: Perforator-based locoregional flaps provide tissue reconstruction with a shorter operative time, length of stay and fewer complications than free flaps in the head and neck. However, the vascular pedicles for common locoregional flaps can be compromised by previous surgery and/or injury and outcomes data based on large case series are lacking within the literature. Our practice has evolved from ‘random’ Keystone flaps to bespoke freestyle perforator subunit-based flaps over the past 6 years and we examined the outcomes data of over 230 cases during this time to examine the outcomes from our approach relative to large published series of free flap reconstructions.

Methods: Over 230 flaps performed over a 6-year period at two clinical centres within Australia were reviewed with institutional ethics approval.  The technique for perforator selection, flap design, elevation and closure are described using operative sequences along with our modifications to subunit-based reconstruction using Keystone flap principles. Prospectively collected data including patient comorbidities, pathology, defect size, flap type and perioperative complications were combined with retrospective data such as complication profile and length of follow up for the analysis. 

Results:Over 230 flaps were performed in the period between 2006 and 2012 for defects ranging from 4cm2 to 121cm2. Median patient age was 76 (range 19-98 years) with an average of 2 comorbidities per patient. The median operative time was under 100 minutes (inclusive of resective time). There was one peri-operative death (Day 5 post-op), 7 major complications including one complete flap loss and 4 partial flap losses requiring operative management. Pre- or post-operative radiotherapy and/or chemotherapy were associated with increased risk of complications.

Conclusion:An analysis of the outcomes from over 230 perforator-based island flaps in the head and neck demonstrates comparable results to free flap reconstruction, but with the added benefits provided by locoregional reconstruction. Our technique has evolved from ‘random’ Keystone flaps through to bespoke flaps based on specific perforators for esthetic unit reconstruction with shorter operative times and lower morbidity than free flap reconstruction.

 

7.20 Occult Neoplasms in Appendicitis: A Single-Institution Experience of 1793 Appendectomies

Posted on December 22, 2014

C. M. Forleiter1, J. A. Schwartz1, D. Y. Lee1, G. J. Kim1  1Mount Sinai School Of Medicine,Mount Sinai Roosevelt Hospital / Department Of Surgery,New York, NY, USA

Introduction: The incidence of appendiceal neoplasms may have been underreported in the past. Patients undergoing incidental appendectomies or appendectomies for chronic appendicitis may be at a higher risk for an occult appendiceal neoplasm. 

Methods:  Retrospective review of a pathology specimen database spanning four years at a tertiary care hospital center.  

Results: A total of 1,793 appendectomy specimens were evaluated.  There were 31 (1.7%) appendiceal neoplasms.  Fourteen neoplasms were discovered in 1,337 (1.0%) cases of acute appendicitis compared to 2 in 41 (4.9%) cases of chronic and 15 in 415 (3.6%) cases of incidental appendectomies (p < 0.001).  Patients with carcinoid tumors were significantly younger compared to others (p = 0.0001).  On multivariate analysis, indication for operation was the only significant factor for predicting a tumor.

Conclusion: Patients undergoing interval or incidental appendectomies may be at a higher risk for appendiceal neoplasm compared to other indications.  Younger patients may be at a higher risk of occult appendiceal carcinoid neoplasms than other age groups.  Pathologic diagnosis in specific high-risk patient groups may be the only way to effectively capture these tumors for optimal treatment. 
 

69.15 Clinicopathologic Factors Associated With a False Negative AUS in Patients With Breast Cancer

Posted on December 22, 2014

I. Nwaogu1, Y. Yan1, J. A. Margenthaler1  1Washington University,Surgery,St. Louis, MO, USA

Introduction: Axillary ultrasound (AUS) has been used in an attempt to identify sub-clinical node-positive disease and improve clinical staging and treatment recommendations. We sought to identify clinicopathologic factors potentially related to false negative AUS results.

Methods: Patients with a clinically node-negative Stage I-II invasive breast cancer who also had a normal AUS were identified from our prospectively maintained database. All AUS studies were performed by dedicated breast radiologists and interpreted as “normal” according to the absence of specific characteristics previously shown to be more commonly associated with metastatic involvement. True- and false-negative AUS studies were compared statistically based on clinical, radiographic, and histologic parameters.

Results:Of the 118 patients with a normal AUS, 25 (21%) were ultimately found to be node-positive on final pathologic assessment following axillary surgery. On bivariate analysis, primary tumor size, lymphovascular invasion (LVI), and Her2neu receptor status were found to be significantly different between true- and false-negative AUS. The average tumor size was smaller in the true-negative group compared to the false-negative group [16 vs 21mm (p< 0.01)]. The presence of LVI was more likely in the false-negative group [11/25 (44%)] compared to the true-negative group [7/93 (8%)] (p< 0.0001). Her2neu receptor status was more likely amplified in the false-negative group [8/25 (32%)] compared to the true-negative group [13/93 (14%)] (p=0.037). No significant difference was noted between groups with regard to patient age, race, body mass index, tumor grade, histologic type, estrogen or progesterone receptor status, and time between AUS and axillary surgery. On multivariate analysis, only the presence of LVI achieved statistical significance (p=0.0007).

Conclusion:AUS is a valuable tool that accurately predicted absence of axillary disease in 79% of patients with clinically node-negative breast cancer. AUS findings may be less accurate in the setting of LVI, and a negative AUS in patients with this feature should be interpreted with caution.

 

69.16 Use of a Recurrence Score In Locally Recurrent/New Primary Breast Cancer

Posted on December 22, 2014

N. C. Vera4, D. Carr4, J. Mullinax1, D. Korz1, W. Sun1, C. Laronga1, S. Hoover1, W. Fulp2, G. Acs3, M. C. Lee1  1Moffitt Cancer Center And Research Institute,Breast Program,Tampa, FL, USA 2Moffitt Cancer Center And Research Institute,Biostatistics,Tampa, FL, USA 3Women’s Pathology Consultants,Ruffolo Hooper & Associates,Tampa, FL, USA 4University Of South Florida College Of Medicine,Tampa, FL, USA

Introduction: Treatment planning for locally recurrent estrogen receptor positive (ER+) invasive breast cancer is controversial. The Recurrence Score (RS) from the 21-gene breast cancer assay (ODX) is commonly used for primary early stage ER+ invasive breast cancer for adjuvant treatment recommendations, but not generally obtained in locally recurrent ER+ tumors. We reviewed our experience with RS first performed on the recurrent tumor.  

Methods: An IRB-approved, single-institution retrospective chart review of a prospective ODX database was performed. Most patients had ODX performed on an initial invasive breast cancer (1o cancer); another set of patients, the minority, had ODX performed on an ipsilateral local recurrence/new primary (2nd cancer); none had clinical evidence of concurrent regional or distant metastasis at presentation. Performance of the ODX assay was based on NCCN guidelines (1o cancer) or physician discretion (2nd cancer). Data collected included demographics, clinical-pathologic variables, surgery type, RS, adjuvant treatment and outcomes. Comparisons between patients with 1o breast cancer and patients with 2nd cancers were made by general linear regression model and the exact Wilcoxon Rank Sum Test. 

Results:594 patients with 1o breast cancer and 7 patients with 2nd breast cancer had ODX and RS.  Median age of patients at time of ODX was 58 years (range 27-84) for 1o cancer and 58.5 years (range 36-63) for 2nd cancers (p=0.411) respectively. The majority of patients with a 2nd breast cancer had a prior history of breast conservation (6/7). Median invasive tumor size of 1o cancer was 1.5cm and 2nd cancer was 1.4cm. One 2nd cancer was ILC, otherwise all documented 1o and 2nd breast cancers were ER+ and of invasive ductal histology. For 2nd cancers, median time from 1o breast cancer surgery to diagnosis with 2nd breast cancer was 92 months (range 13-120)[Table of 2nd cancers]. Median RS was higher in patients with 2nd cancer at 22 (range 15-37) compared to 1o cancer at 16 (range 0-63) (p=0.03). Categorically, more 2nd cancer patients had a high RS (28.6%) than those with 1o cancer (8.1%) but it was not significant (p=0.08). Tumor size, nodal status, degree of ER expression, nuclear grade, number of mitoses, and compliance with endocrine therapy were not significantly different between patients with 2nd cancer and 1o cancer. Overall survival tended to be better in patients with 1o breast cancer (P=0.049).

Conclusion:Performance of ODX in ER+, locally recurrent/new primary invasive breast cancer (2nd breast cancer) should be considered for prognostication and adjuvant systemic treatment recommendations.
 

69.17 Menopausal Status Affects Presentation but Not Outcome in Invasive Lobular Carcinoma

Posted on December 22, 2014

M. Zamanian1, A. Soran1, M. K. Wright1, C. Thomas1, G. M. Ahrendt1, M. Bonaventura1, E. J. Diego1, R. R. Johnson1, P. F. McAuliffe1, K. McGuire1  1University Of Pittsburgh School Of Medicine,Division Of Surgical Oncology, Department Of Surgery,Pittsburgh, PA, USA 2Magee Women’s Hospital Of UPMC,Surgical Oncology,Pittsburgh, PA, USA

Introduction: Invasive lobular carcinoma (ILC) is the second most common form of breast cancer, with rates increasing over the past 10-15 years. ILC has unique molecular and clinical characteristics, distinct from invasive ductal carcinoma. Studies of ILC, especially in the premenopausal population, remain limited. We hypothesize that premenopausal patients diagnosed with ILC will present with higher stage tumors and with lower estrogen receptor (ER) expression and will have poorer disease free and overall survival (DFS, OS).

Methods: A retrospective review of a prospectively collected database identified all pre- and postmenopausal patients treated for ILC at a single institution between 2004 and 2010. Patient and tumor characteristics were collected as well as outcome data. Patients whose menopausal status at diagnosis was not recorded were categorized as postmenopausal if they were over age 50 and premenopausal if they were under age 45. Patients age 46-49 were considered perimenopausal and were excluded. ER/PR (progesterone receptor) expression was measured using H-score (H-score = sum of % nuclear staining x intensity 0, 1+, 2+, 3+, giving a range from 0-300).  The two groups were compared for differences in presentation and outcome using uni- and multivariate analysis.

Results: 87 premenopausal and 226 postmenopausal patients were treated for ILC during the study period. Demographics were well balanced between the groups with the exception of age (p<0.001). Univariate analysis showed significantly larger tumor size (3.4±2.9 versus 2.5±2 cm, p=0.002), higher clinical stage (p=0.003), higher PR H-score (158±91 versus 121±100,p=0.005), and lower ER H-score (216±67 versus 242±65, p=0.004) in premenopausal versus postmenopausal patients, respectively. Significant differences in treatment with surgical and systemic therapy were also identified (Table 1). HER2 status was similar between groups. Multivariate analysis showed menopausal status to be independently predictive of tumor size (p=0.012), ER and PR (p<0.001) H-score and likelihood of receiving chemotherapy (p=0.013). DFS and OS were similar between the two groups (p=0.14 and p=0.16, respectively).

Conclusion: In this retrospective review of patients with ILC, premenopausal patients presented with larger tumors and with lower ER H-scores than post-menopausal patients. Despite these adverse clinical factors, there were no significant differences in DFS or OS. Premenopausal patients received systemic therapy more often, which may have contributed to equivalent outcomes. Further research is needed to understand how local and systemic therapy affect outcome in premenopausal patients with ILC.

69.18 Breast Cancer Outcomes in a Population with a High Prevalence of Obesity

Posted on December 22, 2014

V. C. Herlevic1, R. S. Mowad1, J. K. Miller1, N. A. Darensburg1, B. D. Li1, R. H. Kim1  1Louisiana State University Health Sciences Center – Shreveport,Surgery,Shreveport, LA, USA

Introduction:

Obesity has been associated with poor prognosis in breast cancer. However, most previous studies examined populations with relatively low proportions of obese patients. Given that forecasts predict obesity rates to exceed 50% by 2030, it is important to examine breast cancer outcomes in populations with higher rates of obesity. We hypothesized that obesity, as measured by Body Mass Index (BMI), is associated with decreased overall survival and disease-free survival in patients with invasive breast cancer in a population with a high prevalence of obesity.

Methods:

A retrospective review of a prospectively maintained database was conducted on patients treated for invasive breast cancer at an academic medical center between July 1987 and May 2013. BMI was calculated from each patient’s height and weight at time of diagnosis. Patients were categorized as normal (BMI < 25 kg/m2), overweight (BMI 25 – 30 kg/m2), or obese (BMI > 30 kg/m2), as per the definitions established by the World Health Organization. The endpoints of overall survival and disease-free survival were analyzed.

Results:

A total of 740 patients with invasive breast cancer were included for analysis. Based on BMI, 127 (17.2%) were categorized as normal, 203 (27.4%) were overweight, and 410 (55.4%) were obese. The median follow-up was 49 months. There were 17 deaths (13.3%) in normal patients, 34 (16.7 %) in overweight patients, and 64 (15.6%) in obese patients (p=0.74). By Kaplan-Meier survival analysis, there were no differences in overall survival (p=0.91) or in disease-free survival (p=0.99) between the three groups.

Conclusion:

Obesity is not associated with decreased overall or disease-free survival in a patient population with a high prevalence of obesity. These findings suggest that there may be other factors that contribute to the poor prognosis of obese breast cancer patients observed in populations with lower rates of obesity.

69.19 Breast Density, BMI, and Outcomes in Premenopausal Women with Breast Cancer

Posted on December 22, 2014

M. K. Wright1, A. Soran1,2, M. Zamanian1, C. Thomas2, G. M. Ahrendt1,2, M. Bonaventura1,2, E. J. Diego1,2, R. R. Johnson1,2, P. F. McAuliffe1,2, K. P. McGuire1,2  1University Of Pittsburg,School Of Medicine,Pittsburgh, PA, USA 2Magee Women’s Hospital Of UPMC,Surgical Oncology,Pittsburgh, PA, USA

Introduction:  

Breast density is a well-established risk factor for the development of breast cancer.  Some studies suggest that breast density is associated with a tumorigenic microenvironment within the breast, leading to more cancers and higher stage at presentation. We hypothesize that premenopausal women with dense breasts will present with breast cancer at a  higher stage and will have worse long-term outcomes compared to their non-dense breasted counterparts. 

Methods:

We performed a retrospective study of a prospectively collected database identifying premenopausal women with breast cancer who presented to a single institution between 2006 and 2010.  Premenopausal status was defined as age less than 50 years or no menstrual period for at least one year. Patient and tumor characteristics were collected, as well as long-term outcomes.  Patients were stratified into two categories of breast density: ‘non-dense’, defined as fatty replaced  or scattered fibroglandular densities (BIRADS Density Categories 1 & 2, respectively) and ‘dense’, defined as heterogeneously dense or homogeneously dense (BIRADS Density Categories 3 & 4, respectively). The two breast density groups were compared for differences in presentation and outcomes using univariate and multivariate analyses.

Results:

477 premenopausal women with breast cancer were identified.  Clinicopathologic factors, including age, race, tumor histology, receptor status, and treatment types were well balanced between the two breast density groups.  On univariate analysis, breast density did not correlate with stage at presentation, tumor grade, lymphovascular invasion, clinical stage, treatment type, surgery type or overall survival.  Lower breast density was strongly correlated with higher BMI, poorer disease free survival (DFS), and larger tumor size on univariate analysis (Table 1).  Multivariate analysis also showed that BMI (p = 0.05) and tumor size (p = 0.001) were significantly associated with DFS, whereas breast density was not.  

Conclusion: 

In this retrospective study of premenopausal women with breast cancer, we found that higher breast density was not associated with higher stage at presentation or with poorer outcomes.  This study suggests that higher BMI and tumor size at presentation, although related to breast density, are more predictive of recurrence than breast density in premenopausal patients. Further study is needed to elucidate the link between BMI, breast density and outcome in premenopausal breast cancer.
 

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