68.14 Bleeding Risk after Fine Needle Aspiration of Thyroid Nodules in Patients on Antithrombotic Therapy

Posted on January 18, 2016

R. M. Kholmatov1, T. A. Hassoon1, Z. Al-Qurayshi1, M. Anwar1, F. Murad1, H. Mahmood1, T. K. Thethi2, R. Aslam3, E. Kandil1 1Tulane University School Of Medicine,Surgery,New Orleans, LA, USA 2Tulane University School Of Medicine,Endocrinology,New Orleans, LA, USA 3Tulane University School Of Medicine,Otolaryngology,New Orleans, LA, USA

Introduction: Fine needle aspiration biopsy (FNAB) is relatively contraindicated in patients with suspicious thyroid nodules while on anticoagulant and antiplatelet agents. Our aim is to evaluate the bleeding risk associated with anticoagulation and antithrombotic therapy in patients presenting for FNAB of thyroid nodules.

Methods: After approval from institutional review board, we performed retrospective analysis of patients’ records who underwent FNAB of thyroid nodules by a single surgeon over past 5 years. 608 patients with a mean age of 53.12±14.08 years underwent FNAB of thyroid nodules. 140 (23 %) patients were on anticoagulants (warfarin, heparin, apixaban) or antiplatelet agents (aspirin, clopidogrel). We collected data on patients’ demographic and social history along with the postoperative diagnosis. Statistical analysis was performed using student's t test and Fisher’s exact test for the continuous and categorical variables respectively.

Results: Four out of 468 patients in the control group developed a small hematoma after FNAB, as compared to only one patient in the other group, who was taking warfarin and aspirin (OR 7.93; 95% CI 0.83-75.59, p=0.07). Patients with post FNAB hematomas were managed conservatively without a need for surgical intervention. There was no correlation between post FNAB hematoma and patients’ demographics, social history, ultrasonographic features, or postoperative diagnosis (p>0.05).

Conclusion: FNAB of thyroid nodules in patients who are undergoing anticoagulation is a safe and feasible approach without the need to discontinue anticoagulant therapy. However, further future prospective studies are warranted.

68.15 Comparing Blue Dye Alone with Combined Dye and Isotope in Breast Sentinel Lymph Node Biopsy

Posted on January 18, 2016

K. Tatsuda1, M. Nagahashi1, J. Tsuchida1, K. Moro1, T. Niwano1, C. Toshikawa1, M. Hasegawa1, Y. Koyama1, T. Kobayashi1, S. Kosugi2, H. Kameyama1, T. Wakai1 1Niigata University Graduate School Of Medical And Dental Sciences,Division Of Digestive And General Surgery,Niigata, NIIGATA, Japan 2Uonuma Kikan Hospital,Digestive And General Surgery,Minami-Uonuma City, NIIGATA, Japan

Introduction:

Blue dyes and radioisotope tracers have been used, either alone or in combination, to identify the sentinel lymph node (SLN). Previous studies indicate a superiority of combination of dye and isotope for SLN biopsy in breast cancer patients to a single method of blue dye in terms of lower non-identification and false-negative rates. With increasing experience, however, surgeons had become comfortable to use the single method of dye. The use of blue dye alone remains an attractive option because of its technical simplicity and because it does not require any additional equipment or procedures. In this study, we re-evaluate the practice of performing sentinel lymph node biopsy with blue die alone.

Methods:

A retrospective analysis was conducted of 114 consecutive patients with breast cancer at the authors’ institute between January 2014 and March 2015, when SLN biopsy was offered to all suitable patients with either a method with combined dye and isotope or dye alone. All procedures were done by experienced surgeons for SLN biopsy.

Results:

During the study period, 66 patients underwent SLN biopsy with combined dye and isotope, and 48 patients underwent that with dye alone. The SLN was identified in all patients in each group. There was no difference between SLN biopsy with combined dye and isotope and that with dye alone in terms of operation time, time for SLN procedure, and number of SLN (median; n = 2). A positive rate for SLN metastasis was 19.6% (13/66) for patients underwent SLN biopsy with combined dye and isotope, and 12.5% (6/48) 48 patients underwent that with dye alone; there was no difference between the groups (P = 0.446).

Conclusion:

Our results indicate that SLN with dye alone is feasible for patients with breast cancer with comparable outcome to the combined method. SLN with dye alone remains an option for experienced surgeons because of its technical simplicity and because it does not require any additional equipment or procedures.
This work was supported by the Japan Society for the Promotion of Science (JSPS) Grant-in-Aid for Scientific Research Grant Number 15H05676 and 15K15471 for M.N and 15H04927 for W.T. M.N. is supported by the Uehara Memorial Foundation, Nakayama Cancer Research Institute, Takeda Science Foundation, and Tsukada Memorial Foundation.

68.16 Predictors of Recurrence Following Open Inguinal Herniorrhaphy

Posted on January 18, 2016

P. M. Patel1, A. Mokdad1, A. Webb1,2, S. Huerta1,2 1University Of Texas Southwestern Medical Center,Dallas, TX, USA 2VA North Texas Health Care System,Surgery,Dallas, TX, USA

Introduction: Recurrence following open repair of inguinal hernias continues to be an important complication following repair. We hypothesize that there are factors that can determine recurrence such that these patients can undergo an alternative repair.

Methods: This a retrospective, single institution, single surgeon experience at the VA North Texas Health Care system between July 2005 to July 2015. All patients underwent the same standardized mesh repair. Using recurrence as the dependent variable, univariate analysis (UA) was performed using Fisher’s Exact Test for categorical and Student’s T-Test for continuous variables. Clinically relevant variables and variables with a p ≤ 0.2 were entered in a logistic regression model with recurrence as the dependent variable. Data are expressed as means ± SD and significance was established at a p ≤0.05 (two-sided).

Results: During the study period, 804 patients underwent open inguinal hernia repair (99.3 ± 0.3% male, 60.4 ± 12.4 years-old, BMI 26.7 ± 4.2 Kg/m2, 72.9% Caucasian, American Society of Anesthesiologists class average of 2.5, morbidity rate of 7.8 ± 0.9%) by the same surgeon. Sixteen recurrences were identified (2.0 %). Median follow up was 4.7 ± 2.7 years. Patients with recurrent hernia were less likely to have an indirect hernia (25.0 ±10.8% vs 54.3 ± 1.8%, p=0.02), and more likely to have a small bowel obstruction (6.3 ± 6.1 % vs 0.6 ± 0.3 %, p=0.01), a bowel resection (6.3 ± 6.1% vs 0.5 ± 0.3%, p <0.001), and a longer operative time (76.7 ± 28.7% vs 63.7 ± 22.1%, p=0.02). These patients were also more likely to be smokers (56.3 ± 12.4% vs 32.9 ± 1.7%, p=0.05). Multivariate analysis demonstrated that current smoking history (OR and 95% CI: 3.3; 1.2 – 9.3), OR time (1.1; .1.0 – 1.1), and repair of an indirect inguinal hernia (0.2; 0.04 – 0.5) were independent predictors of recurrence.

Conclusion: Patients with direct complex hernias are more likely to develop a recurrence. Current smokers should be told to stop smoking prior to repair.

68.11 Psychological factors as predictors of successful bariatric surgery

Posted on January 18, 2016

S. Sheikh1, T. Bell1, R. Grim1, P. Hartmann1, V. Ahuja1 1York Hospital,Surgery,York, PA, USA

Introduction: Obesity is commonly associated with a myriad of psychosocial conditions. However, the effects of these conditions in patients undergoing bariatric surgery is relatively understudied. The purpose of this study was to 1) identify psychosocial conditions in bariatric surgery patients, 2) assess changes in weight and psychosocial variables before and after bariatric surgery, and 3) identify psychosocial predictors of successful bariatric procedures at 5 years post-surgery.

Methods: Data of 93 patients undergoing Roux-en-Y gastric bypass surgery with age>18 years, BMI>40kg/m2, and/or had obesity related medical conditions were reviewed. Psychosocial variables were obtained from the Bariatric Surgery Screening Tool, Beck Depression Inventory II, Self-Report Family Inventory, and the Obesity Adjustment Survey (OAS). Factors analyzed included depression, obesity related quality of life (O-QoL), and family functioning. Descriptive statistics, paired-sample t-test and multiple regression were used. Successful bariatric surgery was defined as significant weight loss and few or no surgical complications.

Results: Results indicated that a high proportion (66.7%) of this sample had a behavioral health condition. Of note, 41.5% indicated some form of verbal/emotional abuse, and 20.7% indicate sexual abuse. On average, weight was about 76.09 pounds lower at six months, 94.75 lower at one year, and 84.53 at five years. Weight and measures of depression and obesity-related quality of life significantly improved at 5 years post-surgery. The regression model accounted for 13.9% of the variance; however, only one predictor variable (obesity-related quality of life) was found to be significant (p = 0.014). All other variables did not significantly contribute to predicting weight loss at five years after surgery. No psychosocial variable was predictive of complications.

Conclusion: Obese patients had a higher prevalence of behavioral health conditions such as depression when compared to the general population. However, this data did not reach statistical significance. Patients with a poor preoperative O-QoL were more likely to lose the maximum amount of weight after surgery. However, O-QoL, did not predict the risk of complications after bariatric surgery.

While all psychosocial factors should be considered, this study indicates that preoperative assessment of the O-QoL is important in identifying and optimizing the bariatric surgery candidates and therefore maximizing the success of the procedure.

68.12 Utilization of Intraoperative Cholangiography

Posted on January 18, 2016

M. C. Nally1, P. Patel1, J. Myers1, M. Luu1 1Rush University Medical Center,General Surgery,Chicago, IL, USA

Introduction: The utility of intraoperative cholangiography continues to be debated in the literature. Some surgeons perform routine cholangiography, while most use it selectively as an adjuvant tool in specific clinical situations. There is evidence to suggest that the use of cholangiography decreases the incidence of common bile duct injuries. It is also documented to cause increased operative times and cost, and, with the manipulation of the cystic duct during cholangiography, the procedure itself may actually lead to bile duct injury. Intraoperative cholangiography is also performed when there is a question of choledocholithiasis as it is diagnostic and can allow for therapeutic common bile duct exploration. Although with increasing availability of endoscopy, ERCP remains a pre and post operative option for management of choledocholithiasis.

Methods: A single institution retrospective chart review was performed to identify patients who underwent laparoscopic cholecystectomy completed between 2007 and 2013. Of those patients, the ones who underwent intraoperative cholangiogram were selected for further analysis. Specifically, hyperbilirubinemia, cholangiogram findings, attending surgeon, and need for common bile duct exploration were evaluated.

Results: Of the patients who underwent laparoscopic cholecystectomy (n=1590), 229 cholangiograms were performed (14.4%). Only 8.3% of the cholangiograms reported abnormal findings, which led to fifteen common bile duct explorations (6.6%). Two-thirds of these patients had elevated bilirubin, while the remaining one-third had normal liver enzymes. Twenty different attending surgeons performed intraoperative cholangiography over seven years. One attending performed 129 of these procedures (56%).

Conclusion: Intraoperative cholangiography continues to be used selectively and routinely depending on surgeon preference. When performed, the majority of cholangiograms do not show anatomic or pathologic abnormalities. And, even with the finding of choledocholithiasis on cholangiography, common bile duct exploration is, at times, deferred in favor of pursuing post operative endoscopic retrograde cholangiopancreatography. Overall, from this chart review, there does not appear to be specific indications or benefit of pursuing intraoperative cholangiography.

68.13 Frailty Predicts Postoperative Morbidity/Mortality after Colectomy for C-Difficile Colitis

Posted on January 18, 2016

R. Venkat1, E. Telemi1, O. Oleksandr1, V. Nfonsam1 1University Of Arizona,Surgery,Tucson, AZ, USA

Introduction: With increasing rates of antibiotic use in the aging population of the U.S., Clostridium difficile (C. difficile) infection of the colon is becoming more prevalent. We sought to evaluate the association between frailty and postoperative outcomes after colectomy for C. difficile colitis.

Methods: NSQIP cross-institutional database was used for this study. Data from 483 patients with a diagnosis of C. difficile colitis was used in the study. 73.71% underwent total (n = 356) and 26.29% partial (n = 127) colectomies. Modified frailty index (mFI) is a previously described and validated 11-variable frailty measure used with NSQIP to assess frailty. Outcome measures included serious morbidity, overall morbidity, Clavien IV (requiring ICU), and Clavien V (mortality) complications.

Results:Median age was 70 years, and BMI was 26.9Kg/m2. 44.4% of patients were males. 98.6% of patients were assigned ASA Class 3 or higher. The median mFI was 0.27 (0 – 0.63). As mFI increased from 0 (non-frail) to 0.36 and above, the overall morbidity and increased from 53.3% to 88.1% and serious morbidity increased from 43.3% to 76.1%, respectively. The Clavien IV complications rate increased from 30.0% to 73.9%. Mortality rate has increased from 6.7% to 46.3%. All results were statistically significant at p<0.01. On a multivariate analysis mFI was independent predictor of overall morbidity (AOR: 12.4, p<0.05) and mortality (AOR: 8.3, p<0.05).

Conclusion:Frailty is associated with increased risk of complications in C. difficile colitis patients undergoing colectomy. The mFI is an easy to use tool and can play an important role in the risk stratification of these patients, who generally have significant morbidity and mortality to begin with.

68.08 Comparing Outcomes Following Colorectal Surgery in Patients with and without Diverticulitis.

Posted on January 18, 2016

S. Groene1, C. Chandrasekera1, T. Prasad1, A. Lincourt1, B. T. Heniford1, V. Augenstein1 1Carolinas Medical Center,Division Of Gastrointestinal And Minimally Invasive Surgery,Charlotte, NC, USA

Introduction: Colorectal diverticular disease occurs in about 3% of the population and at times it can result in significant complications such as perforations, abscesses or fistulae. Surgery is recommended for most complicated cases of diverticulitis. The aim of this study was to compare outcomes of patients with and without diverticular disease following colorectal surgery.

Methods: Review of the Carolinas Medical Center (CMC) NSQIP data for colorectal procedures performed from 2013 to 2015 was conducted. Patients were considered to have or had had diverticulitis based upon ICD-9 codes (562.11, 562.13). Demographics, pre-operative co-morbidities, minor and major complications were evaluated using standard statistical methods.

Results: There were 637 patients in the sample; 109 patients had the diagnosis of diverticulitis, 528 with other diagnoses, including neoplasms (63.2%), IBD (2.7%), infectious disease (3.2%), ischemia (4.7%) and obstruction (6.1%). There were no significant differences between the groups in terms of age, race, gender or other medical co-morbidities. Those with diverticulitis underwent laparoscopic surgery more often (75.2% vs 63.5%; p=0.02) than those with other diagnoses. However, those without the diagnosis of diverticulitis tended to have a higher rate of pre-operative steroid use (8.9% vs 1.8%; p=0.01), a higher rate of pre-operative transfusions (7.4% vs 1.8%; p=0.03) and a greater chance of pre-operative weight loss of ≥ 10 pounds (5.5% vs 0.9%; p=0.04). The proportion of emergent cases were similar between the 2 groups (10.1% vs 11.3%; p=0.59). Those with the diagnosis of diverticulitis had a lower rate of post-operative transfusions (3.7% vs 21.8%; p<0.001) and a shorter post-operative length of stay (6.7±5d vs 10.3±9.6d; p<0.001). After controlling for pre-op transfusions, ASA class and pre-op sepsis, multivariate analysis indicated patients with diverticulitis required fewer post-op transfusions with OR 0.17 (95% CI 0.06, 0.49) and had a shorter LOS (adjusted mean13.4d vs 15.3d; p=0.02). There were no significant differences in post-operative surgical site infections, pneumonia, UTIs, sepsis, anastomotic leaks, unplanned returns to the OR, cardiac or renal disease, DVTs/PEs and 30 day mortality between the 2 groups.

Conclusion: Patients with and without diverticulitis had similar demographic characteristics and pre-operative co-morbidities. Those with diverticulitis required fewer transfusions, both pre and post-operatively. They also had a shorter length of stay and did not require more emergent surgeries compared to those without diverticulitis. Surgery, including laparoscopy, can be performed on those with colorectal diverticular disease with similar outcomes to those requiring surgery for other reasons.

68.09 Surgeon Perspectives on Inter-hospital Transfer for Gravely Ill Patients with Acute Surgical Problems

Posted on January 18, 2016

K. Kummerow Broman1,4, M. J. Ward2, B. K. Poulose1, M. L. Schwarze3 1Vanderbilt University Medical Center,General Surgery,Nashville, TN, USA 2Vanderbilt University Medical Center,Emergency Medicine,Nashville, TN, USA 3University Of Wisconsin,Vascular Surgery,Madison, WI, USA 4VA TN Valley Healthcare System,Geriatric Research And Education Clinical Center,Nashville, TN, USA

Introduction: Inter-hospital transfer is resource-intensive and can be burdensome for patients and families. Decisions regarding transfer can be particularly challenging for gravely ill surgical patients, for whom transfer may be arduous and of questionable clinical benefit.

Methods: We conducted semi-structured interviews with general surgeons who refer and accept transfer patients within a regional transfer network. Participants were identified using a combination of snowball sampling, where initial study subjects were asked to identify additional subjects, and purposive sampling where respondents were selected deliberately to increase variability. Surgeons were selected from three community hospitals that refer patients, three regional hospitals that both refer and accept, and one tertiary referral center that accepts transfer patients. We completed 15 audio-recorded interviews that included open-ended questions and three case-based vignettes. Each interview transcript was analyzed by at least two members of the research team using a deductive coding strategy. We used consensus coding to generate higher level analysis about the content regarding surgeon transfer decisions for gravely ill patients with acute surgical problems.

Results:Referring surgeons seek transfer when they identify discordance between patient needs and local resources. When patients are gravely ill, transfer decisions are influenced by clinical uncertainty and a duty to exhaustively pursue treatment options based on surgeon judgement or family request. Accepting surgeons at regional facilities consider local resources, patient ownership, and expected benefit in their decisions to accept patients. Tertiary facility surgeons report a policy to accept all transfer patients based on a perceived responsibility to the region and difficulty making treatment recommendations without in-person assessment, but they express concern that dying patients may be unnecessarily transferred without survival benefit or adequate discussion of local palliative options. Palliative care and expertise in end-of-life communication may be uniquely available in higher level centers, although respondents were conflicted about the appropriate allocation of limited resources, specifically bed availability, for dying transfer patients.

Conclusion:Current policies and practices may fail to identify dying patients who will not benefit from transfer. Remote consultation, cultural shifts in end-of-life communication, and access to palliative care at community hospitals could provide needed support to surgeons, patients, and families while allocating scare tertiary care beds more judiciously.

68.05 Comparison of Outcomes in Colorectal Resections Based on Surgical Technique.

Posted on January 18, 2016

S. Groene1, C. Chandrasekera1, T. Prasad1, A. Lincourt1, B. T. Heniford1, V. Augenstein1 1Carolinas Medical Center,Division Of Gastrointestinal And Minimally Invasive Surgery,Charlotte, NC, USA

Introduction: Laparoscopy has become a common technique for many colorectal resections. Robotic-assisted colorectal surgery is also gaining traction. The aim of this study was to compare outcomes following colorectal resections based on surgical technique.

Methods: Review of the Carolinas Medical Center (CMC) NSQIP data for colorectal resections performed from 2013 to 2015 was conducted. Data were classified as open (O), laparoscopic (L) and robot-assisted (R) cases based on CPT codes and chart review. Demographics, pre-operative co-morbidities, minor and major complications were evaluated using standard statistical methods.

Results: There were 616 patients: 371 in L, 212 in O and 33 in R groups. There were no differences in age, BMI, race or gender. The groups differed in rates of pre-op sepsis (20.8% vs 0.8% vs 0% for O, L and R, respectively; p<0.001), contaminated wounds (53.3% vs 11.9% vs 3%; p<0.001), ASA class 4-5 (29.7% vs 8.7% vs 0%; p<0.001), emergent cases (31.1% vs 1.9% vs 0%; p<0.001), smokers (25.9 vs 15.6 vs 15.2; p=0.001), pre-op ventilator use (11.3% vs 0% vs 0%; p<0.001), and pre-op transfusions (12.7% vs 3.2% vs 0%; p<0.001). Also, there was a significant difference among the groups in post-op transfusions (34% vs 10.2% vs 3%; p<0.001), superficial SSI (9% vs 4.9% vs 0%; p=0.05), post-op patients on ventilators at 48 hours (18.4% vs 1.1% vs 3%; p<0.001) acute renal failure (1.9% vs 0% vs 3%; p=0.001), UTI (9% vs 4% vs 0%; p=0.02), DVTs (3.8% vs 0.8% vs 0; p=0.04), 30 day mortality (10.4% vs 0.5% vs 0%; p<0.001), post-op sepsis (17% vs 4% vs 6.1%; p<0.001) and LOS (13.2±10.1 vs 7.4±7.3 vs 8.7±8.6d; p<0.001). After controlling for wound and ASA class and pre-op sepsis, multivariate analysis indicated that O cases had significantly higher rates of superficial SSI [OR 0.5 (95% CI 0.2,0.9)], organ space infection [OR 0.2 (95%CI 0.07,0.5)], post-op transfusions [OR 0.5(95%CI 0.3,0.8)] post-op ventilator use [OR0.3 (95%CI 0.7,0.8)], sepsis [OR0.4 (95%CI 0.2,0.8)] and LOS (p<0.001) compared to L cases. There was not a significant difference in anastomotic leaks among the groups.

Conclusion: Patients who undergo open colorectal resections are sicker and have more post-operative complications, even when controlling for ASA, wound classification and pre-op sepsis. Laparoscopic and robotic colorectal resections have similar outcomes.

68.06 Bariatric Surgery and its Association With Improved Kidney Function Among African Americans

Posted on January 18, 2016

K. Chawla1, A. Vij1, S. Ajmeri1, A. L. Rodriguez1, G. Gilot1, F. De Souza3, G. Ortega3, C. O. Callender2, T. Fullum2 1Howard University,College Of Medicine,Washington, DC, USA 2Howard University College Of Medicine,Division Of Minimally Invasive And Bariatric Surgery, Department Of Surgery,Washington, DC, USA 3Howard University College Of Medicine,Outcomes Research Center, Department Of Surgery,Washington, DC, USA

Introduction: Obesity is associated with a number of comorbidities including chronic kidney disease (CKD). Bariatric surgery results in significant weight loss and post-operative improvements in estimated glomerular filtration rate (eGFR). There is a paucity of data on the effectiveness of bariatric surgery in improving eGFR among African American patients. We hypothesize that bariatric surgery is associated with improved post-operative kidney function among African Americans.

Methods: We conducted a retrospective analysis of patients who underwent bariatric surgery (roux-en-y gastric bypass and sleeve gastrectomy) between 2008 and 2013. We measured pre- and post-operative BMI and eGFR. Post-operative values were recorded 6 months following surgery. The eGFR was estimated by calculating creatinine clearance (CKD-EPI equation used), and a range of 90-125 ml/min/1.73m2 was considered normal. We categorized patients into three BMI categories – ‘35 ≥ BMI < 40′, ‘40 ≥ BMI < 50′ and ‘BMI ≥ 50′. We compared pre-operative eGFR to the post-operative values for patients with glomerular hyperfiltration (stage I CKD) and patients at CKD stages II-IV. We also analyzed the proportion of patients whose CKD condition improved to a less severe stage post-operatively.

Results: The results include 160 patients whose mean age at the time of surgery was 43.0 years. The overall mean eGFR was 104.6 ml/min/1.73m2 prior to surgery and rose to 110.0 post-operatively (p > 0.05). The mean BMI reduced from 49.1 kg/m2 pre-operatively to 38.3 kg/m2 post-operatively (p < 0.0001). Of the 160 patients, 28 had glomerular hyperfiltration (eGFR > 125) and 40 had stages II-IV CKD (eGFR 15-90) prior to surgery. The patients with stage I CKD had a mean pre-operative eGFR of 133.3, which reduced to 125.3 post-operatively (p = 0.0036). Among CKD stage I patients only those in the ‘40 ≥ BMI < 50′ BMI category encountered significant reduction in eGFR from 135.3 to 125 (p = 0.0258). Patients with stages II-IV CKD had a lower than normal mean pre-operative eGFR of 74.8, which rose to 82.6 post-operatively (p > 0.05). None of the BMI categories for patients with stages II-IV CKD showed significant improvement in kidney function. A stage I CKD resolution rate of 43.8% was seen following bariatric surgery, while 57.1% of patients at stages II-IV CKD improved to less severe stages following surgery.

Conclusion: African American patients experienced an improvement in their renal function following bariatric surgery. Further follow up is necessary to determine the effects of bariatric surgery on long-term renal function among African Americans.

68.07 Granulomatous Mastitis: Conservative vs. Surgical Treatment in a County Hospital

Posted on January 18, 2016

A. J. Green1,2, T. Rana2, P. Twomey1,2, R. Godfrey1,2 1University Of California – San Francisco,East Bay Surgery,San Francisco, CA, USA 2Highland General Hospital,Surgery Department,Oakland, CA, USA

Introduction:

Granulomatous mastitis is a chronic inflammatory disease of the breast that is considered idiopathic and has a debated etiology. The clinical presentation of the disease often mimics breast cancer. There is no consensus on the best treatment and methods range from observation and antibiotics to systemic steroids and mastectomy.

Our objective was to determine if conservative management of granulomatous mastitis without steroids and definitive surgery provides effective management for this disease.

Methods:

A retrospective review of institutional records of Highland Hospital in Oakland, California of all patients with a histopathologic diagnosis of granulomatous mastitis from June 2005 though July 2015. Demographic, clinical and outcomes data were analyzed using summary statistics.

We defined definitive surgery as mastectomy, lumpectomy or excisional biopsy.

Results:

A total of 46 women with granulomatous mastitis were identified. The mean age was 33.9 (range 24 – 55 years). 62.2% of women received conservative management with 85% resolution. This includes 22.2% who received only core needle biopsy or fine needle aspiration (88.9% resolution) and 40% who received incision and drainage (86.7% resolution). 35.6% received excisional biopsy. 68.8% of patients undergoing excisional biopsy also had a BIRADS 4 or higher reading on ultrasound or mammogram. 91.7% of patients with excisional biopsy had resolution of symptoms. A single patient (2.2%) received steroids after failed conservative management and continued to be symptomatic. Conservative management was successful in 87.5% of cases. The mean duration of follow up was 11.8 months (range 1 week to 45 months).

Significantly, 91.3% of patients with granulomatous mastitis were Hispanic. Approximately 30% of our hospital patients are Hispanic.

Conclusion:

Conservative management with interventions limited to aspiration, incision and drainage and antibiotics is frequently effective in the management of granulomatous mastitis. However, the radiologic and clinical presentation can mimic breast cancer, and excisional biopsy is often required to rule out a diagnosis of malignancy. Patients treated without steroids had recovery rates comparable to treatment with steroids reported in the literature.

68.02 Evaluating the Quality of Care Transitions Following Outpatient Surgery

Posted on January 18, 2016

M. McCabe1, R. W. Randle1, H. Chen1,2, C. J. Balentine1 1University Of Wisconsin,Department Of Surgery,Madison, WI, USA 2University Of Alabama,Department Of Surgery,Birmingham, Alabama, USA

Introduction: Improving the quality of care as patients transition from the hospital to home has been highlighted by the Institute of Medicine and the Centers for Medicare and Medicaid Services as a priority area for enhancing patient-centered care. The quality of care transitions has been assessed for complex inpatient medical and surgical patients but has never been evaluated for outpatient surgery. The purpose of this study was to use a validated transitions instrument to determine how well patients were being prepared for outpatient surgery at an academic hospital. We hypothesized that our extensive preoperative education and patient support services would result in excellent preparation for surgery and would be reflected by high scores on the instrument.

Methods: We administered the Care Transitions Measure (CTM), a validated assessment of care transition quality, to patients undergoing outpatient endocrine surgery. The survey measures patient comprehension of medications, treatment and discharge plans. Participants were surveyed at three time points: the pre-operative clinic visit, after surgery on the day of discharge, and at the post-operative clinic visit. The primary endpoint was CTM score at each time point. Secondary outcomes included postoperative complications.

Results: We approached 110 patients and 92 (84%) agreed to participate. Mean CTM scores for complex medical and surgical inpatients typically range from 65-70 on a 100 point scale, but our patients had considerably higher scores at all time points (Figure). After the initial clinic visit, mean CTM was 89 ± 2. After surgery, CTM scores remained high with a mean of 92 ± 1.7 on the day of surgery and 90 ± 2 at the postoperative visit, though none of the differences was statistically significant. These scores indicated that our patients had excellent comprehension of treatment plans, understood their medications, and felt that followup plans were adequately explained throughout their surgical experience. There was no significant difference in CTM scores between patients with and without postoperative complications.

Conclusions: Overall CTM scores in our population were extremely high following outpatient endocrine surgery. There are many mechanisms used at our institution to enhance patient understanding and care coordination including dedicated nursing staff, carefully constructed written educational material, easy access to surgeons by phone/e-mail and reinforcement of education in the clinic. Further work will explore which of these mechanisms is most responsible for our high quality care transitions.

68.03 Does Intraoperative Nerve Monitoring Reduce the Rate of Recurrent Laryngeal Nerve Injury?

Posted on January 18, 2016

B. C. Brajcich1, C. R. McHenry1,2 1Case Western Reserve University School Of Medicine,Cleveland, OH, USA 2MetroHealth Medical Center,Department Of Surgery,Cleveland, OH, USA

Introduction:

Damage to the recurrent laryngeal nerve during thyroidectomy can lead to vocal cord paralysis, resulting in hoarseness and respiratory distress. Prior studies have demonstrated mixed results regarding the role of intraoperative nerve monitoring (IONM) in preventing recurrent laryngeal nerve injury. The purpose of this study was to examine the effect of IONM on recurrent laryngeal nerve injury during thyroidectomy.

Methods:

A retrospective cohort study was performed on patients undergoing thyroidectomy performed by a single surgeon over a 6-year period beginning in 2009 (n=627). Routine intraoperative monitoring was implemented in 2012 and was used in a cohort of 315 consecutive patients. The recurrent laryngeal nerve was routinely identified and traced through its entire course in all patients and the IONM was used solely to confirm the functional integrity of the nerve throughout its dissection. The rate of recurrent laryngeal nerve injury was compared to a cohort of 312 consecutive patients who underwent thyroidectomy during the 3-year period immediately prior to implementation of IONM. Secondary analysis was performed to determine if there was a relationship between nerve injury and patient age, sex, substernal thyroid extension, central neck dissection, re-operative neck surgery, nodule size, thyroid gland weight, or pathology. Subgroup analysis was performed for patients with malignant pathology, substernal thyroid extension, re-operative neck surgery, and central neck dissection.

Results:

Of the 627 patients who underwent thyroidectomy, 7 (1.1 %) had a recurrent laryngeal nerve injury. There was no correlation between the use of the IONM and recurrent laryngeal nerve injury. Of the 531 nerves at risk in the cohort with IONM, 4 (0.75 %) were injured compared to 3 injuries (0.58 %) among the 517 nerves at risk in the cohort without IONM (p>0.05). No secondary measures demonstrated a statistically significant relationship with recurrent laryngeal nerve injury. Subgroup analysis did not show any relationship between IONM and nerve injury.

Conclusion:

IONM had no impact on the rate of recurrent laryngeal nerve injury during thyroidectomy. Further studies with larger sample sizes are necessary to confirm our findings, especially in specific high-risk subgroups.

68.04 Laparoscopic vs. Open Approach for Acute Abdomen in Pregnancy

Posted on January 18, 2016

A. Azim1, P. Rhee1, T. Orouji Jokar1, N. Kulvatunyou1, T. O’Keeffe1, A. Tang1, R. Latifi1, G. Vercruysse1, D. Green1, R. Friese1, B. Joseph1 1University Of Arizona,Trauma Surgery,Tucson, AZ, USA

Introduction:

Laparoscopic surgical technique is a standard of care for common surgical procedure such as appendectomy and cholecystectomy. Pregnant patients are a high-risk group for these surgeries and provide several technical difficulties. The aim of this study was to determine outcomes between open vs. laparoscopic surgical approaches in pregnant patients with acute cholecysitis and acute appendicitis. We hypothesized that laparoscopic procedure is a safe approach in pregnant patients with acute abdomen.

Methods:

We performed a four-year (2008-2011) retrospective analysis of national inpatient sample database. All pregnant patients who underwent operative procedure for the diagnosis of acute appendicitis and acute cholecystitis were included in the analysis. Patients with laparoscopic and open procedures were matched for age, type of admission, day of admission, location and teaching status of the hospital, severity of illness, and indication for procedure by using propensity score matching in 1:1 ratio. Matched samples were compared using t-test (parametric), chi-square, and Kruskall-Wallis (non-parametric) tests.

Results:

A total of 252 pregnant patients with the diagnosis of acute abdomen were identified. 213 required operative intervention. After propensity score matching 128 (64 laparoscopic: 64 open) were included in the analysis. Mean age of the population was 27 ± 6, 54% underwent appendectomy, and 46% underwent cholecystectomy. There was no difference in age (p=0.7), type of operation (p=0.3), day of admission (p=0.3), location (p=0.5) and teaching status of the hospital (p=0.8), severity of illness (p=0.7), and indication for procedure (p=0.9). Hospital length of stay (2.1± 1.9 vs. 3 ± 2, p=0.005) and total charges (22612 [12495-27786] vs. 29552 [16712- 34222], p=0.017) were significantly lower in laparoscopic group. There was no difference in complications (p=0.9). No fetal loss was seen in both groups. Table1 shows the comparison of the outcomes among the two groups.

Conclusion:

Minimally invasive approach to acute appendicitis and cholecystitis in pregnant patients is safe and cost effective. Avoidance of minimally invasive approach in pregnancy for fear of fetal complications is unwarranted.

67.19 Primary Anastomosis Versus Bowel Discontinuity in Damage Control Laparotomy

Posted on January 18, 2016

A. Hassan1, P. Rhee1, A. A. Haider1, N. Kulvatunyou1, T. O’Keeffe1, A. Tang1, R. Latifi1, G. Vercruysse1, D. Green1, F. Randall1, B. Joseph1 1The University Of Arizona,Trauma,TUCSON, ARIZONA, USA

Introduction:

The optimal management of bowel injury in the setting of damage control laparotomy (DCL) is not well defined. The aim of this study was to compare primary anastomosis (PA) versus bowel discontinuity (BD) in DCL at the first operation.

Methods:

An 8-year (2006-2013) retrospective analysis of all patients undergoing trauma laparotomy at our Level 1 trauma center was performed. We included patients with DCL requiring bowel resection. We divided the patients into two groups based on their treatment: PA and BD. Patients in BD group were re-anastomosed during the second operation. Outcome measures were mortality and complications. We compared the two groups for differences in demographics, injury parameters, lab data and outcomes.

Results:

A total of 162 patients had DCL during the study period of which 58 patients (36%) were included in our analysis. 32% (n=20) of the patients had a PA while the remaining 68% (n=38) patients had BD. Overall mortality rate was 34%. There was no difference in patient characteristics and intra-abdominal organ injuries between the two groups (Table 1). On multivariate analysis patients with BD had 4.6 times higher mortality rate compared to patients with PA (OR (95%CI) = 4.6 (1.08-25); p=0.04).

Conclusion:
Patients left in bowel discontinuity had 5 times higher risk of mortality compared to patient undergoing a primary anastomosis. Iatrogenic bowel obstruction after damage control laparotomy may have physiological effects contributing to adverse outcomes.

67.20 Endoscopic Ultrasound After Induction Chemoradiation Therapy Overstages Tumors for Esophageal Cancer

Posted on January 18, 2016

D. Giugliano1, F. Palazzo1, M. Pucci1, E. Rosato1, C. Lamb1, D. Levine1, A. Berger1 1Thomas Jefferson University,Philadelphia, PA, USA

Introduction: Endoscopic ultrasound (EUS) has been shown to be the most accurate method for staging patients with esophageal cancer. After neoadjuvant chemoradiation therapy (CRT), CT and PET scan are often used over EUS for re-staging due to post-treatment fibrosis and inflammation that may make EUS staging inaccurate. The aim of this study was to compare EUS staging and pathologic staging in patients who underwent induction therapy prior to esophagectomy.

Methods: We queried our IRB-approved prospective foregut database to identify a total of 26 patients from 2001 to 2015 who underwent post-induction EUS re-staging for locally advanced esophageal cancer. EUS post-induction stage was compared to pathologic stage. EUS nodal status was determined by nodal morphology and size and not by biopsy.

Results: The majority of patients (n=24, 92.3%) were diagnosed with adenocarcinoma. The average age was 58 years old (range: 41-77 years). Most patients (n=22 patients, 84.6%) were male. EUS over-staged tumors for the majority of patients (n=12, 46.2%). It correctly staged 26.9% (n=7) of patients and understaged 26.9% (n=7) of patients. Tumor size (T) was most often overestimated (n=13, 50.0%), as compared to being correctly estimated in 26.9% (n=7) of patients and underestimated in 23.1% (n=6) of patients. Finally, nodal status (N) was most often correct (n=15, 57.7%), and was underestimated in 26.9% (n=7) of patients and overestimated in 15.4% (n=4) of patients.

Conclusion: Post-neoadjuvant chemoradiation therapy re-staging using EUS most often overstages esophageal tumors. Tumor size is most often overestimated, while nodal status is most often correct. Subsequent therapy should not rely on post-neoadjuvant EUS stage.

68.01 Optimal surgical strategy for esophagogastric junction carcinoma.

Posted on January 18, 2016

M. Yura1, H. Takeuchi1, R. Nakamura1, T. Takahashi1, N. Wada1, H. Kawakubo1, Y. Kitagawa1 1Keio University, School Of Medicine,Department Of Surgery,Shinjuku-ku, TOKYO, Japan

Introduction: Incidence of esophagogastric junction carcinoma is increasing worldwide. However, surgical strategies for this cancer remain controversial. This study aimed to clarify the optimal surgical strategy for EGJ adenocarcinoma.

Methods: We retrospectively reviewed a data base of 87 consecutive patients with EGJ adenocarcinoma who underwent curative surgical resection at Keio University Hospital between January 2000 and December 2013. EGJ carcinoma defined as Siewert’s classification ?Siewert type I, N=11 (13%); Siewert type II, N=68 (78%); Siewert type III, N=8 (9%)?

Results: Of 87 patients, 33 (37%) were pT1 and 54 (63%) were pT2≤. Mediastinal lymph node (MLN) metastasis was observed in 9 patients. Patients with pT2≤ had a higher incidence of mediastinal lymph node MLN metastasis as compared with patients with pT1 (14.8% in pT2≤ and 3.0% in pT1). In the patients with pT1, lower MLN metastasis ?was identified with Siewert type I (1/6; 17%) and not identified with Siewert type II (0/25; 0%). Upper/middle MLN metastasis was observed in four cases with pT2≤?Siewert type I, N=3 (60%); Siewert type II, N=1 (12%); Siewert type III, N=0 (0%)?. Of all patients having pT2≤ carcinoma with the tumor center located below EGJ (N=36), no patients exhibited upper/middle MLN metastasis and one patient (2.7%) had lower MLN metastasis. In the patients with pT2≤ carcinoma that tumor center was located above EGJ (N=18), upper/middle MLN metastasis was observed in three patients (16.7%) and lower MLN metastasis was observed in five patients (27.8%). The transthoracic approach was used in all patients with Siewert type I and 12 patients (17.6%) with Siewert type II. The transabdominal approach was used in the patients with Siewert type II/III ?Siewert type II, N=56 (82%), Siewert type III, N=8 (100%)?.

Conclusion: In the patients with superficial Siewert type II carcinoma, necessity of mediastinal LN resection is very low. For those patients, laparoscopy-assisted proximal gastrectomy may be a minimally invasive surgical technique. MLN lymph node dissection through transthoracic approach seems unnecessary, particularly if the tumor center is located below EGJ.

67.17 Pre‐operative Selective Venous Sampling in Reoperative Parathyroid Surgery

Posted on January 18, 2016

S. Zaheer1, D. Graham1, L. Kuo1, H. Wachtel1, R. Roses1, G. Karakousis1, R. R. Kelz1, D. L. Fraker1 1Hospital Of The University Of Pennsylvania,Department Of Surgery,Philadelphia, PA, USA

INTRODUCTION
Reoperative parathyroid surgery (RPS) can be challenging, especially following bilateral neck dissection (BNE). Noninvasive imaging studies (NIIS) such as ultrasound, sestamibi scan, SPECT and magnetic resonance imaging are less sensitive in this setting. 4‐dimensional cat scan (4DCT), a relatively new imaging method, is superior to other NIIS in localizing parathyroid disease but is not widely available. In such scenarios, selective venous sampling (SVS) may be useful for operative planning. We present the results of SVS in a cohort of NIIS‐negative patients with persistent or recurrent disease.

Methods:
RPS patients enrolled in our institutional prospective endocrine surgery registry from 1997 to 2013 were identified for inclusion in the study. Patients with positive localization by NIIS were excluded from the study. Study patients underwent SVS followed by parathyroid exploration with intra-operative PTH monitoring. SVS results were classified as non-localized, lateralized (identification of the correct side of the abnormal gland) or localized (identification of the correct side and position of the abnormal gland) through an assessment of intra-operative findings and pathologic review. Descriptive statistics were performed. Test characteristics were calculated.

Results:
We identified 165 patients with recurrent/persistent disease necessitating surgical intervention. Of the surgical candidates, 19 patients had negative NIIS and were referred for SVS. The sensitivity of lateralization by SVS was 95% (18/19). The sensitivity of localization by SVS was 44.4% (8/18). The final diagnosis was adenoma in 15 patients, hyperplasia in 3 patients and parathyroid carcinoma in 1 patient. Immediate cure was achieved in 88.9% of patients. Long-term cure was achieved in 15/19 (78.9%) patients, among those who lateralized the cure rate was 14/18 (77.8%). Interestingly, cure was not achieved in 2/8 patients who were localized by SVS. One had parathyroid cancer metastatic to left lower neck and the other had multigland hyperplasia.

Conclusion:
SVS is a useful test for the preoperative localization of abnormal parathyroid glands when other NIIS fail. Despite SVS results, the long-term cure rate in this population remains substantially lower than that reported for initial surgical candidates. SVS is especially important in reoperative cases when 4‐ dimensional CT is not locally available.

67.18 Postoperative Outcomes in Patients Presented with Perforated Bowel: Early vs. Late Intervention

Posted on January 18, 2016

Z. Al-Qurayshi1, E. Kandil1 1Tulane University School Of Medicine,Surgery,New Orleans, LA, USA

Introduction: Time from hospital admission to surgery has been suggested to be a crucial risk factor. In this study, we aim to compare the outcomes of one day delayed surgeries to those done on the same day of admission in patients presented with perforated bowel.

Methods: Time from hospital admission to surgery has been suggested to be a crucial risk factor. In this study, we aim to compare the outcomes of one day delayed surgeries to those done on the same day of admission in patients presented with perforated bowel.

Results: 7,415 discharge records were included. 1,753 (23.5%) patients had delayed intervention, while (76.5%) patients had operation on the same admission date. Next day interventions were more likely to be associated with postoperative complications [OR: 1.24, 95%CI (1.08, 1.41), p=0.002]. However by considering complications types individually; pulmonary complications were higher for next day operations (p<0.01), while same day operation had higher risk of wound complications (p<0.01). Patients who had next day surgery were at risk of a hospital stay of more than 14 days (p<0.001). Hospital located in the Northern region of the United States were more likely to delay the intervention until the next day of admission compared to rest of United States( p<0.001). Additionally, women were at higher risk of next day operation compared to men (p=0.01). The average cost of health services for next day operation was significantly higher compared to same day operation ($33,146.00± 907.96 vs. $ 28,658.00± 414.33, p<0.001).

Conclusion: Delaying surgical intervention for patients presented with perforated bowels is associated with disadvantageous outcomes. Gender and geographical disparities associated with the time of intervention.

67.13 Frozen Section Analysis in the Post-Bethesda Era

Posted on January 18, 2016

T. M. Cotton1, X. Jing1, S. John1, R. Lirov1, B. Miller1, M. Cohen1, G. Paul1, D. Hughes1 1University Of Michigan,Ann Arbor, MI, USA

Introduction:
Limitations of intraoperative frozen section (FS) for indeterminate thyroid lesions are well-appreciated. Studies about FS utility have involved ‘follicular lesions’ (FL) and were before the Bethesda System for Reporting Thyroid Cytopathology (BSRTC) subcategorized indeterminate FNA results into follicular lesions of undetermined significance (FLUS) and suspicious for follicular neoplasm (SfFN). We hypothesize that FS will have less utility with FLUS lesions compared to SfFN due to improved cytological categorization in the post-Bethesda era.

Methods:
From 2008 to 2014, 479 patients underwent thyroid lobectomy. Pre-Bethesda (2008-2011) patients with an FNA diagnosis of FL and post-Bethesda (2011-2014) patients with an FNA diagnosis of FLUS or SfFN who underwent FS were identified. The study group was comprised of 135 patients (65 FL, 45 FLUS, and 25 SfFN). The sensitivity, specificity, PPV, and NPV of FS within these categories was compared to final histopathology.

Results:
In the FL group, 6/65 patients were found to have thyroid cancer within the sampled nodule on histopathology with FS having a sensitivity of 50%, specificity of 100%, PPV of 100%, and NPV of 95%. Three of the six cancer cases were identified on FS and changed the operation in 3/65 FL patients (4.6%). In the FLUS group, 5/45 patients were found to have thyroid cancer within the sampled nodule on histopathology with FS having a sensitivity of 20%, specificity of 100%, PPV of 100%, and NPV of 91%. One of the five cancer cases was identified on FS and changed the operation in 1/45 FLUS patients (2.2%). In the SfFN group, 4/25 patients were found to have thyroid cancer within the sampled nodule on histopathology with FS having a sensitivity of 50%, specificity of 100%, PPV of 100%, and NPV of 91%. Two of 4 cancer cases were identified on FS and changed the operation in 2/25 SfFN patients (8%). No patients were over-treated due to false positive FS and 3/70 patients (4.3%) avoided reoperation across post-Bethesda groups.

Conclusion:
FS had limited value before BSRTC, but is even less useful in FLUS patients in the post-Bethesda era. FS had a higher sensitivity in SfFN than FLUS patients and avoided reoperation in 8% of SfFN patients compared to 2.2% (FLUS) and 4.6% (FL).

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