84.11 Usage of Skin Graft Procedures during the Past Two Decades in the United States

Posted on January 26, 2017

J. Buckley1, R. S. Elliott1, A. Seifi1  1University Of Texas Health Science Center At San Antonio,San Antonio, TX, USA

Introduction:  Often utilized in the setting of serious trauma or burns, skin grafting procedures (SGP) are applied by physicians in order to transplant skin to a different area of the body where skin is absent. Using a robust database, we sought to determine the incidence of SGP for patients in the United States and the impact of an institution’s teaching status on these trends.

Methods:  Utilizing the Nationwide Inpatient Sample database, we identified 1,567,966 discharges involving procedures requiring skin grafts (SGP, CCS Procedure Code 172) from 1997 to 2013 in United States. Year-wise distribution of number and rate of patients who underwent SPG at teaching and non-teaching hospitals was described. Z-test statistic was used to compare the two groups.

Results: During seventeen years of the study period, approximately 60.06% of patients who received procedures involving skin grafts (SGP) were males and 34.19% of patients were between 45 and 64 years old. The total annual number of patients who underwent SGP at all institutions increased insignificantly overall and ranged from 83,903 to 101,285 (Fig. 1, P=0.3185). The rate of patients who underwent skin grafts at all institutions varied insignificantly as well and ranged from 28.5 to 34.7 per 100,000 patients (P=0.2329). Throughout the duration of the study period, the mean number of SGP performed in teaching and non-teaching institutions was 64,505 and 26,832 respectively; with an average of 92,233 SGP occurring in all institutions annually. Annually, the number of patients who underwent SGP at teaching institutions ranged from 53,278 to 76,265, whereas the number of patients at non-teaching institutions ranged from 21,110 to 40,604. Notably, from 1997 to 2004 and from 2006 to 2013, the number of patients who received SGP was consistently and significantly higher for patients treated at teaching hospitals as opposed to those treated at non-teaching hospitals (Fig. 1, P<0.0001). However, from in 2005, there was no significant difference between the numbers of SGP performed by these two types of institutions.

Conclusion: The usage of procedures involving skin grafts (SGP) has been consistent in the United States during the past two decades. Teaching status of institutions has an impact on the utilization of SGP in patients. Future research should attempt to explore whether teaching status affects clinical outcomes for patients after SGP and make a recommendation to our patients regarding where to seek optimal care.

 

84.10 The Impact of the Timing of Radiation in Implant Based Breast Reconstruction: A Systematic Review

Posted on January 26, 2017

J. A. Ricci1, B. T. Lee1  1Beth Israel Deaconess Medical Center,Plastic And Reconstructive Surgery,Boston, MA, USA

Introduction: Postmastectomy radiation (PMRT) in the setting of implant based immediate breast reconstruction has been associated with higher rates of complications and poorer aesthetic outcomes. Many centers have attempted to avoid deleterious complications such as implant loss or capsular contracture associated with PMRT by implementing an algorithmic approach to breast reconstruction. As such, PMRT may be delivered directly to a tissue expander (TE) before an exchange for a permanent implant (PI) or afterwards. However, the literature regarding the optimal timing of radiotherapy and breast reconstruction remains controversial. This study aims to systematically review all recent literature on this subject to identify differences in patient outcomes related to the timing of PMRT.

Methods:  A PubMed literature search was performed to summarize the latest data (2000-2016) regarding the impact of the timing of PMRT on the outcomes of implant based breast reconstruction. The search was conducted using the parameters: breast reconstruction AND radiation AND (implant OR expander). Data was pooled from relevant articles and outcomes compared based on whether PMRT occurred before or after exchange of tissue expander for permanent implant.
 

Results: The search returned 336 articles, of which 20 were acceptable for inclusion. Primary outcomes of interest included capsular contracture and reconstructive failure (implant loss). A total of 2348 patients were identified, with PMRT administered to 1479 before exchange and 869 after exchange. The mean follow-up for all patients was 39.5 months (14.3 to 73.5) and a majority of studies (14, 70%) were retrospective in nature (6 prospective, 30%). Patients receiving PMRT to TE before exchange to PI were at higher risk for reconstructive failure (20.0% vs 13.4%; p= 0.001) while patients receiving PMRT after exchange had higher rates of Grade III/IV capsular contracture (49.4% vs 24.5%; p= 0.0001). The average level of evidence of all studies was III. 

Conclusion: While PMRT remains an undesired event when pursuing an implant-based breast reconstruction, it does not represent an absolute contraindication. However, high rates of significant complications, often necessitating operative intervention, occur regardless of whether PMRT is delivered before or after exchange of TE for PI. Accordingly, a case should be made for the use of autologous breast reconstruction when faced with the prospect of PMRT, regardless of the timing, to improve patient outcomes by avoiding unnecessary complications and prevent unplanned returns to the operating room.

 

84.09 Prealbumin and C-reactive Protein Levels Predict Clinical Outcomes in Burn Patients

Posted on January 26, 2017

S. J. Day1, D. E. Bell1  1University Of Rochester,School Of Medicine And Dentistry,Rochester, NY, USA

Introduction:  Low prealbumin levels in burn patients at admission is an indicator of poor baseline nutrition status, which can negatively influence wound healing. This study aimed to identify the role of prealbumin and C-reactive protein (CRP) levels in predicting clinical outcomes of burn injuries.

Methods:  Retrospective case review was conducted of burn patients admitted to an American Burn Association-verified regional burn center from July 2015 to December 2015. Demographic, injury-related and hospitalization-related variables were assessed for correlation with prealbumin and C-reactive protein (CRP) levels collected within 48 hours of admission. Patients were stratified by normal (≥ 20 mg/dL) or low-normal (< 20 mg/dL) prealbumin levels at admission, and normal (≤ 10 mg/dL) or high (> 10 mg/dL) CRP levels at admission.

Results: 

From July 2015 to December 2015, 131 burn patients were admitted to a regional burn center (69.5% male; mean age, 32 years). Average TBSA burned was 5.17% (range 0.03 – 25.37%), with average 2nd degree burn size of 4.42% TBSA and 3rd degree burn size of 0.77% TBSA.

 

Patients in the two groups of normal (58 patients, 44.3%) vs low-normal (50 patients, 38.2%) prealbumin at admission were matched in age, sex, and TBSA. Compared to patients with normal prealbumin levels, patients with prealbumin < 20mg/dL had longer length of hospital stay (13 days vs 8 days, p < 0.05). Patients admitted with prealbumin < 20mg/dL also had significantly improved prealbumin at discharge (15.52 vs 18.91, p = 0.005). Low-normal prealbumin at admission was associated with higher CRP levels (p < 0.0001).

 

The two groups of normal (56 patients, 42.7%) vs high (36 patients, 27.4%) CRP at admission were matched in sex and TBSA but significantly different in age (30 vs 44 years, p = 0.002). Therefore, we controlled for age by stratifying patients into those ≤ 40 years old, and those older than 40 years. After stratification, we found that in patients ≤ 40 years old, high CRP at admission was associated with longer duration of mechanical ventilation (1.85 days vs 0 days, p < 0.05) and increased hospital cost ($82,079 vs $27,701, p < 0.05). In patients older than 40 years, CRP level at admission was not statistically related to length of stay, hospital cost, or days of mechanical ventilation.

Conclusion: Low prealbumin at admission is predictive of longer length of hospital stay in burn patients of all ages, as age was matched between the normal and low-normal prealbumin groups in our study. In patients 40 years or older, elevated CRP is associated with longer duration of mechanical ventilation and increased hospital cost. Thus, prealbumin and CRP levels at admission should be incorporated into prognostic calculations of burn injury outcomes. 
 

84.08 Readability, Complexity, and Suitability Analysis of Online Lymphedema Resources.

Posted on January 26, 2017

B. N. Tran1, M. Singh1, B. T. Lee1  1Beth Israel Deaconess Medical Center,Plastic And Reconstructive Surgery/Surgery,Boston, MA, USA

Introduction:  As many as 72% of Americans use online health information to aid them in healthcare decision-making. It is, therefore, very important to have resources written at the recommended literacy level. Previous studies primarily focused on readability analysis of online lymphedema literature, consistently showing that they are too advanced for the average American to comprehend.  This study expands such analysis to include complexity and suitability of these materials. 

Methods:  Top ten websites on lymphedema were identified using the most popular search engine, Google. Content of these websites was analyzed for readability, complexity, and suitability using Simple Measure of Gobbledygook (SMOG), PMOSE/iKIRSCH, and Suitability Assessment of Materials (SAM) respectively. PMOSE/iKIRSCH and SAM were performed by two independent raters. Fleiss’ kappa score was calculated to ensure inter-rater reliability. 

Results: Lymphedema literature average SMOG reading grade level was 14.0, above the recommended sixth grade level per the American Medical Association and National Institute of Health. Overall PMOSE/iKIRSCH score was 6.7 corresponding to “low” complexity and requiring a 8th-12th grade education. Fleiss’ kappa score was 80% (p=0.04), interpreted as “substantial” agreement. Overall SAM score was 45% correlating to “adequate” suitability, however this is borderline low for “adequate” category (0-39% Not Suitable, 40-69% Adequate). Fleiss’ kappa score was 76% (p=0.06), interpreted as “substantial” agreement.   

Conclusion: Online lymphedema literature is written above recommended level for readability and complexity. It is adequately suitable for intended audience. Overall, online lymphedema literature is too sophisticated for the average American reader. Further efforts to revise these materials are needed to improve patient’s comprehension and understanding. 

 

84.07 Disparities in Management of Lower Extremity Injuries at a Single, Level 1 Trauma Center

Posted on January 26, 2017

E. K. Awad3, K. Leibl1, C. Kerby2, T. A. Swain2, R. L. Griffin2, T. W. King2  1University Of Wisconsin,Madison, WI, USA 2University Of Alabama at Birmingham,Birmingham, Alabama, USA 3University Of South Alabama,Mobile, AL, USA

Introduction:  The goal of this study was to determine if disparities exist in the care of patients with lower extremity trauma. We aimed to compare rate of limb salvage v. amputation for race, sex, age, and insurance status. We hypothesized that there would be disparities in salvage v. amputation. Uncovering these differences could help target those within disadvantaged populations and help find interventions to improve their quality of care.

Methods:  The institution trauma registry was used to identify patients admitted with lower extremity injuries from 2010-2014. Lower extremity injuries were defined as any injury in the lower extremity below the pelvis and were identified by anatomical region using the abbreviated injury scale (AIS). Whole limb categories were excluded as well as injuries specific to vessels, nerves, and skin as the AIS does not specify anatomical regions for these structures below the knee. ICD-9 procedural codes for amputation were used to identify patients undergoing any amputation below the knee. Patient demographic, injury, and clinical variables were compared by amputation procedure status using the chi-square and t-test for categorical and continuous variables, respectively. Stratified analysis was completed to compare patient characteristics among those with and without amputation.

Results: Between 2010 and 2014, 6902 patients were admitted to a level 1 trauma center with a lower extremity injury, of which 131 patients underwent amputation. 105 of those patients were amputations below the knee (p<0.0001). Among those with leg injuries, those who underwent amputation had significantly longer length of stay (19.7±21.6 versus 8.8±13.3, p<0.0001) and were more likely to be male (79.39%, p=0.0021). No difference was observed for mean age (p=0.9936), race (0.0666), or injury severity score (ISS) (p=0.1495) when comparing those who underwent amputation to those who did not. The time to seek care was significantly longer (p=0.0028) when comparing those who underwent amputation (0.70 days) to those who did not (0.30 days). There was a significant difference (p<0.0001) in payment with a larger portion of those undergoing amputation having payment of other (7.63%) or workers’ compensation (9.92%) when compared to the same payment type among those without amputation.  

Conclusion: There was no significant difference in amputation v. salvage by race, sex or ISS for patients with lower extremity trauma. Patients who underwent amputations were noted to have a longer length of stay and more likely to be male. The results demonstrate a significant difference in the patients who underwent amputation with those undergoing amputation having a payment type of other or workers’ compensation, demonstrating that patients who had private insurance were more likely to receive limb salvage.  Further investigations utilizing a multicenter, nationwide database should be performed to verify and validate these results.

 

84.06 Disparities in the Treatment of Facial Fractures: A Single Center Study

Posted on January 26, 2017

K. E. Leibl1, E. K. Awad3, C. Kerby2, T. A. Swain2, R. L. Griffin2, T. W. King2  1University Of Wisconsin,Madison, WI, USA 2University Of Alabama at Birmingham,Birmingham, Alabama, USA 3University Of South Alabama,Mobile, AL, USA

Introduction:  Previous studies have shown that disparities in treatment and access to care by race, age, and insurance coverage exist in the US. Our goal was to determine if disparities in treatment, specifically surgical versus nonsurgical treatment and time delay from admission to treatment, exist by race, sex, age, and insurance coverage for patients treated for facial fractures at a level 1 trauma center in the southern US.

Methods:  Patients with facial fractures who were admitted for treatment at a level 1 trauma center from 2010-2014 were identified using the trauma registry. ICD-9 diagnosis codes 802-802.9 were used to identify patients with facial fractures. ICD-9 procedural codes were used to determine which patients underwent surgical repair procedures. Patient demographic information, injury characteristics, and clinical data were compared by surgical repair status using a chi-square and t-test for categorical and continuous variables, respectively. Analysis of variance was used for comparison of time to surgery for demographic variables. 

Results: There were 2267 patients with facial fractures from 2010-2014, 473 of which underwent reparative operatory procedures. There was a significant difference in age between those undergoing reparative surgery (40.5±17.4) compared to those who did not undergo surgical procedures (42.8±18.8) (p=0.0088). Those undergoing operative procedures had significantly longer length of stay (13.0±12.8 versus 8.1±13.5, p<0.0001), number of days in the intensive care unit (6.8±9.0 versus 4.3±9.5, p<0.0001), and higher facial abbreviated injury score (2.0±0.6 versus 1.8±0.5, p<0.0001) compared to those who did not. There were no observed differences in surgical status of facial fractures by sex (p=0.6264), race (p=0.8602), payment type (p=0.5044), or injury severity score (p=0.0528). When comparing the time from injury to admission, those undergoing surgical procedures waited longer to seek care when compared to those who did not undergo surgery (0.42 days versus 0.21 days, p=0.0069). Time to facial surgical procedure from admission was slightly longer for females (4.6±6.3 days) compared to males (3.7±4.0 days) (p=0.0643) and for whites (4.2±5.0 days) compared to blacks (3.07±3.8 days) and others (3.3±3.16 days) (p=0.0556).  

Conclusion: Patients receiving nonsurgical care were slightly older than those receiving surgical repair. Female patients undergoing surgical treatment had a slightly longer wait time than males. This data does not support previous studies’ findings of disparities in treatment based on race and insurance status. This may be attributable to the diversity of this trauma center’s patient population and staff and possibly a higher level of cultural competency in treatment. Further investigations utilizing a multicenter, nationwide database should be performed to verify and validate these results.

 

84.05 Early Results in Preventing Lymphedema: A Potential Paradigm Shift in Lymphatic Surgery.

Posted on January 26, 2017

D. Singhal1, M. Hahamoff2, N. Gupta2, D. Munoz2, C. Shaw2, L. Spiguel2, D. Singhal1  1BIDMC,Plastic & Reconstructive Surgery/ Surgery,Boston, MA, USA 2University Of Florida School Of Medicine,Plastic & Reconsruction/ Surgery,Gainesville, FL, USA

Introduction: Lymphedema is a progressive disease with no known cure.  Lymphatic procedures for chronic lymphedema have not been able to deliver consistent results.  More efforts have been put into early prevention. The Lymphedema Microsurgical Preventative Healing Approach (LYMPHA) was introduced in 2009 as a method to prevent lymphedema at the time of axillary lymph node dissection (ALND).  We present our early results with a modified LYMPHA technique at the University of Florida.

Methods: We reviewed our prospectively collected database of all patients with a newly diagnosed breast cancer participating in a lymphedema surveillance protocol at our institution from February 2014 to February 2016. 

Results: Eighty-seven patients participated in our lymphedema surveillance program during the study period with an average age of 60 years, BMI 30, and follow-up of 11.5 months.  Six patients developed lymphedema with the strongest correlation to ALND (p<0.0012).  Of eighteen patients who underwent ALND, 10 did not undergo the modified LYMPHA procedure and 8 completed the procedure.  Fifty percent of patients who did not undergo the modified LYMPHA procedure developed lymphedema (5 patients).  No incidence of lymphedema was detected in patients who underwent the modified LYMPHA procedure. One patient developed lymphedema after sentinel node biopsy and did not undergo modified LYMPHA. (Figure 1)

Conclusion: Our early results demonstrate promising support of the modified LYMPHA procedure in preventing lymphedema in patients undergoing ALND.  If these results are maintained in longer follow-up, this will represent a paradigm shift for the lymphatic surgeon to focus on preventative procedures.

 

84.04 Trends in Reconstructive Breast Surgery at a UK Tertiary Centre Pre & Post Acellular Dermal Matrices

Posted on January 26, 2017

H. K. Kankam1, G. J. Hourston1, L. J. Fopp2, A. A. Agrawal3, S. L. Benyon2, M. S. Irwin2, P. Forouhi3, J. R. Benson3,4, C. M. Malata2,3,4  1University Of Cambridge,School Of Clinical Medicine,Cambridge, CAMBRIDGESHIRE, United Kingdom 2Cambridge University Hospitals NHS Trust,Department Of Plastic Surgery,Cambridge, CAMBRIDGESHIRE, United Kingdom 3Cambridge University Hospitals NHS Trust,Cambridge Breast Unit,Cambridge, CAMBRIDGESHIRE, United Kingdom 4Anglia Ruskin University , Cambridge And Chelmsford,Postgraduate Medical Institute, Faculty Of Health Sciences,Cambridge, CAMBRIDGESHIRE, United Kingdom

Introduction:

Reconstructive breast surgery has evolved in the UK over the last decade with a doubling of the immediate reconstruction rate and the introduction of acellular dermal matrices (ADM). The reported advantages of ADMs (in optimising aesthetic outcome, providing inferolateral implant coverage and decreasing radiation-induced capsular contracture) have resulted in their adoption by plastic surgeons and their increased use in implant-based procedures. This study assesses the temporal and practice-changing impact of ADM on the types of post-mastectomy reconstructions performed in our Unit and the outcomes of implant-only techniques.

Methods:

We conducted a retrospective chart review of all patients undergoing post-mastectomy breast reconstruction at a University Teaching Hospital 18 months before and after adoption of ADM (21/10/2013). Patients were identified from the Unit’s reconstruction diary and plastic surgery theater registers. Demographic, procedural as well as complication data were collected for these two patient cohorts and compared.

Results:

Over the three year period a total of 266 reconstruction patients (340 breasts) with a mean age of 47.5 years were identified; 137 (166 breasts) before and 129 (174 breasts) following introduction of ADM. Reconstructions included autologous tissue-only (44%), implant-only (35%) and combined  (21%) techniques. Implant-only procedures increased from 16% to 53% following the advent of ADM (p<0.01, Chi-square test). The indications for all reconstructions were cancer (69%), risk-reduction (26%), salvage of prior surgeries (4%), and others including burns (1%). For the immediate reconstructions (cancer and risk-reduction groups), there were proportionally more implant-only procedures after the advent of ADMs. The proportion of latissmus dorsi (LD) flap reconstructions decreased after the introduction of ADMs (from 31% to 11%, p<0.01, Chi-square test) as did that of deep inferior epigastric perforator (DIEP) flaps (from 49% to 33%, p<0.01, Chi-square test).

The complications we reviewed (infection, wound breakdown, haematoma, seroma and capsular contracture) for the implant-only procedures were not significantly different whether or not an ADM was used (27% versus 19% without ADM, p=0.38 Chi-square test). The number of implant-only reconstructions that received adjuvant radiotherapy after the introduction of ADM did not differ significantly from that before (20% versus 17% respectively, p=0.83 Chi-square test).

Conclusion:

The present study showed that since ADM introduction to our centre, more breast reconstructions have been of the implant-only type with consequent reductions in the more expensive autolougous techniques. ADM use in post-mastectomy reconstruction has not resulted in increased complications contrary to widespread anecdotal reports. The possibility of post-operative radiotherapy was not seen as a total contraindication for implant-based reconstruction.

84.02 Patient Satisfaction with Bilateral Breast Reconstruction in Risk-Reducing and Therapeutic Mastectomy

Posted on January 26, 2017

F. Kazzazi1, R. Haggie1, P. Forouhi2, N. Kazzazi3, L. Wyld3,6, C. Malata2,4  1University Of Cambridge,Clinical School,Cambridge, CAMBRIDGESHIRE, United Kingdom 2Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust,Cambridge Breast Unit,Cambridge, CAMBRIDGESHIRE, United Kingdom 3Doncaster Royal Infirmary,Jasmine Breast Centre,Doncaster, SOUTH YORKSHIRE, United Kingdom 4Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust,Department Of Plastic And Reconstructive Surgery,Cambridge, CAMBRIDGESHIRE, United Kingdom 5Anglia Ruskin University,Postgraduate Medical Institute, Faculty Of Medical Sciences,Cambridge, CAMBRIDGESHIRE, United Kingdom 6University Of Sheffield,Sheffield, SOUTH YORKSHIRE, United Kingdom

Introduction:

Patients undergoing mastectomy and immediate breast reconstruction (IBR) for cancer may be expected to have different perceptions of long term outcomes compared with those who elect to have this operation as a risk-reducing measure. There are no reports directly comparing patient satisfaction between therapeutic and risk-reducing bilateral mastectomy and IBR. Our null hypothesis is that patients will report the same outcomes after bilateral surgery for cancer compared with risk reducing.

Methods:

Patients undergoing bilateral mastectomy and reconstruction from 2008-2014 at the Cambridge Breast Unit, were identified from a prospective register. The validated Breast-Q™ questionnaire was mailed to all following the “total Dillman method” of administering postal questionnaires. Q-SCORE software was utilised to analyse patient satisfaction and compare the two groups. 

Results:

112 patients had bilateral surgery. Of the bilateral reconstructions 14.3% were therapeutic (median age = 50) and 47.3% were risk-reducing (median age = 43). 38.3% of patients fell in a combined aetiology group of risk-reducing in one breast with therapeutic contralateral mastectomy (median age = 46). The overall response rate was 58.4%. The therapeutic group had higher patient satisfaction than risk reducing group across most domains (therapeutic/ risk-reducing); breast: 68.8/68.3, outcome: 81.3/75.6, psychosocial: 77.9/75.7, sexual: 62.1/53.8, physical: 72.6/74.0 admin: 85.6/84.1. The combination group scored lowest in most domains.

Conclusion:

RRM and immediate reconstruction has been a major advance in the management of patients who may later suffer cancer. The decision to have bilateral RRM is in many patients’ minds is influenced by the availability of IBR. Our study suggests it is important to counsel these patients well because of their lower satisfaction rates however, more investigation is required to understand the lower satisfaction of the combination group.

 

84.01 Umbilical Necrosis Rates After Abdominal Based Microsurgical Breast Reconstruction

Posted on January 26, 2017

J. A. Ricci1, P. Kamali1, B. Becherer1, D. Curiel1, W. Wu1, B. T. Lee1  1Beth Israel Deaconess Medical Center,Plastic And Reconstructive Surgery,Boston, MA, USA

Introduction:  Umbilical stalk necrosis represents a rare, yet important complication after abdominal based microsurgical breast reconstruction, which is both under-recognized and under-studied in the literature.  Once identified, umbilical reconstruction can be an extremely challenging problem. Previously unreported in the literature, this study aims to categorize this problem and identify associated risk factors, in an effort to prevent its occurrence.  

Methods:  All consecutive microsurgical free flaps for breast reconstruction at a single institution from February 2004 to February 2016 were reviewed. Non-abdominal based flaps were excluded. Patients were then divided in to cohorts depending on the development of umbilical necrosis postoperatively. Demographics, surgical characteristics and other complications were compared between the groups. 

Results: A total of 1335 flaps met the inclusion criteria, with 1286 flaps performed in patients who did not develop umbilical necrosis (96.3%) and 49 instances of umbilical necrosis identified (3.5%). Patients who developed necrosis tended to be older (49.4 yrs vs. 52.9 yrs; p <0.01), have higher BMI (31.3 vs. 27.8; p <0.01), have higher rates of hypertension (40.8% vs. 14.1%; p <0.01) and were more likely to be smokers (26.5% vs. 11.4%; p <0.01). Umbilical necrosis was associated with increased flap weight (829.8 g vs. 656.2 g; p <0.01), decreased time allotted to perforator dissection (150 min vs. 169 min; p =0.02) and increased number of perforators dissected per flap (2.5 vs. 2.2; p =0.03). There was no association with flap type (DIEP, SIEA or free TRAM), history of diabetes, previous abdominal surgery, use of preoperative imaging to identify perforators.  Umbilical necrosis was not associated with most complications, but was associated with a concomitant donor site seroma (14.2% vs. 5.1%, p =0.01). A total of six patients underwent eventual reconstruction of the umbilicus.

Conclusion: Umbilical stalk necrosis represents a rare, though serious complication for patients following abdominal based microsurgical breast reconstruction and to date, no series in the literature has focused on this complication. Overall, umbilical necrosis was found to occur at a rate of 3.5% and was found to be associated with several preoperative comorbidities. Additionally, it was associated with several intraoperative characteristics, including larger flap harvest, decreased time spent on perforator dissection and increased number of perforators harvested per flap. This information should help influence surgeon’s intraoperative decision making to prevent the development of this undesirable complication.

 

83.20 Impact of fresh frozen plasma transfusion on long-term outcomes in colorectal liver metastases

Posted on January 26, 2017

Y. Nakaseko1, K. Haruki1, H. Shiba1, Y. Takano1, S. Onda1, F. Suzuki1, M. Matsumoto1, T. Sakamoto1, T. Gocho1, Y. Ishida1, K. Yanaga1  1The Jikei University School Of Medicine,Department Of Surgery,Nishi-Shinbashi, MINATO-KU, TOKYO, Japan

Background: Blood transfusion has been reported to be associated with immunomodulation and poor oncologic outcomes in several malignancies.  The aim of the study was to investigate the influence of the use of fresh frozen plasma (FFP) on long-term outcomes in patients with colorectal liver metastases (CRLM) after hepatic resection.

Patients and

Methods: The study comprised 127 patients who had undergone elective hepatic resection for CRLM between April 2000 and December 2013.  We retrospectively investigated the influence of the use of FFP on recurrence-free survival as well as and overall survival and assessed impact on postoperative markers of inflammation.

Results: In multivariate analysis, more than 4 lymph node metastases of the primary cancer (p=0.001), bilobar distribution (p=0.002), and perioperative FFP transfusion (p=0.005) were independent risk factors for cancer recurrence, while more than 4 lymph node metastases of the primary cancer (p<0.001), presence of neo-adjuvant chemotherapy (p=0.002) and perioperative FFP transfusion (p=0.004) were independent risk factors for poor overall survival. In patients with FFP transfusion, tumor size (p = 0.004), anatomical resection (p<0.001), duration of operation (p = 0.039) and intraoperative blood loss (p < 0.001) were significantly greater.  Moreover, FFP transfusion was associated with higher white blood cell level on postoperative day 3 (p<0.001) and 5 (p=0.010), and lower serum C-reactive protein level on postoperative day 3 (p<0.001) and 5 (p=0.017).

Conclusion: Perioperative FFP transfusion is independently associated with poor long-term outcomes in patients with CRLM after hepatic resection.  FFP may have influence on postoperative inflammation by its immunosuppressive effect.
 

83.19 Using Adenoma Weight and Volume to Predict Multigland Disease in Primary Hyperparathyroidism

Posted on January 26, 2017

J. Lee1, M. B. Albuja-Cruz1, C. Burton1, C. D. Raeburn1, R. McIntyre1  1University Of Colorado School Of Medicne,GI, Tumor And Endocrine Surgery,Denver, CO, USA

Introduction:
Intraoperative parathyroid hormone (ioPTH) monitoring is the current gold-standard for intraoperative determination of multi-gland disease (MGD) in patient with primary hyperparathyroidism (PHPT).   A prior study found that the risk of persistent disease after minimally invasive parathyroidectomy (MIP) is higher if the weight of the resected gland is ≤ 200mg.  The purpose of this study is to determine if the volume and weight of first resected adenoma is a reliable predictor of MGD. This would provide surgeons immediate and inexpensive information to assist with the decision of conversion from a MIP to bilateral neck exploration (BNE). 

Methods:
Retrospective review of prospectively collected data of 469 consecutive patients who underwent initial parathyroidectomy for PHPT at a single tertiary medical center from 2010 to June 2015 was performed.  Intraoperative parathyroid hormone was used in all cases and intraoperative cure was defined by a >50% drop of the preoperative PTH at 10 minutes and within normal limits.  One hundred eighty-five patients met criteria for inclusion in this study.  Data was analyzed for patient demographics, operative procedure, first resected adenoma weight and volume, presence of MGD, complications, cure and persistence disease.

Results:
Of the 185 patients, 74% had a single adenoma and 26% had MGD. The mean weight for the single adenoma group was 846 mg compared to 461mg for the MGD group (P< 0.05).  A weight of ≥200mg was used as a cutoff to distinguish a single adenoma from MGD (sensitivity 87%, specificity 28%, PPV 76%, NPV 45% and accuracy 71%; P= 0.73). 
The mean volume for the single adenoma group was 1.13 compared to 0.5cm3 for the MGD group (P< 0.05). A volume of ≥0.2cm3 was used as cutoff to differentiate a single adenoma from MGD (sensitivity 83%, specificity 35%, PPV 78%, NPV 44% and accuracy 71%; P= 0.82).
Final cure rate for PHPT was achieved in 97% of the patients included in the study.  Then median follow up was 25 months.

Conclusions:
The weight and volume of the first resected adenoma are not accurate measures to determine the presence of multigland disease in patients with PHPT, despite significant difference in mean weight and volume between the single adenoma vs. MGD groups.  Surgeon judgment and ioPTH remains paramount in the in the operative management of this patient population.
 

 

83.18 DNR Orders and High Risk Pediatric Surgery: Professional Nuisance or Medical Necessity?

Posted on January 26, 2017

L. M. Baumann1,2, K. Williams1,2, F. Abdullah1,2, R. J. Hendrickson3, T. A. Oyetunji1,2  3Children’s Mercy Hospital- University Of Missouri Kansas City,Pediatric Surgery,Kansas City, MO, USA 1Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA 2Ann & Robert H Lurie Children’s Hospital Of Chicago,Pediatric Surgery,Chicago, IL, USA

Introduction:  There is a paucity of data in the literature regarding end-of-life care and do-not-resuscitate (DNR) status of the pediatric surgical patient, despite the fact that invasive procedures are frequently performed in very high risk and critically ill children.  There have been significant efforts in adult medicine to enhance discussions around end-of-life care, however, little is known about similar endeavors in the pediatric population.

Methods:  A retrospective review of the National Surgical Quality Improvement Program Pediatric (NSQIP Pediatric) was performed.   Patients <18 years old with ASA class 3 or greater who underwent elective operation in 2012-2013 were identified and included for analysis.  Demographic factors, principal diagnosis, associated conditions, DNR status and mortality were extracted.  Descriptive analysis was performed using Stata 11.

Results: A total of 114,395 records were initially identified, with 20,164 patients meeting the inclusion criteria.  91.6% of patients were ASA III, 8.3% ASA IV, and 0.1% ASA V. Less than 1% (0.18%) of all patients had a signed DNR order prior to operation.  Of severely ill patients defined by ASA IV, only 1 out of a hundred were DNR status.  There were no differences in gender, race, ethnicity or surgical department of patients with and without a DNR order. Of those children who died within 30 days of operation, 11.1% were DNR status.  Notably, 17.1% of children who died within this period had multiple operations performed prior to expiring.

Conclusion:  The rate of documented DNR status is extremely low in the high-risk pediatric surgical population undergoing elective surgery, even amongst severely ill children where systemic disease is a “constant threat to life”. It is unclear if this is due to physician hesitancy or parents’ unwillingness to make this difficult decision.  Regardless, well-informed end-of-life care and DNR status discussions in a patient focused approach are essential in the surgical care of children with complex medical conditions and critical illness. Better documentation of any DNR discussion will also allow better tracking and benchmarking.

83.17 Racial and Ethnic Disparities in Survival of Pediatric Sarcoma

Posted on January 26, 2017

A. J. Jacobs1, E. Lindholm2, C. Fein Levy3, J. D. Fish3, R. D. Glick2  1Hofstra Northwell School Of Medicine,Hempstead, NY, USA 2Cohen Children’s Medical Center,Pediatric Surgery,New Hyde Park, NY, USA 3Cohen Children’s Medical Center,Pediatric Hematology/Oncology,New Hyde Park, NY, USA

Introduction:
Childhood sarcomas are rare diseases, and the interdisciplinary care these patients require is specialized and expensive.  Vast improvements have been made in the diagnosis and treatment of these malignancies over the last decades.  The goal of this study was to determine treatment trends over time and to determine if racial or ethnic disparities exist for pediatric sarcoma patients in the United States.

Methods:
The United States’ National Cancer Institute’s Surveillance, Epidemiology, and End Results database (SEER) was used to identify patients aged 0-21 diagnosed with primary sarcomas from 1973-2012.  Patients were considered by race and ethnicity.  Survival curves were computed using the Kaplan-Meier method and the log-rank test.  Cox proportional hazard regression was used for multivariate analysis.

Results:
A total of 11,502 patients with histologically confirmed sarcoma were included in this study.  A greater proportion of patients were male (57%), and the majority of patients were between ages of 11 and 17 at time of diagnosis. Of the total population, 6877 (60%) patients had soft tissue tumors, and 4625 (40%) patients had bony tumors. The most common soft tissue tumors were non-rhabdomyosarcoma (66%), and the most common bony tumor was osteosarcoma (58%). The majority of patients presented with localized disease (36.9%), followed closely by regional disease 30.8%, and lastly distant disease (18.9%).  When stratified by race, there were significant differences between stage and tumor size at the time of diagnosis between white and non-white patients (Table 1). Among those patients with soft tissue sarcomas, 46% of non-Hispanic White patients received radiation therapy, compared to 40% of non-Hispanic Black patients (p=0.01). There was, however, no significant difference between the proportion of white and non-white patients who underwent surgery (p=0.21).  Overall 10–year survival improved during the study period from 52.5% in 1973-1979 to 65.3% in 2000-2012. The 10-year OS was 64.5% for non-Hispanic White patients, 62.3% for Hispanic patients, and 61.8% for non-Hispanic Black patients (p=0.01).

Conclusion:
While an improvement in pediatric sarcoma survival was seen over the past 4 decades, this survival improvement still lags far behind that of hematologic malignancies.  Racial and ethnic disparities are seen in the treatment patterns and survival of these rare tumors in the United States.  Non-white patients are presenting at a later stage and have overall worse survival than white counterparts.
 

83.16 Use of Prophylactic Radiation Therapy to Prevent Keloid Formation after Thyroid Surgeries

Posted on January 26, 2017

M. A. Anwar2, R. Kholmatov1, F. Murad1, D. Bu Ali1, E. Kandil1  1Tulane University School Of Medicine,New Orleans, LA, USA 2Wayne State University,Detroit, MI, USA

Introduction:

Keloid or hypertrophic scar following thyroid surgery can cause substantial patient distress with diminished quality of life, and poses a significant challenge to treat. Herein we examined the efficacy of prophylactic external-beam radiation therapy (EBR) for prevention of keloid formation in high-risk patients undergoing thyroid surgeries. 

Methods:
We reviewed our medical records between January 2013 and December 2015 to identify the patients with previous history of developing keloids who underwent thyroid surgeries at our institution. All the pertinent data on patients’ demographics, primary diagnoses, surgical procedures, radiation dosage, and outpatient follow-ups was collected. 

Results:
Nine patients with history of keloid formation received external beam radiation therapy for keloid prophylaxis following thyroid surgeries during the study period.  Radiation was initiated within 6 hours after surgeries. Average radiation dose was 1798 ±405 cGY. Patients were followed for an average of 14 ± 5.91 months. Only one patient, who underwent concomitant lateral and central neck dissection in addition to thyroid surgery, developed a keloid in less than 10% 0f her scar. In the remaining eight cases, no post-surgical keloid formation was observed and patients were satisfied with postsurgical scar. 

Conclusion:
To our knowledge, this is the first study to investigate the role of prophylactic EBR in high-risk patients undergoing thyroid surgery. Prophylactic EBR for prevention of keloid formation following thyroid surgeries is feasible and effective in high-risk patients. Further randomized prospective studies are warranted. 

83.14 Efficacy of Oral Antibiotics in Children with Post-Operative Abscess from Perforated Appendicitis

Posted on January 26, 2017

K. L. Weaver1, A. S. Poola1, K. W. Gonzalez1, S. D. St. Peter1  1Children’s Mercy Hospital,Department Of Pediatric General Surgery,Kansas City, MISSOURI, USA

Introduction:
Post-operative intra-abdominal abscess (PIAA) is the most common complication after appendectomy for perforated appendicitis (PA). This results in a protracted  medical course. Intravenous antibiotics by a peripherally inserted venous catheter are commonly employed to treat the abscess. We sought to evaluate the role of oral antibiotics in this population. 

Methods:
A retrospective review was conducted of children between January, 2005 to September, 2015 with a PIAA. Demographics, laboratory values, type and duration of antibiotics, interventions, imaging, length of stay, complications and hospital costs were all analyzed using descriptive statistics. Comparative analysis was performed on those who were treated with oral versus IV antibiotics after diagnosis of PIAA upon discharge utilizing a Pearson chi-square and Fisher’s exact test.  

Results:

103 children, of whom 66% where male with an average age at time of surgery of 11 + 3.6 years were included. Days of symptoms prior to admission was 3.2 + 2.3 days with a WBC of 17.9 + 6.4.  The median time to diagnosis of PIAA from appendectomy was 7 days (range 7-10) with 46% being treated with antibiotics only, 39% requiring drain placement and 15% aspiration. Mean total length of stay was 10 + 3.4 days. Comparing those who were discharged with oral antibiotics (42%) versus IV antibiotic therapy (58%), there was no significant difference in number of days of IV antibiotics prior to PIAA diagnosis, length of drain days if required, or total number of hospitalizations. However, there was a significant difference found in total length of hospital stay (9.1 vs. 10.7, p=0.02) and number of medical encounters required for treatment (3.4 vs. 4.4, p= <0.01). 

Conclusion:
PIAA treatment after appendectomy for PA can be treated with oral antibiotics with equivocal outcomes as IV antibiotic treatment, but with shorter length of hospitalizations and less medical encounters required. 
 

83.15 Use of Ultrasound for Distinguishing Non-Perforated from Perforated Appendicitis in Children

Posted on January 26, 2017

B. C. Weber3, K. G. Gill2, E. L. Riedesel2, R. S. Cartmill4, C. M. Leys1, J. E. Kohler1  1University Of Wisconsin,Pediatric Surgery,Madison, WI, USA 2University Of Wisconsin,Pediatric Radiology,Madison, WI, USA 3University Of Wisconsin,School Of Medicine And Public Health,Madison, WI, USA 4University Of Wisconsin,Wisconsin Surgical Outcomes Research Program,Madison, WI, USA

Introduction:  Acute appendicitis is one of the leading causes of surgery in children. Recent clinical trials suggest that simple acute appendicitis in pediatric patients can often be successfully treated non-operatively with antibiotics. Conversely, perforated appendicitis requires urgent appendectomy or percutaneous drainage and a prolonged course of antibiotics. As treatment strategies for perforated and simple acute appendicitis diverge, effective imaging to identify the presence or absence of perforation preoperatively is increasingly important. Ultrasound has a demonstrated effectiveness in diagnosing acute appendicitis, but its ability to detect perforation has not been well elucidated.

Methods:  We retrospectively analyzed health records of all pediatric patients who presented to a single pediatric Emergency Department with suspected appendicitis from 11/1/2014 to 12/31/2015. We abstracted data from radiology reports, operative notes, and pathology reports to determine the effectiveness of ultrasound at predicting perforated appendicitis based on concordance of ultrasound and surgical findings. We used the only evidence-based definition for perforation that is associated with an increased risk of abscess formation, a hole in the appendix or fecalith in the abdomen at the time of operation.

Results: A total of 480 ultrasounds for suspected appendicitis were performed during the study period. 85.6% of patients with appendicitis were successfully diagnosed using ultrasound. Of these 95 patients, 28 (29.5%) were perforated at operation and 67 (70.5%) were not perforated. The interpreting pediatric radiologist’s impression of perforation was correct 81.1% of the time with a specificity of 86.6% and sensitivity of 67.9%.

Conclusion: These data suggest that ultrasound is a reliable measure for identifying appendicitis and perforation in children with a sensitivity and specificity comparable to reports for computed tomography (CT) scans. The negative predictive value of ultrasound for perforation should allow safe attempts at non-operative management of appendicitis if perforation is not seen.

 

83.13 Readmission and Imaging Outcomes in Pediatric Complicated Appendicitis: a Matched Case-Control Study

Posted on January 26, 2017

K. L. Murphy1, R. P. Foglia1, S. E. Wolf1, A. C. Alder1  1University Of Texas Southwestern Medical Center,Dallas, TX, USA

Introduction:  Currently, the treatment guidelines for perforated appendicitis generally include primary appendectomy or non-operative management followed by an interval appendectomy 6 to 12 weeks post discharge (first-line antibiotics). First-line antibiotics along with abscess drainage and deferred appendectomy is selected with the intent to minimize complications of surgical management. However, investigation of specific, clinically-relevant outcomes identified that primary appendectomy reduced time away from normal activities and was associated with higher family satisfaction, fewer CT scans, and fewer visits to the emergency department. The benefits of each continue to be debated. The aim of this study was to compare clinically-relevant outcomes such as length of stay, imaging rate and readmission between patients selected for first-line antibiotics and first-line appendectomy using a matched case-control approach.

Methods:  The electronic medical record system at Children’s Medical Center was queried for all patients diagnosed with perforated appendicitis who underwent an appendectomy. A total of 3,491 were identified over 4 years.  Among 905 patients with perforated appendicitis, 105 underwent first-line antibiotic therapy. The patients were grouped by intervention, first-line antibiotics vs. first-line appendectomy.  No standardized protocol currently exists for management of delayed appendectomy at our institution.  The 291 patients were matched with a ratio of 1:2 and based on age, gender, and presence of a fecalith on imaging. Data points including length of stay (LOS), total number of imaging scans, and number of visits to the ED and readmission to the hospital were collected. The values are reported as mean and standard deviation.

Results: The first-line antibiotic group had significantly longer primary hospitalization (LOS) in addition to a longer total LOS (158.40 ± 129.10 vs. 108.19 ± 97.91, p < 0.0001; 199.72 ± 142.65 vs. 118.80 ± 93.217, p < 0.0001).  These were readmitted more often (0.21 ± 0.48 vs. 0.08 ± 0.311, p = 0.0026) though ED visits were statistically similar to primary appendectomy (0.17 ± 0.40 vs. 0.10 ± 0.35, p = 0.1024).  Re-hospitalization LOS was not longer (p = 0.2000).  The first-line antibiotic group also underwent more imaging scans during their initial hospital visit as well as after the primary diagnostic scan (1.02 ± 0.46 vs. 0.54 ± 0.57, p < 0.0001; 0.26 ± 0.52 vs. 0.06 ± 0.28, p < 0.0001).

Conclusion: In this study, we found that delayed appendectomy is associated with longer hospital stays, increased hospital admissions, and more imaging scans.  Readmissions are also higher.  These outcomes may be related to selection bias as well as lack of a standardized approach outlining when to scan patients and in access to outpatient surgical care.

                                                                                                                                           

83.12 Are Foley Catheters Needed in the Postoperative Care of Children with Perforated Appendicitis?

Posted on January 26, 2017

S. Mohammed1, Y. R. Yu1,2, R. Sola3, J. T. Lackey1, S. John4, E. Rosenfeld1,2, W. Zhang2, S. D. St. Peter3, S. R. Shah1,2  1Baylor College Of Medicine,Division Of General Surgery,Houston, TX, USA 2Texas Children’s Hospital,Division Of Pediatric Surgery,Houston, TX, USA 3Children’s Mercy Hospital- University Of Missouri Kansas City,Division Of Pediatric Surgery,Kansas City, MO, USA 4University Of Texas Health Science Center At Houston,Houston, TX, USA

Introduction: Patient-controlled analgesia (PCA) is often used for postoperative pain control in children with perforated appendicitis.  Additionally, some providers routinely use postoperative Foley catheters in this population to prevent urinary retention; however, this practice varies by surgeon and institution.  The objective of this study was to determine the rate of urinary retention in this patient population to guide future practice.

Methods: A retrospective review was performed of all pediatric patients (≤ 18 years old) who received PCA postoperatively for perforated appendicitis between July 2015 and June 2016 at two academic children’s hospitals.  Data collected included patient characteristics, intraoperative findings, postoperative narcotic use, and incidence of urinary retention and urinary tract infections.  Urinary retention was defined as the inability to spontaneously void during the postoperative period requiring straight catheterization or placement of a Foley catheter.  Statistical analysis was performed using the Wilcoxon rank test and Fisher’s exact test, as appropriate.  Additional univariate logistic regression analysis was performed to identify risk factors for urinary retention.

Results: A total of 313 patients (mean age 9.5 ± 3.9 years) underwent appendectomy for perforated appendicitis during the study period (175 at Hospital 1 and 138 at Hospital 2). An intraoperative Foley catheter was placed in 22 (13%) patients at Hospital 1, and 107 (78%) patients at Hospital 2 (p<0.0001).  For the combined study population there were 196 (63%) males and the overall postoperative length of stay was 5.6 ± 2.9 days.  The mean PCA morphine usage was 0.4 ± 0.3 mg/kg/day per patient.  Age, gender, and body mass index (BMI) was similar between those that had an intraoperative Foley catheter placed (n=129) and those that did not (n=184).  There were no urinary tract infections in either group.  The urinary retention rate was 4.3% (n=8) for patients without an intraoperative Foley catheter, and 0.8% (n=1) for those with an intraoperative Foley catheter after removal on the inpatient unit (p=0.06).  Univariate analysis of patient characteristics, intraoperative findings, PCA specifics (narcotic type, duration, average daily usage, and basal rate), postoperative length of stay, and postoperative abscess formation did not identify any significant risk factors for urinary retention.

Conclusion: Practice variations exist regarding placement of intraoperative Foley catheters in children with perforated appendicitis.  However, the risk of urinary retention in this population is low despite the use of patient-controlled analgesia.  Based on these results we conclude that children with perforated appendicitis do not require routine postoperative Foley catheter placement to prevent urinary retention.

 

83.11 Optimal Timing of Surgical Intervention for Patients with Gastroschisis and Atresia

Posted on January 26, 2017

H. E. Arnold1, H. Short1, K. Baxter1, C. D. Travers2, A. M. Bhatia1, M. M. Durham1, M. V. Raval1  1Emory University School Of Medicine,Division Of Pediatric Surgery, Department Of Surgery,Atlanta, GA, USA 2Emory University School Of Medicine,Department Of Pediatrics,Atlanta, GA, USA 3Emory University School Of Medicine,Department Of Surgery,Atlanta, GA, USA 4Emory University School Of Medicine,Department Of Pediatrics,Atlanta, GA, USA

Introduction:  Gastroschisis complicated by atresia represents a clinical challenge. In addition to the initial abdominal wall defect repair, these children require subsequent interventions to establish bowel continuity. After definitive abdominal closure, the second surgery is often delayed to enhance bowel recovery. The optimal timing of the second intervention has not been fully investigated. The purpose of this study was to determine if early intervention for patients with gastroschisis and atresia results in improved outcomes compared to late intervention. 

Methods:  Retrospective chart review of patients who underwent surgical repair of gastroschisis between January 1, 2009 and December 31, 2012 was performed at a quaternary children’s hospital. We identified a subset of patients who had gastroschisis complicated by atresia and compared those who had early intervention (<4 weeks) versus late intervention (>4 weeks) to manage the atresia.

Results: Of 143 gastroschisis patients identified, 13 (9.1%) had atresia including 5 (38.5%) primary abdominal wall closures and 8 (61.5%) that were delayed closures using a silo. From definitive closure to subsequent intervention for the atresia, 7 were considered early (<4 weeks, median 9 days), and 6 were considered delayed (>4 weeks, median 49 days). All patients in the early intervention group received ostomies, while patients in the late intervention group underwent primary anastomosis. Overall, 5 patients had major complications including 1 with volvulus, 1 with intestinal necrosis, and 3 with perforations. Of these, only one major complication occurred in the delayed group, which was the case of the volvulus. Excluding those patients with emergent complications (1 patient with necrosis, 1 patient with perforation) that forced earlier than planned intervention, overall length of stay trended toward shorter stays for early intervention patients (66 vs. 98 median days, p=0.30). Early intervention was associated with shorter time to enteral feeds (28 vs. 60 median days of life, p=0.02). 

Conclusion: In this single-center, retrospective review, patients undergoing early intervention for atresia after definitive gastroschisis closure trended toward shorter length of stay and earlier initiation of feeds despite uniformly receiving ostomies. The optimal timing of surgical intervention in this complex patient population warrants further investigation. 

 

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